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S. HRG. 111–76 

HEARING ON PENDING HEALTH-RELATED 

LEGISLATION 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED ELEVENTH CONGRESS 

FIRST SESSION 

APRIL 22, 2009 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

DANIEL K. AKAKA, Hawaii, Chairman 

JOHN D. ROCKEFELLER IV, West Virginia 

PATTY MURRAY, Washington 

BERNARD SANDERS, (I) Vermont 

SHERROD BROWN, Ohio 

JIM WEBB, Virginia 

JON TESTER, Montana 

MARK BEGICH, Alaska 

ROLAND W. BURRIS, Illinois 

ARLEN SPECTER, Pennsylvania 

RICHARD BURR, North Carolina, Ranking 

Member 

JOHNNY ISAKSON, Georgia 

LINDSEY GRAHAM, South Carolina 

ROGER F. WICKER, Mississippi 

MIKE JOHANNS, Nebraska 

WILLIAM E. BREW, Majority Staff Director 

LUPE WISSEL, Republican Staff Director 

(III) 

C O N T E N T S 

APRIL 22, 2009 

SENATORS 

Page 

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

Burr, Hon. Richard, Ranking Member, U.S. Senator from North Carolina ....... 2 

Brown, Hon. Sherrod, U.S. Senator from Ohio ..................................................... 4 

Johanns, Hon. Mike, U.S. Senator from Nebraska ............................................... 6 

Tester, Hon. Jon, U.S. Senator from Montana ...................................................... 7 

Burris, Hon. Roland W., U.S. Senator from Illinois ............................................. 8 

Begich, Hon. Mark, U.S. Senator from Alaska ..................................................... 9 

Sanders, Hon. Bernard, U.S. Senator from Vermont ........................................... 10 

Murray, Hon. Patty, U.S. Senator from Washington ........................................... 12 

WITNESSES 

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

Health, U.S. Department of Veterans Affairs; accompanied by Walter A. 

Hall, Assistant General Counsel, U.S. Department of Veterans Affairs; and 

Joleen Clark, Chief Officer for Workforce Management and Consulting, 

U.S. Department of Veterans Affairs ................................................................. 13 

Prepared statement .......................................................................................... 14 

Written views for the record submitted by VA after the hearing ................ 39 

Response to written questions submitted by: 

Hon. Daniel K. Akaka .................................................................................. 48 

Hon. Patty Murray ........................................................................................ 53 

Hon. Bernard Sanders .................................................................................. 55 

Hon. Jon Tester ............................................................................................. 57 

Map—Location of Veterans Rural Health Resource Centers ................ 62 

Appendix A—VRHRC Project Summaries .............................................. 63 

Atizado, Adrian, Assistant National Legislative Director, Disabled American 

Veterans ................................................................................................................ 81 

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

Response to requests arising during the hearing by Hon. Daniel K. 

Akaka ............................................................................................................. 148 

Hilsabeck, Ammie, R.N., Oscar G. Johnson VA Medical Center, Iron Mountain, Michigan, on behalf of the American Federation of Government Employees, AFL–CIO ................................................................................................ 94 

Prepared statement .......................................................................................... 96 

Response to requests arising during the hearing by Hon. Daniel K. 

Akaka ............................................................................................................. 144 

Heady, Hilda R., MSW, Associate Vice President of Rural Health, Robert 

C. Byrd Health Sciences Center, West Virginia University, and Past President, National Rural Health Association ........................................................... 102 

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

Ibson, Ralph, Senior Fellow for Health Policy, Wounded Warrior Project ......... 107 

Prepared statement .......................................................................................... 109 

Attachment: Sustaining Family Caregiving for Wounded Warriors: 

The Need for a Comprehensive Caregiver Program ........................... 113 

Ortner, Blake C., Senior Associate Legislative Director, Paralyzed Veterans 

of America ............................................................................................................. 132 

Prepared statement .......................................................................................... 133 

Response to requests arising during the hearing by Hon. Daniel K. 

Akaka ............................................................................................................. 143 

Page

IV 

APPENDIX 

Geer, Jerri, (Ret.) Coast Guard Lieutenant; prepared statement ....................... 151 

Brennan, Michael, M.D., President, American Academy of Ophthalmology; 

prepared statement .............................................................................................. 153 

Campbell, Patrick, Chief Legislative Counsel, IAVA; prepared statement ........ 155 

National Association of Veterans’ Research and Education Foundations 

(NAVREF); prepared statement .......................................................................... 157 

Cohoon, Barbara, Deputy Director, Government Relations, The National Military Family Association; prepared statement .................................................... 160 

Nurses Organization of Veterans Affairs (NOVA); prepared statement ............. 165 

Holway, David J., National President, National Association of Government 

Employees, SEIU/NAGE Local 5000; prepared statement ............................... 168 

Long, Luanne, RN, President, Hawai’i Nurses Association, United American 

Nurses, AFL–CIO; prepared statement ............................................................. 170 

(1) 

HEARING ON PENDING HEALTH-RELATED 

LEGISLATION 

WEDNESDAY, APRIL 22, 2009 

U.S. SENATE, 

COMMITTEE ON VETERANS’ AFFAIRS, 

Washington, DC. 

The Committee met, pursuant to notice, at 2:30 p.m., in room 

418, Russell Senate Office Building, Hon. Daniel K. Akaka, Chairman of the Committee, presiding. 

Present: Senators Akaka, Murray, Brown, Tester, Begich, Burris, 

Sanders, Burr, and Johanns. 

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

U.S. SENATOR FROM HAWAII 

Chairman AKAKA. Thank you very much for being so patient. We 

had a vote call and decided to answer the call before we convened, 

so this is why we are starting late at this time. 

Aloha, good afternoon, and welcome to today’s hearing. I call the 

Committee on Veterans’ Affairs of the U.S. Senate to order. 

We have a lengthy agenda that reflects the work of many members on both sides of the aisle. The health care bills before us today 

address crucial issues and seek to improve services to veterans. I 

anticipate that today’s hearing will allow us to develop another 

strong package of veterans health legislation. I will briefly highlight a few of the bills on our agenda. 

Severely injured servicemembers and their families face many 

challenges as they return home. The bipartisan caregivers’ bill, 

S. 801, will give family members the support they need to care for 

the Nation’s wounded warriors in the form of health care, counseling, respite, and financial support. It also will give them the 

training they need to provide the best care possible for their loved 

ones. 

I am joined by Senator Baucus and Senator Begich in supporting 

a bill, S. 734, which would provide much needed services for veterans returning to rural areas. The wars in Iraq and Afghanistan 

have placed extraordinary demands on the country’s National 

Guard and Reserve, with multiple deployments. When they return 

home, it is often to a small town, far from a military base. This bill 

will improve VA’s ability to recruit and retain health care providers 

and encourage VA to use volunteer counselors and telehealth services to reach more veterans. It also expands VA’s ability to pay for 

travel when the only practical way for a veteran to reach a health 

care facility is by air. 

2 

Many other bills on the agenda reflect the dedication and hard 

work of my colleagues in support of the Nation’s veterans. There 

are bills that will eliminate certain copayments for the catastrophically disabled, authorize additional health care facilities, and ensure the availability of services for women veterans and homeless 

veterans. 

Senator Rockefeller has introduced a bill that would remove a 

limitation on VA employees’ collective bargaining rights when employment actions are related to quality-of-care concerns. Many are 

working on this issue, including Luanne Long, who is a nurse from 

Hawai’i and president of the Hawai’i Nurses Association of the 

United American Nurses. Although she is not testifying before the 

Committee today she has submitted a statement for the record; and 

I appreciate her work on behalf of VA employees. 

I am confident that VA’s new leadership will work with the Committee in our efforts to provide comprehensive health care to the 

country’s wounded warriors. We recently held confirmation hearings for the Secretary, the Deputy Secretary, and the Assistant 

Secretary for Public Affairs, all of whom expressed their support 

for the VA health care system. We will be counting on their support as we address many of these issues. 

Dr. Cross, I believe you have been advised, VA will not be permitted to testify today. Indeed, in light of the very late submission 

of the Department’s testimony—it was not received until 8:48 p.m. 

last night—I was inclined to exclude VA entirely, since the members have not had the opportunity to review the testimony. While 

I will submit my questions in writing, I am providing the opportunity for other members to ask questions of you directly if they 

wish. 

I do not suppose that you are directly responsible for the unacceptable lateness of the submission of the Department’s statement, 

but as the designated witness, you have to be the one to hear the 

Committee’s concerns and carry them back to the Secretary and his 

top managers. If the Department is to participate in the legislative 

process, there must be, at a minimum, timely submission of testimony on pending legislation. 

I realize that there are a significant number of bills on today’s 

agenda, but other witnesses were able to review and comment on 

the pending legislation in testimony that was submitted by the 

Committee’s deadline. I will communicate directly with Secretary 

Shinseki, both to learn exactly what happened with respect to today’s hearing and to identify ways to keep this problem from occurring again. 

The record of today’s hearing will remain open for 2 weeks so 

that witnesses can submit supplemental views on any legislative 

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

our markup, tentatively scheduled for late May. 

I want to thank the witnesses for being here today. 

I would like to now call on Senator Burr, our Ranking Member, 

for his opening statement. Senator Burr? 

STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, 

U.S. SENATOR FROM NORTH CAROLINA 

Senator BURR. Thank you. Aloha, Mr. Chairman. 

3 

Chairman AKAKA. Aloha. 

Senator BURR. You have outdone yourself with the number of 

bills we are trying to cover in this hearing, but I will never complain to you about the volume of what we are trying to undertake 

in this Committee, I will assure you. 

Let me start by thanking you, Mr. Chairman, for working with 

me on legislation to provide assistance to the family caregivers of 

seriously injured veterans. I want to single out two special North 

Carolinians, Sarah and Ted Wade. Unfortunately, they are not here 

today, but they have spent many hours reviewing drafts of the bill 

before it was introduced. Their unique perspective on the needs of 

both family caregivers and seriously injured veterans needing fulltime care was absolutely essential in the crafting of this legislation. 

I am also proud to join you, Mr. Chairman, on legislation that 

would create a process under which the VA could be provided with 

a medical care budget 1 year ahead of time. It is very important 

and possible that we will have two appropriations for VA enacted 

this year, the first for 2010, the second for 2011. It will be nice to 

get the VA budget completed well ahead of time for a change. 

I am pleased to see that legislation I introduced to create a voluntary dental insurance benefit for all veterans and survivors of 

veterans enrolled for care at VA is on the agenda. The legislation 

is modeled after the popular TRICARE retiree dental program and 

simply gives veterans the option to pool together and get coverage 

that they might need. 

One of the bills on the agenda that I feel passionately about is 

S. 669, the Veterans’ 2nd Amendment Protection Act. Three other 

Members of the Committee have joined me as cosponsors of the 

bill, along with 12 of my Senate colleagues. The Committee voted 

to approve this bill last Congress and I hope to see it enacted this 

year. As many of you know, if a veteran comes to the VA for help 

and is later determined to need assistance managing benefit payments, their name is sent to the National Instant Criminal Background Check System, known as NICS, which is a government 

database that is used to deny individuals their Second Amendment 

rights. Over 117,000 names have been sent by the VA to this government database since 1998. In contrast, the Social Security Administration sends no names to this government database, despite 

having over five million beneficiaries who require assistance managing their finances. 

I have three problems with this policy. First, I believe our veterans are being unfairly targeted. Second, I believe it is inappropriate for a government employee to be able to make these types 

of decisions. And third, the current process doesn’t even assess 

whether these individuals pose a danger to themselves or to others. 

S. 669 would prohibit VA from sending the names of veterans 

and others to the government database unless—and I stress ‘‘unless’’ so it is clear to everyone—an appropriate judicial authority 

makes the determination that an individual poses a danger to 

themselves or to others, which is the same standard applied to 

every other American. By simply asking for due process, this bill 

respects protection of constitutional rights. We must provide our 

veterans with the due process granted to every other citizen. 

4 

I wish I knew what the position of the Department of Justice was 

on this legislation, Mr. Chairman. You were nice enough to invite 

the Attorney General or his designee to come to testify, and as you 

can see, they are not here. I don’t understand the reason for their 

absence here today. If the current practice is justified, then there 

should be no reluctance to have an administration official testify 

about this bill. In my view, this is the second time in less than 2 

weeks the Administration has tacitly endorsed an effort to unfairly 

target veterans. 

Just last week, the Department of Homeland Security released 

a report entitled ‘‘Right-Wing Extremism,’’ which states that, and 

I quote, ‘‘Returning veterans possess combat skills and experience 

that are attractive to right-wing extremists.’’ unquote, without any 

data to support such a vile claim against our Nation’s veterans. 

The report suggests that those veterans who are, and I quote, 

‘‘. . . disgruntled, disillusioned, or suffering from the psychological 

effects of war,’’ unquote, are more likely to join these groups. 

Again, without any data to substantiate such a claim, a Federal 

Government agency paints our veterans as extremists. This assessment of our veterans is not only misguided, it is an absolute insult 

to every one of them. 

In closing, I would like to submit testimony for the record sent 

to the Committee by Retired Coast Guard Lieutenant Jerri Geer. 

Lieutenant Geer came to VA for help in 2002 because she was having problems with her finances. Shortly thereafter, she received a 

letter telling her that she was placed on the government’s criminal 

database used to prevent the purchase of firearms. What is ironic 

is that Lieutenant Geer doesn’t even like guns. She was simply offended by the arbitrary manner in which her name was placed on 

a list with criminals and people who are threats to themselves and 

to others; and by how easily her rights as an American could be 

violated. I think all of us in this room would be offended if, in fact, 

we were placed on that list. 

I ask my colleagues for their support on S. 669 so that we can 

right what I think is a tremendous wrong. 

I thank the Chair. 

[The testimony of Lieutenant Geer is included in the Appendix.] 

Chairman AKAKA. Thank you very much, Senator Burr. 

Let me call for your statements, Senator Brown, followed by Senator Johanns. Senator Brown? 

STATEMENT OF HON. SHERROD BROWN, 

U.S. SENATOR FROM OHIO 

Senator BROWN. Thank you, Mr. Chairman. 

I would like to thank Deputy Under Secretary Cross for joining 

us today and being able to answer questions. I would like to thank 

Dr. Cross for his previous testimony at a field hearing in New 

Philadelphia, Ohio, 18 months or so ago about veterans in Appalachia which led to legislation that will particularly help rural hospitals and some of the issues we deal with. 

I want to thank the VSOs that are here and the representative 

from AFGE for your assistance. 

The legislation pending before the Committee, all of it is beneficial. In the interest of time, I will focus on two bills that are viVerDate Nov 24 2008 19:35 Oct 22, 2009 Jkt 000000 PO 00000 Frm 00008 Fmt 6633 Sfmt 6633 H:\111TH HEARINGS\042209.TXT SVETS PsN: PAULIN
5 

tally important to my State. In Ohio, there are over one million 

veterans. That number is growing rapidly, as it is elsewhere, as 

men and women return from their service overseas in Iraq, Afghanistan, and deployments all over the world. In the last couple of 

years, I have held some 140 roundtables, at least one in each of 

Ohio’s 88 counties, and several of them have been directly talking 

to groups of 15 or 20 veterans and listening to their ideas and concerns. 

Last year, Petty Officer Glenn Minney, USN (Ret.), an Iraq veteran from Chillicothe in South Central Ohio, shared his transition 

experience after surviving an IED blast. Glenn was treated for his 

headaches with ibuprofen, and for his eye discomfort he was given 

pink eye medication. It wasn’t until nearly 8 months after he was 

injured that Glenn Minney was diagnosed with severe TBI. He advocated for increased attention to eye trauma in relation to TBI to 

prevent other veterans from suffering the months of uncertainty 

that he endured as his eyesight continued to deteriorate. 

TBI and PTSD are intimately related to vision problems as well 

as cognitive issues, memory lapses, anger, frustration, and other 

mental health issues. Glenn Minney is unfortunately not alone, as 

we know. As a result of the wars in Iraq and Afghanistan, there 

is an increasing number of head trauma and Traumatic Brain Injuries. Over one thousand servicemembers have been hospitalized 

with ocular or eye injuries. 

The VA has a critical shortfall in the number of blind rehabilitation outpatient specialists, with nearly one-third of those positions 

unfilled. As more servicemembers return from combat with eye injuries, we have a commitment to ensure they have access to rehab 

specialists. 

To address the gap in access to vision specialists, I introduced 

the Vision Scholars Act of 2009, which we will discuss today. The 

bill would improve VA recruitment of blind instructors while giving 

our Nation’s veterans the comprehensive care they deserve. 

The second bill I would like to briefly discuss improves collective 

bargaining rights of VA employees. All VA employees have a proud 

tradition of faithful service, but they work side-by-side in the same 

facility for our veterans but have unequal rights. Collective bargaining provides vital workplace protection for employees, helping 

to ensure higher safety standards, fair wages, and pension security. 

In 1991, Congress provided VA medical professionals with the 

same labor relations rights held by other Federal employees but 

carved out three exceptions that dealt with direct patient care. In 

the 1990s, labor and management entered into a partnership that 

set a process for resolving disputes, which worked well until the 

Bush administration abandoned the partnership. The narrow exceptions of the law now bar grievances over disputes that Congress 

never envisioned, such as scheduling and floating assignments for 

nurses. As a result, VA health care professionals are unable to negotiate for working conditions that are widely available to other clinicians at the VA and outside, too, for that matter. 

These workplace practices negatively affect recruitment and retention and morale and, ultimately, patient care. The veterans in 

my State and across the rest of this great country deserve the best 

health care and the best health care providers. Many of these proVerDate Nov 24 2008 19:35 Oct 22, 2009 Jkt 000000 PO 00000 Frm 00009 Fmt 6633 Sfmt 6633 H:\111TH HEARINGS\042209.TXT SVETS PsN: PAULIN
6 

viders, as we know—and we urge this more and more in the VA— 

are veterans themselves. That is why I have cosponsored this legislation with Senator Mikulski and my colleagues on this Committee: 

Senator Rockefeller, Senator Webb and Senator Sanders. 

So, I am looking forward to hearing testimony on these two bills 

and beyond. Thank you, Mr. Chairman. 

Chairman AKAKA. Thank you very much, Senator Brown. 

Senator Johanns? 

STATEMENT OF HON. MIKE JOHANNS, 

U.S. SENATOR FROM NEBRASKA 

Senator JOHANNS. Mr. Chairman, thank you very much for the 

opportunity to say a few words. 

Let me, if I might, start out and, just for the record, join in the 

comments made by Ranking Member Burr. I also thought it was 

just completely inexcusable that the head of a Federal Department 

would make such statements about veterans in claiming that they 

pose a risk to our society. We bring them to military service to protect us, and then as they leave military service, to tag them with 

that kind of label is just enormously unfair. 

Let me talk about a recent experience that I had. I was back 

home in Nebraska for a recess and we had a veterans’ roundtable 

where we brought veterans in and representatives of veterans organizations to really talk about whatever was on their mind. It 

wasn’t very long before we turned to health care issues. One of the 

things about this roundtable is we had a spouse there whose husband was suffering from Post Traumatic Stress Disorder. We had 

a veteran there who was continuing to receive care through the 

system. So, we really got some great information. I got some great 

information as to some of the challenges that they are facing. 

The first thing I would like to say on Post Traumatic Stress Disorder—and it is hard to explain unless you have heard a family 

member speak of this—is how devastating it is, not only to the veteran but to the family members—the challenge that the veteran 

and family members face in terms of getting cured. It is something 

that I find just completely unacceptable. Anything we can do in 

this area is going to be a big improvement. 

I would offer this thought. When services are provided by the 

Veterans Administration, it appears to me that the services are 

good. The challenge is how to get those services and how to 

uncomplicate the process by which a veteran can access those services—a very, very important issue. 

The second issue that I wanted to visit is one which is a challenge for many of us on this panel. I come from a State that is a 

combination of large metropolitan communities like Lincoln and 

Omaha, Kearney, Grand Island, and very rural, small communities 

where we really, really struggle to provide services. We are facing 

that problem with medical services and mental health services. It 

is nearly impossible to get the trained personnel into those areas. 

So again, anything that we can do to help in these areas is going 

to find my support. These veterans want to return to where they 

came from, and sometimes that is ranching or farming or taking 

on the family business in a small community in Western Nebraska. 

We want to do everything we can to encourage that. That is very, 

7 

very important to States like Nebraska. But if they need mental 

health services or medical services, we need to figure out ways to 

provide that to them. So, I am very anxious to hear the testimony 

today and very anxious to work with you in solving these problems. 

Mr. Chairman, I will wrap up just by saying, thank you for having this very important hearing. I hope to be a partner with you 

as we work on these issues. Thank you. 

Chairman AKAKA. Thank you very much, Senator Johanns. 

Senator Tester? 

STATEMENT BY HON. JON TESTER, 

U.S. SENATOR FROM MONTANA 

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

all the distinguished witnesses who are here today to discuss pending health-related legislation before this Committee. 

Just last month, after hearing from and working with a lot of 

veterans in Montana, I introduced the Rural Veterans Health Care 

Improvement Act. This legislation would expand health care for 

thousands of Montanans and millions of other veterans who live in 

rural and frontier areas of this country. I want to thank Senator 

Thune and Senator Begich for their work on this legislation and I 

appreciate their interest in this issue. 

The obstacles faced by veterans and providers in rural areas are 

vastly different than those in urban areas. Rural veterans face a 

new combination of factors that create disparities in health care 

not found in larger cities and municipalities. Access, economic factors, cultural and social differences, educational shortcomings, a 

lack of provider and health care services, and the sheer isolation 

of living in remote rural areas all conspire to impede rural veterans 

in their struggle to obtain care and lead a normal, healthy life. 

Without question, our veterans have greater transportation difficulties reaching health care providers. They often travel great distances to reach a doctor or hospital. Sometimes, they just don’t go 

at all. 

I want to share a few statistics from the National Rural Health 

Association to underscore this issue. Ten percent of physicians 

practice in rural America, despite the fact that one-fourth of the 

population lives in these areas. It puts us at a big disadvantage. 

It means it is harder to find a rural veteran a doctor, period. 

Twenty percent of the rural counties lack mental health services 

versus 5 percent of metropolitan counties. This means that our 

rural veterans are less likely to see or have access to mental health 

providers that can diagnose and treat things like PTSD and other 

combat-related mental conditions. 

The suicide rate among rural men is significantly higher than in 

urban areas, particularly among adult male veterans. Who is there 

to intervene, and do we transport them in cop cars for hours to get 

them to mental treatment facilities or a critical care bed? 

And finally, death and serious injury accidents account for 60 

percent of total rural accidents, compared to some 48 percent in 

urban areas. One reason for this increased rate of morbidity and 

mortality is that in rural States, prolonged delays occur between 

the crash, the call for the EMT, and the EMT arriving. This means 

8 

that veterans driving long distances to obtain care are more likely 

to die if involved in a serious motor vehicle accident. 

The statistics are sobering and highlight why we must improve 

health care for veterans who reside in rural areas. The Rural Veterans Health Care Improvement Act of 2009 does several things 

that will help. First, it locks in the current travel reimbursement 

for disabled veterans who travel for health care at 41.5 cents a 

mile. It authorizes the VA to award grants to Disabled American 

Veterans to transport veterans to their medical appointments, and 

it directs the VA to establish an Indian Health Coordinator in 

areas with high Native American veteran populations to improve 

the care given to Native veterans. It authorizes the VA to work 

with community health care centers and provide mental health 

services to Iraq and Afghan veterans in areas where the VA is unable to provide mental health care. 

It is just a start and we have a lot more to do, and I certainly 

appreciate the VSOs for bringing the issue forward and remaining 

focused on our rural veterans. I want to personally thank Chairman Akaka for introducing additional legislation that will complement this bill by improving the VA’s hiring and employee compensation practices. 

With that, I conclude my remarks and I want to thank the panel 

members once again, the Committee, and Chairman Akaka. 

Chairman AKAKA. Thank you very much, Senator Tester. 

Senator Burris? 

STATEMENT OF HON. ROLAND W. BURRIS, 

U.S. SENATOR FROM ILLINOIS 

Senator BURRIS. Thank you, Mr. Chairman. 

Members of the Committee, I hope I am around to get some answers to the questions, because during the recess I visited the Marion VA Hospital down in southern Illinois. My staff, Mr. Chairman, 

had a very difficult time with staff at the VA wanting to know why 

I was coming to Marion. Because Marion has had a few problems, 

they brought staff in from other locations. They brought staff in 

from Washington and they even brought the General Counsel in to 

be at the briefing that I was getting for visiting Marion Hospital, 

I assume because there have been problems there. 

My staff advised me that the staff at the VA were telling them 

that we didn’t give them enough time, that we should have given 

them more time to prepare, and I found that very disconcerting— 

for a Senator to try to visit a veterans hospital just to get educated 

and get a fact-finding tour—that the VA was very defensive in that 

regard. But come to find out they were very accommodating and it 

turned out to be a decent meeting. But I just would like for someone to give me an explanation on why that type of treatment—as 

a Senator, I went to a North Chicago hospital and there was no 

problem. I visited Jesse Brown Hospital and there was no problem. 

But I wanted to go to Marion and they sent in people from Washington and brought in the General Counsel. 

Yes, there have been several veterans who died there as a result 

of incompetent medical care. So I just want to be on the record as 

having expressed my concern about that situation as I compliment 

what we are doing for our veterans. 

9 

And second, this health care issue is very important. Just this 

Saturday, I had over 250 veterans at a town hall meeting I attended. It is called the Coalition of Veterans Organizations, and 

these individuals expressed their main concern is health care— 

health care for women veterans. Women are not the same as male 

veterans. There is special care that women need, and so we must 

be sensitive to those situations. Also, on the dental care issue, we 

must make sure that we move in that direction; and I hope that 

we will hear some testimony in that regard. Mr. Chairman, if I am 

not around because I have got two or three other stops to make on 

other committees, I would hope to be able to bring some questions 

in reference to some issues that I have. 

But I want to go on the record in terms of my commitment to 

those individuals—and this is my favorite expression, Mr. Chairman—that allow us to do what we do because they did what they 

did in protecting this country and fighting for us. And they are entitled to whatever we can give them as taxpayers for their commitment to allow us to be a free country. We cannot forget those individuals who put their lives on the line for us. I will reserve the rest 

of my time, Mr. Chairman. 

Chairman AKAKA. Thank you very much, Senator Burris. 

Senator Begich? 

STATEMENT OF HON. MARK BEGICH, 

U.S. SENATOR FROM ALASKA 

Senator BEGICH. Thank you very much, Mr. Chairman. Thank 

you for holding this hearing to provide an opportunity to hear responses to the legislation sponsored by several of us here including, 

obviously, the Chairman, who has spearheaded many of these 

pieces of legislation. I am a cosponsor on six of these pieces and 

a lot of it for me is to hone in on the obvious health care, and also 

rural health care. 

In Alaska, I think in the last Commerce Committee meeting, I 

coined the phrase ‘‘extreme rural,’’ which is what Alaska is. And so, 

we have very unique situations that I think are also an opportunity 

for some prototype and some experimentation—some new ways to 

deliver health care that could be a model for other States around 

the country, especially those that have kind of mixed urban and 

rural geography—Montana, Nebraska, and others. So, I am going 

to be interested in your responses, especially on rural health care. 

On another issue, reimbursement, not only vehicle miles and 

plane tickets for individuals, but one more step. We have a very 

unique program in Alaska, and during the questions I will ask a 

few more details about your thoughts on it. We have one program 

that actually has three or four, if I am not mistaken, maybe as 

many as five pilots that actually fly out on their own dime with 

their own plane to go help veterans out in rural communities which 

the VA will never get to; no commercial airline will ever get to. 

And so, the reimbursement for them is zero. 

An idea I want to float to see how you would respond is one of 

the issues they asked for—not that they are asking for reimbursement of their time or their effort or their plane—but just some of 

the fuel costs as they reach rural areas, because if the VA had to 

fly these individuals out or pay for that, it would be very, very exVerDate Nov 24 2008 19:35 Oct 22, 2009 Jkt 000000 PO 00000 Frm 00013 Fmt 6633 Sfmt 6633 H:\111TH HEARINGS\042209.TXT SVETS PsN: PAULIN
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pensive. Uniquely so, there is a twist on it, because in Alaska we 

have the highest per capita amount of small planes per person in 

the country. We are in a very unique situation. The plane and bush 

pilot, is the cab driver, and so I want to explore that with you. 

Another issue in Alaska is that we have about 600 homeless veterans. I know in a bigger sense, that may be small compared to 

other communities, but we have very unique climate conditions 

that homeless veterans live in. So, I would be curious—in your expansion, in your opportunities—of what you see down the road in 

regards to homeless veterans. I believe that number is going to 

grow because one of the common denominators among the homeless population is mental illness or issues with mental health. We 

are going to see, I think, a growing percentage and number. 

And then the last question is, what efforts will you make in regards to new technologies? Telemedicine is a powerful technology 

in Alaska. I know the VA is experimenting with that and utilizing 

it. I think Alaska, again, is a great test ground for that and I would 

be interested in your commentary on that. 

But again, Mr. Chairman, thank you for hosting this hearing. I 

am looking forward to the panel’s comments in regards to the legislation. I do believe, based on all the legislation that is in front of 

us, there are opportunities to—I don’t know what the process is. I 

am new to the Senate, but it seems like we could meld some of 

these pieces of legislation into one to really focus in and hone in 

on delivering additional and more supportive rural health care to 

our veterans. And the larger percentage of veterans—from some of 

the data that I have seen in Alaska, at least, and it may be occurring around the country—more and more veterans are living in 

rural areas than urban areas. They are growing to that, not necessarily raw numbers, but in percentage growth. So, again, I think 

rural health care and rural delivery of health care is going to be 

a huge piece of the equation. 

I will end there and say thank you very much, Mr. Chairman, 

for this opportunity. 

Chairman AKAKA. Thank you very much, Senator Begich. 

Let me call on Senator Sanders. 

STATEMENT OF HON. BERNARD SANDERS, 

U.S. SENATOR FROM VERMONT 

Senator SANDERS. Thank you, Mr. Chairman. 

Before I comment on the legislation before us, let me say a word 

about this so-called political controversy regarding the Secretary of 

Homeland Security. Of course, the Secretary of Homeland Security 

did not say anything disparaging about veterans. This is just politics that are the same old, same old. What she was reporting is 

that there has been a significant rise in right-wing extremism in 

this country, including some groups who advocate violence, and 

that they are targeting veterans as well as other groups. That is 

what she said, and I think she is right. We have to be concerned 

about that. 

But Mr. Chairman, in terms of what we are talking about today, 

let me thank you for holding this important hearing. I am also delighted to have the witnesses with us today from the VA and other 

organizations. 

11 

I also want to congratulate the Chairman for his advanced appropriations legislation and to announce what everybody knows, is 

that we finally have a President of the United States who is in support of advanced appropriations. This is a big deal and I think is 

going to make the appropriations process for our veterans a lot 

more secure, a lot more predictable, and it is a huge step forward. 

I congratulate you, Mr. Chairman, and President Obama for taking 

that step. 

In addition, I want to thank Chairman Akaka for including a 

version of Senator Feingold’s and my legislation, S. 315, the Veterans Outreach Improvement Act of 2009, in his omnibus health 

care bill, S. 252, that is on the agenda today. This provision would 

create a VA pilot grant program funded by the Department of Veterans Affairs to give resources to eligible community-based organizations and local and State entities, including Veterans Service Organizations, to conduct outreach programs to inform veterans and 

their families about VA benefits. 

The bottom line is, we could have the best programs in the world 

for our veterans, but if they don’t know about them, it is not going 

to do anybody any good. In Vermont, we have developed an outreach program which is working. I think this concept will help. We 

want veterans to know what they are entitled to. If they want to 

take advantage of it, fine. If not, fine, but they should know about 

it. 

Mr. Chairman, one of the bills included on today’s agenda is another piece of legislation I have introduced, S. 821, a bill to prohibit 

the VA from collecting certain copayments from veterans who are 

catastrophically disabled. This Committee approved a version of 

this legislation last year and it also was passed in the House by 

the very close vote of 421 to nothing. Unfortunately, it was not 

signed into law and I hope we have better luck this year. I want 

to thank the Paralyzed Veterans of America, the Blinded Veterans 

Association, the DAV, and the American Federation of Government 

Employees, who all support this legislation. 

In short, this legislation would eliminate copayments paid by 

catastrophically disabled veterans who are currently considered 

Priority Group 4 veterans, yet are charged fees and copayments as 

if they were in Priority Group 7 or 8. As the Paralyzed Veterans 

of America note in their prepared testimony, ‘‘In 1985, Congress 

passed legislation opening the VA health system to all veterans. In 

1996, Congress revised the law and created a set of rankings or 

priority groups. When this was done, PVA worked to ensure that 

those veterans with catastrophic disabilities would be placed in a 

higher enrollment category known as Priority Group 4. However, 

unlike other Category 4 veterans, if they would otherwise have 

been in Category 7 or 8 due to their incomes, they are required to 

pay all fees and copayments . . .’’ I think clearly that is a miscarriage—a disservice to those veterans who are suffering from 

major physical problems. 

So, Mr. Chairman, I hope very much that we can pass those 

pieces of legislation as well as the others that are before us today 

and I thank you very much. 

Chairman AKAKA. Thank you very much, Senator Sanders. 

Senator Murray? 

12 

STATEMENT OF HON. PATTY MURRAY, 

U.S. SENATOR FROM WASHINGTON 

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

you and Senator Burr for holding this hearing and thank you to all 

the witnesses who are before us today. 

I think everyone on this Committee knows that the health care 

needs of our American veterans are shifting and diversifying and 

health care technologies and techniques are changing, too. So when 

it comes to providing care for our veterans, this really is a time of 

challenge and opportunities. And, of course, with our troops now 

fighting in Iraq and Afghanistan, it is very important that Congress use its legislative powers to make sure that the VA is prepared to meet the health care needs of our veterans tomorrow as 

well as today. 

One of the best ways that I believe we can address the needs on 

the horizon is to pass the Women Veterans Health Care Improvement Act of 2009, which expands and improves health care services 

for our women veterans in the VA system. Women have always 

played a very important role in our military, going back to the 

founding of our country. However, as we all know, in today’s conflicts, women are playing a far different and a far greater role. 

Women now make up about 15 percent of current active duty, 

Guard, and Reserve forces, and because today’s conflicts don’t have 

the clear front lines of past wars, women, like all of our servicemembers today, are on the front lines—riding on dangerous routes, 

guarding key checkpoints, and seeing the horrors of war firsthand. 

Women have historically remained a very small portion of veterans and a small minority at the VA. That is changing. According 

to the VA, there are now 1.8 million women veterans who make up 

more than 7 percent of the total veteran population in the United 

States. And the number of women veterans who are enrolled in the 

VA system is expected to double in the next 5 years. That makes 

female veterans one of the fastest-growing demographics of veterans today. 

So, we cannot overlook the growing number of women veterans 

or their unique needs any longer. We have to make sure that the 

VA is prepared to take care of the needs of these honorable veterans, and that is why Senator Hutchison and I have introduced 

the Women Veterans Health Care Improvement Act of 2009. This 

is legislation that will encourage female veterans to access care at 

the VA by increasing the VA’s understanding of the needs of 

women veterans and the practices that will help them best. 

I know that the VA recognizes they need to improve services for 

our women veterans, and the Department has taken some steps to 

do that. All VA medical centers are now supposed to have full-time 

women veterans program managers to make sure that women veterans’ needs are taken care of. But a lot more needs to be done if 

we are going to ensure that women are able to access care at the 

VA and get the services they need, and that these services are tailored to women’s needs. 

So I believe that planning for the new wave of women veterans 

is going to be difficult and complex, but it is a task that needs to 

be addressed and I hope that this Committee can pass this legislation this year and move it to the President’s desk. 

13 

I also want to mention another bill on the docket today that authorizes the construction of an outpatient clinic at the VA medical 

center in Walla Walla in the southeast corner of my home State. 

Not long ago, the VA came before us and recommended shutting 

down that facility. And I have been very proud to fight alongside 

the veterans in the three-State region served by the Walla Walla 

VA, to save Walla Walla VA and ensure that it has a future. This 

has been a battle very close to my heart—I know the VA knows 

that—because it is critical to 70,000 veterans who are served by 

that facility. 

Since 2003, when this issue first arose, I have used every tool at 

my disposal to make sure that Walla Walla veterans are taken care 

of. I sent letters to the VA Secretary. I contacted President Bush. 

This Committee held a hearing out in Walla Walla to solicit the 

thoughts and concerns of local veterans. And I think all of our veterans in that area sent a loud, clear message that was heard, that 

southeastern Washington needs the existing VA facilities and it deserves a new, modern VA facility, as well. 

So back in November, the VA announced that the Walla Walla 

VA is going to get more than $71 million for the design and construction of a new outpatient clinic to serve those local veterans; 

and I truly want to thank the VA for all of their work on this. I 

was thrilled by that development and it is a major victory for our 

veterans. 

Now, since that money has already been approved, this legislation that is before us today simply authorizes the construction of 

a new multiple-specialty outpatient facility at the Walla Walla VA. 

So after 5 years of uncertainty and a whole lot of veterans speaking 

out, we are almost there. This legislation is key and I really thank 

the Committee for considering it today. I hope we can approve it 

soon and move it forward. 

Thank you very much. 

Chairman AKAKA. Thank you very much, Senator Murray. 

Now let me introduce the first panel. Dr. Gerald Cross, Principal 

Deputy Under Secretary for Health, will be answering questions. 

He is accompanied by Walter Hall, Assistant General Counsel, and 

by Joleen Clark, Chief Officer for Workforce Management and Consulting at VHA. 

I thank all of you for being here today. VA’s full testimony will 

appear in the record. 

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

DEPUTY UNDER SECRETARY FOR HEALTH, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY WALTER A. 

HALL, ASSISTANT GENERAL COUNSEL, U.S. DEPARTMENT OF 

VETERANS AFFAIRS; AND JOLEEN CLARK, CHIEF OFFICER 

FOR WORKFORCE MANAGEMENT AND CONSULTING, U.S. DEPARTMENT OF VETERANS AFFAIRS 

[The prepared statement of Dr. Cross follows:] 

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

UNDER SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS

Good Afternoon Mr. Chairman and Members of the Committee: Thank you for inviting me here today to present the Administration’s views on a number of bills that 

would affect Department of Veterans Affairs (VA) programs of benefits and services. 

14 

With me today are Walter A. Hall, Assistant General Counsel and Joleen Clark, 

Chief Workforce Management and Consulting Officer for VHA. Unfortunately, we do 

not yet have views and estimates on several bills including S. 239, S. 498, S. 699, 

S. 772, S. 793, subsection (f) of S. 252 and S. 821. We will forward those as soon as 

they are available. Our support for the bill provisions discussed below is contingent 

upon VA’s ability to fund such activities within the President’s 2010 budget. 

S. 226 ‘‘RENAMING OF THE HAVRE, MONTANA OUTPATIENT CLINIC’’ 

Mr. Chairman, the first bill on the agenda is S. 226, a bill to rename the Havre, 

Montana VA Outpatient Clinic the Merril Lundman Department of Veterans Affairs 

Outpatient Clinic. VA defers to Congress concerning this matter. 

S. 246 ‘‘VETERANS HEALTH CARE QUALITY IMPROVEMENT ACT’’ 

S. 246 is intended to encourage highly qualified doctors to serve in hard-to-fill positions. Section 2(a) would establish additional standards for appointment and practice as a VA physician. We note that S. 252, Section 104, has substantially similar 

provisions. Section 2(a) would require physicians, both before and following appointment, to disclose lawsuits, civil actions, other claims (whether open or closed) that 

result in payment and settlement payments and judgments that are based on the 

physician’s medical malpractice or negligence, each investigation or disciplinary action taken relating to the individual’s performance as a physician, and written notification from a State of a potential termination of license for cause or otherwise. It 

also would require a physician before appointment and at the time of biennial review of performance to authorize the State licensing board in each State in which 

the physician holds or has held a license to disclose anything in State records concerning such matters. Other provisions of this section would mandate enrollment of 

any privileged physician in the National Practitioners Data Bank (NPDB) Proactive 

Disclosure Service and encourage the hiring of board-certified physicians. VA has 

no objection to these requirements. However, legislation is unnecessary. VA already 

requires physicians to disclose anything that would adversely affect or otherwise 

limit their appointment and/or clinical privileges. Following appointment and at the 

biennial review of performance, VA also requires physicians to authorize the relevant State licensing boards to disclose information. Failure to disclose or provide 

authorization may be grounds for denial of appointment or termination from employment. Mandatory enrollment of VA physicians in the NPDB Proactive Disclosure Service has been required since November 2008. VA has long recognized board 

certification as important evidence of professional attainment and has given it significant consideration in recruiting and hiring physicians. 

VA has no objection to the majority of the provisions in Section 2 relating to 

standards for appointment and practice of physicians in VA medical facilities and 

has already implemented most in agency policy. However, VA strongly opposes the 

requirement in Section 2 for Network Directors to approve physician appointments. 

This will introduce unacceptable and unnecessary delays into the process for appointing physicians. It is unnecessary since significant safeguards have been implemented to strengthen the process of medical staff appointments. Also it is important 

to recognize that granting clinical privileges requires local knowledge, including 

clinical performance and peer-review information, which is not readily accessed at 

the VISN level. 

Section 3 would require the appointment of board-certified physicians as Quality 

Assurance Officers (QAO) at the national, VISN, and facility level. It would also 

mandate a comprehensive review of all quality and safety programs and policies, including a detailed review of the National Surgical Quality Improvement Program 

(NSQIP). A report to Congress of the results of this review would be due within 60 

days of enactment. VA does not oppose Section 3, and has already taken steps to 

increase the involvement of qualified physicians in quality leadership throughout 

the health care system. We note that the needs of smaller facilities can often be met 

by a part-time QAO, who may also have other clinical or administrative duties. 

Under Section 4(a), VA would provide certain incentives, including student loan 

repayment, to physicians for service in hard-to-fill positions. Since we do not believe 

another loan repayment program is necessary, VA does not support this provision. 

VA can currently authorize educational loan repayment incentives to physicians in 

hard-to-fill positions through the Education Debt Reduction Program (EDRP). The 

provisions of S. 246 would establish a second debt repayment program operating 

under separate legal authority and regulatory guidelines, increasing complexity and 

potential confusion. In addition, the legislation creates a loan repayment program 

only for physicians and excludes all other occupations, regardless of the hiring needs 

and priorities of the Department. Current law provides comprehensive incentives 

15 

available to more than 32 health care professional occupations. We estimate that 

the cost of the loan repayment incentive program described in Section 4(a) would 

be $4.6 million in the first year, $54.9 million over five years, and approximately 

$186.5 million over ten years. 

We are opposed to another incentive program in Section 4(a) that would require 

VA to institute a program of tuition reimbursement for a course of education leading 

to board certification for physicians who agree to serve as physicians in VA. We cannot support this provision for several reasons. The time between the granting of tuition reimbursement and when the physician would become board certified is too 

long. Medical school and internship together can take seven years or longer to complete, depending on the specialty. Hard-to-fill specialties would likely have longer 

education requirements. During that time, VA’s priorities and hard-to-fill positions 

can change significantly. Signing a contract today for services and obligations that 

will not begin for several years is subject to many risk factors that cannot be foreseen. Undoubtedly the personal circumstances and career objectives of many physicians would change, administering the contracts and monitoring the program would 

be complex, and the opportunities and occasions for civil court actions could also require substantial resources. Further, many students may fulfill their contract obligations but for one reason or another may not be an appropriate hire for VA at the 

time they are eligible. For example, certification may be beyond the capabilities of 

the graduating students in the tuition reimbursement program. There could be 

many circumstances under which VA’s investment would not pay off but there 

would be insufficient grounds for seeking repayment. Assuming a student would receive the full reimbursement each year, as well as the annual stipend, over an 

eight-year period taxpayers will have invested $280,000 in the student before he or 

she begins working for VA. If upon graduation the doctor does not or cannot fulfill 

his or her employment obligation to VA, such a sizable investment would be very 

difficult to recoup. Considering the amount of the reimbursement and stipend per 

student and the cost of administration, we estimate that the program cost to be 

$283,000 in the startup year, $51.7 million over five years, and $174.7 million over 

ten years. 

Section 4(b) would require VA medical facilities to seek to establish an affiliation 

with a medical school within reasonable proximity of such facility. Mr. Chairman, 

VA strongly supports the concept of affiliations and we are actively engaged in their 

expansion. In 2008, more than 100,000 medical and associated health students, residents, and fellows received some or all of their clinical training in VA facilities 

through affiliations with more than 1,200 educational institutions, including 107 

medical schools. Many of these trainees have their health profession degrees and 

contribute substantially to VA’s ability to deliver cost-effective and high-quality patient care during their advanced VA clinical training. As the Nation’s health care 

system evolves, VA continues to be on the leading edge with innovative education 

and training programs. Therefore, we believe that the statutory requirement to pursue affiliations is unnecessary. 

S. 252 ‘‘VETERANS HEALTH CARE AUTHORIZATION ACT OF 2009’’ 

S. 252 contains seven separate titles addressing a wide range of issues including 

personnel matters, homeless veterans, nonprofit research and education corporations and many health care matters including provisions specific to mental health 

and women veterans health care. Title I contains several provisions intended to enhance VA’s ability to recruit and retain nurses and other health-care professionals 

and set certain standards for appointment and practice of physicians. These provisions are virtually identical to those reported in S. 2969 from the 110th Congress. 

We appreciated the opportunity to work with Committee staff on the prior bill and 

to provide technical comments and operational observations. We note that the reported bill and now Title I of S. 252 address many of our concerns and comments. 

However, there are several provisions we cannot support. 

Section 101 contains provisions for the enhancement of authorities for retention 

of medical professionals. 

Secretarial Authority to Extend Hybrid Status to Additional Occupations 

Subsection (a) would provide the Secretary authority to extend hybrid status to 

additional occupations. It would 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 health care 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 VetVerDate Nov 24 2008 19:35 Oct 22, 2009 Jkt 000000 PO 00000 Frm 00019 Fmt 6633 Sfmt 6621 H:\111TH HEARINGS\042209.TXT SVETS PsN: PAULIN
16 

erans’ Affairs Committees and OMB. Before providing such notice, VA would be required to solicit comments from unions 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, 11.1 percent for 2007 and 10.96 percent for 2008, 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 health care occupations. This bill would give the 

Secretary the ability to react quickly when it is determined that these authorities 

would be useful to help recruit and retain 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 health care. In addition, because this authority involves the conversion of title 5 occupations to title 38 

hybrids, 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 health care occupations 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; 

(E) as the Secretary considers necessary for the recruitment and retention 

needs of the Department. 

(2) Notwithstanding chapter 71 of title 5, United States Code, 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 health care 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 Personnel Management, and the Office of Management 

and Budget 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 (b) provides for probationary periods for part-time (PT) Registered 

Nurses (RN) and revises the probationary period for RNs, both full-time (FT) and 

PT, from 2 years to a maximum of its equivalency in hours, 4180. It also provides 

that a PT appointee 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. We believe this provision is technically flawed and would not be helpful. 

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 as these positions are temporary. 

Prohibition on Temporary Part-Time Nurse Appointments in Excess of 4,180 Hours 

Subsection (c) would add a new section 7405(g) that would provide that part-time 

appointments of RNs are no longer temporary after no more than 4180 hours. After 

completion of the 4180 hours, the RN in essence would be converted to a permanent 

employee under section 7403(a) who has completed the probationary period. VA opposes this provision because it would impair our ability to adapt to changing demands in patient need and resource allocations. VA currently has the authority to 

create temporary appointments for up to three years. If this proposal is enacted, VA 

would lose this valuable flexibility. VA uses this flexibility to manage positions durVerDate Nov 24 2008 19:35 Oct 22, 2009 Jkt 000000 PO 00000 Frm 00020 Fmt 6633 Sfmt 6621 H:\111TH HEARINGS\042209.TXT SVETS PsN: PAULIN
17 

ing periods of changing patient care needs and budgets. Without this current flexibility, VA’s ability to make adjustments in the size of our temporary workforce 

would be limited. VA and its employees would be put into an untenable dilemma 

of either preemptively dismissing employees just prior to the expiration of the their 

probationary periods when patient demand justifies their continued employment or 

allowing a nurse to convert and retain employment, even if patient demand no 

longer justifies that position. In either scenario, patient care would be placed in 

competition with organizational flexibility, while the current system allows VA to 

achieve and maintain both. 

Reemployed Annuitant Offset Waiver 

Subsection (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 opposes this provision as 5 U.S.C. 8344 and 8468 provide the agency access to retired title 38 health care providers. 

Rate of Basic Pay for Section 7306 Appointees Set to Rate of Basic Pay for SES 

Subsection (e) would amend section 7404(a) to add a provision setting the basic 

pay of non-physician/dentist section 7306 employees in accordance with the 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. Equity in pay for executive level managers and consultants is essential to attracting and retaining candidates for key positions. The pay schedule for 

38 U.S.C. § 7306 appointees is capped at the pay rate for Level V of the Executive 

Schedule (currently $143,500). Locality pay is paid up to the rate for Level III (currently $162,900). 

Individuals appointed under 38 U.S.C. § 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 $177,200) pending OPM 

certification that the agency meets all regulatory criteria for certified performance 

appraisal systems, including that the employing agency makes meaningful distinctions based on performance. We estimate the costs of this provision to be $343,917 

in FY 2010 and $3,765,786 over a 10-year period. 

As noted, the SES pay system conditions pay up to EX Level 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 uses the same rating system for its section 7306 executives as it uses for its SES members. OPM has 

certified this system in the past, and just last year recertified VA through July 

2010. For consistency, we 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 section 101(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 and SES Appointees 

Subsection (f) would amend section 7410 to add a new subsection to establish 

‘‘comparability pay’’ for VHA non-physician/dentist section 7306 employees and SES 

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, we recommend that the new administration be given an opportunity 

to review this matter. Public sector executive pay is dramatically below the private 

sector for comparable positions, particularly in the health care sector. This proposal 

would allow VA executives to receive salaries far exceeding executives in other agencies which also must compete with the private sector. It would be a potentially 

precedent-setting departure from the unitary approach to governmentwide SES pay. 

18 

Special Incentive Pay for Department Pharmacist Executives 

Subsection (g) would further amend section 7410 to authorize recruitment and re- tention 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 

proposed by subsection (f), this subsection 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 will provide a retention incentive to about 40 positions: pharmacy 

benefit managers (PBM), consolidated mail outpatient pharmacy (CMOP) directors 

and VISN formulary leaders (VFL). VA supports this provision. Long-standing, severe and worsening pay compression exists within the ranks of senior pharmacy 

program managers in VHA. A national survey performed yearly by the American 

Society of Health System Pharmacists provides evidence that a similar trend exists 

in the private sector. Currently VHA has had extreme difficulty in recruiting pharmacists for leadership positions. Some examples include: the VA Medical Center in 

Bay Pines has not had a permanent Pharmacy Manager for two years; the VA Medical Center, Portland, OR, position has been vacant for one year; the VA Medical 

Center, Asheville, NC, has been vacant over one year; and numerous other facilities 

are experiencing the same recruiting difficulties. Several other facilities with extended vacancies that were recently filled include: the VA Medical Center, Omaha, 

NE, for two years; VA Medical Center Dayton, OH, for two years; and VA Medical 

Center, Las Vegas, NV, vacant for one year. The current pay rate that we are able 

to pay executives varies minimally from staff pharmacist positions and therefore is 

not an incentive to recruit pharmacy executive/those in leadership roles to VA. This 

provision will provide a mechanism to alleviate this compression. VA is still developing costs for this proposal and will submit them for the record when they are 

available. 

Physician/Dentist Pay 

Subsection (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, Guam, Hawaii, and Puerto Rico. These are the only Department facilities to which the title 5 non-foreign cost of living adjustment allowance is applicable. 

Paragraph (2) would amend section 7431(c)(4)(B)(i) to exempt physicians and dentists in administrative or executive leadership provisions from the panel process in 

determining the amount of market pay and pay tiers for such physicians and dentists. In situations where physicians or dentists occupy these leadership positions 

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 these 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 administrative or executive physician/dentist positions that may be excluded from the 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 (i) and (j) relate to RN and Certified Registered Nurse Anesthetist 

(CRNA) Pay. Subsection (i) would amend the current cap for registered nurse from 

EL V to EL IV. VA supports this provision. 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 note that subsection (i) would obviate the need 

for subsection (j) as the two pay scales affected are already tied to each other. We 

19 

estimate the cost of this provision to be $6.16 million for FY 2010 and $72.31 million 

over a 10-year period. 

Subsection (k) would make amendments to the RN locality pay system (LPS). 

These provisions are not helpful and are 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, 

including third party 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 (l) would increase the maximum payable for nurse executive special pay to $100,000. This provision would make the amount of nurse executive pay consistent with the Executive Comparability Pay proposed in section 2(f) of this bill. 

However, special pay of this amount would allow VA nurse executives to receive salaries far exceeding executives in other agencies that also must compete with the private section and there is no evidence that such levels of pay are necessary. Thus, 

VA opposes this provision. 

The caption for subsection (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 (m) as it has serious technical flaws, is unnecessary, and is 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’’ requirement in the current law is intended to ensure 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 proposed in this subparagraph 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 also would 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 (n) would add additional occupations to the exemption to 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. It is not clear 

what positions ‘‘nursing positions otherwise covered by title 5’’ would include. RNs 

are appointed under title 38, LPNs/LVNs are hybrids, and section 101(a)(2) of the 

bill would convert nursing assistants to hybrid. Moreover, it is not apparent why 

20 

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. We 

also note that adopting the title 5 fixed-percentage formula would render unnecessary the section 7455(c)(2) report for exceeding 94 percent of the grade maximum 

and, so, 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) The amount of any increase under subsection (a) in the minimum rate 

for any grade 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. 

VA’s concerns that pay setting authorized by this provision may be subject to collective bargaining are discussed in conjunction with S. 362. 

Section 102(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 Pub. L. 108–445. 

Section 102(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. It would delete current 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. Currently, 

VA has only one employee working on the Baylor Plan. VA opposes this provision 

as providing an unwarranted windfall. 

Section 102(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. 

The problem stems from the 36/40 language requiring three 12-hour tours in a work 

week and because VA defines ‘‘work week’’ as Sunday to Saturday. The problem occurs because the work week requirement prevents scheduling one of the 12-hour 

tours over two different weeks, e.g., 6PM Saturday to 6AM Sunday. 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. 

We would be glad to provide appropriate bill language. 

Section 103 would make amendments to VA’s Education Assistance Programs. VA 

supports these proposals. Section 103(a) would amend section 7618 to reinstate the 

Health Professionals Educational Assistance Scholarship Program through the end 

21 

of 2014. The 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 health care 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 are still determining costs for this provision and 

will forward them to the Committee as soon as they are available. 

Section 103(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 six months. VA’s experience has been that this is not a sufficient period. In several instances, employees applying just missed the six-month 

deadline. In many cases it takes more than six months for employees to become 

aware of this very helpful recruitment and retention program. This proposal offers 

greater flexibility to VA in applying the program. VA also supports the increased 

amounts in light of increased education costs since the program was enacted. We 

note this program can be implemented in a cost-neutral fashion. 

Section 103(c) would authorize VA researchers from ‘‘disadvantaged backgrounds’’ 

to participate in a loan repayment program that the VA may establish using the 

Public Health Service Act authorities for the NIH Loan Repayment Program. We 

agree that loan repayment incentives would be helpful to clinicians with medical 

specialization and research interests who might consider career clinical care or clinical research opportunities relating to the work of VHA. 

Section 104 is nearly identical to S. 246, Section 2(a), which I have previously discussed. 

Section 201 would eliminate two reporting requirements: the Nurse Pay Report 

and the Long-Term Planning Report. VA supports this provision. There would be 

no discernible cost savings associated with this provision. Similarly, VA supports 

Section 202 to amend the Persian Gulf War Veterans’ Health Status Act to change 

the due date of the annual report to Congress from March 1 to July 1. This change 

would have no impact on cost. 

VA also supports Section 203. Section 203 will provide clarification of the legal 

authority beyond the existing regulations that will prevent providers from collecting 

from the beneficiary any amounts in excess of the CHAMPVA determined allowable 

amount. VA favors this provision. There would be no significant cost to VA. 

Section 204, relating to payer provisions for care furnished to certain children of 

Vietnam Veterans, has been made moot by the passage of Pub. L. 110–387, Section 

408, ‘‘Spina Bifida Comprehensive Health Care.’’ 

VA strongly supports Section 205 of S. 252, which would permit VA health care 

practitioners to disclose the relevant portions of VA records of the treatment of drug 

abuse, alcoholism and alcohol abuse, infection with the human immunodeficiency 

virus, and sickle cell anemia to surrogate decisionmakers who are authorized to 

make decisions on behalf of patients who lack decisionmaking capacity, but to whom 

the patient had not specifically authorized release of that legally protected information prior to losing decisionmaking capacity. This provision would only permit such 

a disclosure when the practitioner deems the content necessary for the representative to make an informed decision regarding the patient’s treatment. This provision 

is critical to ensure that a patient’s surrogate has all the clinically relevant information needed to provide full and informed consent with respect to the treatment decisions that the surrogate is being asked to make. 

Section 206 would authorize VA to require that applicants for, and recipients of, 

VA medical care and services provide their health-plan contract information and social security numbers to the Secretary upon request. It would also authorize VA to 

require applicants for, or recipients of, VA medical care or services to provide their 

social security numbers and those of dependents or VA beneficiaries upon whom the 

applicant or recipient’s eligibility is based. Recognizing that some individuals do not 

have social security numbers, the provision would not require an applicant or recipient to furnish the social security number of an individual for whom a social security 

number has not been issued. Under this provision, VA would deny the application 

for medical care or services, or terminate the provision of, medical care or services, 

to individuals who fail to provide the information requested under this section. However, the legislation authorizes the Secretary to reconsider the application for, or reinstate the provision of, care or services once the information requested under this 

section has been provided. Of note, this provision makes clear that its terms may 

22 

not be construed to deny medical care and treatment to an individual in a medical 

emergency. 

Given the significant privacy concerns related to this provision, we defer views 

until further analysis can be made and the new administration is given an opportunity to review this matter. 

Section 207 addresses quality management in VA facilities and establishes quality 

management officer positions at the national, VISN and facility level. Section 207 

is similar to S. 246, Section 3, although the position established is termed ‘‘Quality 

Management Officer’’ (QMO), and there is no stipulation that the position be filled 

by a board-certified physician. Section 207 would require the QMO to be responsible 

for and undertake specific actions to carry out VHA’s quality management program. 

Section 207 additionally would require the National QMO to assess quality of care 

by developing an aggregate quality metric from existing data sources, monitoring 

and analyzing existing measures of quality, and encouraging research and development in the area of quality metrics. Section 207 would authorize appropriations necessary to carry out the quality management program, including $25,000,000 for the 

quality metric provisions during the 2 fiscal year period following enactment. Mr. 

Chairman, we support the intent of these provisions, that is enhancing VA’s quality 

management programs, and have already undertaken actions to achieve many of the 

same goals. We would welcome the opportunity to meet with the Committee to discuss recent actions we have undertaken to improve the quality of care across the 

system, including program oversight related measures. 

Section 208 requires submission of an annual report to Congress describing progress toward implementing provisions of Sections 104 and 207. VA has no objection 

to this requirement and, in fact, supports the concept of transparency in health care. 

We note that a comprehensive Hospital Quality Report was prepared by the Department in 2008 and is updated annually. 

We estimate that the requirement that the VISN Director review all information 

needed for physician appointment would require an additional FTEE (GS 14) at the 

VISN level. We also estimate that the appointment of a board-certified physician to 

serve as QAO at the facility and network levels would require 162 physicians for 

141 medical staffs and 21 networks. We estimate salary and benefits costs for each 

QAO to be approximately $200,000 (actual will vary according to specialty, time 

commitment, and local market factors). We estimate total costs for a FTE MD QAO 

and FTE VISN coordinator to be $35.10 million in the first year, $188.05 million 

over five years, and approximately $413.22 million over ten years. We estimate that 

salaries plus benefits for the new positions will include a 4% increase in costs for 

each subsequent year. 

Section 209 would require the Secretary to conduct a pilot program, in collaboration with the Secretary of Defense, to assess the feasibility of training and certifying 

family caregivers to be personal care attendants for veterans and members of the 

of the Armed Forces suffering from TBI. The pilot program would be conducted at 

three VA medical centers and, if determined appropriate, at one DOD medical center. VA would be required to determine the eligibility of a family member to participate in the pilot programs, and such a determination would have to be based on 

the needs of the veteran or servicemember as determined by the patient’s physician. 

The training curricula would be developed by VA and include applicable standards 

and protocols used by certification programs of national brain injury care specialist 

organizations and best practices recognized by caregiver organizations. Training 

costs would be borne by VA, with DOD required to reimburse VA for the costs of 

training family members of servicemembers. Family caregivers certified under this 

program would be eligible for VA compensation and may receive assessments of 

their needs in the role of caregiver and referrals to community resources to obtain 

needed services. 

VA does not support section 209. Currently, we are able to contract for caregiver 

services with home health and similar public and private agencies. The contractor 

trains and pays them, affords them liability protection, and oversees the quality of 

their care. This remains the preferable arrangement as it does not divert VA from 

its primary mission of treating veterans and training clinicians. Moreover, it does 

not put VA in the position of having to tell family members how, at the risk of losing their caregiver compensation, they have to care for their loved ones. If enacted, 

we estimate the cost of the three-year pilot to be $178.4 million. 

Section 210 would require VA, in collaboration with DOD, to carry out a pilot program to assess the feasibility of providing respite care to family caregivers of servicemembers and veterans diagnosed with TBI, through the use of students enrolled 

in graduate education programs in the fields of mental health or rehabilitation. Students participating in the program would provide respite relief to the servicemember’s or veteran’s family caregiver, while also providing socialization and cogVerDate Nov 24 2008 19:35 Oct 22, 2009 Jkt 000000 PO 00000 Frm 00026 Fmt 6633 Sfmt 6621 H:\111TH HEARINGS\042209.TXT SVETS PsN: PAULIN
23 

nitive skill development to the servicemember or veteran. VA would be required to 

recruit these students, train them in the provision of respite care, and work with 

the heads of their graduate programs to determine the amount of training and experience needed to participate in the pilot program. 

VA does not support section 210. Individuals providing respite care do not require 

advanced degrees, only appropriate training. Respite care does not require specialized skills, and its functions are not applicable to curricula objectives in the graduate degree programs related to mental health or rehabilitation that we are aware 

of. Further, section 210 would require VA to use graduate students in roles that are 

not permissible under academic affiliation agreements, and we have serious doubts 

this proposal would be acceptable to graduate schools. 

Moreover, VA has a comprehensive respite care program. We also have specialized 

initiatives underway for TBI patients to reduce the strain on their caregivers, which 

overlap with this bill. We also provide respite care by placing the veteran in a local 

VA facility for the duration of the respite period. Veterans may receive up to 30 

days of respite care per year. We estimate the costs of conducting the pilot program 

to be $3.5 million in the first year and approximately $11.4 million over five years. 

Section 211 would require the Secretary to carry out a two-year pilot grant program (at five locations selected by the Secretary) to assess the feasibility of using 

community-based organizations and local and State government entities to increase 

the coordination of VA benefits and services to veterans transitioning from military 

service to civilian life, to increase the availability of medical services available to 

these veterans, and to provide their families with their own readjustment services. 

Grantees could use grant funds for purposes prescribed by the Secretary. 

VA opposes section 211 because it is duplicative of the Department’s on-going efforts. Vet Centers are already providing many of the services contemplated by this 

provision. Additionally, VA case managers and Federal recovery coordinators already coordinate the delivery of health care and other VA services available to veterans transitioning from military service to civilian life, including supportive services for their families. VA is committing ever increasing resources to these ends. The 

duplicated efforts required by the bill would likely create significant confusion for 

the beneficiary. 

To the extent the Secretary determines external resources are necessary to provide the services described in the bill, VA already has the necessary authority to 

contract for them. We favor using contracts instead of grants, as the former allow 

VA to respond to changing local needs and assure the quality of services provided. 

That approach also gives us an accurate way to project the cost of the services. This 

provision, on the other hand, would not. It would also not be cost-effective as it is 

likely that a grant awarded under the program would be for an amount significantly 

less than the cost VA incurs in administering the grant. We also note the bill would 

not include authority for VA to recapture unused grant funds in the event a grantee 

fails to provide the services described in the grant. 

Although the proposed pilot project is limited to five locations, the bill does not 

specify the number and amount of the grants to be awarded. We are unable to estimate the cost of this provision due to the lack of specificity. 

Section 212 would authorize VA to contract for specialized residential care and 

rehabilitation services for veterans of Operation Enduring Freedom and Operation 

Iraqi Freedom (OEF/OIF) who: (1) suffer from Traumatic Brain Injury, (2) have an 

accumulation of deficits in activities of daily living and instrumental activities of 

daily living that affects their ability to care for themselves, and (3) would otherwise 

receive their care and rehabilitation in a nursing home. These veterans do not require nursing home care, but they generally lack the resources to remain at home 

and live independently; this represents an extremely small subset of the OEF/OIF 

population. In fact, for FY 2010, VA estimates only 10 veterans would qualify and 

participate in this program. Age appropriate day health and other community programs, VA’s home based primary care, and medical foster homes will be expanded 

to provide these Veterans with long-term specialized rehabilitation services. VA supports this legislation as it would enable us to provide these veterans with long-term 

rehabilitation services in a far more appropriate treatment setting than we are currently authorized to provide. VA estimates the discretionary cost of section 212 to 

be $923,000 for the first year, $12.2 million over five years, and $76.8 over ten 

years. 

Section 213 would amend sections 5701 and 7332 of title 38, United States Code. 

The amendments would authorize VA to disclose individually-identifiable patient 

medical information without the prior written consent of a patient to a third-party 

health plan to collect reasonable charges under VA collections authority for care or 

services provided for a non-service-connected disability. The section 5701 amendment would specifically authorize disclosure of a patient’s name and address inforVerDate Nov 24 2008 19:35 Oct 22, 2009 Jkt 000000 PO 00000 Frm 00027 Fmt 6633 Sfmt 6621 H:\111TH HEARINGS\042209.TXT SVETS PsN: PAULIN
24 

mation for this purpose. The section 7332 amendment would authorize disclosure 

of both individual identifier information and medical information for purposes of 

carrying out the Department’s collection responsibilities. 

Given the significant privacy concerns related to this provision, we defer views on 

this section until further analysis can be made and the new administration is given 

an opportunity to review this matter. 

Section 214 would require VA to enter into a contract with the Institute of Medicine of the National Academies to conduct an expanded study on the health impact 

of Project Shipboard Hazard and Defense (Project SHAD). VA opposes this proposal. 

The 2007 four-year, $3.8 million, VA-sponsored study by the National Academies of 

Sciences (NAS) ‘‘Long-Term Health Effects of Participation in Project SHAD’’ represented an exhaustive effort to locate and evaluate the health of every living or 

deceased SHAD veteran. That study found little or no long-term health effects 

linked to SHAD participation, and spending additional resources with the hope that 

possibly tracking down a small number of additional SHAD veterans might significantly change those results is unrealistic. We have been assured by the NAS group 

who conducted the original study that they have spared no effort in tracking down 

every SHAD participant as part of their study. We estimate that such a study would 

cost $2.5 million. 

When VA is providing inpatient or outpatient care for a patient with Traumatic 

Brain Injury, VA is required to develop an individual plan for the veteran or servicemember. In implementing such plans, 38 U.S.C. § 1710E authorizes the Secretary 

to provide hospital care and medical services through cooperative agreements with 

appropriate public or private entities that have established long-term neurobehavioral rehabilitation and recovery programs. Section 215 would amend this authority 

by defining covered individuals as servicemembers or veterans receiving inpatient 

or outpatient rehabilitative hospital care or medical services for Traumatic Brain Injury to whom the Secretary is unable to provide treatment or services at the frequency or for the duration described in the plan, or for whom the Secretary determines such care is optimal. This provision would also require that facilities participating in such cooperative agreements maintain standards for the provision of treatment or services that have been established by an independent, peer-reviewed organization that accredits specialized rehabilitation programs for adults with Traumatic Brain Injury. 

VA supports this provision but recommends that the plan referenced in this provision be described as the VA Individualized Rehabilitation and Reintegration Plan 

developed in accordance with section 1710C. Further, the bill as currently drafted 

states that the Secretary may not provide treatment or services at the non-VA facility unless the facility ‘‘maintains standards for the provision of such treatment or 

services established by an independent, peer-reviewed organization that accredits 

specialized rehabilitation programs for adults with Traumatic Brain Injury.’’ 

Section 216 would include federally recognized tribal organizations in certain 

State home programs. Specifically, section 216(a) would authorize VA to treat a 

health facility or certain beds in a health facility of a tribal organization as a State 

nursing home for veterans. This would allow VA to pay per diem to the organization 

for the nursing home care of veterans in the home. The home would be required 

to meet the existing standards for State homes and such other standards as VA requires. In addition, the organization would have to demonstrate that, but for treatment in the home, a substantial number of veterans residing in the area would not 

have access to nursing home care, and the Secretary would have to determine that 

treatment of the facility or beds as a State home would best meet the needs of veterans for nursing home care in the area. Finally, tribal organizations would be subject to limitations on the number of beds that could receive per diem under this provision. 

VA opposes Section 216(a). It would be very difficult to maintain a critical mass 

of staff with expertise in the care of frail, elderly patients in such a setting. Moreover, this would duplicate the function of the existing Community Nursing Home 

Program under which VA can pay for the care of Veterans placed in nursing homes 

in the private sector. VA contracts with more than 4,500 community nursing homes 

nationally and can add more as needed to assure Veterans’ access to care. 

Section 216(b) would authorize VA to award grants to tribal organizations for the 

construction or acquisition of state homes in the same manner and under the same 

conditions as grants awarded to States subject to exceptions prescribed by VA to 

take into account the unique circumstances of tribal organizations. This provision 

would require VA to give priority to grant applications from tribal organizations 

that had not previously applied for a grant even if the State in which the tribal organization was located had previously applied for (or received) a grant. 

25 

VA also opposes Section 216(b). The proposal would disenfranchise the states for 

which the construction grant program was expressly established since priority for 

awarding of grants is prescribed in statute and regulation. The first priority is for 

renovations necessary to protect the lives and safety of Veterans residing in the 

home. The second priority is for grants to states, or under this provision, tribal entities, that have never previously received a grant from this program. Since every 

state has received a grant and no tribal entity ever has, all construction and renovation applications from tribes would take precedence over all applications from 

states, except for life safety grants, until all tribal entities that wished to submit 

applications had done so. Since there are more 500 recognized tribal entities, it 

could be years before states are again able to receive grants other than life safety 

grants, and even then they would have to compete with more than 500 eligible applicants instead of the 50 states and a few territories now eligible for the grants. 

The radical change being proposed would be detrimental to the states for which this 

program was specifically established. 

VA estimates the cost of Section 216 to be $2.6 million for the first year, $14.2 

million over five years, and $31.5 million over ten years. 

Section 217 would require the Secretary to carry out a pilot program to assess 

the feasibility and advisability of providing a dental insurance plan to veterans enrolled for VA health care pursuant to section 1705 of title 38 and survivors or dependants enrolled for care under section 1781 of title 38 (CHAMPVA). Under this 

plan, VA would manage and administer a group dental plan. VA opposes section 217 

as this provision would establish an entirely new and dramatically different role for 

VA. 

Section 301 of this bill corresponds to section 101 of S. 597, another bill on today’s 

agenda. This section would require VA to contract with a qualified independent entity or organization to carry out a comprehensive assessment of the barriers encountered by women veterans seeking comprehensive health care from VA, building on 

the VA’s own ‘‘National Survey of Women Veterans in Fiscal Year 2007–2008’’ (National Survey). Many requirements related to sample size and the scope of the survey would apply to the conduct of the assessment. Section 301 would also require 

the contractor-entity to conduct research on the effects of the following concerns on 

the study participants: 

• The perceived stigma associated with seeking mental health care services. 

• The effect of driving distance or availability of other forms of transportation to 

the nearest appropriate VA facility on access to care. 

• The availability of child care. 

• The acceptability of integrated primary care, or with women’s health clinics, or 

both. 

• The comprehension of eligibility requirements for, and the scope of services 

available under, such health care. 

• The perception of personal safety and comfort of women veterans in inpatient, 

outpatient, and behavioral health facilities of the Department. 

• The gender sensitivity of health care providers and staff to issues that particularly affect women. 

• The effectiveness of outreach for health care services available to women veterans. 

• The location and operating hours of health care facilities that provide services 

to women veterans. 

• Such other significant barriers identified by the Secretary. 

Additionally, section 301 would require the Secretary to ensure that the heads of 

the Center for Women Veterans and the Advisory Committee on Women Veterans 

review the results of the comprehensive assessment and submit their own findings 

with respect to it to the Under Secretary for Health and other VA offices that administer health care benefits to women veterans. 

The results of our National Survey will not be available until later in the fiscal 

year. Consequently, we do not think it feasible to enter into a contract for the mandated assessment and research until we have first had a chance to complete and 

fully analyze the results of the National Survey. Only in this way can the assessment and research adequately build on the National Survey and reliably augment, 

rather than duplicate, VA’s efforts in this area. We estimate the cost of section 101 

to be $3.5 million. 

The next section, section 302, corresponds to section 201 of S. 597 and requires 

VA to develop a plan to improve the provision of health care services to women veterans. VA fully supports the evaluation and enhancement of care to women veterans 

and initiated a planning and implementation program in September 2008. Consequently, this provision is unnecessary as the initiative is already underway. 

26 

Section 303 of S. 252 corresponds to section 102 of S. 597. This section would require VA to enter into a contract with an entity or organization to conduct a very 

detailed and comprehensive assessment of all VA health care services and programs 

provided to women veterans at each VA facility. The assessment would have to include VA’s specialized programs for women with PTSD, homeless women, women requiring care for substance abuse or mental illnesses, and those requiring obstetric 

and gynecologic care. It would also need to address whether effective health care 

programs (including health promotion and disease prevention programs) are readily 

available to, and easily accessed by, women veterans based on a number of specified 

factors. 

After the assessment is performed, the bill would require VA to develop an extremely detailed plan to improve the provision of health care services to women veterans, taking into account, among other things, projected health care needs of 

women veterans in the future and the types of services available for women veterans at each VA medical center. VA would then be required to report to Congress 

on the assessment and plan, including any administrative or legislative recommendations VA deems appropriate. What is unclear in the bill is whether the contractorentity conducting the assessment would also be required to develop the follow-up 

‘‘plan,’’ as the terms of section 303 refer to the contractor’s conduct of ‘‘studies and 

research’’ required by that section. VA supports section 303 only if the development 

of the mandated plan would be conducted by a contractor-entity. We estimate the 

total costs of this section to be $4,354,000 during the period of Fiscal Year 2010 

through Fiscal Year 2012. 

Section 304 corresponds to section 202 of S. 597. This provision would require the 

Secretary to establish a program for education, training, certification and continuing 

medical education for VA mental health professionals furnishing care and counseling services for military sexual trauma (MST). VA would also be required to determine the minimum qualifications necessary for mental health professionals certified under the program to provide evidence-based treatment. The provision would 

establish extremely detailed reporting requirements. VA would also have to establish education, training, certification, and staffing standards for VA health care facilities for full-time equivalent employees who are trained to provide MST services. 

We do not support the training-related requirements of section 304 because they 

are duplicative of existing programs. In FY 2007, VA funded a Military Sexual 

Trauma Support Team, whose mission is, in part, to enhance and expand MST-related training and education opportunities nationwide. VA also hosts an annual 

four-day long training session for 30 clinicians in conjunction with the National Center for PTSD, which focuses on treatment of the after-effects of MST. VA also conducts training through monthly teleconferences that attract 130 to 170 attendees 

each month. VA has recently unveiled the MST Resource Homepage, a Web page 

that serves as a clearinghouse for MST-related resources such as patient education 

materials, sample power point trainings, provider educational opportunities, reports 

of MST screening rates by facility, and descriptions of VA policies and benefits related to MST. It also hosts discussion forums for providers. In addition, VA primary 

care providers screen their veteran-patients, particularly recently returning veterans, for MST, using a screening tool developed by the Department. We are currently revising our training program to further underscore the importance of effective screening by primary care providers who provide clinical care for MST within 

primary care settings. 

We object strongly to section 304’s requirement for staffing standards. Staffingrelated determinations must be made at the local level based on the identified needs 

of the facility’s patient population, workload, staffing, and other capacity issues. Retaining this flexibility is essential to permit VA and individual facilities to respond 

to changing needs and available resources. Imposition of national staffing standards 

would be an inefficient and ineffective way to manage a health care system that is 

dynamic and experiences continual changes in workload, utilization rates, etc. 

Section 305 would require VA, not later than six months after the date of enactment, to conduct a pilot program to evaluate the feasibility of providing reintegration and readjustment services in a group retreat setting to women veterans recently separated from service after a prolonged deployment. Participation in the 

pilot would be at the election of the veteran. Services provided under the pilot would 

include, for instance, traditional VA readjustment counseling services, financial 

counseling, information on stress reduction, and information and counseling on conflict resolution. 

We are unclear as to the purpose of and need for this provision. The term ‘‘group 

retreat setting’’ is not defined, but we assume it could not include VA medical facilities or Vet Centers, as we could not limit Vet Center access to any one group of 

veterans. Moreover, it is important to note that many Vet Centers are already well 

27 

designed to meet the individual and group needs of women veterans. We estimate 

that the cost of the pilot would be around $300,000. 

Section 306 mandates a report to Congress to ensure that health care needs of 

women are met and to assess whether there is at least one full-time Women Veterans Program Manager employed at each VAMC. This section is substantially similar to section 103 of S. 597. The report shall include an assessment of whether there 

is at least one full-time employee at each VA medical center who is a full-time 

women veterans program manager. VA does not oppose this provision but we believe 

it is unnecessary. VA is already reporting regularly on the employment of Women 

Veteran Program Managers. To date, 137 of the 144 positions have been filled as 

full-time employees. No additional funds would be required to submit this report. 

Next, section 307 (and the corresponding provision in S. 597, section 204) would 

require the Department’s Advisory Committee on Women Veterans, created by statute, to include women veterans who are recently separated veterans. It would also 

require the Department’s Advisory Committee on Minority Veterans to include recently separated veterans who are minority group members. These requirements 

would apply to committee appointments made on or after the bill’s enactment. We 

fully support section 307. These amendments would help both Committees to better 

identify and address the needs of their respective veteran-populations. 

Section 308 would require the Secretary, commencing not later than six months 

after the date of enactment, to carry out a two-year pilot program, at no fewer than 

three VISN sites, to pay veterans the costs of childcare they incur to travel to and 

from VA facilities for regular mental health services, intensive mental health services, or other intensive health care services specified by the Secretary. The provision 

is gender-neutral. Any veteran who is a child’s primary caretaker and who is receiving covered health care services would be eligible to participate in the pilot program. 

The corresponding provision is in section 205 of S. 597. 

VA is very cognizant of the veterans’ needs for convenient access to health care; 

however, we oppose section 308 as this expansion would divert resources from direct 

medical care. 

We support section 309, which would authorize VA to furnish health care services 

up to seven days after birth to a newborn child of a female veteran who is receiving 

maternity care furnished by VA if the veteran delivered the child in a VA facility 

or in another facility pursuant to contract for service related to such delivery. This 

provision corresponds to section 206 of S. 597. We estimate that the cost would be 

$55.3 million the first year, $293.6 million over five years, and approximately $589.4 

over ten years. 

VA supports Section 401, which would make members of the Armed Forces who 

serve in Operation Enduring Freedom or Operation Iraqi Freedom eligible for counseling and services through Readjustment Counseling Service, but we are concerned 

with the precedent that would be established by providing disparate eligibility to 

veterans of different conflicts. Under this provision active duty combat veterans of 

OEF/OIF would have access to Vet Centers for counseling and related mental health 

services and behavioral health services, including substance abuse assessment, 

counseling, and referral. Active duty veterans of the Persian Gulf War or other prior 

or subsequent combat would not have access to those services. Providing these services to active duty OEF/OIF personnel would cost approximately $3.7 million in the 

first year, $19.8 over five years, and $44.1 million over ten years. DOD has reimbursed VA for services provided to active duty members; however, we have not yet 

discussed the funding of this provision or possible reimbursement rates with DOD 

for readjustment counseling services. 

Until 1996, VA had specific statutory authority to refer ineligible veterans to nonVA resources and to advise such individuals of the right to apply for review of the 

individual’s discharge or release. VA supports Section 402, which would reinstate 

these provisions. Reinstatement of these provisions would give the Vet Centers the 

latitude to help Veterans with problematic discharges with problems deemed by Vet 

Center staff to be related to war trauma, through referral to services outside the 

VA and/or referral for assistance with discharge upgrades when appropriate. The 

total number of Veterans this provision would affect is assumed to be small so the 

costs of this provision would be negligible. 

VA opposes Section 403, requiring VA to conduct a study to determine the number 

of Veterans who have committed suicide between January 1, 1997, and the date of 

the bill’s enactment. VA opposes conducting the study because other information, 

more valuable in guiding VA’s strategy for suicide prevention, is already available 

and is continually being refined through other research and data collection efforts. 

Moreover, we do not believe that the new requirement would yield any additional 

information of significant value. 

28 

Rates and counts of deaths from suicide are available from 2000 onward for Veterans who utilized the VHA Health Care System. In addition, they are available on 

specific cohorts of Veterans including those who served in OEF/OIF and in the first 

Persian Gulf War, whether or not they utilize VHA health care services. Finally, 

they are available on all individuals identified at the times of their deaths as Veterans by their families in the sixteen states that participate in the Centers for Disease Control and Prevention’s National Violent Death Reporting System. VA estimates that the overall cost for conducting such a study would be $2,356,000 in FY 

2010 and $7,224,000 over five years. VA is opposed to Section 404, which would transfer $5 million from VA to the Department of Health and Human Services (HHS) by the end of FY 2010 for a graduate psychology education (GPE) program. This transfer of funds to the GPE Program would reduce funding available for VA programs or services without any clear 

benefit to VA in exchange for those services. VA much prefers to target these funds 

to increasing internship and post-doctoral training positions within VA facilities. VA 

already supports 435 Psychology internship positions in 90 different programs and 

200 postdoctoral fellowship programs in 54 programs. Thus we already provide the 

‘‘training of psychologists in the treatment of Veterans with Post Traumatic Stress 

Disorder, Traumatic Brain Injury, and other combat-related disorders’’ that this legislation aims to achieve. Assuming that this $5 million would become a recurring 

transfer of funds, the estimate over ten years is $50 million. 

Sections 501 and 502 of S. 252 would authorize VA to conduct two five-year pilot 

grant programs under which public and non-profit organizations (including faithbased and community organizations) would receive funds for coordinating the provision of local supportive services for very low income, formerly homeless veterans 

who reside in permanent housing. Under one of the pilot programs, VA would provide grants to organizations assisting veterans residing in permanent housing located on military property that the Secretary of Defense closed or slated for closure 

as part of the 2005 Base Realignment and Closure program and ultimately designated for use in assisting the homeless. The other pilot program would provide 

grants to organizations assisting veterans residing in permanent housing on any 

property across the country. Both pilot programs would require the Secretary to promulgate regulations establishing criteria for receiving grants and the scope of supportive services covered by the grant program. 

The 2005 Base Realignment and Closure process has been completed and local 

plans have already been developed. Therefore the new authority as proposed in section 501 would be ineffective. Further, the Veterans Mental Health and Other Care 

Improvement Act of 2008, Public Law 110–387, Title VI, Section 604 provided authorization for VA to facilitate the provision of supportive services for very low income veterans for veteran families in permanent housing. VA is in the process of 

writing regulations and hopes to offer funding later this year. Section 604 allows 

VA to effectively aid veterans better than either of the two pilots. We respectfully 

suggest that the two pilots are no longer needed and believe that the supportive 

services grants under Pub. L. 110–387 which this Committee approved last year to 

be a more effective way to assist veterans. 

Section 503 of S. 252 would require that VA establish a pilot program for financial 

support of entities that provide outreach to inform certain veterans about pension 

benefits. To this end, the bill would provide VA with additional authority to make 

grants to public and non-profit organizations (including faith-based and community 

organizations) for purposes of providing outreach to inform low-income and elderly 

veterans and their spouses residing in rural areas about potential eligibility for VA 

pension. The bill authorized the expenditure of $1,275,000 from General Operating 

Expenses (GOE) in each of fiscal years 2010 through 2014. Although VA supports 

the intent of Section 503 of S. 252, we oppose the bill because it duplicates ongoing 

outreach efforts by VBA to conduct outreach to low income and elderly veterans and 

their spouses and dependents. If this legislation is enacted, VA would need additional GOE to administer the pilot program and to train the public and non-profit 

organizations to accurately discuss VA benefit programs. 

VA’s outreach efforts to elderly veterans and their survivors include several approaches. We have provided the Social Security Administration with our pamphlet 

‘‘Federal Benefits for Veterans and Dependents.’’ Additionally, we have participated 

and will continue to participate in the annual conference of the American Association of Retired Persons (AARP). This year VA will participate in the National Convention of the Association of Directors of Assisted Living Facilities. From January 

2008 to January 2009 the number of veterans receiving disability pension declined 

about two percent or less than 7,000 veterans. That decline can be almost entirely 

accounted for by the decline in the number of World War II veterans receiving pension. The decline in this population accounted for 85 percent of the decline. The 

29 

Vietnam Era veteran population is only now reaching age 65 where entitlement exists based on age. We expect their participation in the pension program to rise. With 

respect to survivor pension, the number of widow(ers) on the rules has increased 

5,924 or 7.2 percent over the same January to January period. In light of the significantly lower allowable income limits for survivors, this rise is primarily attributable 

to entitlement being established as a result of high medical expenses. The rise is 

reflective of our work with social security and AARP and soon with the assisted living organizations. 

Section 504 of the bill would authorize a 3-year pilot program to assess the feasibility of providing grants to public or nonprofit organizations as a means of providing expanded services to veterans participating in vocational rehabilitation programs under chapter 31 of title 38, United States Code. Under this program, VA 

would provide financial assistance through grants to public or nonprofit organizations that would then establish new programs or activities, or expand or modify existing programs or activities, to provide assistance to veterans participating in vocational rehabilitation programs under chapter 31. The type of assistance to be provided includes transportation, childcare, and clothing to facilitate participation in a 

vocational rehabilitation program or related activity. The pilot program would be 

used to assess the feasibility of providing such expanded services to veterans 

through these types of grants. 

VA supports efforts to facilitate successful completion of vocational rehabilitation 

programs under chapter 31. However, VA does not support the use of grant programs to achieve this objective. The administrative burden associated with creating 

and administering such a grant program would be prohibitive, particularly since VA 

must continue to monitor grantee’s activities to ensure alignment with VA program 

objectives and each program participant’s individual rehabilitation plan. VA personnel already use existing systems to process direct reimbursements to veterans 

for authorized, necessary costs associated with participation in their specific vocational rehabilitation programs. VA believes that, subject to the availability of funding for the purpose, any incentive programs to facilitate completion of vocational rehabilitation programs should be built onto existing VA reimbursement authorities. The Department would be authorized $5 million from the amounts available in 

VA’s GOE account in each of fiscal years 2010 through 2012 to carry out section 

504 of this bill. 

Section 505 would require that not less than one year before the expiration of the 

authority to carry out the pilot programs established under section 501 through 504, 

VA would submit a report to Congress including the following: lessons learned, recommendations on whether to continue such pilot program, the number of veterans 

and dependents served by such pilot program, an assessment of the quality of service provided to veterans and dependents, the amount of funds provided to grant recipients, and the names of organizations that have received grants. 

VA supports sections 601 to section 606 of Title VI, which would update and clarify provisions of Public Law 100–322 authorizing VA-affiliated Nonprofit Research 

Corporations (NPCs). Title VI promulgates revisions that will allow the NPCs to 

better serve VA research and education programs while maintaining the high degree 

of oversight applied to these nonprofits. There are no added costs associated with 

Title VI. VA supports Title VI. 

Subsection (a)(1) of section 701 of the bill would amend section 902(a) of title 38, 

U.S.C., so as to permit VA police officers to: (1) carry VA-issued weapons, including 

firearms, while off VA property in an official capacity or while in official travel status; (2) conduct investigations, on and off VA property, of offenses that may have 

been committed on VA property, consistent with agreements with affected local, 

state, or Federal law enforcement agencies; (3) carry out, as needed and appropriate, 

any of the duties described in section 902(a)(1), as revised, when engaged in such 

duties pursuant to other Federal statutes; and (4) execute any arrest warrant issued 

by a competent judicial authority. Subsection (a)(2) of section 701 would further 

amend section 902 of title 38 to specify that the powers granted to VA police officers 

be exercised in accordance with guidelines approved by the Secretary and the Attorney General of the United States. VA will work with the Department Justice to formulate our views on this proposed legislation. We will submit our views at a later 

date. 

Section 702 of the Committee bill would amend section 903(b) of title 38, U.S.C., 

which governs the uniform allowance for VA police officers, to limit the allowable 

amount to the lesser of: (1) the amount prescribed by the OPM; or (2) the estimated 

or actual costs as determined by periodic surveys conducted by VA. The provision 

would also amend section 903(c) of title 38 to provide that the allowance established 

under subsection (b) of section 902 of title 38, as modified by the Committee bill, 

shall be paid at the beginning of an officer’s appointment for those appointed on or 

30 

after October 1, 2008, and for other officers at the request of the officer, subject to 

the fiscal year limitations established in subsection (b), as modified by the Committee bill. 

VA supports these provisions. Under current section 903, uniformed Department 

of Veteran Affairs Police are paid $400 for an initial uniform allowance, and then 

$200 annually throughout their careers. This is a marginal amount and does not 

cover the actual costs of uniforms and equipment required by the Department for 

our officers. VA Police officer uniforms are required by the Department and purchased by the officers using the statutorily authorized allowance. These amounts 

were last updated in 1991. Our Police Officers generally have to reach into their 

own pockets to supplement both the initial purchases and annual upkeep. 

The Office of Personnel Management (OPM) published new regulations in the 

Federal Register that increase the authorized uniform allowance amount up to $800 

initially and $800 annually. Section 702 would allow the Department to occasionally 

review and increase initial allowances up to the OPM-authorized maximum, if that 

is necessary. 

The Department requires that all VA police officers present an image of professionalism and authority. Authorizing an updated uniform allowance will help to 

achieve that. We also note that uniform allowances are a recruiting tool. We estimate costs at $1.58 million for one year, $6.5 million for five years, and $16.82 million for ten years. 

S. 362 ‘‘REPEAL OF EXCEPTIONS TO RIGHTS OF CERTAIN DEPARTMENT OF VETERANS

AFFAIRS EMPLOYEES TO ENGAGE IN COLLECTIVE BARGAINING’’ 

S. 362 would make matters relating to direct patient care and the clinical competence of clinical health care providers subject to collective bargaining. More specifically, it would repeal the current restriction on collective bargaining, arbitrations, and grievances over matters that the Secretary determines concern the professional conduct or competence, peer review, or compensation of Title 38 employees. 

Last, the bill imposes an unrealistic and unworkable time limit on certain grievance 

appeals. VA strongly opposes this provision. 

Our concern with this bill is its potential to adversely impact VA’s ability to deliver quality patient care. While we appreciate the many positive contributions collective bargaining and labor-management partnership make to VA’s mission, VA 

strongly opposes S. 362, which, if enacted, would imperil VA’s ability to furnish 

timely and quality care for veterans. S. 362 would transfer VA’s Title 38 specific authorities, namely the right to make direct patient care and clinical competency decisions, assess Title 38 professionals’ clinical skills, and determine discretionary compensation for Title 38 professionals, to independent third-party arbitrators and other 

non-VA, non-clinical labor third parties who lack the clinical training and health 

care management expertise to make such determinations. While S. 362 would result 

in a host of untenable situations, we limit our comments here to the most significant 

problems raised by the legislation. 

First, the rules for collective bargaining often lead to protracted negotiations and 

third-party proceedings. On average, it takes 60 days to negotiate national MOUs 

with AFGE, which does not include local-level bargaining which can take as long 

as 30 to 60 days. While this is acceptable for most workplace matters, it is not when 

it comes to providing quality patient care. If this bill were enacted, critical changes 

in patient care (e.g. new, mandated training on care of Traumatic Brain Injury or 

extended hours for mental health facilities) could not be implemented until after national and local bargaining had been completed. This would very likely result in veterans’ experiencing delays or gaps in their receipt of needed clinical care or services. 

Indeed, we foresee the situation where a VA facility is not able to change the standards requiring 24-hour assessments of patients without first engaging in collective 

bargaining, even though immediate patient care concerns are the cause for the 

change. Such delays and the very practice of negotiating clinical matters would be 

an anathema to patient-centered medicine. 

Second, S. 362 would allow Title 38 professionals to grieve matters or file Unfair 

Labor Practice grievances on clinical matters currently exempted from collective 

bargaining. If a grievance were not resolved at the informal stage, it would go to 

a third-party arbitrator for decision. Labor grievance arbitrators and the Federal 

Service Impasses Panel would have considerable discretion to impose a clinical or 

patient care resolution on the parties. VA would have limited, if any, recourse if 

such an external party erred in its consideration of the clinical or patient care issue. 

VA would be bound by that third-party’s decision. As a provider, this is wholly unacceptable. VA clinicians need to make the clinical decisions involving their patients 

31 

to ensure care is furnished in compliance with VA and prevailing medical practice 

standards. 

Moreover, these decisions should not be made by a non-clinical third party who 

is not accountable for ensuring the health and safety of the veterans receiving their 

care through the Department. If the Secretary and the Under Secretary for Health 

are going to be held responsible and accountable for the quality of care provided to 

veterans, it is they who must be able to determine which matters affect that care. 

They must be able to establish standards of professional conduct for, and competency of, our clinical providers based on what is best for Veterans from a medical 

perspective rather than what is the best that can be negotiated through collective 

bargaining or based on what a non-clinical arbitrator or FLRA judge decides is appropriate. At the least, because the third party’s final decision on a clinical matter 

would be imposed on VA, the relevant union should be held accountable and liable, 

along with the Department, for any adverse patient outcomes resulting from the decision. 

Additionally, S. 362 would adversely affect patient care and safety by permitting 

Title 38 providers to file grievances based on changes made in their shifts (e.g., 

whether or not to utilize compressed work schedules) that are needed to maximize 

providers’ skills and best meet patient care needs. VA needs the ability to quickly 

change shift assignments to meet patient needs that cannot be anticipated. Shift 

changes may also be necessitated by a medical emergency. However, S. 362 would 

permit the union to submit a proposal to define what constitutes emergency situations, limiting situations when VHA could schedule staff, such as RNs, to work 

longer than 12-hour shifts. In such a case, the impact on patient care would be fourfold: 

• By imposing a collectively bargained-for definition of ‘‘emergency,’’ the proposal 

would open to grievance and arbitration any management determination that a 

nurse should work beyond 12 hours to meet emergent patient care needs; 

• It would effectively prohibit management from determining that an emergency 

exists when the specific limitations of the bargained-for definition are not met; 

• It could delay adequate nurse staffing for the affected unit, leave the unit 

under-staffed for the entire tour, or force VA into procuring expensive contract care 

that may not equal that of VA employees; and, 

• It would place limitations on management’s ability to mandate a particular 

nurse, with personal professional qualifications that render him/her the preferable 

or necessary patient care provider under the circumstances, to work in an emergency, directly impacting patient care. 

It is even foreseeable that the union could submit a proposal empowering RNs to 

be able to refuse mandatory overtime in excess of 12 hours, even if based on critical 

patient needs. This would effectively prohibit VA from taking any disciplinary action 

against an RN who refused to work more than 12 consecutive hours. If no RN 

agreed to work longer than 12 hours on a particular unit, then the unit would be 

left short-staffed, or VA would need to procure expensive contract care that may not 

equal that of VA employees, either of which would adversely impact patient care. 

This is not to say, however, that any changes in shift assignments at the facility 

level are invariably clinical care matters excepted from collective bargaining. We are 

committed to ensuring that changes in staffing are not the result of any facility’s 

failure to make adequate staffing plans to meet their foreseeable, projected, and routine patient workloads. 

We cannot underscore enough that veterans would find little solace in learning 

that their care was delayed or denied because of our statutory obligation to first 

participate in collective bargaining with the unions on a clinical matter related to 

their care (including staffing), particularly if their medical situation leads to grave 

consequences. Nor could our veteran-patients be expected to understand why their 

VA providers—a coterie of highly qualified, trained, and trusted professionals—have 

no option but to follow the decisions of third-parties with whom they disagree. This 

would be particularly hard for them to accept when the final arbiter is a stranger 

to patient and provider alike and otherwise completely uninvolved in the patient’s 

care. 

S. 362 would also thwart VA’s ability to immediately re-assign staff from direct 

patient care duties to administrative duties based on an allegation that the staff 

committed patient abuse or posed some other danger to patient safety. Until such 

serious allegations can be properly investigated, the only reasonable action VA can 

take to protect patients is to immediately remove that staff member from direct patient care duties. Under the bill, however, such staff reassignments would be subject 

to negotiations, as staff would be able to grieve them. Such decisions should not be 

32 

left to arbitrators, who lack any clinical training and who have no responsibility for 

providing health care. 

Another example of the problems raised by this legislation concerns VA’s Peer Review process, which VA uses to assess the clinical skills of our Title 38 professionals 

and also to assess whether our patients received the high-standard of care they deserve. The Peer Review program is now expressly exempted from collective bargaining under section 7422. S. 362 would change that, permitting non-VA, non-clinical third-parties to assess the clinical skills of our Title 38 professionals and determine whether they are clinically competent in their area of practice. This would be 

an absurdity were it not such a serious threat to our patients’ welfare. 

In addition to clinical-care issues, S. 362 would also result in unprecedented 

changes in how the Federal Government operates. It would permit unions to bargain over, grieve, and arbitrate subjects that are even exempted from collective bargaining under Title 5, including the determination of the amount of an employee’s 

compensation. Permitting Title 38 staff to negotiate the discretionary aspects of 

their compensation would simply be at odds with how other Federal employees are 

treated. Such inequitable treatment among Federal employees cannot be justified. 

By significantly changing VA’s collective bargaining obligations, S. 362 would also 

adversely impact VA’s budget and management rights. It would also skew toward 

a slippery slope the current balance maintained between providing beneficial working conditions for Title 38 professionals and providing quality patient care services 

that are timely and that meet, if not exceed, the diverse, and often complex, medical 

needs of our veterans. 

Congress purposefully left it to the Secretary’s discretion to decide which matters 

would be excluded from collective bargaining. In so doing, Congress implicitly acknowledged that our large, dynamic health care system should not permit real-time 

clinical decisions and clinical management decisions to be decided through the collective bargaining process. The Under Secretary for Health has been delegated the 

authority to make these discretionary determinations. Since 1992, there have been 

no more than 17 decisions issued by the Under Secretary in a one-year period. This 

means that very few section 7422 grievances have been filed and pursued by employees up to the Under Secretary level. This is particularly striking given the number of VA health care facilities and bargaining unit employees at those facilities. 

In fact, our data reflect that, on the whole, our efforts to recruit and retain health 

care professionals (particularly nurses) have been widely successful notwithstanding 

the exceptions from collective bargaining now provided for by section 7422. We are 

glad to share our data with the Committee and brief the members on our continuing 

efforts in this area. 

In view of the foregoing, we strongly oppose this legislation. Although we appreciate the valuable role the unions can play on behalf of their members, this bill 

would give them bargaining rights on clinical care matters that would clearly and 

foreseeably endanger the well-being of our veteran-patients. 

In addition, section 2 of the bill, a proposed new section 7463(f)(1), would impose 

a requirement for VA to decide grievance appeals no later than 60 days after the 

grievance is filed. In many cases however, the grievance examiner’s review could 

take most or all of those 60 days, leaving no time for a review of, and decision on, 

the examiner’s findings and recommendations called for in section 7463(d)(3). If the 

Committee does not forebear in its consideration of S. 362, we suggest that provision 

of the bill be modified to (1) amend section 7463(d)(2) to impose a 120-day time limit 

for the examiner’s review and recommendations, and (2) to amend 7463(d)(3) to impose a 60-day time limit for that section’s review and decision on the examiner’s 

findings and recommendations. 

Finally, section 3 of the bill would amend the Disciplinary Appeals Board statute 

to require the provision of a transcript to the employee three weeks before the submission of post-hearing briefs. We think this unnecessarily constrains the time for 

DABs to consider their decisions, which must be rendered within 45 days of the 

DAB hearing and no later than 120 days after commencement of the appeal. In fact, 

there may be instances where it will be impossible to provide the three weeks and 

meet the 120-day time limit. 

In sum, VA’s ability to manage its health care facilities and to monitor the professional conduct and competence of its employees are management actions that must 

be reserved for the VA professionals responsible for delivering quality patient care. 

S. 404 ‘‘VETERANS’ EMERGENCY CARE FAIRNESS ACT OF 2009’’ 

VA supports S. 404, the ‘‘Veterans’ Emergency Care Fairness Act.’’ This bill would 

expand Veteran eligibility for reimbursement by VA for emergency treatment furnished in a non-VA facility. Under current law, VA is a payer of last resort. ConVerDate Nov 24 2008 19:35 Oct 22, 2009 Jkt 000000 PO 00000 Frm 00036 Fmt 6633 Sfmt 6621 H:\111TH HEARINGS\042209.TXT SVETS PsN: PAULIN
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sequently, a Veteran who would otherwise be eligible for reimbursement or payment 

of private emergency medical expenses is ineligible for the benefit because a third 

party makes partial payment toward the Veteran’s emergency treatment expenses 

pursuant to other contractual or legal recourse available to the Veteran. In these 

cases, Veterans are often left with sizable medical debts for which they are personally liable. VA payment as secondary payer would fully extinguish the Veteran’s liability to the private provider who furnished the emergency treatment. 

It is difficult to cost this proposal without extensive data on Veterans’ personal 

liability for non-VA emergency care expenses. We have estimated the cost based on 

the average payment made by VA for unauthorized non-VA emergency treatment 

of Veterans’ non-service-connected disabilities. We estimate the cost of implementing this draft bill to be $500,000 for FY 2010, $3 million over a 5-year period, 

and $7.8 million over a 10-year period. 

S. 423 ‘‘VETERANS HEALTH CARE BUDGET REFORM ACT’’ 

S. 423 would authorize advance appropriations for certain medical accounts of the 

Department by providing two-fiscal year budget authority. Mr. Chairman, we know 

that Congress and the Administration share the same objective—to ensure VA delivers timely, accessible, and high-quality care that Veterans expect and deserve. On 

April 9, 2009, the President emphasized that care for Veterans should never be hindered by budget delays and expressed support for advanced funding for Veterans’ 

medical care. We believe that advanced funding will ensure that sufficient resources 

are available from the first day of the fiscal year so that the health care needs of 

Veterans can be provided on a timely basis. We look forward to working with Congress to make advanced funding for VA health care a reality. 

S. 509 ‘‘AUTHORIZE A MAJOR MEDICAL FACILITY PROJECT AT THE DEPARTMENT OF

VETERANS AFFAIRS MEDICAL CENTER, WALLA WALLA, WASHINGTON.’’ 

S. 509 would authorize a major medical facility project at the VA Medical Center 

in Walla Walla, Washington, in an amount not to exceed $71,400,000. The project 

includes construction of a new multi-specialty outpatient clinic, campus renovations 

and upgrades, as well as additional parking. Mr. Chairman, funds for this project 

were appropriated last year in Pub. L. 110–329. We support this bill. 

S. 543 ‘‘VETERAN AND SERVICE-MEMBER CAREGIVER SUPPORT ACT OF 2009’’ 

Mr. Chairman, S. 543 describes a pilot program to train, certify and pay family 

caregivers for care provided to an eligible veteran or servicemember. There are similarities between this provision and the previously described section 209 of S. 252, 

which would also establish a pilot program for family caregivers, but there are also 

some significant differences. While S. 252 pertains specifically to veterans or servicemembers with Traumatic Brain Injury, the eligibility criteria set forth in S. 543 

would authorize a much larger and less well-defined population. In addition, S. 543 

differs in the duration and location of the pilot programs and also authorizes the 

inclusion of private facilities in the pilot. S. 543 provides more specificity concerning 

eligibility of family members, veterans and servicemembers, and is more proscriptive in describing the development of the curriculum. It also sets forth a detailed 

mechanism for determining amounts paid to family caregivers. Another provision in 

the bill directs the Secretary to review VA respite care programs, identify options 

for enhancing respite care and enhance the availability of such care. The bill also 

directs the Secretary to collaborate with the Secretary of Defense to develop a pilot 

program to make certain counseling and social services available to each eligible 

family caregiver participating in the pilot program. 

The concerns we identified with section 209 of S. 252 also apply to this pilot program. VA currently contracts for caregiver services with home health and similar 

public and private agencies. The contractor trains and pays the family member, affords them liability protection, and oversees the quality of their care. As previously 

noted, this arrangement is preferable because it does not divert VA from its primary 

mission of treating veterans and training clinicians. 

VA does not oppose the intent of the subsection of this bill addressing respite care 

but believes that it is unnecessary. VA already has a comprehensive respite care 

program that provides Veterans with short-term services to give the caregiver a period of relief from the demands of daily care for the chronically ill or disabled Veteran or active duty servicemember. Respite care services are planned in advance for 

the benefit of the caregiver in conjunction with the necessary medical care of the 

patient. As noted earlier with regard to section 210 of S. 252, Veterans are entitled 

to 30 days of respite care a year in inpatient, community, or other settings. 

34 

VA has two pilot programs underway to expand respite services. VA Voluntary 

Services (VAVS) is establishing and operating a community-based volunteer home 

respite program to benefit Veterans and their primary caregivers. Respite services 

provided through VAVS are in addition to the 30 days of respite care per year. This 

program is underway at ten VA medical centers. A caregiver assistance pilot program is also underway to provide 24-hour in-home respite care at two VA medical 

centers. Additionally, every Veteran and caregiver has access to a VA social worker 

who provides an assessment of individualized needs of the family caregiver with respect to the family member’s role as a caregiver, assistance with the development 

of a plan for long-term care of the Veteran, and implementation of a treatment plan. 

S. 597 ‘‘WOMEN VETERANS HEALTH CARE IMPROVEMENT ACT’’ 

S. 597, is nearly identical to sections 301 through 309 of S. 252. The views expressed regarding those sections are also applicable to the provisions in S. 597. 

S. 658 ‘‘RURAL VETERANS HEALTH CARE IMPROVEMENT ACT OF 2009’’ 

S. 658 contains several sections. I will address each section separately. 

Section 2 would establish the beneficiary travel allowance for mileage at a rate 

of 41.5 cents per mile. It would also require the Secretary amend the VHA Handbook to clarify that the allowance for mileage may exceed the cost of public transportation. VA does not oppose this provision but believes that it is unnecessary. VA 

currently reimburses beneficiary travel mileage at 41.5 cents per mile. Public Law 

110–387 gave the VA Secretary authority, based on availability of funds, to prescribe a rate higher than the Federal employee rate and, using this authority, the 

Secretary raised the mileage reimbursement rate to 41.5 cents per mile effective November 17, 2008. S. 658 would also remove the Secretary’s authority to adjust the 

mileage reimbursement rate when it is determined that such change is appropriate. 

Section 3 directs VA to establish at least one and no more than five, geographically dispersed centers of excellence for rural health research, education, and clinical 

activities. VA opposes this legislation because proposed centers of excellence are duplicative of the Veterans Rural Health Resource Centers (VRHRCs) that were established to improve care and services for veterans residing in geographically isolated 

areas. Provisions within this section are also duplicative of efforts of VA’s Veterans 

Rural Health Advisory Committee which was established to examine ways to enhance VA health care services for Veterans in rural areas by evaluating current programs and identifying barriers to health care. We estimate the cost of Section 3 to 

be $2 million in the first year, $10.8 over five years, and $23.8 million over ten 

years. 

Section 4 would require the Secretary to establish a grant program for State veterans’ service agencies and Veterans Service Organizations to provide innovative 

transportation options to veterans in rural areas. VA supports this provision. Section 4 authorizes appropriations of $3,000,000 annually for fiscal years 2009–2013. 

Section 5 would require the Secretary to create demonstration projects through 

partnerships with the Department of Health and Human Services and the Indian 

Health Service to examine the feasibility and advisability of alternatives for expanding care for Veterans in rural areas. VA does not support this provision as it is duplicative of pilot programs that are required under Section 107 and Section 403 of 

Public Law 110–387. Section 107 of that law requires VA to establish pilot programs 

in rural areas to use contracted community health centers, the Indian Health Service, or other appropriate entities to provide peer outreach, peer-to-peer counseling, 

readjustment counseling, and other mental health services to Operation Enduring 

Freedom and Operation Iraqi Freedom Veterans. The enactment of section 403 requires VA to establish a pilot program under which VA provides health services to 

highly rural Veterans through qualifying non-VA health care providers. Overall, we 

estimate that the demonstration projects outlined in Section 5 would cost $4.4 billion over three years. 

Section 6 directs the Secretary to establish a program to provide peer outreach 

services, peer support services, readjustment counseling services, and mental health 

services to Veterans of Operation Enduring Freedom and Operation Iraqi Freedom, 

particularly those who served while in the National Guard and Reserves. This section would also provide the Secretary the authority to contract with community 

mental health centers and other entities to provide services in areas not adequately 

served by Department facilities. VA opposes this section as it would blur the fundamental distinction between the readjustment counseling services and mental health 

services currently provided by the Department. These services are authorized by 

separate authorities and employ different eligibility criteria. Moreover, they should 

35 

not be combined as they are conceptually and operationally very distinct areas of 

treatment. 

Readjustment counseling is a special community-based counseling service that 

goes beyond medical care to provide combat veterans services needed to facilitate 

a successful readjustment to civilian life. VA’s authority to furnish readjustment 

counseling services already includes the authority to furnish limited mental health 

services necessary for effective treatment of the veteran’s readjustment issues. Vet 

Centers, for example, provide professional treatment for combat-related PTSD, depression, and substance abuse and, if necessary, refer the veteran to VA facilities 

for treatment of additional or more complex mental health needs. In contrast, comprehensive mental health services are furnished as medically needed to all enrolled 

Veterans, regardless of combat status, as part of VA’s standard medical benefits 

package. 

VA currently contracts for readjustment counseling and related readjustment 

services with private sector community mental health agencies and other professional entities. Most of these contract providers are located in rural areas. Similarly, 

VA has authority to contract for mental health services for enrolled Veterans if VA 

cannot provide needed services in a timely manner. In this regard, section 6 is duplicative of existing contract authorities and ongoing activities. 

Vet Centers also provide veteran-peer outreach and counseling. In 2004, VA began 

an aggressive outreach effort, which included hiring theater of combat OEF/OIF 

Veterans to provide outreach services and peer counseling to their fellow veterans. 

To date, the Vet Center program has hired 100 OEF/OIF outreach workers. In addition, the program has seen a significant expansion of its resources. Starting from 

a total of 206 Vet Centers in fiscal year (FY) 2006, there are now 232 Vet Centers, 

and another 39 planned to be operational by the end of FY 2009. Funding to support 

all of the Vet Center program initiatives is included in the program’s annual operating budget. 

Section 7 would establish an ‘‘Indian Veterans Health Care Coordinator’’ at the 

10 medical centers which serve the greatest number of Indian veterans to improve 

outreach to tribal communities, coordinate medical needs with the Indian Health 

Service, expand access and participation in the Veterans Affairs Tribal Veterans 

Representative program, and advocate on behalf of Indian veterans. This section 

would also require the integration of electronic health records between VA and the 

Indian Health Service and would permit the Secretary to transfer medical and IT 

equipment to the Indian Health Service. 

VA does not support Section 7 because the agency is already providing support 

to American Indian Veterans, primarily through our rural health initiatives. VA encourages cooperation and resource sharing between the Indian Health Service and 

VHA to deliver quality health care services and enhance the health status of American Indian and Alaska Native (AI/AN) veterans. VA also maintains the VISN Tribal Veterans Representative (TVR) Program, which provides outreach and open communication to veterans in extremely rural and underserved areas, especially the 

AI/AN and Hawaiian Native (HN) populations. The VISN TVR program trains individuals on outreach techniques to assist, facilitate and encourage veterans to access 

their full range of earned VA benefits. Multiple agencies use VA’s VISN TVR outreach services including the Indian Health Service, Tribal Health Services, Community Health Centers and veterans’ service organizations. VA estimates the cost of 

the provisions in Section 7 at $985,000 in the first year, $5.3 million over five years, 

and $11.6 million over ten years. 

Section 8 would require the Secretary to provide an annual report to Congress on 

matters related to care for Veterans who live in rural areas. VA is not opposed to 

this reporting but we believe it is unnecessary. VA already provides a number of 

periodic reports to Congress on the status of rural and highly rural Veterans. For 

example, Public Law 110–329 requires that the Secretary of the Department of Veterans Affairs report quarterly to the Congress on new rural health initiatives implemented through appropriations funding. The Office of Rural Health also provides 

regularly recurring reports to the SVAC and HVAC. 

S. 669 ‘‘VETERANS 2ND AMENDMENT PROTECTION ACT’’ 

S. 669 would clarify the conditions under which certain persons may be treated 

as adjudicated mentally incompetent for certain purposes. Pursuant to section 

103(e)(1) of the Brady Handgun Violence Prevention Act (Pub. L. 103–159), VA is 

required to provide the Department of Justice (DOJ) with information concerning 

individuals who, due to a determination by VA, are prohibited from purchasing or 

possessing firearms under the standards imposed by 18 U.S.C. § 922(d)(4) and (g)(4), 

which prohibits the purchase or possession of firearms by any person ‘‘adjudicated 

36 

as a mental defective.’’ Under existing DOJ regulations, the phrase ‘‘adjudicated as 

a mental defective’’ includes persons found to be a danger to themselves or others 

and persons found to lack the mental capacity to manage their own affairs. Pursuant to those requirements, VA’s Veterans Benefits Administration (VBA) currently 

provides DOJ with information on persons adjudicated by VA under 38 CFR § 3.353, 

as lacking the mental capacity to contract or manage their own affairs. This information is then included in databases managed by DOJ’s Federal Bureau of Investigation and Bureau of Alcohol Tobacco and Firearms, and serves to prevent, 

through the National Instant Criminal Background Check System, prohibited individuals from purchasing firearms. 

S. 669 would provide that a person VA finds to be mentally incapacitated, mentally incompetent, or experiencing an extended loss of consciousness ‘‘shall not be 

considered adjudicated as a mental defective’’ for purposes of 18 U.S.C. § 922(d)(4) 

and (g)(4), unless a ‘‘judge, magistrate, or other judicial authority of competent jurisdiction’’ concludes that ‘‘the individual is a danger to himself or herself or to others.’’ 

This amendment would revise the reporting requirements contained in title 18 of 

the United States Code, by adding additional prerequisites to the reporting by VA 

to DOJ, of information pertaining to persons VA adjudicates as incompetent. VA 

takes no position on this bill at this point as the Administration is still working 

with the Department of Justice to formulate views. 

S. 734 ‘‘RURAL VETERANS’ HEALTH CARE ACCESS AND QUALITY ACT OF 2009’’ 

I will address individually the several sections of S. 734. 

VA opposes Section 2, which would remove the current cap for the Education Debt 

Reduction Program (EDRP) and would cover the full cost of the principal and interest owed by participants. This section could result in significantly higher awards, 

but would mean significantly fewer people could participate. Moreover, EDRP is a 

reimbursement program, meaning that VA provides awards to employees at the end 

of the year covering their out-of-pocket payments on their loans. In many situations, 

employees would be unable to bear the cost of higher per year awards. For example, 

an individual with a $150,000 loan would have to pay $30,000 on their own before 

VA could reimburse them at the end of the year. We also note by removing the cap 

on loan repayment awards, VA’s programs would be inconsistent with other student 

loan repayment or reimbursement programs in the Federal Government. Moreover, 

this bill does not eliminate the six-month eligibility requirement and thus does not 

improve the retention value of EDRP. VA estimates Section 2 would cost $9.7 million in FY 2010, with a five-year total of $145.9 million and a ten-year total of 

$389.2 million. 

Section 3 proposes to transfer $20 million to the Department of Health and 

Human Services to include VA among the list of facilities eligible for assignment 

of participants in the National Health Service Corps Scholarship Program. VA believes that participation in this program would help attract high caliber researchfocused candidates to VA; however, we believe that VA funding would be better 

spent supporting our current recruitment and retention initiatives, such as the Employee Debt Reduction Program, the Employee Incentive Scholarship Program, or 

the Health Professionals Educational Assistance Scholarship Program, which would 

be resumed under section 103 of S. 252. 

Section 4 of S. 734 would require the Director of the Office of Rural Health (ORH) 

to develop a five-year strategic plan. VA does not oppose this provision but believes 

it is unnecessary. The ORH is already developing a national strategic plan and has 

informed Congress of its planning process. The plan under development will exceed 

the requirements of the bill by enabling ORH to focus on six key areas: access, technology, quality, education and training, collaborations, and workforce recruitment 

and retention. Additionally, the national ORH strategic plan will meet ORH’s mission requirements, which are to promulgate policies, best practices and innovations 

to improve health care services to Veterans who reside in rural and highly rural 

areas, while undertaking ongoing initiatives to find better health care solutions and 

improving overall access. This national strategic plan will include specific goals for 

timely and quality access and incremental milestones for measuring the achievement of these objectives. Telehealth and telemedicine are important elements of 

these objectives and ORH will work in close collaboration with VHA’s Office of Care 

Coordination Services to appropriately include this method of health care delivery. 

VA estimates there would be no significant costs associated with Section 4. 

Section 5 of S. 734 would permit VA to use paraprofessional volunteers and eligible volunteer counselors to support the mission of Vet Centers and outreach efforts. 

VA does not oppose section but believes it is unnecessary as VA already has the 

37 

authority under 38 U.S.C. 513, 38 U.S.C. 7405, and VHA Directive 1620 (September 

28, 2005) to use volunteers for these services to supplement, rather than replace, 

VA compensated staff. Additionally, these authorities permit volunteer assistance by 

physicians, dentists, nurses and other professionally licensed persons to assume full 

responsibility for professional services in their respective fields with the approval 

of the facility Chief of Staff, provided the volunteer is properly privileged and 

credentialed to perform such service and that any activities in which they engage 

are under the supervision of VA-compensated clinical staff. VA estimates there 

would be no significant costs associated with Section 5. 

Because they are either unnecessary or redundant of current activities, VA does 

not support a number of the provisions in Section 6. This section would require VA 

to: (1) carry out a program of teleconsultation for the provision of remote mental 

health and Traumatic Brain Injury (TBI) assessments; (2) carry out a program of 

teleretinal imaging in each VISN, expanding the number of patients enrolled in 

such a program by five percent annually through FY 2015; (3) develop in cooperation with affiliated universities an elective rotation in telemedicine for medical residents; and (4) modify the Veterans Equitable Resource Allocation (VERA) system to 

provide incentives for utilizing telehealth and to incorporate such consultations in 

facility workload data. 

Regarding the first provision, VA has already implemented a national program to 

provide teleconsultation for remote mental health assessments. VA is currently undertaking a pilot of the remote assessment of TBI via teleconsultation in Denver. 

There are also clinical, technological, and business processes that need to be formalized before national implementation. We are working within VA and with external 

partners to establish technical and clinical care standards. The costs that would result from this proposal are insignificant. 

VA similarly does not support the second provision concerning teleretinal imaging. 

VA has already instituted teleretinal imaging programs in each of the 21 VISNs. 

While VA’s teleretinal imaging program is currently growing by more than five percent each year, we do not want this requirement enacted into law because it is overly prescriptive. Advances in technology or clinical care within the next five years 

could produce a more effective approach to treatment, so a requirement to expand 

enrollment in one program that has been superseded by another would run contrary 

to the best interests of our Veterans. VA estimates this proposal would cost 

$455,000 in FY 2010 and would have a five-year cost of $2.5 million. 

While VA supports the concept of expanding opportunities for medical residents 

to participate in telemedicine programs and to gain experience in these technologies, 

we oppose the provision in this bill that would require each facility involved in resident training to develop an elective rotation in telemedicine as it cannot be implemented. The curriculum in medical residency training programs is tightly regulated 

by the Accreditation Council for Graduate Medical Education, which does not approach specific delivery methods as separate from the scientific curriculum. However, VA does provide opportunities for many residents to participate in telemedicine health care delivery and will continue to do so. There are no significant costs 

associated with this provision. 

VA supports subsection 6(c) concerning enhancements of VERA. In the absence 

of appropriate VERA incentives to encourage VISNs and facilities to adopt telehealth, the expansion of telehealth can be delayed and in some cases faces disincentives when compared with other means of care delivery. This proposal would expand 

access to care in areas where telehealth can address unmet patient needs while reducing costs through home telehealth and telemental health. VA estimates no costs 

associated with this provision. 

Section 7 addresses oversight of contracts and fee basis care. From a legal perspective, the provision 7(a) raises issues with regard to prohibited ‘bundling’ of contracts. ‘Bundling’ is combining two or more requirements previously performed 

under separate contracts and thus making it unlikely to be suitable for award to 

small businesses. Many VA Community-Based Outpatient Clinic acquisitions are set 

aside for small business. Our interpretation of ‘‘consolidate such contracts’’ would 

be to make a single contract whenever multiple contracts awarded to the same provider. Upon re-competition, VA would then necessarily advertise that combined requirement and that may make the requirement too large for a small business setaside. Federal Acquisition Regulation 7.107 includes specific determinations that 

have to be made, including anticipated cost savings, for bundling that must be made 

and approved prior to ‘bundling’ contracts. While this section includes a qualifier, 

that each VISN ‘‘to the maximum extent practicable’’ shall consolidate such CBOC 

contracts, if enacted, this section would create a conflict with the bundling rules. 

Further, we do not believe this provision would result in any significant administration or oversight savings or relief. 

38 

Subsections (c), (d), and (e) appear to treat peer review and accreditation as worthy of additional compensation. VA does not support these provisions as we believe 

our obligation is to ensure Veterans receive the highest possible standard of care, 

regardless of where that care is provided. Accreditation and participation in peerreview programs are ‘‘floor requirements’’ that every provider should already meet. 

Moreover, we interpret these provisions as providing the same level of compensation 

for participation in a peer review program as for obtaining accreditation. This would 

create a greater incentive to participate in peer review as there are additional costs 

for the medical practice associated with accreditation that are not present for peer 

review. VA estimates this section would cost $385,000 in FY 2010, with five-year 

costs of $2 million, and ten-year costs of $4.6 million. 

Section 8 would authorize the use of air transportation when travel by air is the 

only practical way to reach a Department facility. We believe this criterion is vague 

and subject to broad interpretation. Even with carefully crafted regulatory implementing language, this criterion could result in substantial confusion for Veterans 

and VA staff and wide variations in actual benefit implementation and administration. Moreover, the benefit outlined in Section 8 would not be limited to veterans 

living in rural areas. The cost of implementing Section 8 is also very difficult to calculate since VA does not know how many Veterans, either currently eligible or eligible under the new legislation, might be considered to require air transport. We cannot precisely predict the distances that will be traveled, how often air travel will 

be required, and any special requirements such as oxygen, gurney, or other special 

needs that may be necessary during flights. Based on available data and assumptions of usage, we estimate the cost of this provision to be $400 million for the first 

year, approximately $2.3 billion over five years and approximately $5.4 billion over 

ten years. 

Finally, VA opposes Section 9, which would create a three-year pilot program offering incentives for physicians who assume inpatient responsibilities at community 

hospitals in health professional shortage areas. VA has no statutory authority to bill 

third-party payers for services provided to non-Veterans in non-VA facilities. A more 

practical approach would be to develop agreements with the community hospital to 

reimburse VA for the care provided by VA physicians to non-Veterans. This would 

remove the logistical challenges of billing for care not provided in a VA facility, not 

documented in VA records, and for which no authority or rate exists. However, VA 

must strongly emphasize that assigning VA doctors to non-VA facilities to provide 

care to non-Veterans is outside of the scope of our mission to care for Veterans and 

other eligible beneficiaries. VA is unable to estimate the cost of this section because 

VA does not currently have authority to treat, bill or collect for care provided to nonVeterans. 

S. 801 ‘‘FAMILY CAREGIVER PROGRAM ACT OF 2009’’ 

S. 801 is divided into four separate sections. I will address each section separately; 

however, VA has not yet evaluated the costs of implementing the provisions of 

S. 801. We will provide an estimate to the Committee as soon as it is completed. 

Section 2 would authorize VA to waive charges for humanitarian care provided 

to caregivers accompanying certain severely injured veterans as they receive medical care. VA does not object to the concept of providing humanitarian medical benefits to caregivers but we must oppose this section. As currently written, Section 2 

identifies an extensive list of family members as potential caregivers and provides 

no criteria regarding the extent or duration of their service to the Veteran. Family 

caregivers could change frequently and we are concerned that the provision of humanitarian care could become a primary factor in designating a caregiver rather 

than that person’s ability to assist the veteran. Further, language that has historically appeared in VA appropriation statutes (requiring reimbursement for hospital 

care and medical services provided to individuals who are not otherwise eligible for 

these benefits) may restrict VA’s ability to waive charges as outlined in this provision of the bill. We are also considering the impact of Section 2 on the implementation of the family medical care provisions of the National Defense Authorization Act 

of 2008 (§ 1672(b) of Public Law 110–181). 

Section 3 of S. 801 addresses family caregiver assistance. I have previously discussed the family caregiver provisions of S. 252 and S. 543, which would require the 

Secretary to conduct pilot programs to assess the feasibility of training family caregivers as personal care attendants. While the eligibility criteria for this section are 

very similar to those in S. 543, S. 801 differs dramatically from S. 252 and S. 543 because it would establish a program of instruction, preparation, training, certification 

and ongoing support for designated family caregivers across VA. The mechanics of 

the program under S. 801 are also different as eligible veterans and their family 

39 

member (or other designated individual) would make a joint application to VA which 

would then evaluate the veteran to identify the personal care services needed by 

that individual and determine if they could be provided by a family member. The 

applicant family member is also evaluated to determine the training they would 

need to provide those services. Unlike S. 252 and S. 253, S. 801 does not address the 

development of the training curriculum. However, it does distinguish between a 

family member who provides personal care services and a family member who is 

designated as the veteran’s primary personal care attendant. The agency would be 

required to provide training, certification, technical support, and counseling to both; 

however, a primary personal care attendant would also be furnished mental health 

services, medical care under 38 U.S.C. 1781, respite care and a stipend. 

VA strongly opposes Section 3. The same concerns identified in conjunction with 

caregiver provisions of S. 252 and S. 543 apply here as well. VA currently contracts 

for caregiver services with various providers and this arrangement is preferable because it does not divert VA from its primary mission of treating veterans and training clinicians. We also would like to reiterate that S. 801 would establish the caregiver program across the agency and we caution against implementing a program 

of this magnitude without first exploring its feasibility and effectiveness. Should the 

Committee decide to proceed with a caregiver assistance proposal, we urge you to 

opt for the program defined in section 209 of S. 252 which would allow VA to conduct a three-year pilot providing assistance to caregivers of TBI patients. Moreover, 

the concerns that I addressed in discussing Section 2 relative to the large cadre of 

eligible caregivers would make this proposal challenging to administer and monitor 

for quality and effectiveness. The administrative burden on VA to re-identify and 

track caregivers could be considerable. 

Finally, S. 801 in general, and Section 3 in particular, would create preferential 

benefits for one generation of Veterans that are not available to others. VA believes 

that caregiver assistance would benefit veterans of all ages and periods of service 

and any initiative to support caregivers should not be limited to post-September 11 

veterans. 

Section 4 would amend VA’s beneficiary travel statute (38 U.S.C. 111) to include 

lodging and subsistence as travel expenses for attendants of certain veterans receiving VA health care. This provision would also define the travel period to include 

travel to and from the facility and the duration of the treatment episode. We believe 

that the proposed amendments would apply to all attendants eligible for beneficiary 

travel under 38 U.S.C. 111, not just those attendants defined by S. 801. VA opposes 

Section 4 as this benefit expansion would divert resources from medical care. In addition, 38 U.S.C. 111 already provides travel benefit attendants for severely injured 

veterans. 

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

ADDITIONAL WRITTEN VIEWS SUBMITTED FOR THE RECORD

THE SECRETARY OF VETERANS AFFAIRS, 

Washington, DC, May 14, 2009. 

Hon. DANIEL K. AKAKA, 

Chairman, 

Committee on Veterans’ Affairs, 

U.S. Senate, Washington, DC. 

DEAR MR. CHAIRMAN: This letter is in response to your invitation to submit for 

the record the Department’s views on six bills, S. 239, S. 498, S. 699, S. 772, S. 793, 

and S. 821. As you know, we received some of these legislative items too late to address in testimony before the Committee on April 22, 2009. In addition, while our 

views remain the same, we are submitting additional information and costs on four 

bills that were addressed in the April 22 testimony, S. 252, S. 404, S. 423, and 

S. 801. Thank you for giving us this valuable opportunity to submit our views before 

the hearing record closes. 

S. 239 ‘‘VETERANS HEALTH EQUITY ACT OF 2009’’ 

Section 2 of the Veterans Health Equity Act of 2009 would amend 38 U.S.C. 1716 

to require the Department to ensure Veterans in each of the 48 contiguous states 

have access to at least one full-service VA hospital or to comparable hospital care 

and medical services through contract with other providers in the State. It also requires VA submit a report to Congress describing the extent to which the DepartVerDate Nov 24 2008 19:35 Oct 22, 2009 Jkt 000000 PO 00000 Frm 00043 Fmt 6633 Sfmt 6621 H:\111TH HEARINGS\042209.TXT SVETS PsN: PAULIN
40 

ment has complied with this provision and the effect this requirement has on improving the quality and standards of care provided to Veterans. 

While VA supports the intent of S. 239, which we believe is to ensure Veterans 

access to medical treatment and hospital care in the State of New Hampshire, we 

are opposed to the bill as drafted because it is vague and confusing. Subsection (b), 

Rules of Construction, discusses ‘‘enhanced care’’ but does not define this term. 

Moreover, this provision indicates that subsection (a) should not be construed to prevent a Veteran from receiving care at a VA hospital in another State but subsection 

(a) addresses only access to care, not the provision of care. Further, subsection (b) 

is silent about providing out-of-state contract care. This is concerning as many Veterans now obtain nearby services from both VA hospitals and contract facilities 

across state lines, but would have to travel considerable distances to receive comparable services within their state of residence. 

We understand that there is considerable interest in establishing a full-service VA 

hospital in Manchester, New Hampshire. VA engages in extensive analysis of factors in order to identify appropriate sites for VA health care facilities. These factors 

include, but are not limited to, projected total Veteran population, Veteran enrollee 

population, and utilization trends. 

To address the needs and concerns of the New Hampshire constituency, VA is providing expanded acute care services to New Hampshire Veterans by means of a contract with a local acute-care facility. This model has been used for nine years to provide VA coordinated care in a safe and cost-effective manner. An expanded contract 

is now being negotiated that will service additional Veterans who are currently 

being transferred to other VA facilities. 

In evaluating the impact and estimating the cost of S. 239, VA focused attention 

specifically on the State of New Hampshire. We have assumed that contractor services would be provided in-state. With these parameters in mind, we estimate that 

the proposal would cost $3.4 million in 2010, approximately $20 million over five 

years, and nearly $48 million over ten years. 

S. 252 ‘‘VETERANS HEALTH CARE AUTHORIZATION ACT OF 2009’’ 

VA provided testimony on many provisions of S. 252 for the April 22, 2009, hearing. Below are the views and costs on provisions of S. 252 that were not provided 

in that testimony. 

Subsection 101(f) would amend 38 U.S.C. 7410 to add a new subsection to establish ‘‘comparability pay’’ for VHA non-physician/dentist section 7306 employees and 

SES employees of not more than $100,000 per employee in order to achieve annual 

pay levels comparable to the private sector. VA requests that the new administration be given an opportunity to review this matter. The estimated cost would be 

$10.35 million in the first year, approximately $54 million over five years and 

$113.3 million over ten years. 

Section 101(g) would provide special incentive pay for Department Pharmacist Executives. We expressed support for this provision in VA’s April 22 testimony; however, our support is contingent upon finding offsets within the 2010 funding level 

requested by the President. VA estimates the cost to be $1.44 million in 2010, $7.72 

million over five years and $16.85 million over ten years. 

Section 103(a) would reinstate the Health Professionals Educational Assistance 

Scholarship Program and extend it through 2014. VA supports the proposal, contingent upon finding offsets within the 2010 funding level requested by the President. 

We estimate the cost to be $725,000 in 2010 and $21,380,000 over the five year period. 

Section 103(b) would make amendments to VA’s Education Debt Reduction Program (EDRP). As the Committee had several questions related to VA’s April 22 testimony on EDRP, we would like to elaborate on our assertion in that testimony that 

section 103(b) can be implemented in a cost-neutral fashion. Specifically, this provision would amend 38 U.S.C. 7683 to increase the authorized EDRP statutory 

amounts to $60,000 and $12,000, respectively. VA generally awards amounts below 

the statutory maximum to ensure a greater number of applicants will receive 

awards. If the award amounts are not limited, fewer applicants will receive them, 

thus limiting the recruitment benefits of the program. Though section 103(b) raises 

the maximum award payable under EDRP, VA would continue to implement the 

program within the existing budget allocation. Currently, $20 million annually is allocated for the program. 

Section 206 would authorize VA to require that applicants for, and recipients of, 

VA medical care and services provide their health-plan contract information and social security numbers to the Secretary upon request. It would also authorize VA to 

require applicant’s for, or recipients of, VA medical care or services to provide their 

41 

social security numbers and those of dependents or VA beneficiaries upon whom the 

applicant’s or recipient’s eligibility is based. Recognizing that some individuals do 

not have social security numbers, the provision would not require an applicant or 

recipient to furnish the social security number of an individual for whom a social 

security number has not been issued. Moreover, VA will assist veterans who are unable to provide a social security number due to homelessness, mental illness, or 

other infirmity to gain access to this information. Under this provision, VA would 

deny the application for medical care or services, or terminate the provision of medical care or services, to individuals who fail to provide the information requested 

under this section. However, the legislation authorizes the Secretary to reconsider 

the application for, or reinstate the provision of, care or services once the information requested under this section has been provided. Of note, this provision makes 

clear that its terms may not be construed to deny medical care and treatment to 

an individual in a medical emergency. 

There is no permanent provision in title 38 to require the provision of information 

concerning health insurance coverage. This section would ensure that VA obtains 

the health-plan contract information. 

This legislation would enable VHA to use social security numbers to accurately 

match an individual’s information with both internal and external sources. Consistent with Executive Order 9397, collection of this information is necessary to 

meet the compelling business needs of the agency. Specifically, social security numbers for veterans, beneficiaries and dependents could be used to match veteran income data with the Internal Revenue Service and the Social Security Administration, allowing VA to carry out its income verification responsibility under 38 U.S.C. 

5317 and 5317A. While VHA has obtained verified social security numbers from the 

vast majority of veterans and spouses through voluntary reporting, there were over 

1 million beneficiaries’ household incomes in 2008 that VHA was unable to match 

because the social security numbers had not been provided. Social security numbers 

are also necessary for data matching with the Department of Defense. Military service data is essential for VHA as medical care eligibility determinations may be 

based on such factors as qualifying military service and service-connected disabilities. In addition, VHA uses social security numbers to collect health care expenses 

from insurance companies as most insurance companies use social security numbers 

to ensure a match. VHA may also obtain or verify individual information from internal VA components, such as the Veterans Benefits Administration (VBA), which 

currently has authority to require social security numbers for compensation and 

pension benefits purposes. 

Be assured that VA would provide the same high degree of confidentiality for the 

beneficiaries’ health plan information and social security numbers as it provides to 

patients’ medical information in its records and information systems. There are no 

direct costs associated with this provision other than administrative costs associated 

with collecting revenue. Those costs will be paid from future discretionary appropriations. Enactment of section 206 would require VA to issue an updated notice of 

privacy practice and review and update all associated information collection forms. 

Section 213 would amend sections 5701 and 7332 of title 38, United States Code. 

The amendments would authorize VA to disclose individually-identifiable patient 

medical information, without the prior written consent of a patient, to a third-party 

health plan to collect reasonable charges under VA collections authority for care or 

services provided for a non-service-connected disability. The section 5701 amendment would specifically authorize disclosure of a patient’s name and address information for this purpose. The section 7332 amendment would authorize disclosure 

of both individual identifier information and medical information for purposes of 

carrying out the Department’s collection responsibilities. Given the significant privacy concerns related to this provision, we defer views on this section until further 

analysis can be made. VA projects revenue from this proposal to be close to $10 million in the first year, $51.4 million over five years, and $113.3 million over ten 

years. 

Section 217 would establish a pilot program on providing dental insurance plans 

to Veterans and survivors and dependents of Veterans. As indicated in our April 22 

testimony, VA opposes this provision. The estimated cost of this pilot is $8 million 

over three years. 

S. 404 ‘‘VETERANS EMERGENCY HEALTH CARE FAIRNESS ACT OF 2009’’ 

This bill would expand Veteran eligibility for reimbursement by VA for emergency 

treatment furnished in a non-VA facility. As discussed in our April 22, 2009, testimony, VA supports this legislation as it would establish VA as a secondary payer 

thereby fully extinguishing a Veteran’s liability to the private provider who furVerDate Nov 24 2008 19:35 Oct 22, 2009 Jkt 000000 PO 00000 Frm 00045 Fmt 6633 Sfmt 6621 H:\111TH HEARINGS\042209.TXT SVETS PsN: PAULIN
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nished the emergency treatment. However, we inadvertently overlooked the absence 

of a specific amendment to 38 U.S.C. 1725 necessary to fully achieve the purpose 

of this legislation. Specifically, S. 404 should further amend 38 U.S.C. 1725 by striking subsection (f)(2)(E). 

Currently, section 1725 grants the authority to reimburse certain Veterans the 

reasonable value of emergency treatment furnished in a non-Department facility. To 

be eligible for reimbursement, among other requirements, a Veteran must be personally liable for the treatment. ‘‘A Veteran is personally liable * * * if the 

Veteran*** has no entitlement to care or service under a health-plan contract.’’ 

38 U.S.C. 1725(b)(3)(B). A health-plan contract includes a State law ‘‘ * * * that requires owners or operators of motor vehicles registered in that State to have in force 

automobile accident reparations insurance.’’ 38 U.S.C. 1729(a)(2)(B); 38 U.S.C. 

1725(f)(2)(E). In other words, a Veteran who is emergently treated in a non-VA facility for injuries sustained in a motor vehicle accident is not, pursuant to 38 U.S.C. 

1725, personally liable for the cost of his treatment if he is required by State law 

to maintain motor vehicle reparations insurance. Consequently, this Veteran would 

not be eligible for reimbursement from VA. To fully achieve the intent of S. 404, language should be added to strike subsection (f)(2)(E) from 38 U.S.C. 1725. This technical amendment would ensure that Veterans required by State law to maintain certain automobile insurance remain eligible for reimbursement for emergency treatment. We estimate the cost of implementing S. 404 to be $500,000 for FY 2010, $3 

million over a 5-year period, and $7.8 million over a 10-year period. Note that our 

support for this provision is contingent upon finding offsets within the 2010 funding 

level requested by the President. 

S. 423 ‘‘VETERANS HEALTH CARE BUDGET REFORM ACT ’’ 

S. 423 would authorize advance appropriations for three critical medical care accounts of the Veterans Health Administration: Medical Services, Medical Support 

and Compliance, and Medical Facilities. These are vital accounts that should never 

fall prey to interruptions of funding. VA shares the President’s support for advance 

appropriations as a way to provide uninterrupted care to our Nation’s Veterans. 

Implementing an advance funding mechanism is not without challenges, and careful planning is needed to ensure timely funding without unintended consequences. 

Budget projections are rarely right on the mark, and the further out they are made, 

the farther off the mark they are likely to be. For an advance appropriations mechanism to function effectively, it must be linked to a forecasting model that is both 

reliable and accurate, to the extent possible. VA’s principal forecasting model is the 

Enrollee Health-Care Projection Model. 

The Enrollee Health-Care Projection Model, or VA Model, is a comprehensive enrollment, utilization, and expenditure-projection model. It was originally developed 

in 1998 in partnership with Milliman, Inc. Through the past 11 years of periodic 

updates and continuous refinement, VA and Milliman have developed a strong partnership that has resulted in a powerful modeling tool. VA guides the overall development of the VA Model and ensures that it meets the needs of stakeholders. VA 

program staff provide expertise on the unique needs of Veterans, patterns of practice in the VA health-care system, and how the system is expected to evolve over 

the next 20 years. Milliman brings specialized expertise, access to extensive 

amounts of health-care utilization data, and excellent research to the overall modeling effort. 

The VA Model produces multi-year projections to inform the VHA budget process, 

estimate the impact of proposed policies, and support strategic and capital planning. 

For each year, the VA Model projects: 

• the number of Veterans expected to be enrolled; 

• the priority level, age, gender, and geographic location of enrolled Veterans; 

• the total health-care demand for enrolled Veterans across 58 health-care services; 

• the portion of that care enrollees are likely to receive from VA versus other 

health-care providers; and 

• the expenditures associated with the projected utilization. 

The enrollment modeling process begins with comprehensive and accurate Veteran population data developed by VA’s Office of the Actuary using a ‘‘VetPop’’ 

model. The Office of the Actuary projects Veteran populations over 30 out-years 

using data from the Census Bureau and the Department of Defense, and mortality 

and supplemental data to develop refined estimates of the current Veteran population and projected future levels. In 2005, independent verification and validation 

of the VetPop model by the Institute for Defense Analysis found the baseline VetVerDate Nov 24 2008 19:35 Oct 22, 2009 Jkt 000000 PO 00000 Frm 00046 Fmt 6633 Sfmt 6621 H:\111TH HEARINGS\042209.TXT SVETS PsN: PAULIN
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eran population estimate to be accurate in providing baseline estimates broken out 

by demographic characteristics such as age and gender. Additionally, VA completes 

a detailed validation annually to assure confidence in the VetPop output. This includes extensive peer review of our methodology and assumptions for parameters as 

well as of our programs, logs and output lists. All results are examined for consistency and compared with previous data and Census estimates. It should be noted the 

accuracy of the total Veteran population is unlikely to change significantly over the 

short term because the Veteran population changes little over the short term. The 

accuracy of the long-term forecast is largely dependent on the accuracy of the projections of deaths and military separations. 

Projections for health-care services VA offers that are comparable to the private 

sector, including inpatient, surgical, and ambulatory care, are based on private-sector benchmarks, which are adjusted for the demographics of the Veteran enrollee 

population and the VA health-care delivery system. Private-sector benchmarks used 

in the VA Model come from the Milliman Health Cost Guidelines, which are updated and expanded annually. These guidelines are a combination of consultants’ 

expertise, research, and actuarial judgment; they also represent the health-care utilization of over 60 million Americans. The guidelines have been validated and used 

extensively by private-sector health plans. The guidelines also provide extensive information on the impact of age and gender, changes in health-care benefits, and 

changes in copayments on health-care utilization. The enormous volume of data allows VA to develop projections at a very detailed level. Projections for services that 

are unique to VA, such as blind rehabilitation, and services where VA has a unique 

practice pattern, such as prosthetics, are developed based on analyses of historical 

VA data. 

The VA Model is supported by in-depth analyses of VA data, including enrollment 

rates, enrollee mortality, morbidity, and reliance on VA versus other health-care 

providers, and VA’s level of health-care management. An annual VHA Survey of Enrollees provides data on enrollee insurance coverage, income, period of service, and 

self-reported health status. The 2008 Survey included new questions developed to 

identify the key drivers of Veterans’ decisions to enroll and use VA health care. 

The VA Model uses utilization and cost trends to project modeled services forward 

20 years into the future from the most recently completed fiscal year, or base year. 

Assumptions about future trends are developed by a workgroup of VA staff and 

Milliman experts on health-care trends. The workgroup reviews VA historical trends 

and historical and estimated future trends in the broader health-care industry in 

developing the assumptions. While there are differences between VA’s closed-panel, 

integrated system and the fee-for-service environment in Medicare and the private 

sector, the broader health-care industry trends serve as a frame of reference for how 

future changes in the provision of health care will impact VA. These trends include 

expected changes in medical-care practice and custom. For example, gall bladder 

surgery is now routinely performed on an outpatient basis, so trends and projections 

now include a reduction in inpatient surgery utilization rates based on this shift. 

The projections are developed at a very detailed level and then aggregated to provide national projections. Projections are developed by 13 priority levels and by fiveyear age bands. Projections are also developed separately for enrollees who used VA 

health care before eligibility reform since they have unique demographic and utilization patterns. Geographically, the projections are developed at the sector level, 

which is the lowest geographic area for which credible projections can be developed 

at the level of detail used in the model. A sector consists of one or more complete 

counties and is fully contained within a single submarket. Over 3,100 counties are 

mapped into 506 sectors. Sector-level projections are then aggregated into 103 submarkets, 80 markets, 21 Veterans Integrated Service Networks (VISNs), and the national level. 

The VA Model has evolved significantly since 1998 and continues to evolve. Plans 

for future model enhancements are developed through an assessment of the predictive capability of various model components or the identification of new data 

sources. For example, we recently assessed the accuracy of the 2008 enrollment and 

patient projections from the 2006 Model, which supported the 2008 Budget. The 

2006 Model projected Veteran enrollment to within 0.3 percent, or 26,607, of actual 

2008 enrollment, while it over-projected patients by 161,166, or 3.3 percent. In the 

last five fiscal years, the average variance between the VA Model’s projection of enrollees and the actual enrollee population was 0.54% under-forecast. In other words, 

slightly more Veterans enrolled than were projected. In the same five years, the average variance between the VA Model’s projection of Veteran patients and actual patients was 1.7% over-forecast. In other words, slightly fewer patients were actually 

seen in Veterans Health Administration than projected. 

44 

Regarding the latest generation of Veterans with service in Operation Enduring 

Freedom (OEF), Operation Iraqi Freedom (OIF), or other theaters, VA initially had 

difficulty modeling this population because we did not have estimates of the total 

force expected to be deployed in these conflicts. However, since 2007, VA has used 

a future force deployment scenario developed by the Congressional Budget Office to 

estimate the number of future OEF/OIF Veterans. We have conducted extensive 

analyses of the enrollment and health care utilization of this population, and with 

each additional year of data, we gain more insight into their unique characteristics. 

The VA Model reflects the fact that OEF/OIF enrollees have exhibited significantly 

different VA health-care utilization patterns than non-OEF/OIF enrollees. For example, OEF/OIF enrollees have an increased need for dental services, physical medicine, prosthetics, and outpatient psychiatric and substance use disorder treatment. 

Alternatively, OEF/OIF enrollees seek about half as much inpatient acute surgery 

care from VA as non-OEF/OIF enrollees. 

The VA Model addresses many but not all areas of the health care budget. Approximately 16 percent of VA’s health care budget is developed through alternative 

models and estimates, and each present challenges in projecting future costs. 

Long-Term Care (both institutional and non-institutional) estimates are developed 

in accordance with the VA’s Long-Term Care Strategic Plan and historical cost and 

workload trends. VA will continue to focus its long-term care treatment in the most 

clinically appropriate and least restrictive setting by providing more non-institutional care than ever before and making more care available to Veterans closer to 

their homes. 

The Civilian Health and Medical Program of the Department of Veterans Affairs 

(CHAMPVA), the Foreign Medical Program, the Spina Bifida Program, and Children of Women Vietnam Veterans estimates are based on the current benefit structure, the mix of users, and workload estimates that reflect historical trends. 

Readjustment Counseling estimates reflect historical trends and the establishment of new Vet Centers and provide for the three major functions of direct counseling for issues related to combat service, outreach, and referral. 

Non-Veteran health-care cost estimates reflect collateral care, consultations and 

instruction for spouses, reimbursable workload from affiliates (such as sharing 

agreements with the Department of Defense), humanitarian care, and preventive 

health occupational immunizations for VA employees. They are based on historical 

workload and cost trends adjusted to reflect the current benefit structure. 

As noted earlier, while VA’s methodology for health-care budget development is 

sound, we recognize the realities of economic, policy and other uncontrollable factors 

which alter the requirements for care and the ultimate costs of it. This limitation 

should be recognized in any proposal to implement an advance appropriations process. Any such proposal should provide flexibility for near-term changes in workload 

or performance needs. 

VA supports the intent of S. 423 and is committed to working with Congress to 

provide our Veterans with the timely, accessible, and high-quality care that they expect and deserve. We also believe that close consultation between Congress, the Administration, and other stakeholders is necessary to develop the details in overcoming the challenges for the implementation of an advance appropriations proposal. 

S. 498 ‘‘DENTAL INSURANCE FOR VETERANS AND SURVIVORS’’ 

Similar to the pilot program proposed in section 217 of S. 252, S. 498 would require the Department to provide a dental insurance plan for Veterans enrolled 

under section 1705 of title 38 and the dependents of Veterans eligible for medical 

care under section 1781. The bill provides the Secretary the discretion to define the 

benefits appropriate for such a dental insurance plan and makes enrollment in the 

insurance plan voluntary. Enrollment would be for a period of time as established 

by the Secretary, who would also establish premiums adjustable on an annual basis. 

The legislation would not impact the Department’s obligations to provide dental care 

to Veterans under section 1712. VA opposes this bill as it would establish an entirely new and dramatically different role for VA. The cost estimate for this proposal 

would be $10 million in the first year, $18 million over five years, and $29 million 

over ten years. All costs for premiums and deductibles would be borne by Veterans 

or dependents. 

S. 699 ‘‘FAR SOUTH TEXAS VETERANS MEDICAL CENTER ACT OF 2009’’ 

The proposed bill would allow the Secretary to carry out the construction of a 

major medical facility project in Far South Texas consisting of a full service DepartVerDate Nov 24 2008 19:35 Oct 22, 2009 Jkt 000000 PO 00000 Frm 00048 Fmt 6633 Sfmt 6621 H:\111TH HEARINGS\042209.TXT SVETS PsN: PAULIN
45 

ment of Veterans Affairs hospital. The bill authorizes appropriation for fiscal year 

2009 such sums as such may be necessary for the project. 

VA does not believe that a full-service hospital is the best approach to providing 

medical care and treatment to Veterans in Far South Texas. VA projections illustrate that this region will see a continued increase in the outpatient workload but 

low levels of inpatient care. VA’s Fiscal Year 2008 Appropriation (Public Law 110– 

161), included authorization for a Major Lease to construct a build-to-suit Health 

Care Center (HCC) in Harlingen, Texas, in collaboration with the University of 

Texas (UT), Harlingen. The HCC will provide primary care, specialty care, mental 

health services, ambulatory surgery and expanded diagnostics and imaging in approximately a 120,000 square foot facility. Agreements will be made with the local 

hospital and UT to provide the required inpatient services. VA has entered into a 

20-year lease for the HCC pursuant to the authorization provided by Congress. 

S. 772 ‘‘HONOR ACT’’ 

Section 2 of the Honor Act of 2009 would require the Secretary to establish a 

scholarship program for qualifying Veterans pursuing a graduate or post-graduate 

degree in behavioral health sciences. Veterans would qualify for this scholarship if: 

(1) during service on active duty in the Armed Forces, they served in a theater of 

combat or during a contingency overseas operation; (2) they were retired, discharged, separated or released from service on or after a date not earlier than August 2, 1990, as specified by the Secretary; (3) at the time of application to the program, they hold an undergraduate or graduate degree that qualifies them for pursuit of a graduate or post-graduate degree in behavioral sciences; and (4) they meet 

other qualifications as established by the Secretary. The scholarship is to include 

tuition, reasonable educational expenses, a stipend and an obligation of service to 

the Department of Veterans Affairs, the Department of Defense, or some combination of both agencies. 

This provision links two important but independent concepts: enhancing educational opportunity for returning soldiers and providing mental health care to Veterans. However, it is not clear that linking these two distinct ideas has merit, as 

the proposed program would entail substantial costs over a long time period while 

producing few tangible benefits. 

It takes an average of two to seven years to become a behavioral specialist suitable for employment in VA. This is a long lead time to wait for behavioral specialists and we have no way of knowing that there will be a need for these behavioral 

health graduates by the time they complete their degrees. Assuming that each Veteran student already has an undergraduate degree, the time estimates for each discipline are summarized below. 

• VA facilities, under the guidance of VHA’s Office of Mental Health Services, 

only hire behavioral health specialists with advanced degrees. In particular, VA relies on doctoral level psychologists, masters level social workers, psychiatric nurses, 

and nurse practitioners to provide the high quality care Veterans deserve. 

• Clinical practice in VA in psychology requires admission into an accredited 

graduate program, four to six years of graduate education, one year of full time supervised internship before receipt of the doctoral degree, and another year of supervised clinical practice before becoming license eligible in most states. VA estimates 

the duration of a scholarship is between six and eight years. 

• Clinical practice as a masters-prepared social worker would require a two year 

masters program, followed by clinical experience. VA estimates the duration of a 

scholarship between two and three years. 

• Clinical practice as a master’s prepared behavioral health nurse or nurse practitioner requires a one to two year master’s program, followed by certification. VA estimates the duration of a scholarship between two and four years. 

VA has had success recruiting internally from VA training programs and externally from the private sector for its mental health staffing needs. Over 3,800 additional mental health workers have been hired in the past three years. VA has also 

developed several successful recruitment resources including expanded funding for 

mental health training. Seventy-three percent of current VA psychologists participated in VA training programs. 

Costs for this proposed program, both direct and indirect, would also be substantial and it is not clear that VA would receive a return on investment from this proposal. Specifically, VA estimates section 2 would cost $5.9 million in fiscal year 

2010, with a five-year total of $32.6 million and ten-year total of $65.2 million. 

Section 3 of the Honor Act of 2009 would require the Department of Defense to 

carry out a program to employ and train qualifying former members of the Armed 

46 

Forces as psychiatric technicians and nurses. VA defers to the Department of Defense for views on this section. 

Section 4 would reinstate provisions originally contained in the initial Vet Center 

legislation (Public Law 96–22, June 13, 1979) that were repealed in October 1996 

(Public Law 104–262). This section is similar to section 402 of S. 252. Reinstatement 

of these provisions would give Vet Centers the latitude to help Veterans with problematic discharges, deemed by Vet Center staff to be related to war trauma, through 

referral to services outside VA and referral for assistance with discharge upgrades 

when appropriate. This provision would give Vet Centers the authority to assist a 

new generation of combat Veterans in resolving problems with the character of their 

discharge. VA estimates that the total number of Veterans this section would affect 

is small, so the costs of the provision would be negligible. 

Section 5 would authorize the Secretary to provide mental health services through 

Vet Centers to members of the regular component of the Armed Forces and readjustment counseling and mental health services to members of the reserve component. It would require any provider who determines the servicemember is a threat 

to himself or herself or others to notify an appropriate official of a military medical 

treatment facility, and would require that official to inform the servicemember’s 

chain of command. 

VA generally supports this provision as it would augment the existing eligibility 

for Vet Centers to include active duty and reserve component servicemembers who 

served in a combat theater of any era. However, we are very concerned by the use 

of the term ‘‘mental health services’’ in proposed sections (f)(1)(A) and (B) as Vet 

Centers provide readjustment counseling but do not provide medical services, to include mental health services. Veterans in need of these services are referred to other 

facilities. We recommend that the proposed subsection (f)(1) be amended to read: 

The Secretary shall, upon the request of a member of the Armed Forces, 

furnish the member through a center the following: 

(A) In the case of a member of a regular component of the Armed Forces, 

readjustment counseling authorized to be provided under this section. 

(B) In the case of a member of a reserve component of the Armed Forces, 

readjustment counseling authorized to be provided under this section. 

By implication the primary target population for Section 5 is OEF/OIF combat 

Veterans; however, combat Veterans of all eras would be eligible. This provision 

would promote early access, education, prevention, and services to combat Veterans 

in a confidential setting that would greatly assist in overcoming the effects of stigma 

and promote access to care. Vet Centers provide services in a community-based environment that does not carry the stigma sometimes associated with some other 

mental health or readjustment care. Many servicemembers want to avoid the perception of having a mental illness that could affect readiness and their careers. The 

Vet Center program promotes early intervention and makes every effort to reduce 

the stigma of seeking assistance. 

This provision would also make confidential Vet Center services available to active duty and reserve component servicemembers through the Vet Center Combat 

Veteran Call Center being implemented in FY 2009. The Call Center will be staffed 

24/7 by combat Veteran peers to provide confidential support and referral information for Veterans and family members regarding the full range of readjustment 

issues following service in a combat zone. 

VA estimates section 5 would cost $3.7 million in FY 2010, with a five-year total 

of $20.2 million and ten-year total of $44.9 million. Our support of this provision 

is contingent upon finding offsets within the 2010 funding level requested by the 

President. 

Section 6 would require that the suicide of certain former members of the Armed 

Forces that occurs during the two-year period beginning on the date of separation 

or retirement from the Armed Forces be treated as a death in line of duty of a servicemember on active duty in the Armed Forces for purposes of survivors’ eligibility 

for certain benefits. The former Armed Forces members who would be covered are 

those ‘‘with a medical history of a combat-related mental health condition or Post 

Traumatic Stress Disorder (PTSD) or Traumatic Brain Injury (TBI).’’ The benefits 

that would be covered are ‘‘[b]urial benefits,’’ Survivor Benefit Plan benefits under 

subchapter II of chapter 73, title 10, United States Code, ‘‘[b]enefits under the laws 

administered by the Secretary of Veterans Affairs,’’ and Social Security Act benefits. 

Furthermore, for purposes of benefits under section 6, the date of death would be 

considered to be the date of separation or retirement from the Armed Forces, except 

that, for purposes of determining ‘‘the scope and nature of the entitlement,’’ the date 

of death would be considered to be the date of the suicide. It appears that this last 

provision (subsection (d)(2)) is intended to provide the date of death for determining 

47 

the effective date of an award or amount of benefits, although this is not clear from 

the bill’s language. Essentially, under section 6 the suicide of a covered individual 

would be treated as a service-connected death for VA benefit purposes. 

VA does not object to section 6. Because it would essentially deem a suicide under 

the specified circumstances a service-connected death, it would, for cases falling 

within its ambit, relieve VA of the administrative burden of having to obtain a medical opinion to determine whether a suicide is due to a service-connected mental disorder. Survivor benefits would be payable based on these suicides the same as they 

would based on any other suicide that DOD determines was in line of duty. This 

amendment would facilitate the expeditious provision of needed benefits to Veterans’ survivors at a very difficult time in their lives. 

However, we would like to note that this provision may have an unintended implication for veterans suffering from depression, PTSD, or other mental disorders. It 

is conceivable that a Veteran whose judgment is clouded by severe depression could 

conjecture that more Federal financial assistance would be provided under this provision than he or she could provide alive, and thus might perceive that the Government was offering a perverse incentive to suicide. We ask that the Committee consider the potential risk of this misperception along with the potential benefits of the 

provision. 

We have several technical concerns with section 6. Subsection (b) identifies the 

covered former Armed Forces members as those ‘‘with a medical history of a combatrelated mental health condition or [PTSD] or [TBI].’’ It is unclear from the provision’s language whether the adjective ‘‘combat-related’’ is meant to modify PTSD 

and TBI as well as mental health condition. In addition, subsection (c)(1) identifies 

‘‘[b]urial benefits’’ as one of the covered benefits, but fails to specify from which Federal department or agency. Subsection (c)(3) identifies as covered benefits ‘‘[b]enefits 

under the laws administered by [VA],’’ which would cover VA burial benefits and 

therefore, implies that subsection (c)(1) refers to another agency. Furthermore, an 

ambiguity would remain even if subsection (c)(1) is intended to refer to VA burial 

benefits. It is unclear whether that term refers only to burial benefits under chapter 

23, title 38, United States Code, or includes benefits such as burial in a national 

cemetery, provided by chapter 24, title 38, United States Code. The bill language 

could be clarified to address these ambiguities. 

Because under current law VA is likely to determine that a suicide under the circumstances described in section 6 is a service-connected death, albeit after more development of the claim, requiring the provision of service-connected benefits, VA estimates no benefit cost associated with this provision if enacted. There also would 

be no additional administrative costs. 

S. 793 ‘‘DEPARTMENT OF VETERANS AFFAIRS VISION SCHOLARS ACT OF 2009’’ 

S. 793 would establish a new scholarship program for individuals who are accepted for enrollment, or currently enrolled, in a program of study leading to a degree 

or certificate in visual impairment or orientation and mobility. In exchange for the 

scholarship assistance, participants would incur a three year service obligation to 

the Department to be fulfilled within the first six years after their graduation. The 

bill would limit to $15,000 the total amount of assistance that a participant who 

is a full-time student could receive during an academic year. It would establish a 

maximum cap of $45,000 on the total assistance that VA could provided to any participant. S. 793 would also require the Secretary to establish terms of participation 

for the program. Participants who fail to meet their service obligations would be 

subject to repayment terms, as established by the Secretary. 

VA appreciates the importance of Blind Rehabilitation Services, as is evident by 

its investment of $50 million to enhance its nationwide continuum of rehabilitative 

care for Veterans and active duty military personnel with visual impairments. VHA 

is the first health care system to completely integrate such services for patients with 

visual impairments into comprehensive health care benefits. This continuum of care 

will establish 55 new outpatient clinics targeting those who are beginning to experience functional loss from visual impairment. New programs also include: 22 new Intermediate Low Vision Clinics; 22 new Advanced Ambulatory Low Vision Clinics; 

and 11 new Outpatient Hoptel Blind Rehabilitation Clinics. The goal of this initiative is to provide rehabilitation services that keep visually impaired Veterans and 

active duty personnel functioning as independently as possible, and integrated with 

their families and communities. 

The Department is committed to ensuring that appropriate staffing of blind rehabilitation outpatient specialists and visual impairment professionals is maintained 

to support this important continuum of care; however, VA must oppose S. 793 because it is unnecessary. The Veterans Health Administration (VHA) analyzes data 

48 

concerning recruitment and retention of health care disciplines annually. The results of this analysis are published each year in the Succession and Workforce Development Plan. This plan provides a detailed, evidence-based analysis that identifies the categories of health professions that could, or should, be targeted with recruitment or retention incentives, including scholarship programs. As part of the 

succession planning efforts, VHA has funded technical career field interns in the 

blind rehabilitation occupation. In 2007, nine interns were funded, in 2008, 20 interns and again in 2009, 20 interns will be funded. We feel continued support in 

the technical career field program will meet the needs of the Department and the 

objectives of the legislation. We do not believe creation of an entirely separate scholarship program would be cost effective. 

It is also important to note that under the bill participants would be treated far 

more leniently than participant’s in VA’s existing scholarship program in the event 

they breach their service obligations. Participants in VA’s Education Incentive 

Scholarship Program (EISP) risk other forms of liability depending on the type of 

breach committed by the participant, including failure to accept the scholarship 

money, failure to complete the program, or failure to obtain licensure. This bill does 

not address the other scenarios covered under the EISP. 

VA estimates the total cost of implementing S. 793 to be $521,000 in fiscal year 

2010, $2.72 million over five years, and $5.7 million over a 10-year period. 

S. 801 ‘‘FAMILY CAREGIVER PROGRAM ACT OF 2009’’ 

VA’s opposition to S. 801 was detailed in the April 22, 2009, testimony. The costs 

for each section of the bill are outlined below. 

Section 2 would amend 38 U.S.C. § 1784 to allow for waiver of charges for hospital 

care or medical services provided to certain family members of Veterans receiving 

VA health care. We project that this provision would cost approximately $330,000 

in 2010, $2 million over five years, and $5.3 million over ten years. 

Section 3 addresses family caregiver assistance. VA has identified 65,798 Veterans with a serious injury incurred on or after September 11, 2001, that would be 

eligible for this program during its first two years. It is expected that an additional 

1,440 Veterans would become eligible each subsequent year. VA estimates that this 

provision would cost $5.056 billion in fiscal year 2010, $26.859 billion over five 

years, and $62.8 billion over 10 years. Note that these costs do not include Veterans 

severely injured prior to September 11, 2001, that may become eligible for this program after the first two years. 

Section 4, Lodging and Subsistence for Attendants, would amend 38 U.S.C. § 111 

to allow for travel, including lodging and subsistence, for the period consisting of 

travel to and from a treatment facility and the duration of the treatment episode 

for certain family members of certain Veterans receiving VA health care. We estimate the cost of this provision to be $8.6 million in 2010, $57.7 million over five 

years, and $163 million over ten years. 

S. 821 ‘‘PROHIBITION ON COLLECTION OF CERTAIN COPAYMENTS FROM VETERANS

CATASTROPHICALLY DISABLED’’ 

This bill would amend 38 U.S.C. 1710 to prohibit a Veteran who is catastrophically disabled from making any payment for the receipt of hospital care or nursing 

home care provided pursuant to section 1710. 

VA has no objection to this proposal. However, we note it is unclear if this proposal is intended to eliminate nursing home co-payments since the legislation refers 

to only section 1710 of title 38, while authority for VA nursing home care falls under 

section 1710A of title 38. We believe any co-payment requirements under this provision would remain in place. We further note the bill does not address pharmacy copayments. 

The Office of Management and Budget advises that there is no objection to the 

submission of this letter from the standpoint of the Administration. 

Thank you again Mr. Chairman, for the opportunity to provide VA’s views on 

these bills. 

Sincerely, 

ERIC K. SHINSEKI. 

49 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. DANIEL K. AKAKA TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

S. 801

Question 1. In written testimony, the Department expressed concern ‘‘that the 

provision of humanitarian care could become a primary factor in designating a caregiver rather than the person’s ability to assist the Veteran.’’ Since the legislation 

states that the designated caregiver receives waived charges for emergency medical 

care in the sole instance he or she is accompanying the Veteran, the likelihood of 

the caregiver receiving health care benefits is very small. Please elaborate as to why 

VA has a reservation with this provision? 

Response. Given the extensive list of persons eligible to be the Veteran’s caregiver, the Veteran may elect to designate, or be under pressure to designate, as 

their caregiver someone who has need for medical care and would benefit greatly 

from the Department of Veterans Affairs’ (VA) providing that care. This person may 

not be the best choice to assist the Veteran with their daily needs. Moreover, the 

legislation does not provide for limits on the number of times or how frequently the 

Veteran may change caregivers. Potentially, a number of persons could receive needed medical care by being designated as caregiver. 

Question 2. The Department objects to section 3 of S. 801 because of a concern 

that it will force VA to create preferential benefits for one group of Veterans. Yet, 

the legislation allows VA to extend this benefit to ‘‘include the largest number of 

Veterans possible.’’ Please explain, in detail, why the Department raises an objection to this provision? 

Response. The number of Veterans meeting the eligibility of section 3 for the first 

2 years of enactment is small compared to eligible Veterans from previous generations. VA believes that any program that would benefit one cadre of combat Veterans over another is inequitable, whether for a 2-year period or permanently. 

VA has been working on the family caregiver issue for some time and believes 

that the newly developed Veteran directed-home and community-based service (VDHCBS) creates a workable infrastructure for family caregivers to be paid for the relevant service they provide. The VD-HCBS program provides Veterans of all ages the 

opportunity to receive home and community based services in a consumer-directed 

fashion that enables them to avoid nursing home placement and continue to live in 

their homes. The VD-HCBS program addresses the home care needs for Veterans 

of all ages, allowing services to be provided to younger, seriously-injured and Traumatic Brain Injury (TBI) Veterans. This program will also help address the demand 

for paid family caregivers in a comprehensive and structured manner. 

We would be pleased to discuss this program and other alternatives to section 3 

of S. 801 with Members of the Committee staff. VA is committed to working with 

the Congress to create a viable family caregiver program. 

S. 734

Question 3. VA’s testimony states that section 2 ‘‘could result in significantly higher educational awards, but would mean significantly fewer people could participate.’’ 

According to a March 2009 CRS report, VA currently provides an average of $38,000 

per award, which is less than the statutory maximum. Is there a problem with funding the Educational Debt Reduction Program? 

Response. Funding for the educational debt reduction program (EDRP) is budget 

driven. There is always a greater demand for EDRP funding than the amount available through centralized funds. Local leadership has the option to further fund 

EDRP awards from its own budget, but that allocation is budget driven as well at 

the local level. EDRP is a reimbursement program, meaning that VA provides 

awards to employees at the end of the year covering their out-of-pocket payments 

on their loans. As a result, the amount that is reimbursed to employees each year 

is limited not only by the amount awarded but also by the amount of loan repayment the employees can reasonably pay themselves. VA generally awards amounts 

below the statutory maximum to ensure a greater number of applicants will receive 

awards. If the award amounts are not limited, fewer applicants will receive them, 

thus limiting the recruitment benefits of the program. 

Centrally, $20 million annually is allocated for EDRP. Because the pay-out is over 

a 5-year period, the amount of funding for new awards authorized each year is approximately $3,000,000 to $3,500,000. This amount is divided among the 21 networks. In addition to these centralized funds, all Veterans Integrated Service Networks (VISN) and medical centers are also able use local funds for EDRP. VISNs 

and medical centers have already committed $883,918 for fiscal year (FY) 2010 out 

of their local budgets to support EDRP awards. 

50 

In addition, Veterans Health Administration (VHA) is not solely reliant on EDRP 

and also uses other recruitment and retention incentives as appropriate. For example, in FY 2007, VHA invested over $66 million in recruitment incentives outside 

of EDRP including over $44 million in retention Incentives and $3.3 million in relocation Incentives. 

Question 4. VA’s testimony states the following: ‘‘EDRP is a reimbursement program, meaning that VA provides awards to employees at the end of the year covering their out-of-pocket payments on their loans. In many situations, employees 

would be unable to bear the cost of higher per year awards.’’ Section 7683(b)(1) of 

title 38 provides that ‘‘The Secretary may make education debt reduction payments 

to any given participant in the Education Debt Reduction Program on a monthly 

and annual basis, as determined by the Secretary.’’ Does this not accord the Department the discretion to determine when such payments are made? 

Response. Reimbursements for EDRP are required to be paid after the loan payment is made by the employee, whether reimbursed monthly or annually. With the 

number of participants and payments being made, monthly reimbursement would 

be onerous on both the employee (having to provide monthly evidence of loan payment prior to reimbursement) and VA in certifying monthly payments and processing reimbursements. Additionally, as there is no statutory minimum service period for EDRP awards, providing reimbursement at the conclusion of each annual 

service period improves retention and is a benefit to VA and Veterans served as it 

encourages employees to remain in service. 

Question 5. VA testimony states that funds proposed to be transferred to the Department of Health and Human Services Corps utilization could be better used to 

support VA’s recruitment and retention programs. Please describe in detail the ways 

in which VA’s current programs provide superior financial recruitment and retention incentives to those found in the National Health Service Corps. 

Response. It is our understanding that simply providing $20 million in funding 

to the Department of Health and Human Services (HSS) for use in the National 

Health Service Corps (NHSC) program will offer no direct benefit or return on investment for VA. VHA health care facilities do not meet the criteria for participation 

in NHSC as the criteria include accepting Medicare, Medicaid, and indigent patients 

(not just Veterans as indigent patients). Federal correctional institutions and Indian 

health care systems are specifically included as eligible in the HSS program language while VHA facilities are not. 

The employee incentive scholarship program for current VA employees was designed following the model provided by HHS as was the now inactive scholarship 

program under title 38 health professionals educational assistance program. 

S. 252 includes language that will re-authorize this scholarship provision giving 

VHA the ability to operate a program similar to the NHSC with a direct service obligation to VA. VA fully supports this provision of the bill. 

Question 6. VA’s testimony states that section 6(a) is not required because VA is 

already carrying out a program of teleconsultation for remote mental health assessments. Please provide information that demonstrates that this process is in place 

at all VA facilities ‘‘that are not otherwise able to provide such assessments without 

contracting with third-party providers or reimbursing providers through a fee basis 

system.’’ 

Response. The provision of mental health services using teleconsultation fits into 

the uniform mental health services package (UMHSP). The UMHSP ensures that 

the balance between VA-provided in-person care, telemental health and contracted 

care is appropriate to ensure the mental health care needs of patients are equitably 

met. VHA has a nationwide framework whereby telemental health care is provided 

and VA facilities can adopt this to comply with the UMHSP. In FY 2008, 149 VA 

medical centers (VAMC) and 353 community-based outpatient clinics (CBOC) were 

actively using teleconsultation capabilities, with 108 VAMCs and 307 CBOCs specifically providing mental health services. This use resulted in a total of 63,598 telemental health consultations nationally. Additionally, VA has readily available capability to provide this care directly to Veterans in their homes with 781 home mental 

health teleconsultation visits occurring in FY 2008. 

Thus, VA is currently able to substantially meet its telemental health requirements. A current limitation relates to inadequate telecommunications bandwidth 

and ensuring suitable space for teleconsultation in clinics. These limitations relate 

equally to any approaches that would seek to contract out telemental health 

services. 

Question 7. VA’s testimony states that ‘‘VA does not support these provisions as 

we believe our obligation is to ensure Veterans receive the highest possible standard 

of care, regardless of where that care is provided.’’ Please explain how fee basis proVerDate Nov 24 2008 19:35 Oct 22, 2009 Jkt 000000 PO 00000 Frm 00054 Fmt 6633 Sfmt 6621 H:\111TH HEARINGS\042209.TXT SVETS PsN: PAULIN
51 

viders are presently evaluated and how VA ensures that such care is of the highest 

quality. 

Response. VA is committed to assuring the highest possible quality of care for 

Veterans, regardless of how and where their care is delivered. This means care consistent with evidence-based practices and proper coordination to assure continuity. 

VA would like to point out that such challenges are not easily met, in part because of well-recognized barriers to coordination in community practices. Additionally, few community physicians have the infrastructure to electronically capture and 

report the clinical variables that VA relies on to ensure quality care. Finally, unless 

a community site meets certain minimal volume thresholds (the statistical rule of 

thumb is approximately 30 unique cases per reporting period), performance metrics 

will have too great an error margin to be usable. 

Recognizing these challenges, a standard set of quality measurement tools for 

both fee basis and contracted care is under development. At present, however, because of the wide range of community capabilities, VHA’s approach to evaluation is 

based on contractually mandated performance elements that are tailored to meet 

specific local requirements. Project HERO, which represents one of VA’s first efforts 

at managing and consolidating contracted care, has allowed us to develop and test 

combinations of metrics, such as facility accreditation, provider credentialing, access 

measures, timeliness, patient safety incident evaluation, clinical documentation submission, patient satisfaction, and others. In addition, the parent VAMC currently 

provides local quality oversight which includes review of selected clinical records, to 

ensure outside care meets our own standards. 

S. 252

Question 8. I appreciate VA’s technical comments on expanding authority for the 

Secretary to move more positions into hybrid status. What is meant by occupations 

which ‘‘would not otherwise be available to provide medical care and treatment for 

Veterans?’’ 

Response. The statement is related to the availability or ease to hire those who 

provide medical care to Veterans. Currently, if title 5 occupations are vacant, the 

facility must go through the process of requesting and waiting for a certificate of 

eligible candidates from a delegated examining unit, versus immediate recruitment 

locally. Additionally, pay flexibilities associated with hybrid title 38 makes it easier 

to pay wages set to be reflective of and competitive with the health care market. 

Question 9. In VA’s testimony regarding EDRP program, it is noted that ‘‘it takes 

more than six months for employees to become aware of this very helpful recruitment and retention program.’’ How is this program a recruitment tool if your employees are unaware of its existence until more than six months after the beginning 

of their employment? 

Response. The offer of EDRP is explained in the announcement or advertisement 

posted for eligible positions. Many times new employees, coming on board, may have 

overlooked the information or not fully understood requirements to immediately 

apply and fill out the paperwork. The way the program is structured now, if the 

application for EDRP is not submitted within the first 6-months of employment, 

they lose their eligibility. This rule also does not allow for flexibility in using the 

EDRP as a retention tool. If a practitioner, who may have a student loan, is planning on leaving employment and was not offered EDRP when hired, it can be offered 

to retain the employee. As the statute is written now, it does not allow for use for 

retention of employees. 

Question 10. According to VA’s testimony, section 302 is ‘‘unnecessary’’ because 

VA initiated a planning and implementation program in September 2008 to evaluate 

and enhance the care of women Veterans. Please provide the Committee with a copy 

of this plan. 

Response. The Women Veterans Health Strategic Health Care Group (WVHSHG) 

developed a women’s comprehensive health implementation planning (WCHIP) tool 

to assist facilities in analyzing their own current health care delivery for women 

Veterans and plan for care delivery enhancement. Every facility was requested to 

put together a multidisciplinary planning and implementation team to address comprehensive primary care for women Veterans. 

The WCHIP tool outlines a ‘‘care gap’’ analysis, a market analysis, and a needs 

assessment, which facilitate the development of a business plan. This plan includes 

resource needs, goals, timelines, budgets, training needs and program evaluation 

metrics to deliver comprehensive health care to women Veterans. 

A final facility-based implementation plan based on a completed WCHIP tool is 

due to the Deputy Under Secretary for Health for Operations and Management by 

52 

August 1, 2009. VA will provide the Committee with a copy of that plan when it 

is available for release. 

Question 11. VA’s testimony argues against section 304’s requirement for staffing 

standards, noting that retaining the flexibility for staffing related determinations ‘‘is 

essential to permit VA and individual facilities to respond to changing needs and 

available resources.’’ How often do individual VAMCs conduct evaluations of staffing 

needs regarding mental health professionals working with Veterans who experienced MST? 

Response. In response to the issuance of the Uniform Mental Health Services 

Handbook last year, VAMCs are currently evaluating their staffing needs and programming related to a wide variety of mental health services, including care for conditions related to military sexual trauma (MST). More broadly, assessment of staffing needs occurs on an ongoing and as needed basis, depending on local needs and 

resources. 

The Office of Mental Health Services’ MST support team also issues an annual 

report summarizing the number of Veterans screening positive for MST at each VA 

facility and the amount of care they subsequently receive for conditions related to 

MST. Facilities are instructed to use these data to assess the adequacy of their current staffing and services. 

Question 12. What specialized training do mental health care professionals receive 

regarding MST? The testimony refers to annual four-day training provided to 30 clinicians. Who are the 30 clinicians, and how are they selected to receive this training? 

Response. On a monthly basis, the MST support team hosts the MST teleconference training series, which cover a variety of topics related to MST. Typically, 

around 120 telephone lines are used, often with more than one listener on each line. 

Recent topics have included overviews of several commonly used evidence-based 

treatment protocols. 

The MST resource homepage is a Web site that serves as a clearinghouse for a 

variety of MST-related resources such as: patient education material; sample training presentations, provides educational opportunities, reports of MST screening 

rates by facility, and descriptions of VA policies and benefits related to MST. The 

Web site hosts discussion forums that allow providers to share information and engage in conversations related to screening and treatment of MST. 

Another major training resource available to VA staff is an independent study 

training course on MST developed by the Veterans health initiative. 

Information on MST has been included in each of the national rollouts of evidence-based therapies conducted by the Office of Mental Health Services. The MST 

support team encourages MST coordinators to attend this training. 

Finally, the MST support team hosts an annual, multi-day training program focused on providing clinical care to MST survivors and MST-related program development. During the first 2-years of the training, attendees were MST coordinators 

selected by VISN leadership based on the training needs of the VISN. Each VISN 

had at least one attendee. This year the number of trainees will be expanded to 50. 

Each VISN will now have two attendees, some of whom may be clinicians only. As 

in previous years, a number of slots will be available for staff from Vet Centers. 

53 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. PATTY MURRAY TO

DR. GERALD M. CROSS, PRINCIPAL DEPUTY UNDER SECRETARY FOR HEALTH, U.S. 

DEPARTMENT OF VETERANS AFFAIRS


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RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. BERNARD SANDERS TO DR. 

GERALD M. CROSS, PRINCIPAL DEPUTY UNDER SECRETARY FOR HEALTH, U.S. DEPARTMENT OF VETERANS AFFAIRS


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RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. JON TESTER TO DR. GERALD

M. CROSS, PRINCIPAL DEPUTY UNDER SECRETARY FOR HEALTH, U.S. DEPARTMENT

OF VETERANS AFFAIRS


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Chairman AKAKA. I will now turn to Ranking Member Senator 

Burr for his questions. Senator Burr? 

Senator BURR. Thank you, Mr. Chairman. 

Dr. Cross, I can’t let you get by without asking about this testimony. I take for granted that the inability to meet the deadline 

was because the Administration didn’t return the testimony. Is 

that correct? 

Dr. CROSS. Senator, that is not how we want to phrase it. I take 

responsibility and I appreciate the Chairman’s comments earlier 

and apologize for the tardiness. 

Senator BURR. Did you or did the VA have it in its possession 

before last night when it was turned in? 

Dr. CROSS. Walter, help me— 

Senator BURR. Listen, this is not the first time I have been on 

this cabbage truck, and it has been in Republican Administrations 

and now it happens to be a Democratic Administration and the 

likelihood is your testimony sat at OMB, and OMB ignored the 

rules of the Committee. Let us all concede that fact. When you got 

your testimony back, how different was it than what you sent? 

Dr. CROSS. Sir, I am not here to point fingers at anyone else. I 

will take responsibility for what I did. 


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Senator BURR. Dr. Cross, I appreciate that. I am trying to figure 

out what you wanted to tell the Committee and what the Administration instructed you through the changes in your testimony you 

were going to say to the Committee, but we will forego that. 

Mr. Hall, as Assistant General Counsel, did you inquire with 

OMB as to whether we would get the testimony so that you could 

meet the rules of the Committee? 

Mr. HALL. Yes, sir. This is, of course, an Administration position. 

We work closely with the Office of Management and Budget and 

other agencies to formulate the Administration’s views. 

Senator BURR. Did they express any concern that they weren’t allowing you to meet the rules of the Committee from the standpoint 

of the timeliness of testimony? 

Mr. HALL. Sir, we worked as hard and fast as we could to address the many issues that were before us. 

Senator BURR. Let us switch to the Second Amendment issue. I 

am disappointed that the VA has not taken a position on this. Let 

me ask you, do you agree with the Justice Department’s request of 

the VA that they continue to submit names? Dr. Cross? 

Dr. CROSS. Sir, the position that we have coming to you is the 

same as what we put in the written testimony, that we have reviewed the proposals and we have deferred officially to the Department of Justice. 

Senator BURR. Well, I didn’t ask about your comments on my legislation. I asked, do you agree with the Justice determination that 

VA should be obligated to provide those names, yet other agencies 

that have people that meet the same legitimate threshold do not? 

Dr. CROSS. I would like to ask my colleague, the General Counsel, to comment on that. 

Senator BURR. Mr. Hall? 

Mr. HALL. Yes, sir. That is the—the Department of Justice administers the Brady Bill. It is their responsibility to determine who 

it is that is required to be reported, the names that are required 

to be reported, and we comply with that—with those instructions. 

Senator BURR. Mr. Hall, do you believe in your opinion of the jurisdiction of the Justice Department. Do they have the ability to reverse this decision on their own, or does it require legislation? 

Mr. HALL. My understanding of the law is that it says the requirement to report is a ‘‘may report.’’ They ‘‘may determine.’’ 

Senator BURR. So one would conclude from that that the Justice 

Department today has the ability to say—— 

Mr. HALL. Sir, I would defer entirely to the Department of Justice as to the interpretation of that law, which they are responsible 

for administering, and they are the—— 

Senator BURR. I am not a lawyer, but please tell me this. Is there 

a significant difference between the word ‘‘may’’ and ‘‘shall’’ from 

a legal standpoint? When you see the word ‘‘may,’’ are you compelled? 

Mr. HALL. You may be. 

Senator BURR. You are using ‘‘may’’ again. [Laughter.] 

The truth is, the Justice Department could—and this is the new 

Justice Department—they could look at this request that they have 

made of VA and they could say, you know, this has been grossly 

misinterpreted; and they could, on their own, pull back the request. 

74 

Mr. HALL. I think that is entirely within the Department of Justice to—— 

Senator BURR. See, I knew if we worked at this, we were going 

to agree on something. 

Dr. Cross, the Committee has heard from veterans, family caregivers, Veterans Service Organizations, that we need to provide 

more support to family caregivers caring for veterans. In your testimony, you mentioned that the Department currently contracts for 

caregiver services with home health agencies and those agencies, 

in turn, are employing family members. Specifically, how many 

family members are currently employed by home health agencies? 

Dr. CROSS. Sir, I don’t know that number, but I am concerned 

that the number is quite small. I think that we need to address 

that. I think that is a real issue that we have to bring forward. We 

think the mechanism is sound, to use those agencies that are already existing or have expertise in this area to help us with this 

challenge which is so very important. But I don’t know the number 

of family members that are currently hired, and I am concerned 

that it is small. I think that we need to address that and find some 

way to increase that number. 

Senator BURR. Do you have any idea of the number of family 

members serving as caregivers, whether they are hired or not? 

Dr. CROSS. Specifically, no, sir. 

Senator BURR. I hope you understand, these are significant 

things that we need to know the numbers on if, in fact, we suggest—and I think your testimony suggests that the way the VA 

currently has it structured is working, and that is that we have 

home health agencies that turn around and hire family members 

to serve as caregivers. And I think what we are going to find out 

is that it rarely happens. Where it does happen, it is probably not 

with the best agreement up front, that the majority of caregivers 

would prefer not to go through a third party. As a matter of fact, 

most of them that supply the service today are doing it because of 

their family member—that they believe can only have the level of 

care if, in fact, they commit to do it. Why we would not provide a 

similar incentive for them to do this, versus to work through a 

third party, is somewhat a mystery to me. 

Has the VA done an assessment to make sure that the arrangements that are currently out there, meaning home care-hired family caregivers, work? 

Dr. CROSS. The way that it works right now is that the care 

managers interact with the veteran to make sure that they are 

being cared for properly. You have raised a very important point, 

though, in regard to the family members, and actually, we have 

asked the staff to look into the possibility of whether or not we can 

even create a preference when we work with those agencies in the 

community—to have a preference for those family members. 

I think, though, that you can understand that there might be 

some challenges for us if we made those family members directly 

employees of the VA, in essence. It would put us, at times, in a difficult position between that situation and the welfare and care of 

that veteran—a primary responsibility itself. Our primary responsibility is, in fact, the care of the veteran. We have to hold people 

responsible for that. Holding a family member responsible for that 

75 

could be a challenge for us. We are much more comfortable at this 

time having these community agencies train and oversee this. 

But I think that you have raised a significant issue as to how 

many family members are actually able to take advantage of this. 

Senator BURR. I thank you for your testimony. I have run over 

my time. If I could say to the Chair, I would like my colleagues to 

know that the father, the sister, and the brother-in-law of Eric 

Edmundson are in the audience today. His father has cared for him 

since the day he took him out of a VA facility. I think it is—those 

that have met Eric understand the challenges he has gone through. 

I know without his dad’s commitment to take care of him as a caregiver, Eric would not have made the progress he has today; and we 

all have great hope that he can continue to make progress. That 

would not have happened if it hadn’t been for a family that basically dropped everything and really made it their life’s commitment 

to serve their son as a caregiver. So I want to thank Edgar and 

Anna and Roger for coming up and taking the time to come to 

Washington today. 

Thank you, Madam Chair. 

Senator MURRAY [presiding]. Thank you very much. 

Dr. Cross, I recently held a press conference on women’s veterans 

issues, and in attendance were several female veterans who were 

part of a group that is known as Team Lioness. The Army has sent 

these female soldiers to serve in a support role for Marine ground 

combat troops in Iraq. And the members of Team Lioness were exposed to some of the bloodiest counterinsurgency battles during 

their service. All of this was done, of course, despite the current 

prohibition on women serving in combat. 

Now, I am told that many members of Team Lioness have not 

had their combat service recorded in their DD–214, which, of 

course, impacts their ability to get compensation or any other ancillary benefits that they earned. In fact, a female veteran who served 

as the mechanic in Team Lioness told me that the VA claims adjudicator she went to see about her PTSD claim didn’t believe that 

she could have any psychological health issues because her military 

records didn’t show any record of combat service. So this is a real 

issue for these women. 

Now, I recognize that this is a DOD problem. But I was hoping 

you could tell me if the VA itself is exploring any options to ensure 

that its compensation and pension staff and its medical staff are 

aware of the combat roles that many women veterans have played 

in Iraq. 

Dr. CROSS. Thank you, Senator. I believe the group that you are 

referring to actually came over and made a presentation at VACO 

headquarters. 

Senator MURRAY. Oh, great. I am glad they did. 

Dr. CROSS. I am looking forward to learning more about them. 

One organization where we do have some options to support them, 

even in that process, is our Vet Centers—for any combat veteran 

returning—to also help them work with DOD or help them work 

with VBA to resolve issues regarding their DD–214. I think that 

would be a very appropriate place for them in our Vet Centers. But 

we can address that systematically with DOD and VBA, as well. 

We are quite willing to do that. 

76 

Senator MURRAY. OK. I think it is important to address that 

with DOD and I appreciate that. But I also think, meanwhile, it 

is important to let VA personnel know that there are women out 

there that did serve in combat so that they don’t hear, well, you 

can’t, it is not on your form, because they did. 

Dr. CROSS. Agreed. 

Senator MURRAY. OK. I have a number of questions I want to 

submit for the record. As you know, Senator Akaka, our Chairman, 

had to leave for a short while. We are going to pass the gavel up 

here among members and I appreciate everybody’s patience as we 

do that, and I am going to turn the gavel over to Senator Sanders. 

Senator SANDERS [presiding]. Thank you. We should put the 

clock on, if we could. 

I want to get to the issue of outreach. My understanding is that 

the VA has opposed legislation that Senator Feingold and I introduced—Section 211 of the broader bill. What we believe very 

strongly is that it is terribly important to have aggressive outreach; 

that there are many veterans who do not know what they are entitled to. As I said earlier, it doesn’t matter what you have if people 

don’t know about it. 

And so what we have proposed is that community, local, State, 

and Federal providers of health care be enlisted in an outreach effort in the form of a pilot program. I say this because my recollection—and somebody can correct me if I am wrong—but I think in 

the early 2000s, maybe 2003 or so, an actual memo went out from 

the VA to halt outreach efforts. I think the VA has never been particularly aggressive, in general, in outreach efforts. They actually 

stopped it. I brought forth an amendment when I was in the House 

to undo that. 

So I think that, especially in rural areas, it is very important 

that every veteran know the benefits they are entitled to. I think 

the VA, in general, is doing better now than they used to. But it 

is no great secret nor will it shock anybody in this room when I 

say that for many years the VA basically did not want veterans to 

know what they were entitled to. Am I right? Because if they don’t 

know what they are entitled to, they can’t take advantage of it and 

we save money. It is a great way to do business. That is no secret. 

Everybody knows that. 

But, I happen to believe that if we pass legislation and veterans 

are entitled to certain benefits, they should know about it, period. 

That is what it is about. That has not always been the case. So we 

want to expand upon what the VA is doing, getting other groups 

involved in it. Dr. Cross, why is that a bad idea? Why aren’t you 

supporting it? 

Dr. CROSS. Senator, let me be very clear. We strongly support 

outreach, and I will list a couple of things that we are doing that 

I think are very consistent with what you are proposing. The bill 

itself and Section 211 itself was opposed because it appeared to be 

duplicative of what the Vet Centers, case managers, and other outreach we are currently doing, which I will elaborate on in just a 

moment. 

We are doing so many other things right now that I want to 

make sure that you are aware of and that you are proud of. We 

were concerned that coming back from OEF and OIF, a number of 

77 

veterans had not contacted us, had not come to a VA medical center. We put in place a contract to call every single one of them, and 

we are doing that by the hundreds of thousands and saying, hey, 

how are you doing? Is there something we can do for you— 

Senator SANDERS. I am aware of that. We spoke to Dr. Peake 

about that. I think that is an excellent step forward. And I do— 

I am aware, as I said a moment ago, that we are doing better. 

Let me just suggest to you, and you tell me this, that you have 

somebody coming back from Iraq with PTSD in rural Vermont. 

What we are doing now in our State is we have people actually 

going out and knocking on his or her door. I think we have got to 

be a lot more aggressive. As I said, I think you are making 

progress, but tell me the problem about why we would not want 

to be even more aggressive, bringing different groups in? 

Dr. CROSS. I don’t think necessarily there is any problem with 

being more aggressive, and I think we all support that. There were 

technical problems, I think, with the language in the bill and how 

it relates to the Vet Centers that we have. The Vet Centers have 

been tremendously successful. 

Senator SANDERS. Vet Centers help. Why don’t we do this? I am 

the first to happily concede that we have been making some 

progress. But you will recall, literally, not so many years ago where 

the VA—am I right on that, Dr. Cross? 

Dr. CROSS. Senator, I think we—— 

Senator SANDERS [continuing]. Didn’t VA actually send out a 

memo telling VAs all over the country to stop doing outreach? 

Dr. CROSS. That may have been before my time, but we agree 

that we made progress. 

Senator SANDERS. My recollection is that is exactly—— 

Dr. CROSS. And the progress was needed. 

Senator SANDERS. OK. So we are making some progress. I want 

to make more progress and I look forward to working with you if 

there are any technical problems in the bill, to see how we can 

work that out. 

Dr. CROSS. And sir, we will make our staff available to meet with 

your staff, to work through any of those issues at any time you 

would like. 

Senator SANDERS. We look forward to working with you. 

Senator Begich? 

Senator BEGICH. Thank you very much. I will have a few questions, but I am busily trying to read your testimony. I am not going 

to try to get into why or whatever. I was a mayor once and I understand how the process goes with OMB. Sometimes it is painful for 

an agency, but I will leave it at that. Yet it is frustrating, because 

I am trying to figure out very quickly where you are on certain 

pieces of legislation, where you are not on certain pieces of legislation. So I have a couple questions and then I will probably go to 

some early parts of the testimony, because that is all I have gotten 

through so far. 

And I may be wrong on this, but I am just trying to remember 

my visit to Alaska. I just came back Monday, but I was there for 

a couple of weeks. If you are a doctor—and I will use Alaska—and 

you are a certified physician and you are going to do contract work 

for the VA, does the VA put you through another certification procVerDate Nov 24 2008 19:35 Oct 22, 2009 Jkt 000000 PO 00000 Frm 00081 Fmt 6633 Sfmt 6601 H:\111TH HEARINGS\042209.TXT SVETS PsN: PAULIN
78 

ess? I guess the question is, why; because if the medical care I am 

getting—I am not a veteran—from that same doctor, I think I am 

getting pretty good quality. Why duplicate that? Why not just get 

them into the process? Why do we waste the time? I mean, you 

have gotten my answer to the question from my perspective by my 

statement, so—— 

Dr. CROSS. I appreciate that, and quite frankly, the process they 

have to go through and that I had to go through when I came in 

is a bit cumbersome. 

Senator BEGICH. Why do we do it? 

Dr. CROSS. Think back to Marion—Marion, Illinois—and what 

happened there a couple of years ago. We believe very strongly that 

the additional safeguards that we have to put in place are very important for the safety and welfare of our veterans. Not everyone in 

the community who is practicing and working in the community is 

someone that we would want working in the VA. 

Senator BEGICH. Is there a way to figure out how to streamline 

it by working with the local agencies that do the board certification 

already, rather than create a whole new system? 

Dr. CROSS. One thing that we have done is contract with an organization to do reports about individual physicians automatically 

for us. We started that in November 2008, to identify any problem 

cases. But quite frankly, that is only for those who are already employed by us. 

Senator BEGICH. So it is not the recruitment of new contract doctors or doctors. 

Dr. CROSS. I think there is more that we could do to streamline 

that process. 

I was thinking about your situation in Alaska and the individuals who fly often to the very rural areas that you mentioned—— 

Senator BEGICH. Right. 

Dr. CROSS [continuing]. And I have asked my counsel sitting next 

to me if there was a technique that we might be able to use to address those, by making them something called WOCs. We will look 

into that. I don’t know the answer at this point. 

Senator BEGICH. That would be great. I would be very interested 

in that. 

The second thing is—again, if my information is wrong, just correct me—but the contract periods that you can do for contract services for doctors or other professionals is 1-year increments with renewals, basically. Am I close on that? [Dr. Cross nods affirmatively.] 

OK. Here is the complaint I hear, It is too short. What do we 

need to do to extend that, yet still give you the flexibility if the contractor is not performing to the levels that you prefer or need? I 

mean, the reality is in 1 year you are not even getting into the 

depths of what potentially is available out there because people 

just don’t want to do it for 1 year. They want more security, up to 

3 years. Besides the appropriation issue, what can we do here to 

fix this problem? 

Dr. CROSS. Now, I am not briefed on that, but I agree with you 

on what you are telling me, that the 1 year is too short. I just got 

my privileges renewed at the Washington VA Medical Center 

where I keep mine. It is for 2 years. 

79 

Senator BEGICH. Well, that is a change. That is good. So could 

you get me some information on that? 

Dr. CROSS. Yes, sir. 

Senator BEGICH. I mean, that is a complaint I have heard. There 

are professionals that want to do it but they think of this 1-year 

increment and decide it is not worth it for what they have to go 

through to get there, and then they are not sure if it extends beyond. We all recognize part of it is budgetary and so forth, but 

more security in that arena, I think, would help ensure a more stable workforce. That is just a thought. 

Dr. CROSS. I agree, sir. Thank you. We will look into it. 

Senator BEGICH. Thank you. I have just a few more seconds left 

and I would just ask this general question. I think it was in your 

earlier—in the very front pages of the testimony. I know the issue 

is about reimbursement. How do you deal with folks who you want 

to get into the system, recognizing it could be 6 or 7 years before 

they are actually finally into it? The specialty they are going for 

may not be worthwhile at that time. But isn’t it true you could go 

back 10 years and you could probably pick the half-a-dozen certain 

types of professional classifications that you always have shortages? 

You can say, OK, this is a group we are going to focus on, knowing there is—like there is right now—a high demand for mental 

health professionals. Five years ago, it was different. But we know 

there is at least a half-a-dozen or more classifications that we want 

to dive into to figure out how to recruit, knowing that it may take 

7 years, but we are going to need them anyway, because there has 

been no time you have had a surplus of physicians. I mean, that 

is a rare occasion—— 

Dr. CROSS. Yes. 

Senator BEGICH [continuing]. You have a surplus of physicians or 

nurse practitioners in the business of health care. 

Dr. CROSS. I am going to ask my colleague, Joleen, to comment 

on that. But first, let me say, becoming a physician is about a 14- 

year process—pre-medicine, medicine, residency, fellowship, all of 

those kinds of things. When I was going through that process, I 

changed my mind about three or four times as to what specialty 

I wanted to go in. So if we targeted one of those specific specialties, 

it may not be what comes out at the other end of the pipe, so to 

speak. 

Joleen? 

Senator BEGICH. Can I add, and no disrespect to the Doctor, but 

67 percent of the care is nurses, physician assistants, which are 

shorter periods of time, 18 months to 36. I know this because we 

have one of the top nursing schools in the country in Alaska, in Anchorage. So, no disrespect to physicians, but there is also a huge 

gap in this other area. So that is—— 

Dr. CROSS. Right. 

Senator BEGICH [continuing]. So there is a shortage that you can 

supply quickly. 

Ms. CLARK. We have a couple of things that we are doing, but 

S. 252 does reinstate that scholarship program and we are hoping 

that that will help us to be able to expand past just physicians and 

help us with nurses and physicians. Also, the VA Nursing Academy 

80 

has just expanded to five additional universities this year and we 

are hoping that that helps us to educate more nurses so that we 

can hire additional nurses. In the last 5 years, we have been able 

to hire—because of the flexibilities that the legislation that has 

been approved by these committees has allowed us—we have been 

able to hire 10,000 additional nurses in the last 5 years, 4,000 additional physicians. The physician pay bill helped us tremendously 

with that. And the legislation in—— 

Senator SANDERS. Does that mean that we have 10,000 more 

nurses in the VA? 

Ms. CLARK. Yes. We had approximately 37,000 5 years ago. Right 

now, actually, we have 49,000. We had 47,000 at the end of the 

year—or, excuse me—— 

Senator SANDERS. And 4,000—— 

Ms. CLARK. Yes, 47,000. Yes. 

Senator SANDERS. Four-thousand more physicians? 

Ms. CLARK. Four-thousand more physicians actually on board, 

yes. So we have been able to do tremendous things. We know there 

are certain areas—especially the rural areas—that we have work 

to do. We have a pilot program going on for recruiters, especially 

in rural areas, to try to target some of those positions that are hard 

to recruit, like the scarce specialty in physicians, some of those 

nurses that are critical care positions and nurses. So, we do realize 

there are going to be those areas that are always harder to fill and 

that we really need to target those specifically. We are working on 

trying some pilots out to see how to best do that. 

Senator BEGICH. Great. Thank you. 

Senator SANDERS. Thank you, Mr. Begich. If that is the span of 

your questioning—— 

Senator BEGICH. I will stop now. 

Senator SANDERS. All right. Thank you, and let me thank the 

panelists and welcome our second panel. 

OK. I am delighted to welcome our witnesses from Veterans 

Service Organizations and advocacy groups to the second panel. I 

appreciate your being here today and we look forward to your testimony. 

First, I want to welcome Adrian Atizado, Assistant National Legislative Director for the Disabled American Veterans. Next, I welcome Ammie Hilsabeck, R.N., of the Iron Mountain, Michigan, VA 

Medical Center, representing the American Federation of Government Employees. Thanks for being here. 

Mr. J. David Cox, R.N., was scheduled to appear today but could 

not because of a death in his family, so please extend our deepest 

condolences to him and his family when you see him. 

We also welcome Hilda Heady, former President for the National 

Rural Health Association. Thank you very much for being here. 

We welcome Ralph Ibson, Health Policy Senior Fellow for the 

Wounded Warrior Project. Thank you very much for being here, 

and a familiar face for this Committee. 

Last, we welcome Blake Ortner, Senior Associate Legislative Director for Paralyzed Veterans of America. 

We thank all of you for joining us today and your full statements 

will appear in the record of the Committee. 

81 

Let us begin with Mr. Atizado. Again, we thank you very much 

for being here. 

STATEMENT OF ADRIAN ATIZADO, ASSISTANT NATIONAL 

LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS 

Mr. ATIZADO. Thank you, Senator. I would like to thank the 

Committee for inviting me to testify at this legislative hearing. We 

appreciate the opportunity to present our views on the 19 bills on 

today’s agenda. Of course, at the Committee’s request, I will limit 

my oral statements to a select few of these important bills. 

Mr. Chairman, the DAV and allies in the partnership for veterans’ health care budget reform believe that S. 423 proposes a reasonable alternative to achieve sufficient, timely, predictable, and 

transparent funding for VA medical care. The bill would authorize 

Congress to appropriate funding for veterans’ health care 1 year in 

advance and provide greater transparency to VA’s health care 

budget formulation process. Equally important, after enactment, 

Congress will retain its oversight authority and full discretion to 

set actual appropriated funding levels for each fiscal year. 

We are delighted to know that this important bill is being considered by the Committee today and we thank the 35 Senators whose 

cosponsorship made this a bipartisan bill, including the ten Members of this Committee. We are encouraged by the Senate action on 

April 3 when it passed a budget resolution that allows advance appropriations for VA medical care, and on April 9, when President 

Obama and VA Secretary Shinseki publicly reaffirmed their support for advance appropriations legislation, as well as in VA’s testimony today. We urge the Committee to approve this bill because 

its passage in the 111th Congress would address DAV’s highest priority in VA health care. 

Mr. Chairman, the DAV recently had occasion to help organize 

and sponsor a Capitol screening of the independent documentary 

film ‘‘Lioness’’ that Senator Murray had mentioned. This is to be 

shown on PBS on June 2. The story is of five Army women who 

served in Marine ground combat teams in Fallujah and Ramadi. 

Their role was to assist in offensive operations by providing body 

weapon searches of Iraqi women and children. These women were 

mechanics and clerks, as the Senator had mentioned, who found 

themselves fighting in some of the most violent counterinsurgency 

combat in this war. 

Now, I mention this because it serves as a reminder that a significant new women veteran population is beginning and will continue to present certain needs that VA has likely not seen before 

and will now need to address. Women veterans are a dramatically 

growing segment of the veteran population, and as mentioned, according to VA, the number of women veterans utilizing VA health 

care will likely double in the next 5 years. 

We believe the Women’s Health Care Improvement Act of 2009 

will allow VA to effectively meet the needs of women veterans. This 

bill is fully consistent with a series of recommendations that have 

been made in recent years by VA researchers, experts in women’s 

health, the VA’s Advisory Committee on Women Veterans, the 

Independent Budget, and the DAV. Our organization was proud to 

work with Senator Murray and the original cosponsors of the bill 

82 

in crafting the proposal. DAV strongly supports this measure and 

urges its approval. 

We also commend the decision to include an earlier version of the 

bill in S. 252, the Omnibus Health Proposal, and we trust that the 

Committee staff and Senator Murray’s staff will work out any differences between these excellent bills. 

With regards to the two bills proposing a caregiver support program, the DAV would like to thank both Chairman Akaka and Senator Durbin on their leadership in this very sensitive matter. We 

are also appreciative of the efforts by Congressional staffs who 

worked with our organization and sought our views in crafting both 

bills. These bills seek to address those informal caregivers of severely disabled veterans who today remain untrained, unpaid, unrecognized, undercounted, and exhausted by their duties. The DAV 

supports both measures, given that our national resolution calls for 

legislation to provide comprehensive support services to caregivers 

of severely injured veterans. 

We believe S. 801, the Family Caregiver Program Act of 2009, 

proposes a more comprehensive program and we ask for the Committee’s approval of that legislation. I would like to note, though, 

that S. 543, as well as the provisions in S. 252, contain worthwhile 

sections and provisions that we hope will be considered by this 

Committee as it finalizes the authorization of this new VA caregiver program. 

Mr. Chairman, this concludes my testimony. I would like to ask 

the Committee to refer to my written testimony for the DAV’s position and comments on the other bills that I did not include in my 

remarks. I would be happy to answer any questions you may have. 

[The prepared statement of Mr. Atizado follows:] 

PREPARED STATEMENT OF ADRIAN ATIZADO, ASSISTANT NATIONAL LEGISLATIVE

DIRECTOR, DISABLED AMERICAN VETERANS

Mr. Chairman and Members of the Committee: Thank you for inviting the Disabled American Veterans (DAV) to testify at this important hearing of the Committee on Veterans’ Affairs. DAV is an organization of 1.2 million service-disabled 

veterans, and devotes its energies to rebuilding the lives of disabled veterans and 

their families. 

Mr. Chairman, the DAV appreciates your leadership in enhancing Department of 

Veterans Affairs (VA) health care programs that many service-connected disabled 

veterans rely upon. At the Committee’s request, the DAV is pleased to present our 

views on nineteen (19) bills before the Committee today. 

S. 423—VETERANS HEALTH CARE BUDGET REFORM AND TRANSPARENCY ACT OF 2009

Mr. Chairman, while great strides have been made to increase the level of VA 

health care funding during the past several years, there is a long history of significant delays in actually receiving those funds. Notwithstanding notable improvements over the past two years, including passage of a regular appropriation on September 30, 2008, VA has received its annual funding for veterans’ health care late 

in 19 of the past 22 years. Unlike Medicare’s mandatory trust funds, the VA must 

rely on Congress and the President to pass a new discretionary appropriations law 

each year to provide VA hospitals and clinics with the funding they need to treat 

sick and disabled veterans. 

Due to the late and unpredictable budget process, VA is increasingly challenged 

to properly treat the physical and mental scars of war for all veterans needing care. 

Further, not knowing when or at what level VA will receive funding from year to 

year—or whether Congress would approve or oppose the Administration’s proposals—hinders the ability of VA officials to efficiently plan and responsibly manage 

VA health care. 

83 

Broken financing causes unnecessary delays and backlogs in the system: hiring 

key staff is put off, or just not done, while injuries like PTSD or Traumatic Brain 

Injury (TBI) are too often not diagnosed or treated in a timely manner. Since 2001, 

the number of VA patients has grown by two million—a 50 percent increase—and 

our newest generation of veterans has increasingly complex mental and physical 

health care needs that will require a lifetime of care. Moreover, a 2007 report by 

the VA’s Office of Inspector General concluded that 27% of the injured veterans 

seeking treatment at VA facilities had to wait more than 30 days for their first appointments. 

For the past decade, the DAV and its allies in the Partnership for Veterans 

Health Care Budget Reform—a coalition of nine veterans service organizations with 

a combined membership of eight million veterans—have sought to fundamentally 

change the way veterans health care is funded. While mandatory funding has been 

the focus over the past several years, the Partnership helped develop and fully endorsed S. 3527, the Veterans Health Care Budget Reform Act, introduced in the 

110th Congress. This legislation was endorsed by The Military Coalition, comprised 

of 35 organizations representing more than 5.5 million members of the uniformed 

services—active, reserve, retired, survivors, veterans—and their families. 

We believe this legislation, the successor to S. 3527, proposes a reasonable alternative to achieve the same goals as mandatory funding, by authorizing Congress to 

appropriate funding for veterans’ health care one year in advance, and by adding 

more transparency to VA’s health care budget formulation process. With the goal 

of ensuring sufficient, timely, and predictable funding through advance appropriations, Congress retains full discretion to set actual appropriated funding levels for 

each fiscal year. The legislation does not eliminate, reduce or diminish, but rather 

enhances, Congress’s ability to provide strong oversight over VA programs, services 

and policies. 

We at DAV are delighted to know this important VA health care funding reform 

bill is being considered by the Committee today. We thank the 32 Senators who 

have given this bill co-sponsorship on a bipartisan basis, including ten of the 15 

Members of this Committee. Also, only in recent days have we confirmed in a meeting with President Obama and Secretary Shinseki that both the President and the 

VA Secretary fully endorse the Senate’s decision to make provision for advance appropriations for VA health care funding for Fiscal Year 2011 in the Fiscal Year 2010 

Senate budget resolution. We hope the Committee would approve, that the Senate 

and House would pass, and that President Obama would sign S. 423 into law. 

Passage of the Veterans Health Care Budget Reform and Transparency Act in the 

111th Congress would address DAV’s highest priority in VA health care; thus, we 

urge its enactment. 

S. 597—WOMEN VETERANS HEALTH CARE IMPROVEMENT ACT OF 2009

Title I, Section 101 would require the Secretary to submit a report to Congress 

on existing stigma and other barriers that impede or prevent women from accessing 

health care and other services from VA. The bill would require an assessment of 

its existing health care programs for women veterans, and an evaluation of the 

needs of women who are currently serving, and women veterans who have completed service, in OIF/OEF. 

Section 102 would require VA to contract with a non-VA entity to study the 

health consequences is women veterans from environmental and occupational exposures while serving in OIF/OEF. 

Section 103 would require the VA to report to Congress on whether there is at 

least one established full-time women veterans program manager at each VA medical center. 

Title II, section 201 requires the Secretary to identify available services, personnel 

and other resource requirements to develop a plan and make recommendations to 

appropriately meet the future health care needs, including mental health care 

needs, of women who served in OIF/OEF. 

Section 202 would make improvements in VA’s ability to assess and treat veterans who have experienced military sexual trauma (MST) by requiring a new training and certification program to ensure VA health care providers develop competencies and the use of evidence-based treatment practices and methods in caring 

for these conditions consequent to MST. The Secretary would be required to establish staffing standards to ensure adequacy of supply of trained and certified providers to effectively meet VA’s demands for care of MST. Section 202 would also require VA to ensure appropriate training of primary care providers in screening and 

recognizing symptoms of sexual trauma and procedures for prompt referral and 

would require qualified MST therapists for counseling. Under this authority the SecVerDate Nov 24 2008 19:35 Oct 22, 2009 Jkt 000000 PO 00000 Frm 00087 Fmt 6633 Sfmt 6621 H:\111TH HEARINGS\042209.TXT SVETS PsN: PAULIN
84 

retary would also be required to provide Congress an annual report on the number 

of primary care and mental health professionals who received the required training, 

the number of full-time employees providing treatment for MST and PTSD in each 

VA facility, and the number of women veterans who had received counseling, care 

and services associated with MST and PTSD. 

Section 203 would establish a non-medical model pilot program of counseling in 

retreat settings for recently discharged women veterans who could benefit from VA 

establishing off-site counseling to aid them in their repatriation with family and 

community after serving in war zones and other hazardous military duty deployments. 

Section 204 would require recently separated women veterans to be appointed to 

certain VA advisory committees. 

Section 205 would authorize a two-year pilot program in at least three VISNs of 

providing subsidies for child care services expenses for qualified veterans receiving 

mental health, intensive mental health or other intensive health care services, 

whose absence of child care might prevent veterans from obtaining these services. 

‘‘Qualified veteran’’ would be defined as a veteran with the primary caretaker responsibility of a child or children. The authority would be limited to subsidizing expenses. 

Section 206 would amend title 38, United States Code to authorize a period of not 

more than seven days of VA-provided or authorized contract care for the newborn 

infant child of a woman veteran. 

Mr. Chairman, women veterans are a dramatically growing segment of the veteran population. The current number of women serving in active military service 

and its Guard and Reserve components has never been larger. According to VA, the 

number of women veterans utilizing VA health care will likely double in the next 

2 to 4 years. We expect they will undoubtedly use other VA benefits in addition to 

health care. Also, women are serving today in military occupational specialties that 

take them into combat theaters and expose them to some of the harshest environments imaginable, including service in the military police, medic and corpsman, 

truck driver, fixed and rotary wing aircraft pilots and crew, and other hazardous 

duty assignments. VA must prepare to receive a significant new population of 

women veterans in future years, who will present needs that VA has likely not seen 

before in this population. 

We recently had occasion to help organize and sponsor a Capitol screening of the 

independent documentary film Lioness, to be shown on the Public Broadcasting System on June 2, 2009. It is the story of five Army women who served in Iraq, in regular military occupational specialties, but who were pressed into service in Marine 

ground combat teams in Fallujah and Ramadi, Iraq, to assist in offensive operations 

providing body weapons searches of Iraqi women and children, to ensure the safety 

of the Marines and other Iraqi civilians. These women, who were not trained as infantry combatants, were exposed to some of the most violent counterinsurgency combat hazards in this war. 

This comprehensive legislative proposal is fully consistent with a series of recommendations that have been made in recent years by VA researchers, experts in 

women’s health, VA’s Advisory Committee on Women Veterans, the Independent 

Budget, and DAV. DAV was proud to work with Senator Murray and the original 

cosponsors of the bill in crafting this proposal. A similar bill was introduced in the 

House (H.R. 1210) on a bipartisan basis by Representatives Herseth Sandlin and 

Representative Moran of Kansas. DAV strongly supports this measure and urges 

the Committee to approve it and move it toward enactment. 

FAMILY CAREGIVER SUPPORT SERVICES

S. 543—VETERAN AND SERVICEMEMBER CAREGIVER SUPPORT ACT OF 2009

This legislation would establish a pilot program at six locations, with one required 

to be conducted at a VA facility in a rural area and another at a qualified private 

rehabilitation facility. The proposed pilot program would provide support services 

and financial assistance to family caregivers of veterans or members of the military 

seriously injured in the line of duty since September 11, 2001. VA would provide 

training and certification of family caregivers, and of an alternate caregiver to relieve a primary caregiver, if deemed necessary. Once trained and certified, family 

caregivers would receive payments for the care they provide. 

In addition, the bill would require VA and DOD to make available to caregivers, 

mental health and support services, on the assumption that the need for services 

would be related to their role as caregivers. VA would be required to conduct a survey of family caregivers to better understand the value of the services they provide 

85 

and to assess and report to Congress on the effectiveness of these pilot programs. 

Furthermore, if the pilot programs are successful, they could be expanded nationwide. 

While we support the spirit of this bill, appreciate Senator Durbin’s leadership in 

introducing it, and would not object to its passage, we believe a number other provisions are necessary to underwrite a more fully developed caregiver support program. 

S. 801—FAMILY CAREGIVER PROGRAM ACT OF 2009

Section 2 of this bill would amend Section 1784, title 38, United States Code, to 

require VA to waive any charges for emergency medical care provided on a humanitarian basis to family caregivers while accompanying certain severely injured veterans. This provision would only apply to family caregivers of those veterans whose 

injury was sustained on or after September 11, 2009, and such injuries meet a prescribed level of severity. 

Section 3 of this bill would create a new VA program for family caregivers or personal care attendants of severely injured veterans. The goal of this program would 

be to allow eligible veterans to reside in their communities and maintain their quality-of-life with caregiver assistance. We note that veterans, or servicemembers 

awaiting discharge for their injuries sustained on or after September 11, 2001, and 

in need of personal care services, would be the first categories to be eligible for this 

program. The DAV believes the program proposed in this bill would be beneficial 

to all disabled veterans, and we thank the Chairman for including a provision in 

the bill to address this matter. Specifically, for all other veterans, the Secretary 

would be required to make a determination two years following enactment of this 

bill to ‘‘include the largest number of veterans possible’’ in this program. 

Taking on the role of a family caregiver is a personal choice made by the family 

member and the veteran affected. We believe this bill would respect the privacy of 

this decision, and recognizes the contributions caregivers make to the health and 

well being of severely injured veterans. Under this program, more than one caregiver could receive basic instructions. In addition, only one caregiver would be certified by VA as the primary personal care attendant of a veteran after completing 

basic instructions provided by VA and any additional training identified by an evaluation of the veteran’s needs. To assist in completing the required training and certification, this bill would require VA to provide for necessary travel, lodging, and 

per diem to the caregiver, and respite care to the veteran as needed during such 

caregiver training and certification. 

To support and sustain caregivers, the bill would provide ongoing assistance such 

as mental health counseling, eligibility for the Civilian Health and Medical Program 

of Veterans Affairs (CHAMPVA), payment of a stipend, and other critical services 

such as respite care. Even though most family caregivers take great pride in providing care to their loved ones so that these veterans can remain at home, the physical, emotional and financial consequences can be overwhelming for them without 

support, with respite services being a good example thereof. Research has shown 

that providing respite for caregivers can have a positive effect on the health of the 

caregiver as it provides the much needed temporary break from the often exhausting challenge imposed by constant attendance of a severely disabled person. Currently, VA’s system for providing respite care is fragmented and inflexible, governed 

by local policies for Community Living Center (formerly VA Nursing Homes) and 

Adult Day Care programs. As part of the ongoing assistance this bill proposes, VA 

would be required to provide no less than 30 days annually, including 24-hour respite care. The DAV is hopeful this provision will encourage VA to establish clearer 

policies expecting every Community Living Center and Adult Day Care Program to 

provide priority for age-appropriate respite care for severely injured veterans. 

The DAV believes that family caregivers are motivated by empathy and love, but 

they are also often dealing with guilt, anger and frustration. The very touchstones 

that have defined their lives—careers, love relationships, friendships, and their personal goals and dreams—have been sacrificed, and they face a daunting lifelong 

duty as caregivers. Put simply, family caregivers of severely disabled veterans, who 

are vital for VA’s patient-centric care provided in the least restrictive settings, must 

not remain untrained, unpaid, unappreciated, undercounted, and exhausted by their 

duties. 

DAV Resolution No. 165 was passed by the delegates to our most recent national 

convention. That resolution calls for legislation that would provide comprehensive 

supportive services, including but not limited to 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. Accordingly, the DAV supports this measure. We thank Senator 

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Akaka for introducing this bill and congressional staffers for working with DAV to 

address the unmet needs of caregivers of severely injured veterans. 

This bill is an important measure and DAV urges the Committee’s approval. In 

addition, we believe S. 543, as discussed above, contains worthwhile provisions that 

we hope will be considered by this Committee as it finalizes the authorization of 

these new benefits. 

S. 658—RURAL VETERANS HEALTH CARE IMPROVEMENT ACT OF 2009

Section 2 of this bill would amend Section 111, title 38, United States Code, to 

insert a fixed rate of 41.5 cents for the purposes of VA’s travel beneficiary program. 

Reimbursement at this rate may exceed the cost of travel by public transportation 

regardless of medical necessity. We note section 401 of Public Law No. 110–387, enacted October 10, 2008, amended the federal veterans’ benefits provisions to repeal 

a requirement that the Secretary of Veterans Affairs adjust the amounts deducted 

from payments or allowances made by the VA for beneficiary travel expenses in connection with health care whenever the payment or allowance is adjusted. It required 

the Secretary to use the same mileage reimbursement rate in beneficiary travel as 

for government employees use of privately own vehicles on official business as authorized in title 5, United States Code. A report is required no later than 14 months 

upon enactment of the Act. 

Section 3 of this bill would require VA to establish at least one and no more than 

five Centers of excellence for rural health research, education, and clinical activities. 

Section 4 would require the Secretary to establish a transportation grant program 

to veterans service organizations to allow for other transportation options to assist 

veterans residing in highly rural areas to travel to VA facilities. 

Section 5 would require the VA’s Office of Rural Health to conduct demonstration 

projects with the goal of expanding care in rural areas. 

Section 6 of the bill would require the VA to establish a contract care program 

through community mental health centers and other ‘‘qualified entities’’ for the provision of certain readjustment, mental health, peer counseling and similar services 

to OIF/OEF veterans and their dependents in rural and remote regions. The program would be restricted to areas determined by the Secretary to be inadequately 

served by direct VA services. 

Section 7 of the bill would establish a Native American health care coordination 

function in the 10 VA medical centers that serve the greatest number of Native 

Americans per capita, with specification of the duties associated with the new function. Also, the bill would require the Secretary and the Secretary of the Interior to 

execute a memorandum of understanding that would ensure the health records of 

Indian veterans may be transferred electronically between the Indian Health Service and the Veterans Health Administration (VHA). 

Section 8 would require an annual report to Congress as a part of the President’s 

budget on a variety of matters concerned with rural veterans. 

The conference report accompanying the Consolidated Appropriations Act of 2008, 

specified that $125 million of the funds provided for Veterans Medical Services 

should be used to increase the travel reimbursement rate. The Consolidated Security, Disaster Assistance, and Continuing Appropriations Act of 2009, provided an 

additional $133 million to increase the beneficiary travel reimbursement mileage 

rate to 41.5 cents per mile, while freezing the deductible at current levels. Subsequently, the Veterans’ Mental Health and Other Care Improvements Act of 2008 revised VA’s beneficiary travel program to establish a mileage reimbursement rate 

equal to that for Federal employees when a government vehicle is available, but the 

individual chooses to use their own vehicle. Further, Public Law 110–387 changed 

the mileage deductible to $3 for each one-way trip; $6 per round trip; with a calendar month cap of $18 as specified in title 38, United States Code, section 111(c)(1) 

and (2) for travel expenses incurred on or after January 9, 2009. 

The DAV appreciates Senator Tester’s leadership in improving health care for veterans residing in rural areas. We support enactment of this bill as consistent with 

our DAV Resolutions 159 (on beneficiary travel policy) and 177 (on access to rural 

health care), adopted by our membership at DAV’s 2008 National Convention. 

S. 404—VETERANS’ EMERGENCY CARE FAIRNESS ACT OF 2009

This bill would amend subparagraph (b)(3)(C) of section 1725, title 38, United 

States Code, by striking the words ‘‘in whole or in part’’ where they appear in current law. The bill would also add new language to clarify Congressional intent that 

VA would be required to assume responsibility as payer of last resort in a case in 

which an otherwise eligible veteran has private insurance coverage that pays a portion or part of the cost of an episode of emergency care in a private facility. Under 

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the bill, VA would pay the remainder of the veteran’s obligation, less any required 

copayments under the associated private insurance coverage. 

While the bill also provides the date of the enactment as the effective date, many 

veterans have been adversely affected by the VA’s non-reimbursement for emergency treatment under the current law. This bill provides VA discretionary authority to reimburse veterans for emergency treatment provided prior to the date of enactment who have been financially harmed under the VA’s current non-reimbursement policy. 

DAV supports the purposes of this bill and appreciates the sensitivity of the Committee leadership in developing an effective solution to a nagging problem plaguing 

both service-connected and nonservice-connected veterans who rely on VA to meet 

their primary health care needs, but who find themselves confronted by medical 

emergencies. 

S. 252—VETERANS HEALTH CARE AUTHORIZATION ACT OF 2009

Sections 101, 102, and 103. These provisions would aid VA in retaining health 

care professionals in the VA system, and clinical executives in facilities and in VA 

Central Office; would limit VA’s use of overtime, clarify policies on weekend duty 

and use of alternative work schedules for nurses; and, would improve VA’s educational assistance programs. DAV provided detailed testimony during the 110th 

Congress on these matters in S. 2969, from which its sections 2, 3, and 4 were incorporated as sections 101, 102, and 103 in this bill. 

Mr. Chairman, DAV has no resolution adopted by our membership addressing 

these specific matters, but we are strong supporters of VA as a preferred Federal 

employer. We believe these provisions in general would be supportive of that goal; 

therefore, DAV would not object to their enactment. Nevertheless, we note that our 

colleagues in the VA labor community appear to be deeply concerned about ceding 

additional authority to the Secretary to expand the ‘‘hybrid’’ title 5—title 38 appointment authority without further authorization by Congress. Labor has made the 

point strongly that VA should first be held accountable for disclosing the manner 

by which the Department has carried out prior authority in dealing with hybrid appointments across more than 20 career fields. Based on VA’s apparent struggle to 

establish qualification and classification standards for some of the occupational 

classes already included in the hybrid appointment authority, we believe Federal 

unions may have a valid basis for those concerns. Therefore, we defer to their expertise in this case and ask the Committee’s further consideration of those matters in 

sections 101, 102 and 103 in Title I of the bill in recognition of the concerns of labor. 

Section 104. DAV provided testimony in the past Congress on S. 2377, Section 2 

thereof which has been incorporated as Section 104 of this bill. 

DAV has no adopted resolution from our membership on these specific issues. 

Under current policy, VA is required to investigate the background of all appointees, 

including verifying citizenship or immigration status, licensure status, and any significant blemishes in appointees’ backgrounds, including criminality or other malfeasance. The facility in question that likely stimulated the sponsor to introduce 

S. 2377 was not in compliance with those existing requirements, thus raising questions about VA’s ability to oversee its facilities in the area of physician employment. 

Corrective action was taken by the VA Central Office when some unfortunate incidents related to these lapses came to light at that particular facility, and VA has 

advised that it has strengthened its internal policies. 

We appreciate and strongly support the intent of the bill to stimulate recruitment 

and to promote VA physician careers with various new incentives, and, while it 

seems clear that additional oversight is necessary, we trust that the new reporting, 

State licensure and certification requirements in the bill would not serve as obstacles to physicians in considering VA careers in the future. 

Section 201. At the Chairman’s request, DAV provided testimony in the 110th 

Congress on Title III of S. 2984, which has in part been incorporated as Sections 

201 through 206 of this bill. Although DAV has no resolutions specific to the matters entertained in S. 2984, we were generally supportive of the provisions in that 

bill with the exception of those matters in section 304 (now in section 201 of this 

bill). We believe in both instances of its knowledge of, and oversight in, VA practices 

with regard to compensating nursing personnel and in conducting long-term strategic planning, that these reporting requirements should be retained. We are particularly concerned at the prospect of VA’s discontinuing its construction-related reporting with the Committee relying primarily on VA’s annual budget proposal as a 

source for relevant information on construction planning. The current reporting requirement in Section 8107 of title 38, United States Code, covers extensively more 

than simply the requested facility construction and leasing authorizations contained 

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in the annual budget for a given year. We believe both Congress and the community 

of veterans service organizations, in properly representing and protecting veterans’ 

interests, need to continue receiving comprehensive reports on VA’s strategic plans, 

including its major construction planning. 

Sections 202–206. DAV takes no positions on these matters, but offers no objections to their enactment. 

Sections 207–208. These sections would establish health care quality management 

officers and new functions nationally, regionally and locally in the VHA, and would 

require a series of reports to document progress in quality management. DAV provided testimony in the 110th Congress on S. 2377, section 3, which has been incorporated as Sections 207 and 208 of this bill. DAV has no adopted resolution from 

our membership on these specific issues; however, we expressed our appreciation 

and strong support the intent of S. 2377 and do so again with respect to these provisions. While it seems clear that additional oversight is necessary given the VA Office of Inspector General’s January 2008 report documenting unacceptable practices 

at the VA Medical Center Marion, Illinois, that served in part as an impetus for 

section 207 in this bill, we trust that the new reporting, State licensure and certification requirements in the bill would not serve to dampen future physicians’ interest in considering VA careers. 

Sections 209 and 210. These provisions would establish training and certification 

pilot programs, an innovative respite program for family caregivers, and new health 

care trainees in caring for severely brain-injured veterans. DAV provided testimony 

in the past Congress in support of Sections 2 and 3 of S. 2921, which have been 

incorporated as Sections 209 and 210 of this bill. 

Section 211. DAV provided previous testimony in the past Congress on S. 2796, 

which has been incorporated as Section 211 of this bill. This section would establish 

a five-site pilot program to facilitate veterans’ use of community-based organizations 

to ensure they receive the care and benefits they deserve in transitioning from military to civilian life. The program would be conducted through VA grants to community-based organizations with the goal of providing information, outreach, mental 

health counseling, benefits, transition assistance, and other relevant services in 

rural areas and in areas with a high proportion of minority veterans. 

While we have no adopted resolution from our membership supporting this precise 

concept, DAV believes this is a well-intentioned proposal. We have some concerns 

about VA becoming a granting agency for such broad purposes, but we believe if it 

is targeted and carefully managed by VA, this function could be an important and 

creative new tool in rural and remote areas where establishing a direct VA service 

presence would be impractical. If this section is enacted, we also recommend VA 

carefully craft the services expected from a grantee in the area of aiding these veterans with their VA disability benefits claims. These are highly technical matters 

and require the assistance of expert service officers from the states, the veterans 

service organization (VSO) community and the Veterans Benefits Administration 

through its veterans benefits counselor function. Finally, for any health care involvement associated with these grants, we urge VA to coordinate this new grant 

program through its Office of Rural Health. With these caveats, DAV supports the 

enactment of this section. 

Section 212. DAV provided previous testimony last Congress on S. 2889, which 

has been incorporated as section 212 of this bill. Section 212 would provide VA a 

specific contracting authority to obtain specialized residential care and rehabilitation services for OIF/OEF veterans who are suffering from TBI and who are exhibiting such cognitive deficits that they would otherwise require admission to nursing 

home facilities. DAV Resolutions 161 and 164, adopted by our members at our 2008 

national convention, call for strengthening and enhancing VA long-term care programs for service-disabled veterans, and for addressing comprehensively the needs 

of disabled veterans of all wars who suffer from TBI. Again, we ask the Committee 

to consider broadening the eligibility for this new contract residential rehabilitation 

care option in Section 212 of the bill to any veteran with a service-incurred TBI. 

Section 213. This section was incorporated from Section 6 of S. 2889 from the 

110th Congress. This section would authorize VA to disclose the name and address 

of a member of the armed services or of a veteran to a third party insurer in order 

to bill for collections of reasonable charges for care or services provided for an individual’s nonservice-connected condition(s). DAV does not have a resolution from our 

membership on this matter; therefore, DAV takes no position on this provision. 

Section 214. This section would require VA to contract with the Institute of Medicine for an expanded study related to veterans’ health-related exposures from participating in Project Shipboard Hazard and Defense (‘‘Project SHAD’’). DAV does not 

have a resolution from its membership on this matter. However, the DAV believes 

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sure of sick and disabled Persian Gulf War Veterans and in recognition of DAV Resolution 022, adopted at our 2008 National Convention, which opposes any rule or 

provision that would authorize use of servicemembers for human experimentation 

without their knowledge and informed consent. 

Section 215. DAV provided previous testimony during the last Congress on Section 

4 of S. 1233, which has been incorporated in part in Section 215 of this bill. We note 

that in passing Public Law 110–181, the National Defense Authorization Act for Fiscal Year 2008, Section 1703 did not follow the language contained in Section 4 of 

S. 1233 of the last Congress. We believe Section 215 of this measure would clarify 

that veterans with Traumatic Brain Injury have a right to access community-based 

rehabilitation, but only when VA cannot provide the care and when the non-VA provider is accredited and adheres to appropriate VA clinical and rehabilitation standards. We support Section 215 of this measure which contains the same two key implied presumptions that we supported in Section 4 of S. 1233 in the 110th Congress: 

(1) that the VA must have the capacity to be the provider of choice, and (2) that 

proximity to care is a key component to ongoing rehabilitation and community reintegration for the traumatically brain-injured veteran. 

Also, we support the implicit goal of this section to give VA an incentive to further 

develop its capacity to provide high quality specialized care. VA’s four lead Polytrauma Rehabilitation Centers have achieved and maintained, without qualification, 

accreditation from the Commission on the Accreditation of Rehabilitation Facilities 

for acute inpatient TBI rehabilitation programs; however, to date and to our knowledge not a single VA facility has achieved accreditation for outpatient, home-based, 

residential or community based TBI rehabilitation. We urged this Committee then, 

as we do now, to encourage VA to seek such accreditation at Level II and Level III 

poly-trauma sites. 

Section 216. This section would make federally-recognized tribal organizations eligible to participate in VA’s State extended care grant programs, including the treatment of existing beds in tribally-owned health facilities as State veterans home beds 

for purposes of the per diem subsistence program administered by VA. 

DAV does not have a resolution from its membership on this specific matter, but 

as a part of the Fiscal Year 2010 Independent Budget, DAV has expressed concerns 

about the status of the State extended care construction grant program, and in particular, with respect to the fact that nearly $1 billion in backlogged construction, 

new home and renovation grants are pending in VA Central Office, affecting existing State veterans homes in nearly every State. Given this backlog and Congress’s 

inability to appropriate sufficient funding annually to properly maintain this system, we are concerned that adding as many as 500 tribal organizations to the competition for these severely limited funds will only serve to diminish the existing 

State home program. Therefore, we ask that the Committee withhold approval on 

this section to enable our staffs to work toward an acceptable compromise to enable 

tribal organizations to participate more directly in this unique VA-State partnership. 

Section 217. We appreciate the intent of the bill which would require VA to contract with a dental insurer to administer a new dental plan provided under a threeyear pilot program. Moreover, each individual covered by the dental insurance plan 

would be required to pay the entire premium for coverage under the dental insurance plan, in addition to the full cost of any copayments. DAV Resolutions 167 and 

172 support legislation to amend title 38, United States Code, section 1712, to provide outpatient dental care to all enrolled veterans, but without any additional costs 

to be borne by the veteran or their survivors and dependents. 

Title III—Women Veterans Health Care. For Title III of this measure, sections 

301–309, we refer this Committee to our views on S. 597, the Women Veterans 

Health Care Improvement Act of 2009, contained herein. We believe the small differences in the two bills can be worked out by your able staffs. We strongly support 

improved services for women veterans, are deeply grateful to the Chairman and 

Members of this Committee for their interest in women’s health, and urge the Committee to report an appropriate compromise bill during this session. 

Sections 401 and 402. DAV provided previous testimony during the last Congress 

on Sections 2 and 3 of S. 2963, which have been incorporated as Sections 401 and 

402 of this bill. While DAV has no resolutions from our membership supporting the 

specific matters entertained by these sections, we believe each of these proposals 

would be helpful to survivors of military servicemembers and veterans whose lives 

are lost to suicide. Therefore, DAV supports the purposes of these sections and 

would have no objection to their enactment. 

Section 403. DAV provided testimony during the last Congress on Section 3 of 

S. 2899, which has been incorporated as Section 403 of this bill. DAV has no adopted resolution from our membership dealing specifically with suicides in the veteran 

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population. However, we agree that full and accurate data on the issue of suicide 

is crucial to VA’s ability to reduce veterans’ suicides. Also, and more importantly 

in our view, DAV believes strongly that improving, expanding and enhancing VA’s 

mental health programs across the board, including those dealing with depression, 

adjustment disorders, PTSD, mild-to-moderate Traumatic Brain Injury, marital and 

family relations (including readjustment from long deployment separations), and 

substance-use disorders—particularly with early interventions, will not only provide 

more effective care but can stem suicidal ideation in untreated or poorly treated 

populations. 

Section 404. We note that Public Law 110–329, the Consolidated Security, Disaster Assistance, and Continuing Appropriations Act, 2009, includes provisions (Section 227) very similar to Section 404 of this measure, so we are concerned that this 

provision may be unnecessary or duplicative of current law. Nevertheless, DAV does 

not have a resolution from our membership on this specific matter; therefore, we 

take no position. 

Title V—Homeless Veterans. DAV provided testimony during the last Congress on 

S. 2273, which has been incorporated as Title V of this bill. The Independent Budget 

for Fiscal Year 2010 included a series of recommendations that are consistent with 

the five sections under this title; therefore, we support its purposes and urge its enactment. 

Title VI—Nonprofit Research and Education Corporations. DAV provided previous 

testimony last Congress on S. 2969, which has been incorporated as Title VI of this 

bill. While DAV has no adopted resolution on this particular matter, DAV is a 

strong supporter of a robust VA biomedical research and development program. We 

believe enactment of this Title would be in that program’s best interest, and therefore, we urge its enactment. 

Sections 701 and 702. These sections are derived from Sections 401 and 402 of 

S. 2984 from the 110th Congress. These provisions would expand certain authorities 

set out in title 38, United States Code, relating to VA police officers so as to better 

reflect the current scope of their duties and responsibilities, and would modify the 

authority of VA to pay an allowance to VA police officers for the purchase of police 

uniforms. DAV has no resolution from its membership on this specific matter; therefore, we have no position on this measure. 

S. 821—A BILL TO AMEND TITLE 38, UNITED STATES CODE, TO PROHIBIT THE SECRETARY

OF VETERANS AFFAIRS FROM COLLECTING CERTAIN COPAYMENTS FROM VETERANS

WHO ARE CATASTROPHICALLY DISABLED, AND FOR OTHER PURPOSES. 

Mr. Chairman, thousands of veterans survive catastrophic traumas in civilian life. 

Some of them have been able to surmount the tremendous challenges imposed on 

them by accidents or disease, and have been able to rejoin the workforce to be productive citizens. We believe they should not face the double jeopardy of catastrophic 

disability and an additional financial penalty of paying VA copayments in order to 

access VA health care and services. These veterans, many permanently wheelchair 

bound and spinal cord injured, already spend thousands of their own dollars annually on health-related supports and services that able-bodied veterans do not need 

to bear, or even think about. If a catastrophically ill or spinal-cord injured veteran 

succeeds in the daunting personal quest to remain in, or re-join, the labor force, we 

believe the government where possible ought to provide that veteran proper incentives to remain employed, in this case by forgiving VA copayments. 

In conjunction with DAV’s national resolution from our membership calling for 

legislation to repeal all copayments for military retirees and veterans’ medical services and prescriptions, and as a partner organization constituting Fiscal Year 2010 

Independent Budget, the DAV fully supports this provision. It matches the Independent Budget’s recommendation that veterans designated by VA as being catastrophically disabled for the purpose of enrollment in health care eligibility priority 

group four (4) should be made exempt from health care copayments and other fees. 

We note this legislation was passed by the House in the past Congress but was not 

considered by the Senate. We urge this Committee to approve and move this provision to enactment during this Congress. 

S. 793—DEPARTMENT OF VETERANS AFFAIRS VISION SCHOLARS ACT OF 2009

This measure would direct the Secretary of Veterans Affairs to establish and 

carry out a scholarship program of financial assistance for individuals who: (1) are 

accepted for, or currently enrolled in, a program of study leading to a degree or certificate in visual impairment or orientation and mobility, or both; and (2) enter into 

an agreement to serve, after program completion, as a full-time VA employee for 

three years within the first six years after program completion. It would set maxVerDate Nov 24 2008 19:35 Oct 22, 2009 Jkt 000000 PO 00000 Frm 00094 Fmt 6633 Sfmt 6621 H:\111TH HEARINGS\042209.TXT SVETS PsN: PAULIN
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imum assistance amounts of $15,000 per academic year and $45,000 in total per 

participant. The legislation would require pro-rata repayment for failure to satisfy 

education or service requirements, while allowing the Secretary to waive or suspend 

such repayment whenever noncompliance is due to circumstances beyond the control 

of the participant, or when waiver or suspension is in the best interests of the 

United States. 

DAV has no resolution on this issue adopted by our members; however, the Independent Budget for Fiscal Year 2010 contains a series of recommendations for VA 

improvements in its vision care programs. One such recommendation urges VA to 

require its health care networks to restore clinical staff resources in inpatient blind 

rehabilitation centers and increase the number of full-time Visual Impairment Services Team coordinators. This measure would improve recruitment for these positions. On that basis, DAV fully supports the intent of this bill. 

S. 772—HONOR ACT OF 2009, A BILL TO ENHANCE BENEFITS FOR SURVIVORS OF CERTAIN

FORMER MEMBERS OF THE ARMED FORCES WITH A HISTORY OF POST TRAUMATIC

STRESS DISORDER OR TRAUMATIC BRAIN INJURY, TO ENHANCE AVAILABILITY AND

ACCESS TO MENTAL HEALTH COUNSELING FOR MEMBERS OF THE ARMED FORCES AND

VETERANS, AND FOR OTHER PURPOSES. 

This bill would create a scholarship program within VA to produce graduate-level 

behavioral sciences practitioners among qualified veterans, in exchange for specified 

obligated Federal service in either the VA or the Department of Defense health care 

systems. It would also create a Defense program of employment, training and deployment of combat veterans as psychiatric technicians and nurses, to serve in future combat zones as determined by the Secretary of Defense. The bill would reauthorize Vet Centers to refer former military servicemembers with character of discharges that make them ineligible as veterans, to community resources for counseling and other mental health services, and it would specifically authorize serving 

members of the Armed Forces to be eligible for counseling and related mental health 

services at VA’s Vet Centers. The bill would deem certain post-deployment suicides 

among combat veterans to have been deaths in the line of duty. Finally, this bill 

would require a series of reports to Congress dealing with its provisions. 

DAV has no resolution adopted by our membership specific to these issues; however, we believe this to be a helpful bill, particularly with respect to the Vet Center 

related provisions. Therefore, we would offer no objection to its enactment. 

S. 498—A BILL TO AMEND TITLE 38, UNITED STATES CODE, TO AUTHORIZE DENTAL INSURANCE FOR VETERANS AND SURVIVORS AND DEPENDENTS OF VETERANS, AND FOR

OTHER PURPOSES. 

This measure is similar to Section 217 of S. 252 with the exception that under 

this measure the provision of dental insurance by VA would not be a pilot program 

with respect to duration and location of availability. As discussed in our views on 

section 217, we appreciate the intent of this bill. However, DAV Resolutions 167 and 

172 support legislation to amend title 38, United States Code, section 1712, to provide outpatient dental care to all enrolled veterans but without any additional costs 

to be borne by the veteran or their survivors and dependents. 

S. 669—VETERANS 2ND AMENDMENT PROTECTION ACT

Under the terms of this bill, in absence of a judicial determination of mental incompetency, VA would be prohibited from reporting an individual veteran’s identity 

or competency status to any authority that could restrict that veteran from his or 

her Second Amendment rights to bear arms. 

The DAV has no resolution from its membership on this issue and, therefore, we 

take no position on this bill. 

VHA WORK FORCE

S. 246—A BILL TO AMEND TITLE 38, UNITED STATES CODE, TO IMPROVE THE QUALITY

OF CARE PROVIDED TO VETERANS IN DEPARTMENT OF VETERANS AFFAIRS MEDICAL

FACILITIES, TO ENCOURAGE HIGHLY QUALIFIED DOCTORS TO SERVE IN HARD-TO-FILL

POSITIONS IN SUCH MEDICAL FACILITIES, AND FOR OTHER PURPOSES. 

Mr. Chairman, this bill is very similar to S. 2377, introduced in the 110th Congress. We appreciate and strongly support the intent of the bill to stimulate recruitment and to promote VA physician careers with various new incentives, and, while 

it seems clear that additional oversight in physician appointments is necessary, we 

trust that the new reporting, State licensure and certification requirements in the 

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bill would not serve as obstacles to physicians in considering VA careers in the future. 

We noted in testimony on May 21, 2008 to the Senate Committee on Veterans’ 

Affairs on S. 2377, the predecessor version of this bill, VA raised a number of valid 

concerns with respect to State licensure limitations this bill would impose on VA 

physicians. We ask the Committee to take those concerns into account as you consider the merits of this bill. 

S. 362—A BILL TO AMEND TITLE 38, UNITED STATES CODE, TO IMPROVE THE COLLECTIVE

BARGAINING RIGHTS AND PROCEDURES FOR REVIEW OF ADVERSE ACTIONS OF CERTAIN EMPLOYEES OF THE DEPARTMENT OF VETERANS AFFAIRS, AND FOR OTHER PURPOSES. 

Mr. Chairman, this bill would restore bargaining rights for clinical care employees 

of the VHA that were eroded over the past eight years by the former Administration. A similar version of the bill was introduced in both bodies in the 110th Congress but did not advance. 

DAV does not have an approved resolution from our membership on the specific 

VA labor-management dispute that prompted the introduction of this bill. However, 

we believe labor organizations that represent employees in recognized bargaining 

units within the VA health care and benefits systems have an innate right to information and reasonable participation that result in making VA a workplace of choice, 

and particularly to fully represent VA employees on issues impacting working conditions and ultimately patient care. 

Congress passed section 7422, title 38, United States Code, in 1991, in order to 

grant specific bargaining rights to labor in VA professional units, and to promote 

effective interactions and negotiation between VA management and its labor force 

representatives concerned about the status and working conditions of VA physicians, nurses and other direct caregivers appointed under title 38, United States 

Code. In providing this authority, Congress granted to VA employees and their recognized representatives a right that already existed for all other Federal employees 

appointed under title 5, United States Code. Nevertheless, Federal labor organizations have reported that VA has severely restricted the recognized Federal bargaining unit representatives from participating in, or even being informed about, 

human resources decisions and policies that directly impact conditions of employment of the VA professional staffs within these bargaining units. We are advised 

by labor organizations that when management actions are challenged, VA officials 

(many at the local level) have used subsections (b), (c) and (d) of section 7422 as 

a statutory shield to obstruct any labor involvement to correct or ameliorate the 

negative impact of VA’s management decisions, even when management is allegedly 

not complying with clear statutory mandates (e.g., locality pay surveys and alternative work schedules for nurses, physician market pay compensation panels, etc.). 

Facing VA’s refusal to bargain, the only recourse available to labor organizations 

is to seek redress in the Federal court system. However, recent case law has severely weakened the rights of title 38 appointees to obtain judicial review of arbitration decisions. Title 38 employees also have fewer due process rights than their title 

5 counterparts in administrative appeals hearings. 

It appears that the often hostile local environment consequent to these disagreements diminishes VA as a preferred workplace for many of its health care professionals. Likewise, veterans who depend on VA and who receive care from VA’s physicians, nurses and others can be negatively affected by that environment. 

We believe this bill, which would rescind VA’s refusal to bargain on matters within the purview of section 7422, through striking of subsections (b), (c) and (d), and 

that would clarify other critical appeal and judicial rights of title 38 appointees, is 

an appropriate remedy, and would return VA and labor to a more balanced bargaining relationship on issues of importance to VA’s professional workforce. VA 

clearly has indicated vigorous disagreement with the intent of the measure, but has 

not to date been willing to compromise its position in refusing to bargain across a 

wide group of issues that are dubiously defined by VA as ‘‘direct patient care.’’ 

Given the stalemate, our only recourse is to endorse the intent of the bill, yet continue to hope that VA and Federal labor organizations can find a basis for compromise. 

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S. 734—A BILL TO AMEND TITLE 38, UNITED STATES CODE, TO IMPROVE THE CAPACITY

OF THE DEPARTMENT OF VETERANS AFFAIRS TO RECRUIT AND RETAIN PHYSICIANS IN

HEALTH PROFESSIONAL SHORTAGE AREAS AND TO IMPROVE THE PROVISION OF

HEALTH CARE TO VETERANS IN RURAL AREAS, AND FOR OTHER PURPOSES. 

Section 2 of this bill would enhance VA’s existing education debt reduction program by removing the current dollar limitation ($44,000 per participant) and equating it to the actual level of debt and interest payable by individual employees of the 

Department, with amended procedures for offers and acceptances of such debt reduction employment incentives. Section 3 of the bill would include certain VA medical facilities, located in health professional shortage areas, in the list of facilities 

eligible for assignment of participants in the National Health Service Corps scholarship program administered by the Department of Health and Human Services 

(HHS). The section would require VA to transfer to HHS $10 million to carry out 

the purposes of the section. Section 4 of the bill would require VA’s Office of Rural 

Health to develop and submit to Congress a five-year strategic plan, with specifications of the content of this report. 

Section 5 of the bill would enhance VA’s Vet Centers to meet needs of veterans 

of OIF/OEF through the establishment, training and deployment of volunteers, 

paraprofessionals and veteran-students to provide counseling and other mental 

health services to OIF/OEF veterans in established Vet Centers. Section 6 of the bill 

would establish a new section 1709, title 38, United States Code, to establish consultation and teleretinal imaging functions in the VHA, including the establishment 

of clinical and technical standards to carry out these programs; and amendments 

to VA’s internal allocation (VERA) and workload reporting data systems to accommodate and give creditable resources to VA facilities conducting such programs. 

Section 7 of the bill would improve oversight and administration of contract and 

fee basis care authorized by the Department. It would require VA to consolidate contracting for community-based outpatient clinics (CBOC) at the VHA Network (VISN) 

level to the maximum extent practicable; establish rural outreach coordinators at 

each CBOC with a majority of enrolled veterans who reside in ‘‘highly rural’’ areas; 

establish incentives to obtain accreditation of participating fee-basis private providers, and to encourage these providers to participate in VA’s peer review system. 

Section 8 of the bill would amend section 111, title 38, United States Code, to provide reimbursement for airfare and other actual necessary expenses to certain enrolled veterans when air travel is the only practical way for such veterans to gain 

access to direct VA health care, with conforming changes to section 111. 

Section 9 of the bill would establish a pilot program wherein full-time VA physicians would be authorized to assume attending responsibilities for primary care or 

mental health services at community hospitals located in health professional shortage areas, with financial incentives for them to assume these responsibilities, and 

including establishment of a series of rules to govern and control such participation. 

Mr. Chairman, this bill largely conforms with recommendations of the IB for Fiscal Year 2010, particularly in respect to the provisions related to rural health, continuity of care, innovations, quality of care, and improving access to direct VA 

health care. Also, it comports with the IB recommendations with respect to better 

coordinating and improving the quality of contract and fee-basis care. On this basis, 

DAV fully supports the intent of this bill and urges the Committee to approve it. 

VHA FACILITIES

S. 226—TO DESIGNATE THE DEPARTMENT OF VETERANS AFFAIRS OUTPATIENT CLINIC IN

HAVRE, MONTANA, AS THE MERRIL LUNDMAN DEPARTMENT OF VETERANS AFFAIRS

OUTPATIENT CLINIC. 

This is a local matter, and DAV takes no position on this bill. 

S. 239—A BILL 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 IN

THE STATE OR RECEIVE COMPARABLE SERVICES PROVIDED BY CONTRACT IN THE

STATE. 

Mr. Chairman, while the bill is a general mandate that every state have a ‘‘fullservice’’ VA medical center within its borders, the circumstances surrounding the 

bill make clear that its intent is to restore the VA Medical Center in Manchester, 

New Hampshire. As such, this is a local matter, and DAV takes no position on this 

bill. 

94 

S. 509—TO AUTHORIZE A MAJOR MEDICAL FACILITY PROJECT AT THE DEPARTMENT OF

VETERANS AFFAIRS MEDICAL CENTER, WALLA WALLA, WASHINGTON, AND FOR OTHER

PURPOSES. 

This is a local matter, and DAV takes no position on this bill. 

S. 699—TO PROVIDE FOR THE CONSTRUCTION OF A FULL SERVICE HOSPITAL IN FAR

SOUTH TEXAS BY THE SECRETARY OF VETERANS AFFAIRS. 

This is a local matter, and DAV takes no position on this bill. 

Mr. Chairman, this concludes DAV’s testimony. We appreciate the opportunity to 

have provided our views on these bills. I will be pleased to respond to any questions 

that you or other Members of the Committee may have. 

Senator SANDERS. Thank you very much. 

Ms. Hilsabeck? 

STATEMENT OF AMMIE HILSABECK, R.N., OSCAR G. JOHNSON 

VA MEDICAL CENTER, IRON MOUNTAIN, MICHIGAN, ON BEHALF OF THE AMERICAN FEDERATION OF GOVERNMENT 

EMPLOYEES, AFL–CIO 

Ms. HILSABECK. Mr. Chairman and Members of the Committee, 

my name is Ammie Hilsabeck and I am a Registered Nurse at the 

Oscar G. Johnson Iron Mountain VA Medical Center in the Upper 

Peninsula of Michigan. It is a great honor for me to be here to testify on behalf of S. 362 on behalf of my union, the American Federation of Government Employees, and also the veterans that I 

take care of each and every day. 

In Iron Mountain, I am a union steward for the AFGE Local 

2280 and I work the evening shift in the emergency room. I am 

also the evening NOD, or the nursing officer of the day. I provide 

direct patient care to the veterans who come into the emergency 

room. I also manage additional services that are needed to take 

care of these veterans. I work with the nurses and the doctors 

within the entire hospital, making sure that all units are properly 

staffed on the evening shift. I handle a wide range of duties and 

tasks from within the hospital, and calls from veterans from the 

outside of the hospital. 

The AFGE greatly appreciated the chance to meet with Secretary 

Shinseki on this issue 2 days ago. The Secretary gave us his commitment that he would look into the issue and continue the dialog 

with us through a future meeting before finalizing his position. 

Therefore, it was especially disappointing to read the VA’s testimony for today’s hearing and see all the inaccurate statements 

about how bargaining rights work and how we want to use them 

are back again. 

All we are saying is that Title 38 employees deserve equal rights 

to voice their concerns in the workplace. To accuse us of wanting 

to use these rights to interfere with patient care is unfair and not 

based on law or fact. To accuse us of wanting to block supervisors 

from quickly removing employees who are abusing patients from 

the workplace is also unfair and not based on law or fact. 

I can’t deny the fact that I provide patient care. That is my job. 

I take care of veterans every day. So, of course, every concern I 

have about doing my job relates to patient care in some way, but 

that is not interfering with direct patient care. That is not telling 

management how to treat diabetes or PTSD or which specialist to 

hire or how much to spend on a new imaging machine. Collective 

95 

bargaining is about resolving labor-management disputes about 

conditions of employment. 

The right to a grievance is not a temporary restraining order 

forcing immediate action by supervisors or absolute right for employees to walk off the job. It is only the right to require management to come to the table to discuss what is already happening in 

the workplace, or a policy that has been proposed, or to hear the 

employee’s side of the story if he or she has been accused of improper conduct or poor performance. 

All we are saying is that it makes no sense to treat one part of 

the VA health care workforce differently than another. If a psychologist can bargain over these issues, why can’t a psychiatrist? If an 

LPN can negotiate over these issues, why can’t a Registered Nurse? 

If military hospital nurses or physicians can file grievances on employment matters that impact patient care, why can’t we at the VA 

have these rights when we do the same jobs? 

I want to tell you what it is really like to work without a voice 

and without a chance to address concerns when you are caring for 

veterans in an emergency room every day and why we could provide better care for our veterans if management was willing to sit 

down and negotiate over employment issues. 

My managers recently made a decision that critically ill veterans 

would no longer be stabilized in our critical care unit but rather 

in the emergency room where I work. They would not negotiate, 

however, with us about what the ER nurses would need to take 

care of these veterans and the amount of responsibility in terms of 

training the emergency room nurses, equipment that was needed, 

medications, and supplies. We were also kept in the dark when 

management decided that our imaging reading services would 

sometimes be contracted out and sometimes not be contracted out, 

which means delayed care for our veterans. All we want is to negotiate things like this so we can meet our guidelines and provide the 

right care in a timely manner. 

Dr. Cross complains that we want to negotiate over what constitutes an emergency for mandatory overtime. He suggests that 

we would use the grievance process to stop managers from responding to emergencies with extra nurse coverage. All we wanted was 

VA central office to define ‘‘emergency’’ in advance of future emergencies and with one national definition so that over time, policies 

did not vary from hospital to hospital. Over a dozen States have 

that definition, so why won’t the VA protect the safety of its veterans in the same way? 

VA’s testimony also states that if we have the right to negotiate 

over management policies on compressed work schedules, which 

means three 12-hour days a week, which is common in other hospitals, that we are once again interfering with shift changes needed 

for medical emergencies. We can’t prevent urgent shift changes, 

but we could be able to plan in advance with management about 

shifts that will make our nurses want to stay at the VA. 

Speaking of wanting to stay at the VA, things have changed a 

lot since I arrived in 2002. We are no longer— 

Senator SANDERS. If you could please wrap up. 

Ms. HILSABECK. OK. We are no longer treated like professionals 

whose views on anything matter. We are always in fear of arbiVerDate Nov 24 2008 19:35 Oct 22, 2009 Jkt 000000 PO 00000 Frm 00099 Fmt 6633 Sfmt 6601 H:\111TH HEARINGS\042209.TXT SVETS PsN: PAULIN
96 

1Most VHA employees are covered by one of three major personnel systems: • Title 38 covers eight positions: registered nurses (RN), physicians, dentists, physician 

assistants, optometrists, chiropractors, podiatrists and expanded duty dental auxiliaries. 

• Title 5 covers the most VHA positions and includes nursing assistants and medical 

technicians. All Title 5 employees at VHA have full bargaining rights. 

• Hybrid Title 38, the newest system, applies Title 38 rules to hire and appoint employees 

and Title 5 rules to bargaining. Therefore, hybrids, including psychologists, social workers, 

LPNs and pharmacists have full bargaining rights. 

trary and unfair discipline or terminations. We are seeing doctors 

and nurses get hired by the VA and leave within 1 week. I would 

like to stay at the VA; yet, me and my colleagues have so many 

pressures—to care for veterans without adequate support, coupled 

with hostile managers telling us Section 7422 does not let us speak 

up about anything—it is becoming harder and harder not to leave. 

[The prepared statement of Ms. Hilsabeck follows:] 

PREPARED STATEMENT BY AMMIE HILSABECK, REGISTERED NURSE, OSCAR G. JOHNSON VA MEDICAL CENTER, IRON MOUNTAIN, MICHIGAN, ON BEHALF OF AMERICAN

FEDERATION OF GOVERNMENT EMPLOYEES, AFL–CIO 

Mr. Chairman and Members of the Committee: The American Federation of Government Employees (AFGE) appreciates the opportunity to testify today on pending 

health-related legislation. AFGE represents nearly 160,000 employees in the Department of Veterans Affairs (VA), more than two-thirds of whom are Veterans 

Health Administration (VHA) medical professionals on the front lines treating the 

physical and mental health needs of our veteran population. 

S. 362

Overview 

AFGE strongly supports S. 362 to amend the law that provides Title 38 medical 

professionals with collective bargaining rights: Section 7422 of Title 38 (hereinafter 

‘‘Section 7422’’). Bargaining rights enable labor-management disputes over matters 

that affect working conditions to be resolved efficiently through grievances, arbitrations and negotiations. 

S. 362 is needed to clarify which workplace issues are covered by Section 7422. 

VA human resource policy interprets Section 7422 to deprive Title 38 employees of 

the same bargaining rights used every day by other VHA employees covered by Title 

5 bargaining rights law.1

For example, registered nurses currently have far fewer bargaining rights than 

licensed practical nurses (LPN) and nursing assistants (NA) working at the same 

facility; psychiatrists cannot grieve over routine working conditions while social 

workers and psychologists working at the same mental health clinic can do so. 

S. 362 also would give VA registered nurses, doctors and dentists the same bargaining rights as registered nurses, doctors and dentists performing the same type 

of work at military hospitals and Federal prison facilities, who are covered by Title 

5 bargaining rights. 

Last year, VHA testified before this Committee that enacting this legislation 

would ‘‘jeopardiz[e] the lives of our veterans.’’ We believe that what jeopardizes patient care is arbitrarily preventing certain clinicians from speaking up about working conditions that impact the quality and safety of patient care. What hurts patient 

care is management’s unfettered discretion to ignore laws recently enacted by Congress to improve VHA recruitment and retention of registered nurses and physicians, especially in the face of growing national shortages. (In 2008, VHA ranked 

RNs and physicians as the top two ‘‘mission-critical occupations for recruitment and 

retention.’’) 

VHA policy did not always single out Title 38 employees for unequal treatment. 

In fact, in 1996, labor and management entered into an agreement about how to 

interpret Section 7422 to limit the number of disputes over what matters could be 

negotiated. They agreed to interpret ‘‘direct patient care’’ narrowly and allow grievances over routine matters such as nurse schedules and pay surveys. During that 

period, VHA also recognized the importance of affording full collective bargaining 

rights to all employees. In a 2002 VHA directive, that ‘‘applie[d] to all categories 

of employees in VA,’’ the agency stated that collective bargaining ‘‘safeguards the 

public interest’’ and ‘‘facilitates and encourages the amicable settlement of disputes 

between employees and their employers involving conditions of employment.’’ A year 

97 

later, the new administration began singling out Title 38 employees and severely 

curtailing their bargaining rights. 

We agree with VHA that collective bargaining is a valuable safeguard. AFGE 

urges passage of S. 362 so that access to this safeguard and effective dispute resolution tool does not depend of which personnel system applies, or whether the patients 

are veterans, active duty personnel or Federal prisoners. In addition, this legislative 

change will ensure the use of consistent personnel policies even when administrations change. (Opponents of this legislation have not expressed objection to the other 

two bill provisions. Section 2 of the bill would provide Title 38 employees with the 

right to appeal arbitrator decisions to court and Section 3 would strengthen their 

right to a hearing transcript following agency personnel hearings.) 

Exceptions to Title 38 Bargaining in Current Law 

Current VA policy severely limits Title 38 bargaining rights by applying the three 

exclusions to bargaining in Section 7422 very broadly: direct patient care, peer review, and compensation. 

Contrary to Congressional intent, since 2003, VHA has applied an overly broad 

interpretation of the ‘‘direct patient care’’ exception to prohibit bargaining over a 

wide range of indirect patient care matters related to routine working conditions 

such as scheduling and assignments. Congress clearly intended to narrowly define 

the ‘‘direct patient care’’ exception as limited to medical procedures physicians follow 

in treating patients. In contrast, Congress cited guidelines for RNs wishing to trade 

vacation days as falling outside the exception. (H. Rep. No. 101–466 on H.R. 4557, 

101st Cong., 2d Sess., 29 (1990).) 

VHA’s interpretation of the compensation exception is also overly broad and contrary to Congressional intent. VHA applies this exception not just to negotiation 

over the setting of pay scales (which is clearly prohibited already by Title 5 for all 

Federal employees), but also entitlements to ‘‘additional pay’’ such as overtime, 

weekend pay and retention pay that Congress has specifically enacted to ensure a 

fair and desirable workplace. 

How collective bargaining rights are used in the healthcare workplace 

Collective bargaining is an efficient dispute resolution process that requires management and labor to participate in grievance hearings, arbitrations and negotiations over conditions of employment. For example, collective bargaining requires 

labor and management to participate in grievance hearings about nurse overtime 

pay is paid according to law, and negotiations over training for new computer systems. Otherwise, management can simply walk away, leaving employees with no recourse to resolve a dispute, even when it involved a matter that could hurt patient 

care, such as excessive mandatory nurse overtime or assignment of nurses to new 

hospital units without adequate training. 

Contrary to what opponents have contended, collective bargaining cannot be used 

to: 

• Require management to negotiate over disputes related to the agency’s mission 

such as medical procedures or the qualifications of medical professionals; 

• Prevent the employer from removing an unfit employee from the workplace; 

• Allow employees to ‘‘walk off the job’’ and abandon patients in order to participate in a grievance hearing or negotiation session. 

VHA ‘‘7422’’ Policy Wastes Health Care Dollars on Unnecessary Disputes 

The ambiguous exceptions in Section 7422 need to be eliminated. They are unnecessary because Title 5 already clearly prevents Title 38 employees from interfering 

with management’s mission. This policy also wastes patient care dollars because it 

results in many costly, time-consuming and demoralizing labor-management disputes. Opponents point to the number of Undersecretary of Health (USH) decisions 

published each year. They fail to point out that the actual number of disputes is 

far greater for two reasons. First, not every USH decision is published. Second, even 

though the USH has the sole authority to make these determinations, local human 

resource personnel regularly make unauthorized decisions denying employees their 

rights to grieve and negotiate. (The fact that VHA has not curbed this widespread, 

unauthorized practice is also troubling.) Many employees never challenge decisions 

made at the facility level because they are discouraged by the unlikelihood of success. The USH ruled in favor of management in 100% of the published cases in 

2003, 2005, 2006 and 2007, and in all but two cases in 2004. 

Employees and their representatives are also discouraged from seeking USH review because of the lengthy process required. Many cases take several years to 

reach the USH. VHA waited seven years to invoke Section 7422 to block a challenge 

98 

by Asheville, North Carolina operating room nurses over unfair policies on weekend 

pay. 

Opponents of S. 362 contend that Title 38 employees will use their expanded bargaining rights to interfere with patient care, but they have not, and cannot, point 

to a single example of attempts to interfere in this matter or in the setting of pay 

scales. A review of all published USH decisions since 2003 reveals that the vast majority involve routine disputes over matters such assignments, schedules and noncompliance with pay rules, and none relate to medical procedures or pay scales. 

Elimination of the exclusions in Section 7422 will not result in employee interference with patient care or setting of pay scales because Title 5 already sets clear 

limits on the scope of bargaining for all VHA employees, as discussed shortly. Section 7106(a) (which also covers Title 38 employees) clearly states that management 

rights—the determination of the agency mission, budget and organization—are not 

subject to bargaining. Similarly, employees cannot interfere with pay rates; Chapters 53 and 71 of Title 5 have always barred all Federal employees from bargaining 

over the setting of pay scales. In contrast, Section 7103(a)(14) of Title 5 makes it 

clear that Federal employees can only bargain over ‘‘conditions of employment.’’ 

Multiple decisions by the Federal Labor Relations Authority (FLRA) confirm that 

Title 5, standing alone, would prohibit Title 38 employees from interfering with direct patient care. More specifically, the FLRA has ruled that the union cannot require negotiations on even when services are to be provided to the public for ‘‘mission’’ reasons. It follows that Title 5 prevents a union from forcing negotiations over 

the substance of patient care. 

Collective bargaining increases accountability and improves patient care 

Current policy prevents RNs, physicians and other Title 38 employees from challenging workplace policies that lessen the quality and safety of patient care. For example, research on nurse overtime has clearly shown that exhausted nurses are 

more likely to make medical errors. In 2004, Congress enacted legislation to limit 

mandatory overtime except in cases of emergency. When local directors invoked the 

‘‘emergency’’ exception to cover up for poor staffing policies, AFGE tried to negotiate 

with VHA for a nationally uniform definition of the term, but VHA refused. 

Bargaining rights play a valuable role in agency innovation. A decade ago, VHA 

implemented two new health care information technology (IT) systems: Computerized Patient Record Systems and Bar Code Medication Administration. These health 

care IT innovations helped transform the VA into a world-class health care system 

and national model. When these systems were introduced, labor used its bargaining 

rights to negotiate over training and IT support to ensure that Title 38 nurses could 

provide patient care effectively and without interruption during computer breakdowns. Sadly, under current VHA policy, these negotiations would be prohibited as 

interfering with ‘‘direct patient care.’’ Full bargaining rights for VHA doctors and 

nurses will allow them to once again make valuable contributions as the new administration undertakes major IT changes. 

In contrast, nurses and doctors who work at Department of Defense (DOD) and 

Bureau of Prison (BOP) healthcare facilities have been able to use their full rights 

to positively impact patient care. For example, physician assistants (who would fall 

under Title 38 at the VA) participated in negotiations over all 19 BOP health services program statements currently in effect, including ‘‘Health Services Quality Improvement,’’ ‘‘Infectious Disease Management,’’ and ‘‘Health Information Management.’’ 

In summary, AFGE urges this Committee to support S. 362 to provide all VHA 

clinicians with the same bargaining rights. This legislation will vastly reduce the 

number of wasteful, demoralizing labor-management disputes at medical facilities 

and allow all of VHA’s dedicated clinicians to make positive contributions to health 

care delivery. 

S. 252

Overview 

AFGE thanks Chairman Akaka for his leadership in introducing legislation again 

this year to address the needs of front-line VHA nurses for more competitive pay 

and schedules, increased loan assistance and equal rights for part-time nurses, and 

we urge passage of these provisions. However, we strongly oppose the provision to 

expand the Hybrid Title 38 personnel system, and therefore urge the Committee to 

strike this language from the bill and substitute a provision for further study of this 

poorly functioning, nascent personnel system. Age’s objections to other provisions in 

this bill are discussed below. 

99 

Section 101(a): This provision would immediately transfer over 11,000 nursing assistants from Title 5 to Hybrid Title 38 status, and allow the Secretary to transfer 

over 20,000 more Title 5 employees to Hybrid status. Further expansion of this broken system could be disastrous. Therefore, we urge lawmakers to strike Section 101 

(a) from the bill and substitute language to request a comprehensive study of the 

Hybrid Title 38 system to determine if and how can be fixed prior to further expansion. 

The Hybrid Title 38 personnel system has failed to meet its top objective: flexible, 

expedited hiring of healthcare personnel at the facility level. The system is currently 

plagued by so many delays during the initial boarding process and ongoing hiring 

and promotion processes that VHA has had to hire additional staff just to deal with 

current backlogs and problems. For example, it took more than four years for social 

workers and some psychologists to be ‘‘boarded’’ (transferred to the Hybrid system 

from Title 5). VHA social workers report that it can take more than six months to 

hire new social workers. Hiring is so cumbersome and slow that in many cases, it 

is still faster to hire under Title 5. Proponents of Hybrid expansion contend that 

the Title 5 hiring process is too slow, but it is worth noting that the VA recently 

hired 4,000 new Title 5 disability claims processors without delay. 

In addition, veterans’ employment rights appear to be weaker under Hybrid Title 

38 than under Title 5, depriving hundreds of veterans employed by VHA of the ability to enforce their rights through the Merit System Protection Board and Labor Department. Further study is needed to clarify the scope of veterans’ preference under 

different VHA personnel systems prior to placing more employees under the Hybrid 

system. 

Promotion policies are less equitable under the Hybrid system as well, which impacts VHA recruitment and retention. Currently, Hybrid Title 38 employees have 

little or no recourse if management refuses to allow them to go before professional 

standards board to be considered for promotion ‘‘above the journeyman level.’’ Even 

when promotion is recommended, management can refuse to promote. This has 

greatly impacted social workers and psychologists, among others. 

In summary, AFGE urges further study of the Hybrid Title 38 system prior to 

further expansion, to determine if and how the system can be improved, or whether 

Title 5 (and possibly new Title 5 streamlined procedures) would better serve VHA’s 

workforce needs. It will also be worthwhile to examine how VHA recruitment and 

retention of specific professions is faring under the Hybrid system, for example, 

mental health providers, licensed practical nurses and pharmacists. 

Section 101(b) and (c): AFGE strongly supports these provisions. Part-time VA 

registered nurses (RN) have ‘‘fallen through the cracks’’ of Title 38 for too long. 

Under current law, a RN hired on a full-time basis can become a permanent employee after two years. In contrast, RNs who are hired as part-time can never obtain 

personnel rights and benefits associated with permanent status. It is equally unfair 

that RNs who worked for years on a full-time basis lose all their rights when they 

convert to part-time, for example, to start a family or care for elderly relatives. 

These provisions provide a simple, equitable fix: After the equivalent of two years 

of work, part-time nurse achieve the same status as their full-time counterparts, 

and nurses who have already achieved permanent status retain it when they change 

to a part-time schedule. 

Section 101(d)–(f): AFGE takes no position on these provisions 

Section 101(g): AFGE opposes this provision to pay $40,000 recruitment and retention bonuses to pharmacist executives. These large bonuses should only be put 

into law after a showing of clear evidence of a national recruitment and retention 

problem for all VHA pharmacist positions (including pharmacists and pharmacist 

techs working directly with patients). For example, this Committee recently relied 

on a comprehensive study of recruitment and retention problems for Certified Registered Nurse Anesthetists to support pay adjustments for them. We estimate that 

this proposed pay increase change would allow a pharmacy executive in Washington 

State to earn over $173,000 and a pharmacy executive in Salem, Virginia, to earn 

$183,000. 

Section 101(h): We take no position on Section 1(h)(1) on non-foreign COLAs. 

We object to Section 1(h)(2) that would allow VHA to set the market pay differently for management physicians and dentists than practitioners providing 

hands-on care. We see no justification for exempting no practicing physicians and 

dentists from the same peer-based compensation panel system used by practitioners 

providing direct care. Congress enacted this elaborate system in 2004 (Pub. L. 108– 

445) specifically to ensure that market pay was set fairly and at a level that was 

competitive with pay offered by other local health care employers. Exempting management clinicians from this statutory pay process will undermine Congressional intent and increase pay decisions based on favoritism rather than market conditions. 

100 

We urge the Committee to strike this provision and instead, conduct oversight of 

the 2004 law prior to making any further amendments to it. 

We strongly object to Section 1(h)(3) that would allow pay reductions based on 

changes in board certification or reduction of privileges. The board certification provision will disproportionately impact newer physicians and dentists who are required to qualify for renewal of their board certification every ten years (unlike 

older practitioners whose board certification is permanent). VHA should create new 

incentives, not disincentives, to recruit and retain new clinicians. Many VA clinicians have difficulty securing the leave to renew their certification in a timely manner. Therefore, this will also disproportionately impact clinicians in rural hospitals 

and other facilities that are short-staffed. Similarly, we object to tying pay to privileges as they are completely within management’s discretion. Currently, management can provide themselves with full privileges even though they do not see patients, but arbitrarily restrict or deny privileges of hands-on physicians and dentists 

in retaliation for voicing their concerns through avenues such as union grievances, 

lawsuits and complaints to the Inspector General. 

Sections 101(l) and (n): AFGE supports this provision to adjust the pay caps for 

Cranes (as already discussed) and Lens (whose modest wages often hit the pay cap 

when annual Federal pay raises are provided). 

Sections 101(j) and (l): AFGE opposes these provisions to provide significant increases in base pay and retention bonuses (‘‘special pay’’) to nurse executives. This 

represents a 400 percent increase over five years. (In 2004, Congress enacted a 

$25,000 ceiling on nurse executive retention bonuses.) We estimate that in North 

Carolina, this would allow some nurse executives to earn almost $240,000, and in 

Washington State, $243,000. AFGE opposes such a large increase absent sufficient 

evidence of a national recruitment and retention problem for VHA nurse executive 

positions. 

Section 101(k): AFGE supports this provision to provide additional director training on the RN third party locality pay survey process. This will assure that surveys 

are conducted properly and will result in VHA pay that is competitive with the private sector. Providing employees and their representatives with survey data about 

their own pay is also a common-sense fix that will lead to greater accountability. 

Sections 101(m): AFGE supports this provision to ‘‘fine tune’’ the rules for overtime and shift differential pay of all VHA nurses to ensure fair and consistent payment of additional pay, and keep VHA competitive with other employers applying 

similar rules. 

Section 102 (a–b): AFGE supports this provision to provide clearer language to 

limit mandatory overtime for RNs and extend this limit to other nursing positions, 

as well as protect against retaliation for refusal to work a prohibited schedule. The 

definition of ‘‘emergency’’ is consistent with state nurse overtime laws that already 

protect other nurses from excessive mandatory overtime. AFGE notes, however, that 

under current VHA policy on Title 38 collective bargaining, RNs will not be able 

to enforce their rights to refuse to work prohibited schedules (but Lens and NAs 

with Title 5 bargaining rights will be able to seek enforcement through grievances). 

Section 102(c): AFGE supports this provision to encourage greater use of alternative work schedules (AWS) by VHA. AWS is valuable nurse recruitment and retention tool as it is widely offered in the private sector. AFGE notes, however, that 

under current VHA policy on Title 38 collective bargaining, RNs will be unable to 

enforce their rights to AWS if VHA continues to refuse to offer it (in contrast to 

LPNs and NAs with full bargaining rights.) 

Section 103: AFGE supports these improvements to VHA loan assistance programs including greater access to this assistance by current employees seeking additional training. 

Section 104: AFGE generally supports strong standards for physician appointments but notes that most of these proposed requirements are already in practice 

at VHA. AFGE opposes VISN approval of physician appointments: this will bog 

down an already slow hiring process and further impede the VA’s ability to hire 

physicians. AFGE calls for further study of the impact of tying performance to board 

certification prior to implementing this provision; it could have an adverse impact 

on VHA’s ability to recruit physicians without enhancing quality of care. More generally, as already discussed, AFGE urges the Committee to conduct oversight of a 

broad range of physician issues, including implementation of the base, market and 

performance pay provisions in the 2004 physician and dentist pay bill, the ‘‘24/7’’ 

rule and other scheduling matters, panel sizes, continuing medical education reimbursement and board certification. 

Section 201: AFGE strongly opposes elimination of this modest annual reporting 

requirement that holds VHA accountable to Congress for its nurse locality pay policies. We see no benefit, and only problems, with allowing VHA to conduct critical 

101 

nurse recruitment and retention policies in secrecy, especially given the need for 

highly effective pay policies during this growing national nursing shortage. More 

generally, the process of setting front-line nurse locality pay or nurse executive retention bonuses should be far more transparent. 

Sections 202–214: AFGE takes no position on these sections. 

Section 215: AFGE supports increased access to TBI care but is concerned about 

the minimal oversight provisions in this section. Therefore, AFGE urges the Committee to conduct regular oversight into all contract care arrangements, including 

the ongoing Project HERO pilot operating in four VISNs, to ensure that veterans’ 

needs are well served by non-VA providers in terms of quality of care, coordination 

of care, timeliness of care and geographic accessibility. In addition, oversight of all 

contract care arrangements should include consideration of the impact of diverting 

patients and patient care dollars on the VA’s capacity and budget for providing inhouse care, a comparison of the cost and quality of patient care with care provided 

through increased in-house capacity and providing care through VHA’s extensive 

telehealth system. The long range impact of contract care on the VA’s role as a leading researcher and training ground for practitioners across the country should also 

be evaluated. 

Section 216: AFGE has not taken a position on this section 

Section 217: AFGE opposes this provision to pilot a contract dental care program. 

AFGE supports instead VA-provided outpatient dental care to all enrolled veterans 

without imposing additional costs on them or their families. 

Title III: AFGE takes the same position on Title III of this bill and S. 597. We 

fully support provisions to improve and expand health care services to women veterans and their families. 

Title IV: AFGE has not taken a position on this section. 

Title V: AFGE has not taken a position on this section. 

Title VI: AFGE has not taken a position on this section. 

Title VII: AFGE supports these provisions for VA police officers. AFGE also recommends the additional language providing that in the event that an offense takes 

place in the presence of the officer while off Department property, he or she may 

take appropriate action to—protect life, and may exercise any authority authorized 

by an express grant of authority under applicable Federal, State or local law. 

S. 821

AFGE supports this legislation to eliminate copayments from veterans who are 

catastrophically disabled. 

S. 801

AFGE supports this legislation to provide assistance to family caregivers. 

S. 793

AFGE supports this legislation to increase tuition assistance for individuals training for positions to care for the visually impaired. 

S. 772

AFGE has not taken a position on this bill. 

S. 734

AFGE supports this bill, including much needed provisions to increase oversight 

of contract care. As already discussed (see Section 215 of S. 252), AFGE urges the 

Committee to conduct comprehensive oversight of all contract care arrangements 

and should coordinate activities under this program with oversight of Project HERO 

that already operates in four VISNs. 

S. 699

AFGE has not taken a position on this bill. 

S. 658

AFGE supports this legislation to improve access to health care for rural veterans. 

In Section 6, AFGE urges greater oversight of contract care consistent with our recommendations in our comments on Section 215 of S. 252 and S. 734. 

102 

S. 597

AFGE supports this legislation to improve health care services for women veterans and their families. 

S. 543

AFGE has not taken a position on this bill. 

S. 509

AFGE supports this bill for construction of new facilities and other improvements 

at the Walla Walla, WA VAMC. 

S. 498

AFGE has not taken a position on this bill. 

S. 423

AFGE supports this legislation to authorize advance appropriations for VA health 

care. 

S. 404

AFGE supports this legislation to expand eligibility for emergency medical care. 

S. 246

AFGE has not taken a position on this bill. 

S. 239

AFGE has not taken a position on this bill. 

S. 226

AFGE has not taken a position on this bill. 

Senator SANDERS. Thank you very much. 

Ms. Heady? 

STATEMENT OF HILDA R. HEADY, MSW, ASSOCIATE VICE 

PRESIDENT OF RURAL HEALTH, ROBERT C. BYRD HEALTH 

SCIENCES CENTER, WEST VIRGINIA UNIVERSITY, AND PAST 

PRESIDENT, NATIONAL RURAL HEALTH ASSOCIATION 

Ms. HEADY. Thank you. I am thrilled to be able to present to the 

distinguished members of the panel. I am the Associate Vice President for Rural Health at the Robert C. Byrd Health Sciences Center at West Virginia University and I was honored last summer to 

have been appointed by former Secretary Peake to the National Advisory Committee on Rural Health in the VA. 

NRHA is the rural voice for 62 million Americans who call rural 

their home; and NRHA has focused on the issue of rural veterans 

and studied policy matters since 1997. We particularly want to address some of the measures in S. 734 and S. 658 today. 

Rural Americans have responded every time the country has 

gone to war. I am from a very small rural Southern community and 

a family that can trace its generations in American wars all the 

way back to the American Revolutionary War, and with the exception of the War of 1812 and the Spanish-American War, I have had 

members in all of these combats. 

One of my uncles served with General Patton in World War II 

and stormed the beaches of Normandy, returned home to become 

a sharecropper in Northern Alabama, and died of a heart attack at 

the age of 41 as a rural veteran who never received VA benefits. 

103 

He left a young widow and five children. If Senator Akaka’s bill, 

S. 734, had been the law of the land in those years following World 

War II, perhaps access to health care would have been closer to his 

small rural community and perhaps high-quality trained primary 

care physicians, whose training was supported by the incentives in 

the bill such as the National Health Services Corps, the Education 

Debt Reduction Program, and training in post-deployment health 

issues, may have enabled a physician to detect his heart disease 

and prevent his premature death, and perhaps his children would 

not have grown up with a single mother struggling to provide for 

them. 

In brief, NRHA supports the increase of access and building on 

the current successes of the CBOCs, mobile clinics, and outreach 

clinics, and certainly the Vet Centers. We need more rural outreach 

coordinators in each VISN that serve high numbers of rural veterans, as pointed out in this bill, because these individuals are involved in contracting fee-for-services with existing rural providers. 

And we need to focus special efforts on recruiting existing rural 

providers in these areas to work under these contracts with the 

VA. 

Linking quality of VA services with quality rural civilian services 

just simply makes sense, and as long as quality standards of care 

and evidence-based medicine guide the treatment for rural veterans, then we strongly support these collaborations with community health centers, critical access hospitals, other rural hospitals, 

and rural health clinics. 

We need to increase the access to mental health care services, 

particularly for those with PTSD and Traumatic Brain Injury. We 

need more TBI case managers. The current load of TBI case managers do not adequately address those individuals who are in rural 

areas. Rural areas suffer from very limited health care professionals, and where 75 percent of primary care HPSAs are located 

in rural areas, 85 percent of our shortage areas in mental health 

are in rural areas. The provisions of S. 734 that call for the increases in training of mental health providers and volunteer counselors would go a long way to helping in that area. 

Travel reimbursement will also address some critical needs, especially air service for those individuals that are in highly rural 

areas. 

We also call for an increase in the collaboration around research 

that will look at non-enrolled veterans. Most of the research that 

is currently done by the VA is only done on secondary databases 

of veterans who are enrolled, and since we know that the VA only 

serves 39 percent of veterans, then we are leaving out 61 percent 

of those veterans, and we know that a number of those individuals 

are in rural areas. This would be a natural tie-in to the Centers 

of Excellence that are called for in Senator Tester’s bill, S. 658. 

I want to commend Senator Murray for introducing the women 

veterans bill and I think that we need to point out that among the 

15 percent total number of women that are in the military service 

right now, 37.5 percent of those women are African-American 

women and we need to pay special attention to this population as 

they become veterans and in need of our services. 

104 

Thank you very much for the legislation. This is a huge agenda, 

and with very little exceptions, the National Rural Health Association is very pleased to support most of these efforts. Thank you. 

[The prepared statement of Ms. Heady follows:] 

PREPARED STATEMENT OF HILDA R. HEADY, MSW, ASSOCIATE VICE PRESIDENT OF

RURAL HEALTH AT THE ROBERT C. BYRD HEALTH SCIENCES CENTER, WEST VIR- GINIA UNIVERSITY, NATIONAL RURAL HEALTH ASSOCIATION, PAST PRESIDENT

Chairman, Akaka, Ranking Member Burr, and Members of the Senate Committee 

on Veterans’ Affairs: Thank you for the honor and the opportunity to speak to you 

today about the health care needs of our rural veterans. I am Hilda Heady, Associate Vice President of Rural Health at the Robert C. Byrd Health Sciences Center 

at West Virginia University, a committee member of the VA Veterans Rural Health 

Advisory Committee, and past president of the National Rural Health Association 

(NRHA). The NRHA provides leadership on the issues that affect the health of the 

62 million Americans who call rural home and has long focused efforts on improving 

the physical and mental health of our rural veterans. 

Since our Nation’s founding, rural Americans have always responded when our 

Nation has gone to war. Whether motivated by their values, patriotism, or economic 

concerns, the picture has not changed much in 230 years. Simply put, rural Americans serve at rates higher than their proportion of the population. Though only 19% 

of the Nation lives in rural areas, 44% of U.S. Military recruits are from rural 

America. And, sadly, according to a 2006 study of the Carsey Institute, the death 

rate for rural soldiers in our current war in Iraq is 60% higher than the death rate 

for those soldiers from cities and suburbs. Given this great commitment to service 

from our rural communities, we need to do more to resolve the health care barriers 

that face rural veterans. 

There is a national misconception that all veterans have access to comprehensive 

care. Unfortunately, this is simply not true. Access to the most basic primary care 

is often difficult in rural America. Access for rural veterans can be daunting. Combat veterans returning to their rural homes in need of specialized care due to war 

injuries (both physical and mental) will likely find access to that care extremely limited. Scarcity of mental health and family counseling services is also a problem for 

rural veterans in need of these services. 

Simply put, because there are a disproportionate number of rural Americans serving in the military, there is a disproportionate need for veteran’s care in rural areas. 

While the VA has increased the number of Community Based Outpatient Clinics 

(CBOCs), Outreach Health Centers, Home Based Care, or other outreach service 

programs in rural communities, it is not reasonable to expect that the VA can put 

a CBOC or one of these other services in every community where our rural and 

highly rural veterans live. We can, however, increase access to approved sources of 

care to overcome the difficulty rural veterans experience in attempting to receive 

timely, appropriate care. 

In West Virginia, more than half of all our veterans live in rural areas. Veterans 

represent over 14% of our population and that is growing: the state of West Virginia 

supports a military complex of Army and National Guard, Army and Air Reserve 

Components, plus Navy and Marine Reserve Units. Many of our soldiers in these 

units are serving their second or third tour of duty in Iraq or Afghanistan, but hopefully will return home soon. A vast number will return home to rural communities 

scattered across the state, often several hours’ drive from veteran health care facilities. Many will simply forego care because this access is so difficult. 

The NRHA strongly supports specific solutions to meet the challenges of providing 

quality care to our rural veterans. The NRHA believes that improving access to care 

for our Nation’s rural veterans must be a priority for both the Administration and 

Congress, and submits the following recommendations: 

1. Increase Access by Building on Current Successes 

Community Based Outreach Centers (CBOCs) open the door for many veterans 

to obtain primary care services within or close to their home communities. Additionally, Outreach Health Centers and mobile clinics meet the needs of many rural veterans. NRHA applauds the success of these programs as well as recent increases 

in Federal appropriations. Expansion of these critical services is needed. 

2. Increase Access by Collaborating with Non-VHA Facilities 

Approximately 20% of veterans who enroll to receive health care through the VHA 

live in rural communities. In addition, the VA currently serves only 39% of all veterans, so we know that a number of rural veterans rely upon their local, civilian 

105 

health care system for services and some may not receive any care. With an evergrowing number of veterans returning home to their rural communities after military service, these rural health care systems must be prepared to meet their needs. 

While CBOCs and Veteran Outreach Centers provide essential points of access, 

there are not enough of these facilities in rural communities. Furthermore, CBOCs 

do not provide a full range of care and the low volume of veterans in some communities may never be able to support one of these centers. Simply put, more providers, specifically trained in post-deployment health conditions and care, are needed to serve the increasing number of rural veterans. Collaboration with existing 

rural health care facilities provides a cost-effective, timely and quality solution to 

this problem. 

Linking the quality of VA services with rural civilian services can vastly improve 

access to quality health care for rural veterans. Our goal is not to mandate care to 

our veterans, but to provide them a choice, a local choice. As long as quality standards of care and evidence-based medicine guide treatment for rural veterans, the 

NRHA supports collaboration with: 

• Community Health Centers. These centers serve millions of rural Americans and 

provide community-oriented, primary and preventive health care. More importantly, 

FQHCs are located where rural veterans live. A limited number of collaborations 

between the VHA and Community Health Centers already exist and have proven 

to be prudent and cost-effective solutions to serving eligible veterans in remote 

areas. These successful models should be expanded to reach all of rural America. • Critical Access Hospitals and other rural hospitals. These facilities provide comprehensive and essential services to rural communities and are specific to rural 

states. If these facilities are linked with VHA services and models of quality, access 

to care would be greatly enhanced for thousands of rural veterans. • Rural Health Clinics. These clinics serve populations in rural, medically-underserved areas and comprise a vital piece of the safety-net system. In many rural and 

frontier communities, RHCs are the only source of primary care available. 

The above rural health facilities are the cornerstone of primary and preventive 

quality health care in rural America. Each is required to meet Federal requirements 

for quality, provider credentialing and the use of health information technology. 

Current collaborations with the VHA in Wisconsin, Missouri and Utah are strong 

examples of success. Expanding the levels of collaboration will vastly increase access 

to care in a cost-effective manner. 

The NRHA is pleased that the Rural Veterans Access to Care Act was signed into 

law last October. This act establishes a three-year pilot program in several rural 

regions of the country to allow the most underserved rural veterans to take advantage of existing quality rural health providers, such as Critical Access Hospitals, 

community health centers and rural health clinics. The pilot project is relatively 

small and requirements to qualify are rigid a veteran must live at least 60 miles 

from a VA primary care facility like an outpatient clinic, 120 miles from a VA hospital or 240 miles from a VA specialized-care facility when seeking that care. Despite these defects, this legislation is an important step in the right direction, but 

so much more must be done. 

S. 658, the Rural Veterans Health Care Improvement Act, is an important next 

step because it will allow even greater access to care or rural veterans. Specifically, 

one section authorizes the Office of Rural Health to improve or expand care for rural 

veterans through a series of demonstration projects that includes coordination with 

Community Health Centers, Critical Access Hospitals and Indian Health Services. 

We thank Senator Tester for introducing this bill and for this Committee’s examination of it. 

Additionally, S. 734, the Rural Veterans Health Care Access and Quality Act of 

2009, is yet another crucial step. This Act establishes a pilot project that would provide financial incentives for physicians who serve in a Health Professional Shortage 

Area to provide primary care or mental health services to rural veterans. Such a 

program could go far in improving access to care for rural veterans, especially meeting the great unmet mental health needs of our Nation’s veterans. The NRHA applauds Chairman Akaka for introducing this important bill. Care must be taken 

that laudable efforts to increase provider care for our veterans does not exacerbate 

the current provider shortage in rural areas. Because access to primary care in 

rural America is at crisis levels for all both civilian and non-civilian patients, it is 

also important to be mindful that any incentives do not inadvertently reduce providers at non-VA facilities. 

3. Increase Access to Mental Health and Brain Injury Care 

Currently, it appears that Traumatic Brain Injury (TBI) will most likely become 

the signature wound of the Afghanistan and Iraqi wars. Such wounds require highly 

106 

specialized care. The current VHA TBI Case Managers Network is vital, but access 

to it is extremely limited for rural veterans—expansion is needed. 

Additionally, mental health needs of combat veterans deserve special attention 

and advocacy as well. Access to mental health services is a problem in many small 

rural communities. In fact, 85% of all mental health shortages are found in rural 

America. A lack of qualified mental health professionals, shortage of psychiatric hospital beds and the negative stigma of mental illness, often result in many rural residents not getting the care they so desperately need. These problems are exacerbated 

for veterans who live in rural communities—too often members of our military return home to a civilian community where the cultural expectation is self-reliance 

and to solve one’s own problems. In a civilian health care system where few may 

understand military experience or the special needs of combat veterans, we need to 

do more to prepare our primary care providers who will serve these veterans. 

Although Vet Centers provide mental health services, they are not consistently 

available at the local, rural level. More resources are needed in order to contract 

with local mental health providers, hire additional mental health providers and/or 

contract with Critical Access Hospitals (CAHs) and other small rural hospitals. The 

provisions in S. 658 that give the VA the clear authority to contract-out mental 

health services for certain rural veterans is strongly supported by the NRHA. However, without addressing the national need for more mental health providers in 

rural areas and include post-deployment and/or combat related mental health disorders, the greater impact of S. 658 may be hampered. 

4. Target Care to Rural Veterans 

A. Needs of the Rural Family. Rural veterans have an especially strong bond with 

their families. Returning veterans adjusting to disabilities and the stresses of combat need the security and support of their families in making their transitions back 

into civilian life. The Vet Centers do a tremendous job of assisting veterans, but 

their resources are limited. The NRHA supports increases in funding for counseling 

services for veterans’ and their families. 

B. Needs of Rural Women Veterans. More women serve in active duty than at any 

other time in our Nation’s history. And more women are wounded or are war casualties than ever before in our Nation’s history. 

Targeted and culturally competent care for today’s women veterans is needed. 

Rural providers should also be trained to meet the unique needs of rural, minority, 

and female veterans. 

5. Improving the VA Office of Rural Health 

The NRHA calls on Congress and the VA to fully implement the functions of the 

newly created VA Office of Rural Health to develop and support an ongoing mechanism to study and articulate the needs of rural veterans and their families. 

Additionally, efforts to increase service points for rural veterans have, in large 

part, not been fully supported by the VA Administration itself. The VA has not consistently supported attempts to collaborate with rural health. It is my hope that 

with a new Administration and the newly formed VA Rural Health Advisory Committee, previous barriers will be eradicated and the VA Office of Rural Health will 

lead the way in expanding access options for rural veterans. Furthermore, the 

NRHA strongly encourages greater coordination between the Rural Health Consultants housed in each VISN and state-level rural health officials in their region. Specifically, quarterly meetings with State Office of Rural Health and State Rural 

Health Association officials would be prudent. 

S. 734 provides important direction for the VA Office of Rural Health. The requirement of establishing a strategic plan to implement specific workforce recruitment and retention goals is imperative for increasing access to care for rural veterans. However, we must again be mindful that any strategic plan to increase providers at VA facilities does not inadvertently increase the current shortage crisis at 

non-VA facilities. To this end, collaboration between the Federal Office of Rural 

Health Policy within HRSA and the VA Office of Rural Health is critical and must 

be established to best take advantage of the many efforts to reduce provider shortages in rural areas already underway within HRSA. 

6. Explore ways to coordinate benefits for dual eligible veterans 

As the veteran population ages, a growing number of veterans are eligible for both 

VHA health benefits and Medicare. The combination of two partial benefits packages should ensure the best possible care for our veterans, but the co-payments and 

Medicare Part D requirements may not be affordable for many veterans. Coordination of benefits would allow veterans to utilize the different resources offered to 

them effectively to receive high quality care close to home. 

107 

7. Increase research on defining the rural veteran population 

Without good research about the rural veteran population, we cannot possibly expect to ensure their good health. Epidemiological studies are needed to identify the 

locations and populations of veterans in various rural areas of the country. These 

studies must provide information about race, gender, place of residence, health care 

needs, service-related health issues and service utilization. With only 39 percent of 

veterans enrolled in VA health care benefits, and most VA research conducted on 

secondary bases of enrollees, we know that non-enrollees who may be rural, less 

than honorably discharged, and other veterans in need, are not included in this research. We need to broaden avenues for quality research which would provide information about how to best serve the veteran population who are currently not enrolled. The NRHA would encourage the VA to collaborate with the six Federal Office 

of Rural Health Policy/HRSA-funded Rural Health Research Centers to explore this 

research. 

CONCLUSION

While many opportunities for improvement exist in providing care to veterans in 

rural communities, the VA is to be commended for the excellent service provided 

in many of its facilities. However, we must never forget that many veterans forgo 

care entirely because of access difficulties to VA facilities. Providing health care in 

rural communities requires unique solutions, whether it is to veterans and their 

families or the general population. Additionally, we must all be mindful of long-term 

needs and costs of our sailors and soldiers. The wounded veterans who return today 

won’t need care for just the next few fiscal years; they will need care for the next 

half century. 

Both S. 734 and S. 658 are crucial pieces of legislation that will vastly improve 

the access to health care for our Nation’s rural veterans. Adopting the legislation 

and other strategies referenced in this written testimony will vastly improve the 

lives of the millions of veterans who live in rural America. Their service to their 

Nation affords them no less. 

Thank you again for this opportunity. 

Senator BEGICH [presiding]. Thank you for your testimony. The 

Chair keeps rotating, so you have to bear with us. 

Mr. Ibson, please. 

STATEMENT OF RALPH IBSON, SENIOR FELLOW FOR HEALTH 

POLICY, WOUNDED WARRIOR PROJECT 

Mr. IBSON. Thank you. Mr. Chairman and Members of the Committee, thank you for inviting Wounded Warrior Project to testify 

about pending legislation, particularly S. 801, a measure that 

would direct VA to develop a nationwide comprehensive wounded 

warrior family caregiver program; and S. 543, which calls for a pilot 

program to assess the feasibility of providing such support. 

Both bills recognize the extraordinary burdens being shouldered 

by family caregivers. Like wounded warriors themselves, family 

caregivers must adjust to a new normal in taking on what may be 

a lifetime of committed care. 

Wounded Warrior Project knows firsthand the challenges these 

family members face and believes the time has come to create a 

comprehensive nationwide program to sustain that caregiving. The 

establishment of such a program is our top legislative priority and 

we offer our overwhelming support for S. 801, the Family Caregiver 

Program Act of 2009. 

We applaud Chairman Akaka’s leadership in taking up this important issue and working so closely with Ranking Member Burr 

to craft this strong bill. 

S. 801 incorporates all the elements we believe are essential to 

helping families sustain the caregiving needed by our wounded 

warriors. We have reached that view based on exhaustive research 

108 

on family caregiving needs documented in a paper we would like 

to submit for the record. [Please find ‘‘Sustaining Family 

Caregiving for Wounded Warriors: The Need for a Comprehensive 

Caregiver Program’’ after Mr. Ibson’s prepared statement] 

S. 543, also before the Committee, would provide some of the supports we view as critical, but the measure falls short, in our view. 

It would not provide the full range of needed supports and is limited in scope to a 2-year pilot involving relatively few facilities. We 

believe the time for pilot programs is long past. 

Family caregivers are a vital link in the rehabilitation of severely 

wounded warriors, but these families have no assurance of ongoing 

governmental support. That lack of support threatens to take its 

toll. Studies show that family caregivers experience an increased 

likelihood of stress, depression, and mortality as compared to their 

non-caregiving peers. Caregiving takes an economic toll, as well. 

Let me share just two examples from among the many caregivers 

with whom we have worked closely. Jennifer was forced to leave 

her teaching job to care for her husband, who was struck by an 

IED in Iraq in 2005. His injuries resulted in total blindness and 

severe TBI and he is on medications to control seizures and many 

other problems. In her 3 years of full-time caregiving, Jennifer has 

received no training of any kind and no supplemental income. She 

had not been made aware of any VA respite care program when we 

interviewed her recently. 

Charlene, another caregiver, lost her job after 2 months of caring 

for her wounded warrior son, who sustained severe TBI in 2003 

and requires full-time care. She has health care coverage, but only 

through her husband’s health program, and they pay significant 

premiums for that care, having gone from a two-income to a single 

income family. Charlene recently underwent a heart biopsy and 

heart catheterization and states plainly that her caregiving activities are extremely stressful. 

Without ongoing support, many of these family caregivers will 

simply find themselves unable to cope. The ultimate cost of failing 

to address their urgent needs is surely to increase the risk of veterans being needlessly institutionalized at great cost. 

I was struck, and perhaps others of you on the Committee were, 

as well, that VA expresses its opposition to S. 801 in part on the 

ground that it would, quote, ‘‘divert from the primary mission of 

treating veterans and training clinicians.’’ I can think of no higher 

calling in law or policy than the care, rehabilitation, and well-being 

of wounded warriors. That is the essence of what S. 801 is about 

and it is disappointing that the Department’s testimony misses 

that point. 

Further, the Department offers as a solution a position that I 

think Senator Burr ably demolished, but a position articulated last 

September in hearings on the House side, proposing that caregivers 

might be employed by home health agencies. Senator, as you ably 

pointed out, the VA has no evidence to show that that is a workable solution. In the months since last September, nothing has 

changed and no evidence was put on the table to suggest that this 

is at all plausible. It simply isn’t a mechanism by which to support 

family caregivers. S. 801 is just such a mechanism and it has our 

full support. 

109 

We would welcome the opportunity to discuss the elements of the 

bill in greater detail, including what some families see as a need 

for somewhat greater flexibility in the bill’s oversight provisions. 

But above all, we urge the Committee to make enactment of S. 801 

a top priority. 

Thank you for taking up this important issue. I would be pleased 

to address any questions you might have. 

[The prepared statement of Mr. Ibson follows:] 

PREPARED STATEMENT OF RALPH IBSON, SENIOR FELLOW FOR HEALTH POLICY, WOUNDED WARRIOR PROJECT

Chairman Akaka, Ranking Member Burr, Members of the Committee: Thank you 

for inviting Wounded Warrior Project (WWP) to testify about pending legislation, 

particularly S. 801, a measure that would direct the Department of Veterans Affairs 

to develop a nationwide, comprehensive wounded warrior family caregiver program, 

and S. 543, which calls for a pilot program to assess the feasibility of providing such 

support. 

Both bills recognize the extraordinary burdens being shouldered by family caregivers of our Nation’s latest generation of wounded warriors, and both seek to support these critical stakeholders in the rehabilitative process. Family caregivers, like 

their wounded warrior, often must adjust to their own ‘‘new normal’’ as they embark 

on what may be a lifetime of committed care for their veteran. The time has surely 

come to create a robust, nationwide wounded warrior family caregiver program to 

address the urgent needs of these family members. The establishment of such a program is Wounded Warrior Project’s top legislative priority, and we offer our overwhelming support for S. 801. 

Wounded Warrior Project knows firsthand the challenges these family members 

face. We work daily with thousands of our alumni to ensure they become the most 

successful and well adjusted wounded warriors in the Nation’s history. Through our 

nationwide family caregiver outreach and retreat program, Wounded Warrior 

Project is gathering vital data needed to more appropriately support family caregivers in the rehabilitation of their wounded warriors. This program provides these 

caregivers much needed respite, counseling, and training. Family caregiver retreats 

are comprised of participants facing similar challenges based on their unique family 

roles and experiences. Separate retreats are organized for wives, mothers, and fathers of wounded warriors. Also, we will be holding a caregiver summit in Washington, DC, in late June, and we expect that our family caregivers will visit many 

of you on the Committee. 

WOUNDED WARRIOR PROJECT SUPPORTS S. 801

WWP strongly supports S. 801, ‘‘The Family Caregiver Program Act of 2009.’’ This 

bill reflects a keen understanding of the needs of both severely wounded warriors 

and the devoted loved ones who selflessly care for them. That understanding is reflected in the establishment of a program that would fully address the long unmet 

needs of family caregivers while ensuring the well-being of our most profoundly 

wounded warriors. Mr. Chairman, we applaud your leadership in taking up this important issue and working with the Ranking Member to craft this strong bill. Not 

only does S. 801 meet a dire and well-established need, but it builds on an array 

of services—some of which are already provided at many, but not all, VA facilities. 

These services are simply not currently integrated in a comprehensive manner to 

support family caregivers. 

The Department of Veterans Affairs (VA) has mounted a number of pilot programs to assist family caregivers, and various elements of the VA system already 

provide many of the services family caregivers need. Thus, there already exists a 

strong foundation to take the next logical step and establish a nationwide program 

of comprehensive support. S. 543, ‘‘The Veteran and Servicemember Caregiver Act 

of 2009,’’ would provide some of the supports we view as critical to sustain family 

caregiving. But the measure falls short. It would not provide family caregivers the 

full range of needed supports (providing simply for study with regard to needed respite and health care), and it is limited in scope to a two-year pilot program to be 

carried out at not fewer than six facilities. We believe that the time for pilot programs is past. 

S. 801, in contrast, proposes just the type of comprehensive solution Wounded 

Warrior Project recommends and fully supports. Our wounded warriors and those 

family members who care for them have compelling needs. S. 801 meets those needs 

110 

head on. We commend the Chairman, the Ranking Member, and all the Committee 

co-sponsors for introducing this urgently needed legislation. 

The Need for Family Caregiver Support 

While many wounded warriors substantially recover from their wounds and are 

able to live independently, some have sustained such profound injuries that they 

will likely need ongoing personal care and assistance for a very long time. These 

individuals usually want to return to, or remain in, their homes, and strongly resist 

being institutionalized. In-home care by a loved one also affords the wounded warrior greater access to community-based care, a right that has already been affirmed 

by the Supreme Court in its Olmstead v. L.C. decision. Most warriors want to be 

cared for by their loved ones, if possible, rather than by agency personnel. Most families want the same for their wounded warrior. But the extraordinary demands of 

caregiving invariably take a toll on family caregivers—physically, psychologically, 

emotionally, and financially. 

Our research makes one thing abundantly clear—very little institutional attention 

is being paid to family caregivers though they are a vital link in the veteran’s rehabilitation process. The President’s Commission on Care for America’s Returning 

Wounded Warriors, the Dole-Shalala report, provided powerful data on the nature 

and magnitude of the problem. Among its findings, the Commission reported that: 

• Among OEF/OIF servicemembers surveyed, ‘‘33% of active duty, 22% of reserve 

component and 37% of retired/separated servicemembers report that a family member or close friend relocated for extended periods of time to be with them while they 

were in the hospital.’’ 

• Among OEF/OIF servicemembers surveyed, ‘‘21% of active duty, 15% of reserve 

component, and 24% of retired/separated servicemembers say friends or family gave 

up a job to be with them or act as their caregiver.’’ 

The Well-Established Burden on Family Caregivers 

The impact of long-term caregiving on the families of severely disabled individuals 

in the general population has been extensively studied. These findings underscore 

the need wounded warrior family caregivers have for the array of services provided 

for in S. 801. 

Studies indicate, for example, that proper caregiver training can reduce the 

chances of injury for both the caregiver and the recipient. They show further that 

well-trained caregivers are less likely to use costly, formal supports. 

Highlighting the need for access to counseling and other health care services, the 

studies also show that family caregivers experience an increased likelihood of stress, 

depression, and mortality as compared to their non-caregiving peers. Those who provide care 36 hours or more per week are more likely than non-caregivers to experience depression and anxiety. Women who provide that level of care to a disabled 

spouse are six times more likely to experience symptoms of depression and anxiety. 

Studies also suggest that with each incremental increase in assistance with activities of daily living (ADLs), spousal caregivers experience a greater risk for serious 

illness. Caregivers report poorer levels of perceived health, more chronic illnesses, 

and poorer immune responses to viral challenges. 

Finally, economic issues associated with caregiving cannot be ignored. The literature suggests that informal (unpaid) caregiving is incompatible with full-time 

employment. Research shows that even small reductions in work hours to provide 

unpaid care can result in significant lost wages and a reduction in the caregiver’s 

future pensions and retirement savings. Also, while not specifically addressed in the 

research, a reduction in long-term wages will obviously result in a reduction in future social security benefits. 

Wounded Warrior Project works closely with the family caregivers of our wounded 

warriors and sponsors frequent caregiver retreats. We have learned firsthand that 

our caregivers experience the same profound challenges so thoroughly documented 

in the literature. 

Let me share just two examples from among the many with whom we work closely. In late 2005, one of our alumni was struck by an Improvised Explosive Device 

while serving in Iraq. He was permanently and totally blinded, has severe TBI, and 

is on medications to control seizures and a host of related issues. His wife was 

forced to leave her teaching job permanently to care for her husband. She is assisted 

daily by her mother. In the three years she has been a full-time caregiver, she has 

received no training of any kind, no supplemental income, and has health care coverage only because she is covered by TRICARE which does not extend to her mother. She was completely unaware of any VA respite care program when we interviewed her. She lives 90 miles from the nearest VA facility. 

111 

The mother of one of our alumni lost her job after two months of caring for her 

son, a severely wounded warrior injured in April 2003, who requires full-time care. 

She only has health care coverage because she is covered by her husband’s health 

care program, but they pay significant premiums for that care. They have gone from 

a two-income family to a one-income family. She has had a heart biopsy and heart 

catheterization done recently and states plainly that her caregiving activities are extremely stressful. She worries about their finances and health care coverage. 

The impact on family members such as these of having to care for severely 

wounded veterans for extended periods of time—and in many cases, for life—can be 

overwhelming. From the moment one or more family members meet their returning 

wounded warrior, they come face-to-face with their ‘‘new normal.’’ 

From the moment they are injured, the wounded warrior and their family members are forced to make decisions about who will provide routine, daily care. While 

the decision to care for a loved one—a commitment vital to that wounded warrior’s 

recovery—may come easily, the burden of caregiving itself can take an enormous toll 

on the family. Family caregivers may be forced to take extended leaves of absence 

or permanently leave their jobs, losing retirement plans, health care plans, savings 

plans, and benefits plans in the process. In many cases, the wounded warrior requires personal assistance around the clock and may need specialized, daily care 

which the family caregiver is neither trained nor emotionally equipped to handle. 

At present, few family caregivers receive training, and they have no formal support 

network. Many have no access to health care, respite care, counseling, or a way to 

replace lost income. 

The High Cost of Doing Nothing 

These family caregivers are, in many cases, the ‘‘first responders’’ to wounded veterans in need. They are often the first ones to detect new challenges to the veteran’s 

rehabilitation and the ones most capable of implementing a positive response to 

those challenges. Without an appropriate level of support, many of these family 

caregivers will simply find themselves unable to cope. Over the long-term, such a 

tragic outcome will ultimately result in an enormous cost to our wounded warriors, 

their families, and to the health care system which will likely be called upon to care 

for them. 

Setting aside the obligation we owe these warriors and their loved ones, the ultimate cost of failing to address the urgent needs of wounded warrior family caregivers is almost certainly much greater than the cost of establishing a comprehensive wounded warrior family caregiver program for all who need ongoing support. 

S. 801 clearly recognizes this reality. 

There is Currently no Comprehensive, Nationwide Wounded Warrior Family Caregiver Program 

While S. 801 envisions a comprehensive nationwide program, it is important to 

note that many VA medical centers already provide some of the very services and 

supports proposed in the bill, including respite care and family education and counseling. But none provide all of these services. Nor do they focus in a comprehensive, 

coordinated way on family caregivers. Family caregivers need more than piecemeal 

services and support. They have a profound need for the kind of robust national program proposed in S. 801. Based on the experience of our wounded warriors, we believe such a program would contribute enormously to the recovery and rehabilitation 

of severely wounded warriors. Moreover, we believe it would avert what is otherwise 

likely to be a growing need for long-term institutional care. In short, establishing 

a comprehensive family caregiver program such as the one envisioned by S. 801 is 

not only the right thing to do for our wounded warriors, but a fiscally prudent one. 

Given the handful of very limited and inconsistent wounded warrior family caregiver programs and support services now available, families are coping largely on 

their own. VA testified last year that it provides home health services to veterans 

in many areas through contract arrangements with some 4,000 home health agencies. But many of the families of our newest generation of wounded warriors consider such services—even if they are available locally—a poor alternative to the care 

provided by a devoted parent, sibling, spouse, or friend. Local services vary greatly 

in both quality and quantity. There is no nationwide training standard and no cultural training for local agencies addressing the unique needs of young, severely 

wounded veterans, particularly those with TBI, PTSD or other psychological health 

issues. Additionally, for family caregivers who need financial support to enable them 

to care for their wounded loved ones, VA has no answer other than to refer them 

to these same local agencies for possible employment. 

Legislation is now urgently needed to avert foreseeable family tragedies through 

creation of a nationwide, comprehensive wounded warrior family caregiver program 

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such as the one proposed in S. 801. At its core, this legislation would meet a vital 

need for those seriously wounded warriors who require extensive personal care. This 

legislation would provide an option not now available to many severely injured veterans whose families cannot meet or sustain their loved ones’ caregiving needs. 

S. 801 Provides the Kind of Comprehensive Support that Family Caregivers Need 

Informed by the experience of our wounded warriors and their families, Wounded 

Warrior Project enthusiastically supports passage of S. 801. It lays a comprehensive 

and needed foundation for a VA-administered family caregiver program comprised 

of three basic elements: training and certification, provision of support services, and 

a modest monthly allowance. Participation would be predicated on an objective, clinical determination of a veteran’s need for extensive daily caregiving, and the family 

caregivers’ capacity to provide the needed assistance. 

Under S. 801, an individual who, with the veteran’s assent, agrees to serve as the 

veteran’s Primary Personal Care Attendant, and who successfully undergoes training and achieves certification, would be provided the support and services needed 

to sustain that role. This support and these services would include counseling and 

needed mental health services; technical support, including access to a Web portal 

linked to a wide range of nationwide family caregiver support services; 30 days of 

annual respite care; CHAMPVA health care coverage; and a modest monthly allowance. Other family members can also receive basic family caregiver training, and, 

upon certification, have access to counseling and technical assistance. 

S. 801 provides the full array of support needed by family caregivers while establishing a framework that balances the needs of the wounded warrior and the family 

caregiver. The legislation provides VA the needed latitude to design and administer 

the program, but also directs VA to consult with wounded warriors, family caregivers, VSO’s and other pertinent organizations during the design and initial implementation phases. 

We anticipate that VA would employ an interdisciplinary process to determine the 

need for caregiving assistance. Such a process would include an objective assessment of the veteran’s need for caregiving assistance in performing such routine activities of daily living as feeding, dressing, bathing and other personal hygiene 

needs. This assessment and a VA family caregiver recommendation would in no way 

obligate the family. It would simply provide the veteran and family an additional 

option where feasible and appropriate. 

VA would provide all training and certification at no expense to the servicemember or designated family caregiver. VA’s responsibility to these family caregivers would not end with training and certification. S. 801 sets the framework to 

provide direct technical support, including information, assistance, and counseling, 

and to address routine, emergency, and specialized caregiving needs in a timely 

manner. 

To be effective and sustaining, a family caregiver program design must address 

the intense burden of daily caregiving. S. 801 does so by including such program 

elements as respite care of not less than 30 days annually, to include 24-hour per 

day respite, tailored to meet each Primary Personal Care Attendant’s needs. 

A viable program must also provide a means of protecting the health of a family 

caregiver who undertakes the weighty commitment of providing ongoing primary 

care of a wounded warrior. S. 801 meets that important need by making Primary 

Personal Care Attendants eligible for medical care under the CHAMPVA program. 

Finally, cognizant that many family members must forego employment and often 

relocate to provide care to a loved one, the authors of S. 801 have met a critical 

need by providing the Primary Personal Care Attendant a modest monthly stipend 

based on the level of daily care provided. S. 801 would direct VA to establish a 

schedule of allowances tied to the amount the Department would pay a commercial 

home health care agency to provide a commensurate level of personal, daily care authorized for that veteran. 

We should note that our focus on the importance of family caregiver assistance 

outlined in Section 3 of S. 801 does not, in any way, indicate a lack of support for 

the other provisions of S. 801. Section 2 waives charges for humanitarian care provided to family members accompanying certain severely injured veterans receiving 

care at a VA, VA-contracted, or ‘‘fee-basis’’ facility. Section 4 authorizes VA to pay 

lodging and subsistence to attendants who travel with a disabled veteran to receive 

treatment at a VA facility. These additional proposals serve as logical, additional 

components of a nationwide family caregiver program, and have our full support. 

We welcome the opportunity to discuss the elements of S. 801 in more detail, including what some families see as a need for greater flexibility in the bill’s oversight 

provisions. But, above all, we urge the Committee to make enactment of S. 801, 

‘‘The Family Caregiver Program Act of 2009,’’ a top priority. 

113 

Thank you for your interest in this important issue. I’m pleased to address any 

questions you or other Members of the Committee have at this time. 

[The paper referenced by Mr. Ibson follows:] 


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Senator BEGICH. Thank you very much, Mr. Ibson. 

Mr. Ortner, before you start, I want to say I enjoyed playing in 

the poker tournament the Paralyzed Veterans Association had. I 

am glad I came in second. [Laughter.] 

Mr. ORTNER. Well, we were glad to have you there. 


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132 

Senator BEGICH. It was a pleasure to be there. Please, your testimony. 

STATEMENT OF BLAKE C. ORTNER, SENIOR ASSOCIATE 

LEGISLATIVE DIRECTOR, PARALYZED VETERANS OF AMERICA 

Mr. ORTNER. Paralyzed Veterans of America would like to thank 

Chairman Akaka, Ranking Member Burr, and Members of the 

Committee for the opportunity to present our views on pending legislation before the Committee. Due to the number of bills today, I 

will limit my remarks to only a few, but want to assure the Committee that we are interested in all legislation dealing with our Nation’s veterans. 

First, on behalf of Paralyzed Veterans of America and our 20,000 

members, I want to thank the Chairman, Ranking Member Burr, 

and other Members of the Committee for introducing and cosponsoring S. 423, the Veterans Health Care Budget Reform and Transparency Act of 2009. This legislation will reform the VA budget 

process by providing advance appropriations for veterans health 

care, ensuring timely and predictable funding for VA. We look forward to working with you to pass this critical legislation. 

PVA supports S. 821 to prohibit the Secretary of VA from collecting copayments from catastrophically disabled veterans, legislation critical to PVA members, many of whom receive 85 to 90 percent of their care from VA. As Senator Sanders mentioned, PVA 

worked hard to ensure that those veterans with catastrophic disabilities were allowed to enroll in Priority Group 4, even though 

their disabilities were non-service-connected and regardless of income. However, unlike Category 4 veterans, they would still be required to pay fees and copayments. PVA believes this is unjust. 

VA recognizes these veterans’ unique specialized status on the 

one hand by providing specialized service for them in accordance 

with its mission to provide for special needs. Unfortunately, these 

veterans are not casual users of VA health care. Because of the nature of their disabilities, they require a great deal of care and a 

lifetime of services. In most instances, the VA is the only and the 

best resource for a veteran with spinal cord injury. Because of the 

amount of care required, these copays rapidly add up. 

In the last Congress, a House bill received unanimous support 

from Republicans and Democrats as well as VA. Unfortunately, the 

Senate never took action on the measure and the legislation was 

never enacted. On March 5, 2009, Mrs. Halvorson introduced legislation in the House, H.R. 1335, that will again attempt to remove 

this burden. Together with S. 821, we hope to finally resolve this 

issue during the 111th Congress. 

Regarding family caregiver services, we applaud the introduction 

of both S. 801, the Family Caregiver Program Act of 2009, and 

S. 543, the Veteran and Servicemember Caregiver Support Act of 

2009, and strongly support this legislation. This training and assistance is a critical aspect of preparing caregivers to care for a 

family member. The only concern that PVA would like to address 

is the significant use of the word ‘‘may’’ instead of ‘‘shall’’ in requirements of the Secretary. Our fear is that if VA is faced with 

the budget challenges that inevitably will occur, the value of the 

caregiver programs may be lost as they fall under the budget axe. 

133 

There are approximately 44 million individuals across the United 

States that serve as caregivers on a daily basis. Their contributions 

are invaluable economically as they obviate rising costs of traditional institutional care. The services rendered by caregivers are 

also priceless socially and emotionally as they allow ailing and disabled veterans to live more independently and often in their comfort of their own homes with friends and family. 

Many of the pieces of legislation being considered today have to 

do with increasing the number of health care professionals in the 

VA system, in particular, those in hard-to-serve areas. 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 VA health care professionals and those individuals necessary to support their efforts are the core of VA’s primary mission. 

PVA appreciates the comprehensive nature of S. 252 and supports the overall provisions of the legislation. It clearly outlines 

multiple approaches to increasing the competitiveness of VA for 

hiring health care providers. These programs will provide incentives for new hires or to keep already skilled employees in the VA 

system. 

Contributing to the problem for veterans is the need for care in 

rural America. Forty percent of nearly two million VA health care 

users reside in rural areas and 44 percent of newly returning veterans from OEF and OIF live in rural areas. PVA supports the provisions of S. 246, S. 734, and S. 658. 

Finally, the number of rural veterans is increasing, but in addition, there has been a dramatic increase in the number of women 

veterans now using VA facilities. PVA fully supports S. 597, the 

Women’s Veterans Health Care Improvement Act of 2009, language 

that has been incorporated into S. 252. Women have played a vital 

part in the military service throughout our history and current estimates indicate that there are 1.8 million women veterans, comprising nearly 8 percent of the U.S. veterans population. VA must 

act now to prepare to meet the specialized needs of women who 

have served. 

PVA sincerely appreciates the opportunity to provide our views 

on this important legislation and would also like to point out that 

much of the legislation presented today is discussed in greater detail in the current edition of the Independent Budget. 

This concludes my testimony. I would be happy to answer any 

questions you may have. 

[The prepared statement of Mr. Ortner follows:] 

PREPARED STATEMENT OF BLAKE C. ORTNER, SENIOR ASSOCIATE LEGISLATIVE

DIRECTOR, PARALYZED VETERANS OF AMERICA

Chairman, Akaka, Ranking Member Burr, and Members of the Committee, on behalf of Paralyzed Veterans of America (PVA), I would like to thank you for the opportunity to present our views on pending legislation before the Committee. We 

hope that the Senate Committee on Veterans’ Affairs will take our concerns under 

consideration as it moves its legislation forward in the 111th Congress. Mr. Chairman, we appreciate the legislative successes that veterans have realized under your 

leadership and we look forward to continued success in the future. PVA continues 

to work on issues important to our members, veterans with spinal cord injury or 

dysfunction, specifically, and to all veterans. 

134 

S. 423—THE ‘‘VETERANS HEALTH CARE BUDGET REFORM AND

TRANSPARENCY ACT OF 2009’’ 

Chairman, Akaka, on behalf of PVA and our 20,000 members, I want to thank 

you and the other Members of the Committee, for introducing S. 423, the ‘‘Veterans 

Health Care Budget Reform and Transparency Act of 2009,’’ that will reform the 

Department of Veterans Affairs (VA) budget process by providing advance appropriations for veterans’ health care. Your legislation was developed in consultation 

with the Partnership for Veterans Health Care Budget Reform (the Partnership)— 

a group that consists of nine major veterans service organizations, including Paralyzed Veterans of America. For more than a decade, the Partnership has worked to 

achieve a sensible and lasting reform of the funding process for veterans’ health 

care. While the Partnership has long advocated converting VA’s medical care funding from discretionary to mandatory funding, there has been virtually no movement 

in Congress in this direction. 

The Veterans Health Care Budget Reform and Transparency Act would ensure 

that the goals of the Partnership—sufficient, timely, and predictable funding—are 

met. Historically, advance appropriations have been used to make a program function more effectively, better align with funding cycles of program recipients, or provide insulation from annual partisan political maneuvering. By moving to advance 

appropriations, veterans’ health care programs will accrue all three of these benefits. 

To enhance the budget process even further, the legislation includes provisions to 

add transparency and oversight to VA’s internal budget forecasting model. Due to 

the complex nature of VA’s actuarially-based Model, S. 423 will require GAO to conduct an annual audit and assessment of the Model to determine its validity and accuracy, as well as assess the integrity of the process and the data upon which it 

is based. GAO would submit public reports to Congress each year that would assess 

the Model and include an estimate of the budget needs for VA’s medical care accounts for the next two fiscal years. Providing Congress with access to the Model 

and its estimates of VA health care’s resource needs, would create greater confidence in the accuracy of advance appropriations for veterans’ medical care, as well 

as validate future requests for emergency supplemental appropriations. 

Additionally, the Senate budget committee agreed with the value of advance appropriations for VA and included language in their recent budget resolution calling 

for advance appropriations for the VA medical care appropriation. Moreover, President Obama recently reaffirmed his support for advance appropriations. PVA 

strongly supports S. 423. 

S. 821—ELIMINATION OF CO-PAYMENTS FOR PRIORITY GROUP 4 VETERANS

PVA supports S. 821, to prohibit the Secretary of VA from collecting co-payments 

from catastrophically disabled veterans and we applaud Senator Sanders for introducing this important and overdue legislation. This legislation is critical to PVA 

members, many of whom receive 85 to 90 percent of their care from the VA. 

In 1985, Congress approved legislation which opened the VA health system to all 

veterans. In 1996, Congress again revised that legislation with a system of rankings 

establishing priority ratings for enrollment. Within that context, PVA worked hard 

to ensure that those veterans with catastrophic disabilities would be placed in a 

higher enrollment category. To protect their enrollment status, veterans with catastrophic disabilities were allowed to enroll in Priority Group Four even though their 

disabilities were non-service-connected and regardless of their incomes. However, 

unlike other Category Four veterans, if they would otherwise have been in Category 

Seven or Eight, due to their incomes, they would still be required to pay all fees 

and co-payments, just as others in those categories do now for every service they 

receive from VA. 

PVA believes this is unjust. VA recognizes these veterans’ unique specialized status on the one hand by providing specialized service for them in accordance with 

its mission to provide for special needs. The system then makes them pay for those 

services. Unfortunately, these veterans are not casual users of VA health care services. Because of the nature of their disabilities they require a lot of care and a lifetime of services. In most instances, VA is the only and the best resource for a veteran with a spinal cord injury, and yet, these veterans, supposedly placed in a higher priority enrollment category, have to pay fees and co-payments for every service 

they receive as though they had no priority at all. 

We were pleased that the House Committee on Veterans’ Affairs approved and the 

House of Representatives eventually passed legislation—H.R. 6445—to eliminate 

this financial burden placed on catastrophically disabled veterans during the 110th 

Congress. In fact, the House bill received unanimous support from Republicans and 

135 

Democrats as well as the VA. Unfortunately, the Senate never took action on the 

measure and the legislation was never enacted. On March 5, 2009, Mrs. Halvorson 

introduced legislation in the House of Representatives, H.R. 1335, that will again 

attempt to remove this unjust burden. Together with S. 821, we hope that with your 

leadership, we will finally be able to resolve this issue during the 111th Congress. 

S. 801—THE ‘‘FAMILY CAREGIVER PROGRAM ACT OF 2009’’ 

S. 543—THE ‘‘VETERAN AND SERVICEMEMBER CAREGIVER SUPPORT ACT OF 2009’’ 

Regarding family caregiver services, we applaud the introduction of both S. 801, 

the ‘‘Family Caregiver Program Act of 2009’’ and S. 543, the ‘‘Veteran and Servicemember Caregiver Support Act of 2009’’ and strongly support the legislation. While 

we believe S. 543 certainly expands caregiver assistance opportunities, we prefer 

the provisions of S. 801 because it is more broadly focused. This training and assistance is a critical aspect of preparing caregivers to care for a family member. PVA 

would like to thank the congressional staffs for their work on both S. 801 and S. 543 

to insure these critical issues are properly addressed. The only concern that PVA 

would like to address in the legislation is the significant use of the word ‘‘may’’ instead of ‘‘shall’’ in areas identifying requirements of the Secretary. Our fear is that 

if VA is faced with the budget challenges that inevitably will occur, will all the 

value of the caregiver programs be lost as they fall to the budget ax. This must not 

be allowed to happen. 

There are approximately 44 million individuals across the United States that 

serve as caregivers on a daily basis. The contributions of caregivers in today’s society are invaluable economically as they obviate the rising costs of traditional institutional care. The services rendered by caregivers are also priceless socially and emotionally, as they allow ailing and disabled veterans to live more independently and 

often in the comfort of their own homes with their friends and family. 

As the veteran community is aware, family caregivers also provide mental health 

support for veterans dealing with the emotional, psychological, and physical effects 

of combat. Many PVA members with spinal cord injury also have a range of co-morbid mental illnesses, therefore, we know that family counseling and condition specific education is fundamental to the successful reintegration of the veteran into society. Providing education and training to family caregivers will pay dividends in 

care well beyond any costs associated with the program. 

The aspects of personal independence and quality care are of particular importance to veterans with spinal cord injury/dysfunction. Paralyzed Veterans has over 

60 years of experience understanding the complex needs of spouses, family members, friends, and personal care attendants that love and care for veterans with life 

long medical conditions. As a result of today’s technological and medical advances, 

veterans are withstanding combat injuries and returning home in need of medical 

care on a consistent basis. Such advances are also prolonging and enhancing the 

lives and physical capabilities of injured veterans from previous conflicts. No matter 

the progress of modern science, these veterans need the health-care expertise and 

care from a health team comprised of medical professionals, mental health professionals, and caregivers. As a part of the health care team, caregivers must receive 

ongoing support to provide quality care to the veteran. It is for this reason, we are 

happy to see that S. 801 includes provisions for conducting caregiver assessments 

that identify the needs and problems of caregivers currently caring for veterans. The 

VA must also work to enforce and maintain an efficient case management system 

that assists veterans and family caregivers with medical benefits and family support 

services. 

Our experience has shown that when the veteran’s family unit is left out of the 

treatment plan, the veteran suffers with long reoccurring medical and social problems. However, when family is included in the health plan through services such 

as VA counseling and education services, veterans are more apt to become healthy, 

independent, and productive members of society. 

S. 772—THE ‘‘HONOR ACT OF 2009’’ 

PVA supports this legislation and would like to thank Senator Bond for his introduction of S. 772, the ‘‘Honor Act of 2009.’’ Mental health issues continue to be a 

growing problem for those who have witnessed the horrors and traumatic events of 

war. Evidence continues to show that the prevalence of mental illness is high in veterans who have served in Iraq and Afghanistan. Combat exposure coupled with long 

and frequent deployments are associated with an increased risk for Post Traumatic 

Stress Disorder (PTSD) and other forms of mental illness. In fact, the VA reports 

that Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) vetVerDate Nov 24 2008 19:35 Oct 22, 2009 Jkt 000000 PO 00000 Frm 00139 Fmt 6633 Sfmt 6621 H:\111TH HEARINGS\042209.TXT SVETS PsN: PAULIN
136 

erans have sought care for a wide array of possible co-morbid medical and psychological conditions, including adjustment disorder, anxiety, depression, PTSD, and 

the effects of substance use disorder. 

The impact of a veteran’s mental illness is far reaching and obviously has serious 

consequences for the individual veteran being affected, but perhaps less obvious are 

the serious consequences, stemming from a veteran’s mental illness, that confront 

his or her spouse, their children and other family members. With this in mind, Paralyzed Veterans believes that Congress should formally authorize, and VA should 

provide, a full range of psychological and social support services as an earned benefit to family and non-family caregivers of severely injured and ill veterans. 

The scholarships and other provisions of S. 772 create opportunities to increase 

the number of mental health professionals to provide for veterans with mental 

health challenges. Additionally, we applaud provisions expanding Vet Center opportunities for those who would not be authorized counseling services. But PVA believes that Vet Centers should also increase coordination with VA medical centers 

to accept referrals for family counseling; increase distribution of outreach materials 

to family members with tips on how to better manage the dislocation; improve reintegration of combat veterans who are returning from deployment; and provide information on identifying warning signs of suicidal ideation so veterans and their 

families can seek help with readjustment issues. PVA believes that an effective 

mental illness family counseling and education program can improve treatment 

outcomes for veterans, facilitate family communication, increase understanding of 

mental illness, and increase the use of effective problem solving and reduce family 

tension. 

S. 669—THE ‘‘VETERANS 2ND AMENDMENT PROTECTION ACT’’ 

Regarding S. 669, the ‘‘Veterans 2nd Amendment Protection Act,’’ PVA has not 

taken a position on this legislation. 

S. 252—THE ‘‘VETERANS HEALTH CARE AUTHORIZATION ACT OF 2009’’ 

S. 246—THE ‘‘VETERANS HEALTH CARE QUALITY IMPROVEMENT ACT’’ 

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 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 front line 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. By the number of bills today regarding the subject of staffing of VA, we can see it is of concern to the Committee as well. 

Mr. Chairman, PVA appreciates the comprehensive nature of S. 252, the ‘‘Veterans Health Care Authorization Act of 2009’’ and supports the overall provisions 

of the legislation. It clearly outlines multiple approaches to increasing the competitiveness of VA for hiring health care providers including changes to pay computation, exemptions from limitations on competitive pay and opportunities for additional nurse pay. In addition, changes to educational assistance programs and employee retention programs will provide incentives to keep those already skilled employees in the VA system. 

Given the Veterans Health Administration’s (VHA) leadership position as a health 

system, it is imperative that VA aggressively recruit health care professionals and 

work within established relationships with academic affiliates and community partners to recruit new employees. In order to make gains on these needs, VA must update and streamline its human resource processes and policies to adequately address the needs of new graduates in the health sciences, recruits, and current VA 

employees. Today’s health care professionals and other staff who work alongside 

them need improved benefits, such as competitive salaries and incentives, child 

care, flexible scheduling, and generous educational benefits. VA must actively address the factors known to affect current recruitment and retention, such as fair 

compensation, professional development and career mobility, benevolent supervision 

and work environment, respect and recognition, technology, and sound, consistent 

leadership, to make VA an employer of choice for individuals who are offered many 

attractive alternatives in other employment settings. 

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 

137 

retention challenges for medical care employers nationwide and is making access to 

quality care difficult for consumers. 

VA’s ability to sustain a full complement of highly skilled and motivated personnel will require aggressive and competitive employment hiring strategies that 

will enable it to successfully compete in the national labor market. VA’s employment 

success within the VHA will require constant attention by the very highest levels 

of VA leadership. Additionally, Members of Congress must understand the gravity 

of VA personnel issues and be ready to provide the necessary support and oversight 

required to ensure VA’s success. The legislation presented today demonstrates without doubt that the Committee understands these issues. 

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. 

Contributing to the problem for veterans is the need for care in rural America. 

The tremendous increase in veterans due to the wars in Afghanistan and Iraq is 

leading to greater numbers of veterans located in rural areas where only 10 percent 

of physicians practice. Additionally, those living in rural areas generally are more 

likely to live below the poverty line. 

Because 40 percent of nearly 2 million VA health care users reside in rural areas, 

including 80,000 who live in highly rural areas, they often have worse physical and 

mental health quality-of-life. Exacerbating the problem is that 44 percent of newly 

returning veterans from OEF/OIF live in rural areas. While VA may be working in 

good faith to address its shortcomings in rural areas, it clearly still faces major challenges and hurdles. 

PVA supports the provisions of S. 246, including loan repayment, tuition reimbursement and other incentives, if fully implemented, should help alleviate some 

level of this challenge by providing incentives to physicians to accept service in 

hard-to-fill positions. We applaud Senator Durbin for his far reaching initiative to 

provide for all veterans, even though they may live far from our urban centers. 

Mr. Chairman, we also applaud the inclusion of language from S. 246 in S. 252 

to insure the disclosure of certain physician information before their appointment 

to VA regarding lawsuits and civil actions against the individual for medical malpractice. Physicians providing care to our honored veterans must be of the highest 

quality. PVA understands that in this era of often frivolous medical lawsuits, physicians may be challenged and may settle lawsuits for which there was no medical 

wrongdoing. PVA believes the best way to guarantee the highest quality of physician in the VA system is to be forthright with information and allow the full examination of the record to prevent any future doubts. Additionally, the establishment 

of Quality Management Officers as outlined in both S. 252 and S. 246 should help 

insure the highest quality of care is provided to our veterans. 

PVA strongly supports provisions of S. 252 regarding Nonprofit Research and 

Education Corporations. This legislation will modernize and clarify the existing statutory authority for VA-affiliated nonprofit research and education corporations 

(NPCs). This bill will allow the NPCs to fulfill their full potential in supporting VA 

research and education, which ultimately results in improved treatments and high 

quality care for veterans, while ensuring VA and congressional confidence in NPC 

management. 

Since passage of Public Law 100–322 in 1988 (codified at 38 U.S.C. § 7361–7368), 

the NPCs have served as an effective ‘‘flexible funding mechanism for the conduct 

of approved research and education’’ performed at VA medical centers across the 

Nation. NPCs provide VA medical centers with the advantages of on-site administration of research by nonprofit organizations entirely dedicated to serving VA researchers and educators, but with the reassurance of VA oversight and regulation. 

During 2007, 85 NPCs received nearly $230 million and expended funds on behalf 

of approximately 5,000 research and education programs, all of which are subject 

to VA approval and are conducted in accordance with VA requirements. 

NPCs provide a full range of on-site research support services to VA investigators, 

including assistance preparing and submitting their research proposals; hiring lab 

technicians and study coordinators to work on projects; procuring supplies and 

equipment; monitoring the VA approvals; and a host of other services so the principal investigators can focus on their research and their veteran patients. 

138 

Beyond administering research projects and education activities, when funds permit, these nonprofits also support a variety of VA research infrastructure expenses. 

For example, NPCs have renovated labs, purchased major pieces of equipment, 

staffed animal care facilities, funded recruitment of clinician-researchers, provided 

seed and bridge funding for investigators, and paid for training for compliance 

personnel. 

Although the authors of the original statute were remarkably successful in 

crafting a unique authority for VA medical centers, differing interpretations of the 

wording and the intent of Congress, gaps in NPC authorities that curtail their ability to fully support VA research and education, and evolution of VA health care delivery systems have made revision of the statute increasingly necessary in recent 

years. S. 252 will allow the NPCs to better serve VA research and education programs while maintaining the high degree of oversight applied to these nonprofits. 

The legislation reinforces the idea of ‘‘multi-medical center research corporations’’ 

which provides for voluntary sharing of one NPC among two or more VA medical 

centers, while still preserving their fundamental nature as medical center-based organizations. Moreover, accountability will be ensured by requiring that at a minimum, the medical center director from each facility must serve on the NPC board. 

This authority will allow smaller NPCs to pool their administrative resources and 

to improve their ability to achieve the level of internal controls now required of nonprofit organizations. 

The legislation also clarifies the legal status of the NPCs as private sector, taxexempt organizations, subject to VA oversight and regulation. It also modernizes 

NPC funds acceptance and retention authorities as well as the ethics requirements 

applicable to officers, directors and employees and the qualifications for board membership. Moreover, it clarifies and broadens the VA’s authority to guide expenditures. 

PVA has been a strong supporter of the NPCs since their inception, recognizing 

that they benefit veterans by increasing the resources available to support the VA 

research program and to educate VA health care professionals. 

S. 597—THE ‘‘WOMEN VETERAN HEALTH CARE IMPROVEMENT ACT OF 2009’’ 

As stated above, the number of rural veterans is increasing, but in addition, there 

has been a dramatic increase in the number of women veterans now using VA facilities. PVA fully supports S. 597, the ‘‘Women Veterans Health Care Improvement 

Act of 2009,’’ language that has been incorporated into S. 252. Women have played 

a vital part in the military service throughout our history. In the last 50 years their 

roles, responsibilities, and numbers have significantly increased. Current estimates 

indicate that there are 1.8 million women veterans comprising nearly 8 percent of 

the United States veteran population. According to Department of Defense (DOD) 

statistics, women servicemembers represent 15 percent of active duty forces, 10 percent of deployed forces, 20 percent of new recruits, and are a rapidly expanding segment of the veteran population. 

Historically, women have represented a small numerical minority of veterans who 

receive health care at VA facilities. However, if women veterans from Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) continue to enroll at the current enrollment rate of 42.5 percent, it is estimated that the women using VA 

health care services will double in two to four years. 

As the population of women veterans undergoes exponential growth in the next 

decade, VA must act now to prepare to meet the specialized needs of the women 

who served. Overall the culture of VA needs to be transformed to be more inclusive 

of women veterans and must adapt to the changing demographics of its women veteran users—taking into account their unique characteristics as young working 

women with childcare and eldercare responsibilities. VA needs to ensure that 

women veterans’ health programs are enhanced so that access, quality, safety, and 

satisfaction with care are equal for women and men. 

This legislation is meant to expand and improve health care services available in 

the VA to women veterans, particularly those who have served in OEF/OIF. More 

women are currently serving in combat theaters than at any other time in history. 

As such, it is important that the VA be properly prepared to address the needs of 

what is otherwise a unique segment of the veteran population. 

Title I of S. 597 would authorize a number of studies and assessments that would 

evaluate the health care needs of women veterans. Furthermore, these studies 

would also identify barriers and challenges that women veterans face when seeking 

health care from the VA. Finally, the VA would be required to assess the programs 

that currently exist for women veterans and report this status to Congress. We believe each of these studies and assessments can only lead to higher quality care for 

139 

women veterans in the VA. They will allow the VA to dedicate resources in areas 

that it must improve upon. 

Title II of the bill would target special care needs that women veterans might 

have. Specifically, it would ensure that VA health care professionals are adequately 

trained to deal with the complex needs of women veterans who have experienced 

sexual trauma. Furthermore, it would require the VA to develop a pilot program to 

evaluate the feasibility and advisability of providing reintegration and readjustment 

services to recently separated women veterans in a retreat setting. Additionally, the 

legislation calls for the inclusion of recently separated women veterans on advisory 

committees to allow them to provide their unique perspective as veterans issues are 

considered. This together with programs to subsidize child care for certain women 

veterans receiving health care and those receiving maternity care, will provide an 

excellent environment that considers the unique needs of women veterans. While 

many veterans returning from OEF/OIF are experiencing symptoms consistent with 

PTSD, women veterans are experiencing unique symptoms also consistent with 

PTSD. It is important that the VA understand these potential differences and be 

prepared to provide care. 

PVA views this proposed legislation as necessary and fully supports the Chairman’s decision to include the language of S. 597 within S. 252. The degree to which 

women are now involved in combat theaters must be matched by the increased commitment of the VA, as well as the Department of Defense, to provide for their needs 

when they leave the service. We cannot allow women veterans to fall through the 

cracks simply because programs in the VA are not tailored to the specific needs that 

they might have. Finally, we would encourage the Committee to review the extensive policy section in the FY 2010 edition of The Independent Budget—‘‘Women Veterans’ Health and Health Care Programs.’’ 

S. 793—THE ‘‘DEPARTMENT OF VETERANS AFFAIRS VISION SCHOLARS ACT OF 2009’’ 

As in previous bills, S. 793, the ‘‘Department of Veterans Affairs Vision Scholars 

Act of 2009,’’ provides increased services for an additional at-risk group, veterans 

with vision impairments. PVA has consistently supported the protection of specialized services and supports S. 793. As with other specialty fields, VA suffers from 

a shortage of blind rehabilitation specialists. The scholarship program proposed in 

this legislation should encourage individuals to enter this field to provide rehabilitation services to veterans with visual impairments. However, it is critical that the 

provisions of the legislation concerning outreach and the publication of the program 

be aggressively pursued. Those who may take advantage of the scholarship program 

will be unable to if they do not know about it. 

S. 362—TO IMPROVE COLLECTIVE BARGAINING RIGHTS AND PROCEDURES

PVA supports S. 362 introduced by Sen. Rockefeller that will more quickly resolve 

adverse actions and set deadlines for final decisions. 

S. 734—THE ‘‘RURAL VETERANS HEALTH CARE ACCESS AND QUALITY ACT OF 2009’’ 

S. 658—THE ‘‘RURAL VETERANS HEALTH CARE IMPROVEMENT ACT OF 2009’’ 

PVA recognizes that there is no easy solution to meeting the needs of veterans 

who live in rural areas. These veterans were not originally the target population of 

men and women that the VA expected to treat. However, the VA decision to expand 

to an outpatient network through community-based outpatient clinics reflected the 

growing demand on the VA system from veterans outside of typical urban or suburban settings. As discussed previously regarding S. 246, 40 percent of nearly 2 million VA health care users reside in rural areas, with 44 percent of newly returning 

veterans from OEF/OIF living in rural areas. 

PVA supports S. 734, the ‘‘Rural Veterans Health Care Access and Quality Act 

of 2009,’’ and its provisions to increase the number of health care professionals in 

rural areas. Enhancement of the education debt reduction program at VA for those 

who accept placement in rural areas is an efficient method, though it is only one 

method. In addition, the pilot program on incentives for physicians who assume inpatient responsibilities may also encourage health care professionals to locate in 

rural areas. But these are short term fixes. For this reason we welcome the legislation’s call for a five-year strategic plan by VA with goals for recruitment and retention of health care personnel in rural areas. The challenge of this problem must be 

met by multiple solutions. The inclusion of legislative provisions to expand teleconsultation and telemedicine can help to provide services that may not be generally 

available to rural communities. 

140 

PVA supports S. 658, the ‘‘Rural Veterans Health Care improvement Act of 2009,’’ 

which includes additional methods for improving rural health care. The creation by 

VA of Centers of Excellence for rural care research, education and clinical activities 

may help shed light on how best to provide services in rural areas. PVA supports 

the oversight of these centers by the Director of the Office of Rural Health (ORH) 

and encourage close coordination among the centers and the ORH if more than one 

center is established. The most important provision may be to develop and implement innovative clinical activities and systems of care for veterans in rural areas. 

In addition, demonstration projects on alternatives for expanding care may be beneficial. While all these ideas are welcome, the greatest need still is for qualified 

health care providers to be located in rural settings. Only significant incentives and 

opportunities for these professionals will bring them to these often remote areas. 

PVA also supports the provisions of S. 658 dealing with our Native American veterans by establishing Indian Veterans Health Care Coordinators as well as provisions for a program of readjustment and mental health care services to veterans 

who have served in Operation Iraqi Freedom and Operation Enduring Freedom. 

S. 404—THE ‘‘VETERANS’ EMERGENCY CARE FAIRNESS ACT OF 2009’’ 

Mr. Chairman, PVA strongly supports S. 404, the ‘‘Veterans’ Emergency Care 

Fairness Act of 2009’’ which will remove an unfair burden on our veterans. The legislation will expand eligibility for emergency medical care for some veterans. Currently, veterans who have a third-party insurance provider that pays a portion of 

medical expenses in the event of an emergency, do not have the balance of their 

medical expenses covered by the VA. Having the VA function as a secondary payer 

should eliminate that situation. It will prevent the VA from denying payment for 

emergency service at non-VA hospitals when a veteran is partially covered by their 

third-party insurance. 

S. 498—AUTHORIZE DENTAL INSURANCE FOR VETERANS AND SURVIVORS AND

DEPENDENTS

Regarding S. 498, legislation to authorize dental insurance for veterans and survivors and dependents of veterans, PVA recommends caution in pursuing this legislation. We are concerned with the provisions which appear to establish VA as an 

insurance company, with the Secretary providing dental insurance, identifying dental benefits and treatment, establishing premium rates and managing enrollment 

and disenrollment. S. 252 includes similar language, but establishes the program as 

a pilot. This is a direction that PVA believes is inappropriate for VA. If this need 

is sufficiently significant for VA to establish an insurance program, PVA recommends that existing VA facilities and capability be expanded to meet this need. 

S. 239—THE ‘‘VETERANS HEALTH EQUITY ACT OF 2009’’ 

The intent of S. 239, the ‘‘Veterans Health Equity Act of 2009,’’ is to ensure veterans receive care close to their homes to avoid the time and health hazards of traveling long distances for care. Though the idea of contract care for those displaced 

from VA facilities appears like the simple and obvious choice, there are many drawbacks with the use of VA contracting authority. 

VA already has contracting ability, but it is generally limited to care VA cannot 

provide at its facilities. Allowing an expansion of this authority to provide for general care has the potential to result in the decline of VA as a system of care for 

veterans as more and more locations seek to provide care closer to the veteran and 

away from VA facilities. PVA believes that while this may be useful for some veterans, those with the greatest need for VA care, those with catastrophic spinal cord 

injuries and disease and other specialized services that depend on a well funded VA 

system, will see reduced availability of services provided most effectively by VA. 

While PVA is seriously concerned about the ability of VA to continue providing 

high quality specialized services, we also recognize the serious challenges faced by 

veterans in states with limited VA facilities. PVA acknowledges something must be 

done, and it is VA’s responsibility to determine what steps should be taken to address this problem. Mr. Chairman, we would encourage VA to examine possible alternatives to provide care that will not damage or interfere with the care system 

and services currently provided to veterans. Though PVA believes that any outside 

contract care which meets the standard of VA services will be more expensive, an 

examination of this option, with appropriate coordination of care to ensure veterans 

are receiving the best care possible, may be an option for a future program. However, any pilot or demonstration program implemented by VA should use separately 

designated and appropriated funds outside of VA’s normal budget and must ensure 

141 

coordination with VA to maintain a continuity of records between contract care providers and VA to protect veterans when they return to a regular VA care facility. 

In a time of tight budgets and increasing need due to returning Afghanistan and 

Iraq combat veterans, the pressures on VA to find less expensive and more widely 

available methods to provide care for these veterans can become overwhelming. But 

any modifications to VA care must ensure that veterans most in need of the specialized care provided best by VA do not suffer from any changes made to the system. 

S. 226—MERRIL LUNDMAN DEPARTMENT OF VETERANS AFFAIRS OUTPATIENT CLINIC

S. 509—AUTHORIZE MEDICAL FACILITY IN WALLA WALLA, WASHINGTON

S. 699—FAR SOUTH TEXAS VETERANS MEDICAL CENTER ACT OF 2009

PVA has no position on these proposed bills. All deal specifically with local issues 

or needs and we believe they should be considered within the local needs for facilities and the ability to provide veterans’ services. PVA believes naming issues should 

be considered by the local community with input from veterans organizations within 

that community. For construction projects and the authorization of new facilities, 

PVA believes that if a demonstrated need exists, VA should establish facilities that 

will provide the best care for veterans in the area. 

Mr. Chairman, PVA sincerely appreciates the opportunity to provide our views on 

this important legislation and would be pleased to provide any additional information. We would also point out that much of this legislation is discussed in much 

greater detail in the 23rd edition of The Independent Budget. 

This concludes my testimony and I will be happy to answer any questions you 

may have. 

Senator BEGICH. Thank you very much. 

Senator Burr, do you want to start with questions? 

Senator BURR. Thank you, Mr. Chairman. 

I would like to thank all of our witnesses on the second panel for 

your valuable testimony and the insight that all bring to the table 

on the issues. I am going to focus on two areas very quickly, and 

I am going to pick on you, Adrian. I could ask the guys at the end 

of the table down here, but I am going to spare them. 

Does the DAV think it is appropriate that the names of servicedisabled veterans are sent to NICS when Social Security recipients 

aren’t for the same circumstances? 

Mr. ATIZADO. Well, sir, I appreciate the question in light of my 

colleagues at the end of the table. In our testimony, if you will note 

that we don’t have a resolution on this issue. Whether or not our 

organization would support or oppose a bill really depends on what 

our membership passes at our national convention, and since we 

don’t have a resolution on this specific matter, we can’t take a position on the bill, Senator. 

Senator BURR. And I appreciate that. I know how the member 

organizations operate up here—let me just say for the benefit of all 

three—because there were no positions from any. 

I think that when you have a population that entrusts you with 

the issues that are of great importance to them, when you have one 

that I think is a constitutional question, I think you have to go 

above and beyond to sell to the members why their voice should be 

heard. I am not sure that there is any veteran of the 117,000 that 

are out there that are sitting at home saying, ‘‘You know what? 

This was appropriately applied to me.’’ And I am not sure that 

members of all the organizations aren’t sitting at home saying, ‘‘I 

hope that never happens to me.’’ I am not sure that anybody is 

wishing this to happen. 

This needs to be reversed. It does. And I think that every organization that represents veterans should look at this as a potential 

142 

loss of their individual rights and engage their membership. Granted, it is not number 1 on everybody’s list; I understand that. But 

I don’t think we have the ability to pick and choose which ones we 

are going to be engaged in and which ones we are not. So, I hope 

you will take it back to the annual meeting and propose that you 

do take a position as strongly as you can. And Blake, also with you; 

and Ralph, if appropriate, with you. 

If I didn’t miss anything, I think most of you were supportive of 

the Family Caregiver Act and I believe that this is vitally important that we move forward. 

I will defend the VA for a little bit. They had many more responsibilities and they have got to make sure that the overall architecture that they set up continues to work and function. And I think 

that it puts a higher threshold on the Chairman and me to work 

with VA to make sure that what we are attempting to do works 

within that framework, and I pledge to them to continue to do that. 

But I also pledge to you that at the end of the day, we are going 

to have a caregiver program that provides for those family members that choose to take care of their loved ones. I think it is in 

the best interest of those veterans who have been injured. It is in 

the best interest of the family that feels the closest to them and 

desires the most—as much of a recovery that they possibly can 

have. And clearly, since we offer this to other populations in America—typically that care is extended through Medicaid in different 

fashions determined by States—I don’t know why the Veterans Administration should be excluded from it. 

So, I appreciate the comments all of you have made. Where you 

still have issues that are thorny or rough, I look forward to working with you on any language where we might need to make 

changes to smooth that out. Once again, I thank you. 

Senator BEGICH. Thank you very much, Senator Burr. 

I have a 4:30, so I am going to ask a couple of questions, and 

then, Senator Burr, I will come back to you for any additional questions; and then I will close it off. 

I do have a couple of questions that the Chairman wanted to ask, 

so I am going to ask them on his behalf. The first one is to Mr. 

Ortner. The PVA testified in 2007 against the VA partnering with 

the Centers for Medicare and Medicaid Services to utilize critical 

access hospitals. Does the organization still object to that or have 

they modified their position, or are you aware of that? 

Mr. ORTNER. I am not aware. I would be happy to take that for 

the record and I will go back and we will get an answer for the 

Chairman. 

Senator BEGICH. That would be great. That was a couple of years 

ago and there may have been a change since then. But if you could 

follow that up and give it to the Committee, that would be fantastic. 

Mr. ORTNER. And I wasn’t present at PVA at the time that was 

testified. 

Senator BEGICH. I love it. We newbies. I get to say, that all happened last year; I wasn’t here. So I am with you on that. But thank 

you very much. 

[Response to the request follows:] 

143 

PARALYZED VETERANS OF AMERICA, 

Washington, DC, May 20, 2009. 

Hon. DANIEL K. AKAKA, 

Chairman, 

Committee on Veterans’ Affairs, 

U.S. Senate, Washington, DC. 

DEAR MR. CHAIRMAN: Thank you for the opportunity to respond to questions from 

Paralyzed Veterans of America’s (PVA) April 22, 2009 testimony on pending legislation before the Committee. 

Regarding Mr. Begich’s question on your behalf in reference to PVA’s 2007 testimony against VA partnering with the Centers for Medicare and Medicaid Services 

to utilize critical access hospitals, PVA would like to offer the following response for 

the record. 

I believe the Chairman was referring to PVA’s June 14, 2007, testimony to the 

House Committee on Veterans’ Affairs Subcommittee on Health. PVA expressed its 

concerns about demonstration projects between VA and the Centers for Medicare 

and Medicaid Services. PVA believed that congressional legislation may have been 

‘‘jumping the gun’’ and getting ahead of the Office of Rural Health’s ability to assess 

demonstration projects. 

PVA’s position has not changed. The Office of Rural Health (ORH) was established to develop policies and identify and disseminate best practices and innovations to improve health-care services to veterans who reside in rural areas. This is 

a noble goal and ORH is now established and working its mandated activities, but 

it is still relatively new and at the threshold of tangible effectiveness. But more specifically, PVA does not believe it is the proper role of Congress to legislate specific 

solutions to rural health problems. It is much more critical that Congress provide 

aggressive oversight to ensure VA is providing the high quality of care veterans are 

due, regardless of their location. It is not simply enough to increase the access to 

care. VA increasing its fee based care will provide greater access, but at what longterm cost to the veteran. 

ORH must concentrate on its coordination role. Public Law 109–461, the ‘‘Veterans Benefits, Health Care, and Information Technology Act of 2006,’’ which established the Office of Rural Health and its mission requirements, in Section 213 of 

the law requires VA to work at the local level with, among other institutions, critical access hospitals located in rural areas. The intent was to increase the awareness of veterans and their families of the availability of VA health care and how 

they can access such care from VA. Congress should emphasize this coordination 

role and demand from ORH specific examples of its success or progress toward success. This is where Congress can provide the greatest overall impact on rural care. 

Additionally, the Office of Rural Health should have the opportunity to develop 

programs that will help provide high quality health care to the rapidly increasing 

number of rural veterans. Congress needs to provide the stringent oversight to insure ORH is meeting the goals of policies and practices on care which is of the same 

quality or better than that provided at VA facilities. ORH must not only disseminate 

the practices and innovations, but should monitor that its recommendations are 

being implemented and if not, why. 

The Office of Rural Health has a daunting mission. With over 40 percent of veterans living in rural areas and almost 80,000 living in ‘‘highly rural’’ locations, VA 

must develop new and innovative techniques to care for these veterans. But these 

challenges in no way permit providing lesser quality care than these deserving veterans would receive from any other VA facility. This must be ORH’s first mission. 

More information on the concerns of PVA and other VSOs regarding rural health 

care issues is contained in The Independent Budget for Fiscal Year 2010 produced 

by AMVETS, Disabled American Veterans, Paralyzed Veterans of America and the 

Veterans of Foreign Wars. 

Sincerely, 

BLAKE C. ORTNER, 

Sr. Associate Legislative Director. 

Senator BEGICH. Mr. Ibson, many of the VA’s current caregiver 

pilot programs do not include—and I know some of you already testified on this, but I want to put his question on the record so the 

answer is crystallized here. Current caregiver pilot programs do 

not include financial support for the caregiver—something you 

talked about as well as others. Can you tell the Committee why 

144 

caregivers need the monetary stipend in addition to counseling, 

training, and other forms of support? Specifically, why monetary is 

important, if you could add to that and then we put that into the 

record, that would be fantastic. 

Mr. IBSON. Surely. I think the experience we have seen with 

caregivers is, as I indicated, that their lives have been completely 

irrevocably altered. Family members have left their jobs to be at 

the bedside of their loved ones and have not left that bedside. Economic concerns have been set aside in what becomes a self-sacrificing mode. Ultimately, that burden will take its toll, not only in 

terms of mental health, emotional health, overall health, but economically, as well. We see a need to sustain that caregiving, and 

in order to do so, it is our view that a broad array of services is 

needed to provide adequate supports—not simply emotional support, not simply respite, not simply counseling and training, but a 

financial stipend, as well—to sustain the caregiving. 

Senator BEGICH. Thank you for that. 

I will just give you 2 seconds here. I have a nephew who has 

spina bifida and Medicaid; I have another nephew who is his caregiver and gets a stipend. I just wanted to make sure the Chairman 

had his question, but I also am very sensitive to the issue and 

making sure that the economic opportunities are there because it 

does put lots of stress for all the reasons you have just said. 

Let me ask, if I can, just one more. I will not do well with your 

name. I will do my best. Mr. Atizado and also Ms. Hilsabeck, this 

is for both of you. The Chairman noted your testimony, which indicates the DAV’s and the AFGE’s full support of S. 743, the Rural 

Veterans Health Care Access and Quality Act of 2009, in part because it improves oversight of contract and fee-based care. Could 

you comment on why you see the need to improve oversight in this 

area? If you could be just brief, but just again emphasize a little 

bit of your testimony, again, crystallizing it for this question, either 

one of you. 

Ms. HILSABECK. Thank you for the question, but I wouldn’t be 

really prepared to answer that. I would have the AFGE—the 

union—get that information. 

Senator BEGICH. OK. That would be fair. If you can get that information to the Chairman, that would be fantastic. 

Ms. HILSABECK. OK. 

Senator BEGICH. Thank you. 

[Response to the request follows:] 

RESPONSE TO REQUESTS ARISING DURING THE HEARING BY HON. DANIEL K. AKAKA

TO AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, AFL–CIO 

At the April 22, 2009 hearing, Senator Begich requested that AFGE elaborate on 

the statement in its written testimony on S. 734 about the need for oversight of VA 

contract and fee basis health care, especially the Project HERO pilot project, 

Generally, AFGE is deeply concerned about the lack of adequate oversight of all 

VA contract health care arrangements, in terms of 

• Lack of cost effectiveness; 

• Inferior quality of care for specialized veterans’ needs; 

• Lack of coordination between contract providers and VA providers; and 

• Long range impact on contract care on VA’s internal capacity to meet veterans’ 

health care needs through direct care, research and academic affiliations. 

145 

1The conference report for the 2006 VA appropriations law is the only source of authority for 

Project HERO. The following 196 words addressed the need for contract care management, and 

were never intended to serve as the basis for this vast pilot project: 

Contract Care Coordination—The conferees support expeditious action by the Department to 

implement care management strategies that have proven valuable in the broader public and private sectors. It is essential that care purchased for enrollees from private sector providers be 

secured in a cost effective manner, in a way that complements the larger Veterans Health Administration system of care, and preserves important agency interest, such as sustaining a partnership with university affiliates. In that interest, the VHA shall establish through competitive 

award by the end of calendar year 2006, at least three managed care demonstration programs 

designed to satisfy a set of health system objectives related to arranging and managing care. 

The conferees encourage the Department to formulate demonstration objectives in collaboration 

with industry and academia, and the Secretary will report objectives to the Committees on Appropriations of both Houses of Congress within 90 days of the enactment of this Act. Multiple 

competitive awards and designs may be employed that may incorporate a variety of forms of 

public-private participation. The demonstrations, in satisfying the objectives to be enumerated, 

must be established in at least three VISNs, be comprehensive in scope, and serve a substantial 

patient population. 2See statement by VA National Program Manager Greg Eslinger in February 2009 news report. http://wcco.com/health/project.hero.veterans.2.939294.html 

I. FEE BASIS CARE

With regard to fee basis care specifically, we believe that many VA medical facilities are over relying on fee basis care, in violation of the statutory requirement that 

these arrangements only be made when VA in-house care is ‘‘scarce’’ i.e. not available. Our members regularly report that managers at their facilities turn to costly 

fee basis care rather than make effective staffing plans or utilize the recruitment 

and retention tools enacted by Congress to fill nurse and physician vacancies (e.g. 

nurse locality pay and alternative work schedules, physician market pay and performance pay). Overreliance on fee basis care also threatens the quality of care: fee 

basis providers lack the expertise and specialization of VA providers who exclusively 

treat veterans within the VA system, and they are less familiar with unique combat 

related injuries such as Traumatic Brain Injury. 

We have heard that a number of facilities are currently facing budget shortfalls— 

despite unprecedented budget increases from Congress—because they are providing 

and more of their care through expensive fee basis arrangements. 

Recommendation: We urge Congress to conduct oversight into the current status 

of VA’s fee basis program, including expenditures by each VA medical facility on fee 

basis care, credentials of fee basis providers, effectiveness of coordination between 

contract providers and VA providers, and the adequacy of VA personnel needed to 

arrange and oversee fee basis arrangements. 

II. PROJECT HERO

Project HERO has been touted as the cure for all the woes of fee basis care. Nothing could be further from the truth. This pilot project was implemented without adequate Congressional authority.1 It has been conducted in near secrecy. It is draining 

VA medical centers of substantial portions of their budgets and resulting in reductions of the very in-house personnel needed to effectively arrange and oversee contract care. It is costing the VA more than fee basis care arranged directly by VA 

personnel. It has not resulted in greater access for rural veterans and in fact, is impeding access for many veterans who are being forced to go to HERO providers and 

travel further when they prefer to receive their care within the VA. 

The reach of Project HERO is enormous: the pilot covers 33 states in 4 VISNs 

(8, 16, 20 and 23) and by the VA’s own admission, now covers thirty percent of all 

veterans enrolled in the VA.2 Yet, on the HERO webpage, it describes HERO as ‘‘a 

pilot program that helps Veterans access the health care they need when specific 

medical expertise or technology isn’t available inside the VA health care system’’ (emphasis added). Clearly, a 30% penetration rate is directly contrary to HERO’s own 

stated goal of supplementing, not supplanting, VA’s in-house services. 

Based on reports from the field, it appears that HERO may not be consistently 

fulfilling other key commitments it made on its VA webpage: 

• ‘‘When Veterans need care that’s not available at their local VA medical 

center... Project HERO supplements VA care with credentialed quality medical 

and dental providers to quickly meet their needs.’’ 

• ‘‘HVHS (Humana Veterans Health Services) is committed to contacting Veterans for appointments within five days, and both HVHS and Delta Dental arrange 

for Veterans to see specialists within 30 days. Veterans also wait less than 20 minutes to see the doctor or dentist once they’ve checked in for their appointments.’’ 

146 

3 AFGE has information that Humana may be charging the VA 105% of Medicare plus a referral fee per patient. In contrast, it is our understanding that when VA arranges its own contract 

(‘‘fee basis’’ care) it pays the providers 100% of Medicare and there are no other fees involved. 4 AFGE has received reports that several local facilities, including Minneapolis, Black Hills 

and Seattle have gone into budget shortfalls because of increasing costs for HERO and other 

contract care. 

• ‘‘Veterans have peace of mind knowing their medical and dental records are returned to VA so their primary doctors and dentists can provide more informed, continuous care over time.’’ 

• ‘‘Veterans can trust VA is using resources wisely while maintaining high quality 

care. With Project HERO, HVHS and Delta Dental offer consistent, competitive pricing and they send invoices directly to VA for payment.’’ 

The VA has also not kept its commitment to keep labor organizations adequately 

informed about HERO, which it identifies as a ‘‘partner’’. They have not met AFGE’s 

multiple requests for a face-to-face briefing, and at best, have supplied a few very 

general PowerPoint presentations to the AFGE VA Council leadership at group 

meetings. Our members on the front lines of health care have been given no role 

in overseeing or consulting on the use of HERO care. 

We have brought our concerns to Senator Johnson, Chair of the Senate Mil-ConVA Appropriations Subcommittee. South Dakota is also one of the states most heavily impacted by HERO to date. (Generally, the HERO pilot is VISN 23 is the most 

developed but we also are aware of HERO activity in VISNs 8, 16, and 20.) 

Recommendation: The following are the questions that we have raised with appropriators. We hope this Committee will also conduct oversight to secure answers to 

these questions. 

I. Source of funding for HERO 

a. Which designated accounts are used to fund HERO administrative costs at 

each level (VA Central Office (VACO), VISN office and facility)? 

b. Which accounts are used for payments to HVHS and Delta Dental for the 

services they arrange, related referral fees, etc. 

c. Are fee basis dollars used to cover any HERO costs? If yes, what statutory 

authority does the VA rely on to use fee basis dollars? 

II. Cost Effectiveness3

a. What is the fee arrangement between VA and contractors for different 

types of care, and how do these fees relate to the Medicare fee schedule? 

b. What other costs are billed to the VA, e.g. referral fees? 

c. Provide data on all payments to contractors since the inception of the pilot 

project. 

d. Provide data on all administrative costs incurred at each level for the VA 

to operate this pilot project since HERO’s inception. 

III. Impact on Medical Center budgets4

a. For each facility participating in HERO, provide data indicating the percentage of the facility’s budget that has been used to cover HERO fees, administrative costs and other HERO expenses. 

b. For each facility participating in HERO, provide data indicating staffing 

levels for positions relating to care coordination (with HERO contractors and 

other contract care providers) including clinical care coordinators. 

c. For each facility participating in HERO, provide data on staffing policies 

(e.g. hiring freezes), vacancies and other staffing changes since the date that the 

facility began participation in HERO. 

IV. Impact on quality of patient care 

a. Provide copies of all provider networks established by HVHS and Delta 

Dental to date. 

b. What criteria are used to screen candidates for the HVHS and Delta Dental provider networks? 

c. What if any complaints has the VA received regarding HVHS and Delta 

Dental providers? 

d. What type of orientation is required for providers participating in HVHS 

and Delta Dental networks? 

e. How does the VA (at each level) oversee the quality of care provided by 

HERO network providers? 

f. What procedures are in place to ensure that contract providers make proper 

referrals (to the VA or outside the VA) when veterans need specialty care or 

other referrals? 

147 

g. Provide data indicating the number and type of referrals, and provider 

name and address, for each referral made by contract providers since the inception of the pilot project. 

h. Are the contractors required to provide the same level of care provided for 

equivalent services at the VA, e.g. physician or nurse, primary care or specialist? 

i. What are the skill levels of personnel employed by the contractors who coordinate referrals and care with the VA? 

V. Other care coordination issues 

a. Provide a copy of procedures for sharing of medical records between the VA 

and the contractors, and their network providers. 

b. What safeguards are in place to ensure that sharing of records protects veterans’ personal health information? 

c. Provide all reports received to date regarding problems with medical record 

exchanges between the VA and the HERO contractors. 

d. Provide a copy of procedures used to ensure that contractors provide other 

medical services timely and properly, including prescriptions and prosthetics. 

VI. Impact on access 

a. What geographic criteria do contractors use to identify and recruit providers to their network? 

b. What percentage of VA referrals have contractors been unable to fill due 

to lack of geographically accessible providers? 

c. What percentage of VA referrals have contractors been unable to fill due 

to lack of appropriate specialists? 

d. Provide data indicating travel times required for veterans using HVHS and 

Delta Dental providers, in comparison to travel times required to equivalent 

providers within the VA or fee basis providers contracting directly with the VA. 

e. Provide data indicating the HERO contractors’ success in meeting HERO’s 

stated commitment of contacting veterans for appointments within five days, arranging for veterans to see specialists within 30 days and limiting the amount 

of time the veteran waits at the provider’s office to less than 20 minutes after 

checking checked in for their appointments 

f. What reports has the VA received of dissatisfaction by providers who contracted with HVHS or Delta, or evidence of reluctance by medical professionals 

or other providers (including dialysis facilities) to join the HVHS or Delta Dental networks? 

g. What are the VA’s criteria for determining which patients to refer to HVHS 

and Delta Dental, rather than treat in-house or refer to a fee basis provider arranged directly by the VA? Has the VA imposed any fixed quotas on facility directors as to the number of patients that must be referred to HERO contractors? 

VII. Oversight and Evaluation 

a. Describe all efforts by HVHS and Delta Dental to provide performance data 

and other information to lawmakers and partners (academic affiliates, VSOs 

and labor unions)? Provide all materials provided to lawmakers and partners. 

b. What criteria were used to award the initial contract to HVHS and Delta 

Dental? Was the award made competitively? Provide a copy of first year contracts with HVHS and Delta Dental. 

c. What criteria were used to award the second year contract to Humana and 

Delta Dental? Provide a copy of the second year contract. 

d. What criteria were used to award additional specialty area contracts to 

Humana and Delta Dental during the first year? Provide copies of all such contracts. 

e. Provide copies of all evaluations completed to date and all pending evaluations conducted by VA to determine the impact of HERO on the quality, timeliness and accessibility of veterans’ care, patient satisfaction and cost effectiveness. 

VIII. Patient Satisfaction 

a. What information is provided to veterans regarding referrals to HERO contractors? Are they informed that they have a right to refuse an outside referral? 

Please provide copies of all documents provided to veterans about HERO and 

the referral process. 

b. Have any veterans been told that if they refuse a referral to HVHS or 

Delta Dental, that they will be denied VA care? Are facilities permitted to impose this requirement? 

c. What oversight has the VA conducted to ensure that veterans are fully informed of their rights in the referral process? 

148 

d. Provide data on the out-of-pocket medical costs incurred by all veterans 

using HERO providers who faced these additional costs. 

e. What information is given to veterans about the safeguarding of their medical records when their cases are referred outside the VA? 

XI. IMPACT ON RESEARCH: What evaluations has the VA done to determine 

the impact of HERO on VA’s research capacity? Is HERO causing VA and academic 

researchers to lose volunteer patients needed for research programs? 

XII. IMPACT ON ACADEMIC AFFILIATES: What evaluations has the VA done 

to determine the impact of HERO on VA’s relationship with academic affiliates and 

opportunities for medical training? The impact on VA’s medical school and other 

health professions training programs at the local level when a large portion of subspecialty work is diverted outside the VA and university systems? Is HERO causing 

medical schools and the VA to lose the very patients they need for teaching purposes. 

Mr. ATIZADO. Senator Begich, thank you for the question. The 

DAV believes that oversight for VA’s fee-basis program is needed 

simply because this program is fraught with problems: anywhere 

from the IT infrastructure or software that is utilized, the training 

of the people that run the fee-basis program; as well as the care 

that is purchased; the way it is not coordinated or lack of coordination. In fact, VA right now is conducting a project called Project 

HERO that is supposed to answer most of the concerns that we 

have about fee-based and contract care that VA currently does. We 

are learning more about that program, but if you would like, I can 

provide you a more detailed answer for the record. 

RESPONSE TO REQUESTS ARISING DURING THE HEARING BY HON. DANIEL K. AKAKA

TO ADRIAN M. ATIZADO, ASSISTANT NATIONAL LEGISLATIVE DIRECTOR, DISABLED

AMERICAN VETERANS

Question. The Chairman noted your testimony, which indicates the DAV’s and the 

AFGE’s full support of S. 734, the Rural Veterans Health Care Access and Quality 

Act of 2009, in part because it improves oversight of contract and fee-based care. 

Could you comment on why you see the need to improve oversight in this area? 

Response. Current law places limits on VA’s ability to contract for private health 

care 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 with exception to Section 403 in Public Law 110–387, the Veterans’ Mental Health and Other 

Care Improvements Act of 2008. This provision directs VA to conduct a three-year 

pilot program under which a highly rural veteran who is enrolled VA health care 

and who resides within a designated area of a participating VISN may elect to receive covered health services through a non-VA health care provider at VA expense. 

According to VA, 41 percent (over 3.2 million) of its enrolled veteran population 

live in rural and highly rural areas, and approximately 40 percent of veterans receive some of their care from a non-VA health care provider. This represents a significant portion of the enrolled veteran population that has an identifiable need for 

expanded access to VA health care. 

However, increased use of VA purchased care whether through contract and/or 

fee-base can silently shift the balance of clinical material that will result in unintended consequences for VA, unless carefully administered. Chief among these is the 

diminution of established quality, safety, and continuity of VA care for rural and 

highly rural veterans. It is important to note that VA’s specialized health care programs, authorized by Congress and designed expressly to meet the specialized needs 

of combat wounded and ill veterans, such as the blind rehabilitation centers, prosthetic and sensory aid programs, readjustment counseling, polytrauma and spinal 

cord injury centers, the centers for war-related illnesses, and the national center for 

Post Traumatic Stress Disorder, as well as several others, would be irreparably impacted by the loss of veterans from those programs. Also, the VA’s medical and prosVerDate Nov 24 2008 19:35 Oct 22, 2009 Jkt 000000 PO 00000 Frm 00152 Fmt 6633 Sfmt 6621 H:\111TH HEARINGS\042209.TXT SVETS PsN: PAULIN
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thetic research program, designed to study and, hopefully, cure the ills of injury and 

disease consequent to military service, could lose focus and purpose were serviceconnected and other enrolled veterans no longer physically present in VA health 

care. Additionally, title 38, United States Code, section 1706(b)(1) requires VA to 

maintain the capacity of its specialized medical programs and not let that capacity 

fall below the level that existed at the time when Public Law 104–262 was enacted 

in 1996. Unfortunately some of that capacity has dwindled. 

We recommend the principles of our recommendations from the ‘‘Contract Care 

Coordination’’ section of the Independent Budget (IB) for Fiscal Year (FY) 2010 be 

used as a guide for VA to develop an integrated program of contract care coordination for veterans who receive care from private health care providers at VA expense, 

while mitigating the aforementioned unintended consequences that diminish VA 

health care. 

RURAL OUTREACH COORDINATORS

The DAV believes much can be done to improve the use of purchased non-VA care. 

For example, components of a coordinated care program should include a care and 

case management system to assist every veteran and each VAMC when a veteran 

must receive non-VA care. Notably, a provision in Section 7 of S. 734 would require 

VA to establish rural outreach coordinators at each CBOC with a majority of enrolled veterans who reside in ‘‘highly rural’’ areas. 

Ostensibly, these rural outreach coordinators would fall under VA’s Office of 

Rural Health (ORH), whose mission includes identifying and implementing new initiatives such as increasing mobile clinics, establishing new outreach clinics, expanding fee-based care, exploring collaborations with Federal and non-Federal community partners, operating the Rural Health Resource Centers, accelerating telemedicine deployment, developing workforce recruitment initiatives, developing web-based 

information delivery methods and funding innovative pilot programs. Notably, VA’s 

budget submission for FY 2010 projects an increase in fee workload of 24 percent 

from 2008, and an increase in rural health spending through the ORH of $380 million from 2009. 

As part of the IB, the DAV believes veterans who receive private care at VA expense and authorization should be required to participate in the care coordination 

program, with limited exceptions. This provision of S. 734 would require the coordinator at a clinic to be responsible for coordinating care and collaborating with community contract and fee-basis providers with respect to the clinic. We believe this 

is a good first step in care coordination for rural and highly rural veterans enrolled 

in the VA. 

CONSOLIDATION OF COMMUNITY-BASED OUTPATIENT CLINIC (CBOC) CONTRACTING

As part of the IB, the DAV believes consolidated CBOC contracting offers VA a 

way to standardize the health care benefits to veterans served by individual VAMCs 

and provides greater efficiencies and cost savings to help meet the increasing health 

care needs of veterans in rural or underserved areas and areas not directly served 

by a VA medical facility. 

Specifically, consolidated CBOC contracting would provide greater continuity of 

care and uniformity of benefit; simplify contract administration and oversight allowing for more efficiency; responsive capacity by sharing of health care providers based 

on demand; provide consistent and uniform medical care services; consolidate training on VA programs and procedures, including use of Veterans Health Information 

Systems and Technology Architecture (VistA); and standardized CBOC reporting. 

We invite the Committee to read more details on this issue in the FY 2010 IB article, ‘‘Community Based Outpatient Clinics.’’ 

ESTABLISH INCENTIVES TO OBTAIN ACCREDITATION OF PARTICIPATING FEE-BASIS PRIVATE PROVIDERS, AND TO ENCOURAGE THESE PROVIDERS TO PARTICIPATE IN VA’S

PEER REVIEW SYSTEM

The DAV believes VA’s health delivery system must promote and ensure health 

care quality and value, and protect veterans’ safety. The Veterans Health Administration (VHA) has created a culture of quality by measuring important clinical outcomes, many of which fall within the domain of primary care. In addition, part of 

VA’s quality of care includes the many safeguards built into the VA system through 

its patient safety program, evidence-based medicine, electronic health record and 

bar code medication administration. Loss of these safeguards, ones that are generally not available in private sector systems, would equate to diminished oversight 

and coordination of care, and ultimately may result in lower quality of care for those 

who deserve it most. 

150 

An important tool to expand access to VA health care in rural areas is its use 

of fee care. Notably, sections 212(b) and (c) of Public Law 109–461 requires an extensive assessment of the existing VA fee-basis system of private health care, and 

eventual development of a VA plan to improve access and quality of mental health 

and long-term care for enrolled veterans who live in rural areas. To further such 

requirements, section 7 of S. 734 seeks to establish incentives to obtain accreditation of participating fee-basis private providers, and to encourage these providers to 

participate in VA’s peer review system. Each VA rural outreach clinic is part of a 

VA network and maintains VA’s quality standards. When conducted systematically 

and credibly, peer review can result in both immediate and long-term improvements 

in patient care by revealing areas for improvement in individual providers’ practice. 

Mr. Chairman, you mentioned VA currently has no standardized procedure in place 

to ensure non-VA purchased care veterans receive in the community are of equal 

or better quality than that which they would receive directly from VA. This provision is consistent with the principles of the recommendations from the ‘‘Contract 

Care Coordination’’ section of the IB for FY 2010. 

Senator BEGICH. Very good. If you could do that, that would be 

great. 

I just got a note that a vote has started, so I am going to just 

close it up and say thank you all again for your testimony, for both 

panels. Again, for information for all, the Committee’s markup is 

scheduled for May 21 and it is the hope of the Chairman that at 

that time, we will move a number of these bills presented today. 

For the Administration witnesses, we ask that you review all the 

bills that are going to be up for markup and submit your views no 

later than 1 week prior to markup—by May 14—especially after 

the Chairman’s commentary today. I would even have it back by 

May 13—be 1 day early. That would be good. He would like your 

commentary on the bills prior to May 14. 

I know many of you have submitted testimony for the record. We 

appreciate that. Again, markup will be on May 21 on several of 

these bills. 

At this time, I will adjourn the meeting and thank you all for 

testifying. 

[Whereupon, at 4:32 p.m., the Committee was adjourned.] 

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A P P E N D I X 

PREPARED STATEMENT OF LT. JERRI GEER, USCG (RET.), SEATTLE, WA 

Chairman Akaka, Ranking Member Senator Burr and Committee Members: I am 

LT. Jerri Geer, USCG (Ret.) and I am extremely grateful to be asked to speak with 

you today. I am honored to be here. Thank you. 

I live in the Seattle, Washington, area and go to the Seattle VA Medical Center 

for my health care. 

To begin, I live with the challenges of Bipolar Disorder. I have struggled with this 

disability for over thirty years and have always been responsible for my health and 

personal aspects of my life. Being Bipolar, I have had difficulties with my finances 

over the years, but have always been responsible for my debts and have never been 

late on my payments. I have always paid my debts in full. My FICO scores are between 783 and 785, which are considered excellent. However, in the fall of 2002, 

I was very afraid that I had gotten into a financial situation that I might not be 

able to handle. I thought I could trust my social worker and my psychiatrist at the 

Seattle VAMC, so I finally asked for help. This is when all the trouble started. They 

informed me about a program through the Seattle VA Regional Office that helps 

Veterans with their finances. After being told what I thought were all the facts 

about the program, I asked to be put in it. My psychiatrist wrote a letter to request 

this for me. A red flag immediately went up when I read the word incompetent in 

that letter. I asked my social worker what that meant and she said it was just a 

term the VA uses for this program; that it was unfortunate the VA couldn’t find 

a better term for my situation. I asked her if this had any legal consequences outside the VA and she said no. Neither she, nor my psychiatrist, ever told me about 

the Brady Act—National Instant Criminal Background Check System (NICS). This 

letter is dated December 2, 2002. I really wanted to get help, so I signed the letter. 

I didn’t know about the Brady Act until I received my proposed rating letter of 

January 23, 2003, adjudicating me incompetent and I was to be assigned a fiduciary. In the letter it stated I was permanently barred from purchasing a firearm. 

Because I don’t like guns, I didn’t pay any attention to it. It took until May 2003 

before I met my Field Investigator. During this time, I had read Suze Orman’s 

books on finances and had actually regained control of my finances. When my Field 

Investigator saw what I had done, she said I really didn’t need to be in the program 

and would recommend that to my psychiatrist. My psychiatrist didn’t agree and 

wanted me to be on supervised pay and not have a payee. I only saw my Field Investigator twice: in the beginning, May 2003; and at the end, a year later in May 

2004. During this period I managed my own affairs. 

At my last meeting with my Field Investigator I was reminded once again I was 

permanently barred from purchasing a firearm. At that point, I realized I needed 

to know what that really meant. I received my competency rating November 19, 

2004. I started researching the Brady Act later in January 2005. This is when I discovered the real ramifications and became concerned and angry that I was not told 

about this NICS when I volunteered to be put into the fiduciary system. I told my 

social worker and psychiatrist of my anger and fears. Apparently the VA Regional 

Office failed to inform the VA Medical Center about this NICS-Brady Act. If my psychiatrist had known, she would not have put me in this program. I was never incompetent and she knew I just wasn’t the kind of person that should be in this 

NICS database. She apologized and said she was ignorant about this. I think she 

152 

was genuinely upset that she was not informed. Other patients had also been put 

in this system that were not incompetent. In my heart, I feel I was deceived, however unintentionally. 

I decided this was an egregious miscarriage of justice. I spent at least three 

months researching on the internet and found information and misinformation concerning the Brady Act. Since I have no legal background, I tried earnestly to obtain 

information from the VA and the NICS, both of which kept pinging me back and 

forth between the two, saying the other could only remove my name from this database. I called the NICS for information three times and each time I received three 

different answers to the same question, ‘‘How can I remove my name from the 

NICS.’’ They essentially told me the original agency that adjudicated me incompetent is the only one that can remove my name, which would be the VA. 

I put a claim through the DAV to the Seattle VA Regional Office requesting they 

remove my name from the NICS in April 2005. I waited until June 2005 for a response, but none came. I decided to see Senator Patty Murray’s staff member, Ms. 

Muriel Gibson in Seattle for help. She sent a Congressional Inquiry to the VA Regional Office in June 2005. 

The VA responded in August 2005 to Senator Murray’s Congressional Inquiry saying they could not remove my name, but sent a pamphlet giving me information on 

how to contact the NICS to remove my name. The pamphlet instructed how to appeal, but only after trying to purchase a firearm and the last paragraph indicated 

the original agency would be a key factor in the appeal. I felt the NICS appeal process was another path that would again put responsibility back on the original agency—the VA. 

Therefore, Ms. Gibson and I decided to send a letter to the VA Judiciary Council 

asking them to remove my name from the NICS in August 2005. I waited until December 2005 for a response. None came. Ms. Gibson then contacted the VA Judicial 

Council which stated a reply had been sent in October 2005. Needless to say, I did 

not receive it. Ms. Gibson was faxed the response which again said the NICS was 

the only agency that can remove my name and only after I tried to buy a firearm. 

Since my stance of not wanting to buy a gun would be compromised, a letter was 

again sent to the VA Judiciary Council in December 2005 explaining my request. 

The VA sent another response dated March 2006 which denied my request once 

again to Senator Murray’s office; however, I did not receive this letter until May 

2007. 

At this point, my spiritual needs were becoming serious and I turned to my Chaplain at the VA Medical Center. She called the attorney at the VA Regional Office 

and the attorney said she had never heard of this issue and referred my Chaplain 

to the Chief of Security at the VA Medical Center in Seattle. 

Back in July 2005, I began to realize I seemed to know more about the NICS than 

the Federal Government. Even when a mistake has been made by the VA, a name 

cannot be removed. This, in my opinion, takes away my right to ‘‘due process’’ which 

is my Fifth Admendment Right and my Second Admendment Rights. So, I made a 

desperate move to write Chairman Craig on July 16, 2005. I also sent the same letter to the Chairman of the House Committee on Veterans’ Affairs and Ranking 

Members of both the Senate and House of Representatives. Fortunately, Chairman 

Craig’s staff member, Major David Buffaloe, USA, took the letter seriously and 

began researching this issue. He contacted me and told me that neither he nor other 

staff members knew about this and together we all began a journey that has led 

me to testify before you today. 

I believe the Brady Act is not only an illegal act pertaining to veterans, but an 

ethical, civil rights, and privacy issue. I find it unbelievable that a Federal agency 

such as the Veterans Administration would make an agreement with another Federal agency without at least researching the various laws concerning the appropriateness of such an agreement. I feel the VA did little or no oversight and failed 

to protect the rights of veterans, their children and spouses. I later learned from 

Major David Buffaloe that the VA was also putting the names of veteran’s children 

into the NICS when they became orphaned or for other reasons. This is unconscionable. Anyone with an ounce of sense would know the terrible ramifications of such 

153 

an act when these children become adults. It makes me believe that there is no one 

at the helm in the VA and the VA is derelict in its duties. 

The Brady Act was not created to put innocent children’s names in the NICS nor 

innocent adults. It is too broad, overreaching and is flawed. I do believe it was born 

out of fear, high emotions, feelings of not having control over the escalating violence 

in this country, ignorance, stereotyping and a belief system about the mentally ill 

that is vastly untrue and antiquated. It was well intended; however, it has cast a 

very wide net and innocent people have been swept into it, simply because they 

swim in the same ocean. 

Before any citizen has their Constitutional Rights removed, it should be done only 

through a court of law and the right of legal council. Now, I do understand there 

are special circumstances, but it should always be done though a court of law. Right 

now felons have more legal rights than veterans. 

After researching this issue, rbecame aware that this quest to remove my name 

from the NICS was not just about me, but about all veterans whose names are also 

sacred. This situation has been devastating to me. I feel my name has been stolen 

and my honor has been tainted. My whole sense of safety has been destroyed. I need 

my name removed from the NICS because I am not a ‘‘mental defect’’ and ‘‘a threat 

to public safety’’ and I was never ‘‘incompetent.’’ This is very detrimental to my 

health. In the past, I have been open about my Bipolar Disorder, however, after this 

experience, of being plunged into the dark abyss of bureaucracy and indifference in 

the last four and a half years, I realize I have been putting myself at risk of being 

unjustly feared, judged and seen as a threat to public safety no matter who I shared 

my life with. 

Mr. Chairman, in creating such a law as the Brady Act with its vast misunderstandings, I believe Congress has increased the potential violence with firearms. For 

who would want to subject themselves to the stereotyping, stigmatization, alienation, fear, loss of friends, family, jobs, and much more in voluntarily seeking Mental Health Care? It takes an immense amount of courage, responsibility and a wanting to be a positive member of society to seek this help. Instead of vilifying people 

who seek help, we need, as a moral society to make such people the pillars of society 

and, in a sense, heroes. Then, you will have a safer society. Otherwise, I fear we 

are only creating more Mr. John Hinckley’s walking among us. 

The irony of my situation is that I do support gun control and advocate for nonviolence. I also understand the concerns of law-abiding citizens who enjoy or feel a 

need to own a firearm. 

Mr. Chairman, I want to thank Senator Larry Craig while he was The Chairman 

of this Committee for his support, and his staff members, especially Major David 

Buffaloe, USA, for his exemplary work in researching this issue and helping me 

along the way. His kindness and compassion will always be with me. 

I want to end by saying, ‘‘The benchmark of any society is its justice and there 

can be no freedom and honor without justice.’’ 

PREPARED STATEMENT OF MICHAEL BRENNAN, M.D., PRESIDENT, 

AMERICAN ACADEMY OF OPHTHALMOLOGY

Chairman Akaka and Ranking Member Burr: I am Michael Brennan, President 

of the American Academy of Ophthalmology. The Academy appreciates the opportunity to present its views on S. 252, the Veterans Health Care Authorization Act 

of 2009. The Academy is the largest national membership association of Eye M.D.s 

with more than 27,000 members, over 17,000 of which are in active practice in the 

United States. Eye M.D.s are ophthalmologists, medical and osteopathic doctors who 

provide comprehensive eye care, including medical, surgical and optical care. More 

than 90 percent of practicing U.S. Eye M.D.s are Academy members. 

The Academy strongly supports Section 101 of the Veterans Health Care Authorization Act of 2009 which would authorize the Department of Veterans Affairs (VA) 

to extend Title 38, United States Code (U.S.C.), employment status to certain employees. We believe that this authority would enable the conversion of eye technicians within the Veterans Health Administration (VHA) from their existing non-specific health technician status into a Title 38 Hybrid Series specific for eye care techVerDate Nov 24 2008 19:35 Oct 22, 2009 Jkt 000000 PO 00000 Frm 00157 Fmt 6601 Sfmt 0190 H:\111TH HEARINGS\042209.TXT SVETS PsN: PAULIN
154 

nicians. The inclusion of eye technicians into the hybrid classification system would 

improve the ability of VA to recruit and retain qualified eye technicians by ensuring 

that personnel are hired based on knowledge, training and experience and to compensate eye technicians at a level more competitive with the private sector. 

Improving VA’s ability to recruit and retain qualified, experienced eye technicians 

is more crucial than ever today. Over the past decade, the eye care workload in the 

veterans’ health care system has dramatically increased. Between 2001 and 2008, 

ophthalmology and optometry clinic visits and unique patients have increased 80 

percent. In Fiscal Year (FY) 2008, there were 2.36 million eye clinic visits for 1.39 

million veterans. As the veteran population ages, their complexity of care also increases. Diabetic retinopathy, macular degeneration, glaucoma, and cataracts are 

diseases that are highly prevalent in the aging veteran population. 

The complexity of eye care will further increase as Operation Enduring Freedom 

(OEF) and Operation Iraqi Freedom (OIF) veterans return home. According to the 

Office of VA Research, combat eye trauma is the second most common injury experienced by military personnel serving in Iraq and Afghanistan. Veterans with a history of ocular battle injuries are at high risk for developing retinal detachments, 

traumatic cataracts, and glaucoma. Delayed Traumatic Brain Injury (TBI) neurovisual complications can occur years after the initial injury. The ever increasing 

prevalence of combat eye trauma and TBI-related visual complications will place 

even greater demands on VA’s eye care services for years to come. 

Traditionally, eye clinics in the VA health care system have been staffed with untrained technicians who are hired as Title 5 employees under the Health Technician 

GS–0640 Series which covers a range of health care positions, including such diverse jobs as phlebotomist and laboratory technician. The ability of VA to recruit 

trained eye care personnel (including eye technicians, ophthalmic photographers and 

opticians), is hampered by a lack of an appropriate eye care personnel series and 

standards. There are no formal position descriptions for eye care personnel in the 

VA, leaving each medical center to create its own position description, which reduces consistency throughout the veterans’ health care system. Moreover, there are 

no established salary ranges for eye care personnel in the VA system, making it difficult to recruit qualified applicants. Medical centers are forced to post an eye care 

professional position as a ‘‘health technician’’ and use convoluted language and special qualifications to avoid selecting an unqualified applicant. These constraints 

make it difficult for the VA to attract the most talented eye care technicians in the 

community. 

Under Title 5 employment, positions are graded according to classification standards and employee pay is determined based on the position classification, not on the 

individual qualifications of the person occupying the position. This policy has hindered the VA from achieving the highest efficiencies of care as the addition of one 

trained technician to one eye care provider has been shown to have a positive impact on workload. For example, one technician improves the workload of an optometrist an average of 14 percent while one technician improves the workload of an 

ophthalmologist an average of 36 percent. In 2009, eye technicians are expected to 

have the knowledge, training and experience to perform highly technical, state-ofthe-art, diagnostic procedures including: 

• Ultrasonography; 

• Digital computerized imaging and fluorescein angiography; 

• Pachymetry; 

• Optical coherence tomography; 

• Scanning laser ophthalmoscopy; and 

• Automated perimetry. 

The addition of trained eye care technicians and photographers to an eye clinic 

is a relatively cost-efficient way to improve veteran access to eye care and increase 

productivity. 

The Title 38 Hybrid Conversion Series was developed to help recruit and retain 

employees in highly competitive health care occupations. These positions are considered Title 38 positions but also retain some features of Title 5 positions. Under Title 

38 Hybrid, the grade and salary of each position is based on the duties of the position and how the candidate’s qualifications compare to the VA Standard. A profesVerDate Nov 24 2008 19:35 Oct 22, 2009 Jkt 000000 PO 00000 Frm 00158 Fmt 6601 Sfmt 0190 H:\111TH HEARINGS\042209.TXT SVETS PsN: PAULIN
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sional standards board determines which candidates are qualified through a peerreview process. Education, training and experience all can be considered as qualifications. Several health care technical series have already been converted to the 

Title 38 Hybrid Series; many of these series involve diagnostic testing that is similar to ophthalmic technicians (ultrasonography, angiography, electrophysiological 

testing, etc.). 

The demand for quality ophthalmic medical technicians is on the rise, and employment opportunities for these technicians are only expected to increase. In 2006, 

the Joint Commission on Allied Health Personnel in Ophthalmology, Inc (JCAHPO) 

applied to the U.S. Bureau of Labor and Statistics to list ophthalmic medical technicians as a separate occupational classification. Earlier this year, the Bureau of 

Labor and Statistics’ 2010 Standard Occupational Classification (SOC) Committee 

recommendations included a new classification for ophthalmic medical technicians 

(Classification Number: 29–2057). This new classification recognizes the more advanced, clinical and overall medically detailed skills and knowledge of ophthalmic 

medical technicians and will increase the competitiveness of qualified technicians in 

the job market. 

In closing, the Academy strongly supports the enactment of S. 252, the Veterans 

Health Care Authorization Act of 2009, because we believe it will provide the VA 

with the authority it needs to properly address the growing demand for eye care 

services. Once enacted, we would urge the Department of Veterans Affairs to use 

its new authority to convert eye technicians from their current classification to a 

Title 38 Hybrid classification as quickly as possible. Qualification standards for eye 

care technicians already have been developed for implementation by the VA through 

a joint ophthalmology/optometry collaboration. Creating a Title 38 Hybrid series for 

eye technicians in VA would enable VA to recruit and retain qualified eye technicians into the Veterans Health Care Administration and would increase the ability 

of VA to provide excellent, yet efficient eye care to our Nation’s veterans. 

Thank you for your consideration. 

PREPARED STATEMENT OF IAVA SUBMITTED BY PATRICK CAMPBELL, CHIEF

LEGISLATIVE COUNSEL, OPERATION IRAQI FREEDOM (2004–2005) 

ADVANCE APPROPRIATIONS

S. 423, Veterans Health Care Budget Reform and Transparency Act of 2009 (Akaka) 

IAVA strongly endorses this legislation. For nineteen of the last twenty-two years, 

the VA budget has been passed late, forcing the largest health care provider in the 

Nation to ration care. Imagine trying to plan for next month’s bills without knowing 

your next paycheck. That’s what we ask veterans’ hospitals to do almost every year. 

Advance appropriations will ensure that the quality of care for veterans will no 

longer be compromised by budget delays. With the strong support of the President, 

bipartisan leadership in Congress, and the support of every major veterans organization, S. 423 can and must move forward this year. 

MENTAL HEALTH

S. 658, Rural Veterans Health Care Improvement Act of 2009 (Tester) 

We are pleased to offer support for S. 658. According to the GAO, more than 25 

percent of veterans enrolled in VA health care live over 60 minutes driving time 

from a VA hospital. This legislation would implement a multi-pronged approach to 

delivering quality health care to rural veterans: creating rural centers of excellence, 

funding new transportation grants and demonstration projects, and authorizing the 

VA to build local peer outreach and support services. S. 658 would also expand current counseling capacity by allowing the VA to contract with local community health 

centers. With nearly one third of all returning veterans suffering from invisible psychological injuries, S. 658 will allow veterans to support one another and receive the 

counseling they need. 

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S. 772, Honor Act of 2009 (Bond) 

S. 772 will address one of IAVA’s top legislative priorities: ending the shortage 

of mental health professionals in the military and at the VA. This legislation provides incentives for retiring or separating military personnel and combat veterans 

to pursue an advanced degree in behavioral health. It will build a new generation 

of counselors with combat experience, and will help ensure that our men and women 

in uniform receive mental health care from personnel that understand military culture. The legislation also gives active-duty servicemembers the same access that veterans have to Vet Centers, expanding the pool of mental health care options available to our troops. In addition, the Honor Act takes a number of other innovative 

steps to address the mental health needs of troops and veterans. It allows servicemembers to present their records to the VA for screening, irrespective of their discharge, so that veterans do not fall through the cracks. The legislation also guarantees survivor benefits for any servicemember who commits suicide within 2 years 

of separation or retirement, provided they have a documented history of combat-related PTSD or TBI. Finally, by providing comprehensive training to educate troops 

on Post Traumatic Stress Disorder, the legislation will mitigate the confusion and 

stress that servicemembers feel when trying to identify mental health resources. For 

all of these reasons, IAVA wholeheartedly endorses S. 772. 

S. 669, Veterans 2nd Amendment Protection Act (Burr) 

Two years ago, this Committee considered critical suicide prevention legislation 

called the Joshua Omvig Suicide Prevention Act. When this desperately-needed bill 

came to the Senate floor for a vote, rumors spread that the legislation would cause 

veterans seeking help for PTSD to lose their Second Amendment rights. Although 

even the NRA stated that the Joshua Omvig bill would have no impact on gun 

rights, critical sections of the Suicide Prevention Act were watered down. Although 

there is still no danger a veteran will lose their right to carry a firearm for seeking 

treatment for PTSD, we offer our support for this legislation in the hopes it will 

quell any fears veterans might have about seeking treatment for mental health injuries. 

FEMALE VETERANS

S. 597, Women Veterans Health Care Improvement Act of 2009 (Murray) 

IAVA is honored to offer our full support for S. 597. By 2020, the proportion of 

women veterans using VA health care is expected to reach 15 percent. This vital 

legislation will assess barriers to VA care that women face; plan for women’s future 

VA health care needs; ensure full-time women veterans program managers at every 

VA medical center; authorize the VA to care for the newborn children of female veterans; enhance Military Sexual Trauma (MST) training for VA mental health professionals; build a pilot program to evaluate providing child care subsidies to qualified veterans; and create a pilot program to study readjustment counseling for 

women veterans in group retreat settings. 

FAMILY CAREGIVERS

S. 801, Family Caregiver Program Act of 2009 (Akaka) 

IAVA is proud to put our full support behind S. 801, which will ensure that family 

caregivers who care for their injured loved ones receive compensation and benefits 

that honor their service to their wounded warrior. This bill will provide a living stipend, health care benefits, training, and support to family caregivers. 

S. 543, Veteran and Servicemember Caregiver Support Act of 2009 (Durbin) 

S. 543 is also a strong caregiver support bill. Like S. 801, it provides a living stipend and training to family caregivers, but offers a narrower scope of services than 

S. 801, and the legislation is limited to a 2-year pilot program. We support S. 543, 

but would prefer S. 801. 

VA HEALTH CARE

S. 699, Far South Texas Veterans Medical Center Act of 2009 (Cornyn) 

The Far South Texas Veterans Medical Center Act is a critical piece of legislation 

that will improve access to health care for many of our returning veterans. With 

more than 114,000 veterans residing in the South Texas area, and a high rate of 

deployment from the Texas National Guard and Reserve units stationed there, it is 

unconscionable that the nearest acute inpatient care facility is almost 6 hours away. 

The Capital Asset Realignment for Enhanced Services study found that fewer than 

3 percent of its enrollees in the Valley-Coastal Bend Market of VISN 17 reside withVerDate Nov 24 2008 19:35 Oct 22, 2009 Jkt 000000 PO 00000 Frm 00160 Fmt 6601 Sfmt 6621 H:\111TH HEARINGS\042209.TXT SVETS PsN: PAULIN
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in its acute hospital access standards. This bill will help correct this dire situation. 

Veterans in South Texas must be provided access to the care they were promised 

after fighting for this Nation. 

S. 734, Rural Veterans Health Care Access and Quality Act of 2009 (Akaka) 

IAVA is proud to support S. 734, enhancing retention within the Veterans Health 

Administration, expanding care at Vet Centers, and expanding VA health care in 

rural areas. S. 734 ensures that the VA recruits and retains the highest quality 

medical professionals by removing the cap on the Education Debt Reduction Program and making VA medical centers eligible for assignment in the National Health 

Service Corp Scholarship Program. Additionally, S. 734 expands the mental health 

services offered by the Vet Centers by allowing mental health care professionals to 

act as volunteer counselors for the VA. S. 734 also expands outreach to rural areas 

by allowing for expanded teleconsulting and treatment to veterans who are not able 

to travel due to distance or infirmary, and allows the VA to reimburse a veteran 

for airfare when ground transportation is not feasible. 

S. 498, Establishing VA Dental Care for Veterans and their families (Burr) 

IAVA is proud to support S. 498, extending VA dental care to veterans and their 

families by allowing them to purchase a VA dental insurance plan. Dental coverage 

has long been a gap in the benefits offered to veterans of the armed services, and 

IAVA fully supports allowing veterans and their families to take advantage of the 

high quality of care that is offered by their local VA. 

STATEMENT FOR THE RECORD SUBMITTED BY THE NATIONAL ASSOCIATION OF

VETERANS’ RESEARCH AND EDUCATION FOUNDATIONS (NAVREF) 

S. 252, ‘‘VETERANS HEALTH CARE AUTHORIZATION ACT OF 2009,’’ TITLE VI, NONPROFIT

RESEARCH AND EDUCATION CORPORATIONS (LEGISLATION TO UPDATE AND CLARIFY

PROVISIONS OF THE LAW AUTHORIZING THE VA-AFFILIATED NONPROFIT RESEARCH

AND EDUCATION CORPORATIONS, 38 U.S.C. §§ 7361–7366)

The National Association of Veterans’ Research and Education Foundations 

(NAVREF) thanks Senator Daniel K. Akaka, Chairman of the Committee on Veterans’ Affairs, for incorporating title VI, ‘‘Nonprofit Research and Education Corporations’’ in S. 252, the ‘‘Veterans Health Care Authorization Act of 2009’’ and for 

holding a hearing on this and other important health-related legislation. Upon enactment by Congress, title VI of this legislation will update and clarify provisions 

of the law authorizing the VA-affiliated nonprofit research and education corporations. 

NAVREF is the membership organization of the 82 VA-affiliated nonprofit research and education corporations (NPCs) originally authorized by Congress under 

Public Law 100–322, and currently codified at sections 7361 through 7366 of the 

United States Code. NAVREF’s mission is to promote high quality management of 

the NPCs and to pursue issues at the Federal level that are of interest to its 

members. NAVREF accomplishes this mission through educational activities for 

its members as well as interactions and advocacy with agency and congressional officials. Additional information about NAVREF is available on its Web site at 

www.navref.org. 

BACKGROUND ABOUT THE NPCs 

In 1988, Congress allowed the secretary of the Department of Veterans Affairs to 

authorize ‘‘the establishment at any Department medical center of a nonprofit corporation to provide a flexible funding mechanism for the conduct of approved research and education at the medical center.’’ [38 U.S.C. § 7361(a)] At this time, 82 

NPCs provide their affiliated VA health care systems and medical centers with a 

highly valued means of administering non-VA Federal research grants and private 

sector funds in support of VA research and education. 

The fundamental purpose of the nonprofits is to serve veterans by supporting VA 

research and medical education to improve the quality of care that veterans receive. 

For example, a seed grant provided by the Palo Alto Institute for Research and Education (PAIRE) to a gastroenterology clinician-investigator resulted in his finding 

that an easily overlooked type of abnormality in the colon is the most likely type 

to turn cancerous, and is more common in this country than previously thought. 

This finding, reported on the front page of the March 5, 2008, New York Times and 

in the Journal of the American Medical Association, is changing colonoscopy practices and may well lead to widespread earlier detection of a cancer that is preventable or curable through surgery. During 2008 PAIRE made nine similar awards to 

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VA Palo Alto investigators in the hope of equally significant research success down 

the road. Similarly, a few years ago funds administered by the Seattle Institute for 

Biomedical and Clinical Research (SIBCR) allowed a psychiatry clinician-investigator to test use of Prazosin, an inexpensive, already approved drug, for treatment 

of veterans with debilitating post-traumatic stress-related nightmares. The SIBCR 

funding allowed the investigator to accumulate positive preliminary data that then 

led to DOD and NIH awards to further test this promising treatment. 

Last year, the NPCs collectively administered more than $250 million with expenditures that supported approximately 4,000 VA-approved research and education 

programs. These nonprofits are dedicated solely to supporting VA and veterans. 

This includes providing VA with the services of nearly 2,500 without compensation 

(WOC) research employees who work side-by-side with VA-salaried employees, all 

in conformance with the VA background, security and training requirements such 

appointments entail. 

Beyond administering research projects and education activities, these nonprofits 

support a variety of VA research infrastructure and administrative expenses. As described above, they have provided seed and bridge funding for investigators; staffed 

animal care facilities; funded recruitment of clinician researchers; paid for research 

administrative and compliance personnel; supported staff and training for institutional review boards (IRBs); and much more. 

LEGISLATION WOULD ENHANCE AND CLARIFY NPC AUTHORITIES

The purpose of title VI of S. 252 is to modernize and clarify the 1988 statute after 

20 years of experience under its current terms. The NPCs have already proven 

themselves to be valued and effective ‘‘flexible funding mechanisms for the conduct 

of approved research.’’ VA’s most recent annual report to Congress regarding the 

NPCs stated, ‘‘The VA-affiliated NPCs continue to make a substantial contribution 

to the VA research and education missions.’’ This legislation will further enhance 

their value to VA. 

The objectives of this legislation are consistent with the findings in the May 2008 

VA Office of Inspector General (OIG) review of five NPCs and VHA’s oversight of 

them. VHA is working hard to address the shortcomings in oversight that the OIG 

identified. NAVREF and the NPCs are working equally hard to ensure that NPCs 

have appropriate controls over funds and equipment (including strengthening the 

documentation for all transactions), and that all NPC officers, directors and employees are certifying their awareness of the applicable Federal conflict of interest regulations. While NAVREF firmly believes that NPC boards and administrative employees strive to be conscientious stewards of NPC funds, NAVREF thanks the OIG 

for its thorough review of those five NPCs and for bringing to light these areas in 

need of improvement. 

It is noteworthy that the OIG report cited no misuse of funds or instances of conflicts of interest, no dual compensation of Federal employees and no fraud. However, 

we take very seriously the OIG finding that these NPCs nonetheless may not have 

had adequate controls over some of the funds they manage. Two major provisions 

in title VI of S. 252 directly address this finding: 

First, section 601 allows voluntary formation of ‘‘multi-medical center research corporations.’’ That is, two or more VA medical centers may share one 

NPC, subject to board and VA approval, while preserving their fundamental nature as medical center-based organizations. This provision—the centerpiece of 

the legislation—will allow interested VA facilities with small research programs 

to join with larger ones. Or several smaller facilities may pool their resources 

to support management of one NPC with funds and staffing adequate to ensure 

an appropriate level of internal controls, including segregation of financial duties. 

Second, the last item in section 604(a)—‘‘(e) Policies and Procedures’’—addresses the OIG criticism by broadening VA’s ability to guide NPC expenditures. The only constraint on VA is that such guidance must be consistent with 

other Federal and State requirements as specified in laws, regulations, executive orders, circulars and directives—of which there are many—applicable to 

other 501(c)(3) organizations. The purpose of this limitation is to prevent the 

possibility of imposing on NPCs conflicting requirements and to ensure that 

they remain independent ‘‘flexible funding mechanisms.’’ 

Title VI of S. 252 provides a number of other welcome enhancements to the NPC 

authorizing statute. 

• Section 603(b)(2) of the bill broadens the qualifications for the two mandatory 

non-VA board members beyond familiarity with medical research and education. 

159 

This will allow NPCs to use these board positions to acquire the legal and financial 

expertise needed to ensure sound governance and financial management. 

• Section 603(c) deletes the overly broad stipulation in the current statute that 

these non-VA board members may not have ‘‘any financial relationship’’ with any 

for-profit entity that is a source of funding for VA research or education. This absolute prohibition conflicts with regulations applicable to Federal employees with respect to conflicts of interest, which are invoked for all NPC directors and employees 

in section 7366(c)(1) of title 38, United States Code. Unlike the standard currently 

applied to NPC board members, Federal conflict of interest regulations provide 

means of recusal as well as de minimus exceptions. Additionally, the current prohibition may be applied to any individual who has accepted compensation or reimbursement from a for-profit sponsor of VA research for purposes unrelated to VA 

research, thereby eliminating many otherwise desirable and qualified individuals 

from serving on NPC boards. 

• Section 604(a)—(a)(1)(C) increases the efficiency of NPC administration of funds 

generated by educational activities. This clause allows NPCs to charge registration 

fees for the education and training programs they administer, and to retain such 

funds to offset program expenses or for future educational purposes. However, it 

also explicitly sustains the existing prohibition against NPCs accepting fees derived 

from VA appropriations. 

• Section 604(a)—(a)(1)(D) provides NPCs with authority to reimburse the Office 

of General Counsel (OGC) for legal services related to review and approval of Cooperative Research and Development Agreements (CRADAs), the form of agreement 

used to establish terms and conditions for industry-funded studies performed at VA 

medical centers and administered by NPCs. Although OGC is already obligated to 

review these agreements without reimbursement, the funds generated under this 

provision would help OGC to staff Regional Counsel offices to accommodate the substantial workload these agreements entail and to provide training for VA attorneys 

in CRADA requirements and related VA policies. The NPCs support making these 

reimbursements. 

• Section 604(a)—(b)(2) of the legislation provides VA with authority to reimburse 

NPCs for the salary and benefits of NPC employees loaned to VA under Intergovernmental Personnel Act (IPA) assignments conducted in accordance with section 

3371 of title 5, United States Code. This provision responds to recent OIG questions 

asking whether such reimbursements are allowable and permits VA to continue to 

benefit from this efficient and cost-effective mechanism to acquire the temporary 

services of skilled research personnel. 

• Section 604(a)—(b)(3) establishes explicit authority for VAMCs to accept funds 

provided by NPCs that may fall outside of VA’s gift acceptance authority. It also 

allows VAMCs to retain such funds locally and to deposit them in the appropriate 

VA account without having to route them through the Treasury, necessitating cumbersome steps to get the funds to the right VA account. Finally, this provision 

makes these reimbursements ‘‘no year’’ money to give VAMCs needed flexibility in 

timing for use of the funds. 

Although VA has broad authority to accept gifts (38 U.S.C. § 8301), many NPC 

payments to VAMCs are more accurately described as reimbursements to the VAMC 

or payments for services and may not be consistent with VA’s gift acceptance authority. For example, NPCs typically reimburse VAMCs for the cost of clinical services provided exclusively for research purposes; VA employees’ time spent on NPCadministered programs; and animal per diems. This clause also will allow VA to resolve longstanding VAMC uncertainty about how to treat such reimbursements and 

will let the VAMC that incurred the cost retain the amounts reimbursed. Currently, 

VAMCs must send such reimbursements to the Treasury and then the Fiscal Office 

must use a cumbersome process to bring the funds back to the VAMC. 

Title VI of S. 252 also contains a number of useful clarifications of NPC status 

and purposes. 

• Sections 601(b), (c) and (d) codify—without changing—the legal status of the 

NPCs as state-chartered, independent organizations exempt from taxation under 

section 501(c)(3) of the Internal Revenue Service (IRS) code and subject to VA oversight and regulation. Clause 601(c) codifies the congressional intent, previously expressed in the House report that accompanied the original NPC authorizing statute 

(H. Rept. 100–373), that nonprofits established under this authority would not be 

corporations controlled or owned by the government. As a result, this legislation resolves longstanding differences of opinion among stakeholders, overseers and funding sources about the legal status of NPCs. 

• Section 602(a)(1) of the legislation establishes that in addition to administering 

research projects and education activities, NPCs may support ‘‘functions related to 

160 

the conduct of research and education.’’ This resolves differences of opinion about 

the appropriateness of NPC expenditures that support VA research and education 

generally, such as purchase of core research equipment used by many researchers 

for multiple projects, and enhances the value of NPCs to VA facilities. • Section 604(a)—(c) ascertains that all NPC-administered research projects must 

undergo ‘‘scientific’’ rather than ‘‘peer’’ review. This change recognizes that peer review is not necessary or appropriate for all research projects administered by NPCs. 

However, the legislation leaves in place the overarching requirement for VA approval and the medical center’s Research and Development Committee remains in 

a position to determine on a case-by-case basis whether a project also requires peer 

review as a condition of VA approval. 

In addition to these enhancements and clarifications, title VI of S. 252 legislation 

reorganizes the NPC authorizing statute to put all provisions regarding their establishment and status in one section; describes their purposes in another; and gathers 

in one section the clauses enumerating their powers. Other revisions are largely 

technical and conforming amendments. 

PROPOSED LEGISLATION PRESERVES MEASURES PROVIDING OVERSIGHT OF NPCs 

Title VI of S. 252 makes no changes in VA’s power to regulate and oversee the 

NPCs. Further, NPC records remain fully available to the Secretary and his designees; to the Inspector General; and to the Government Accountability Office 

(GAO). Likewise, NPCs are still required to undergo an annual audit by an independent auditor in accordance with the sources—Federal or private—and the 

amount of their prior year revenues, and they must submit to VA an annual report 

that includes the resulting audit report along with detailed financial information 

and descriptions of accomplishments. 

In the wake of the Sarbanes-Oxley Act and changing Federal Accounting Standards Board (FASB) auditing standards, even the most basic form of nonprofit audit 

has become an effective means for assessing an organization’s financial controls. Additionally, the percentage of NPC funds subject to audits conducted in accordance 

with OMB Circular A–133, the most rigorous level of applicable auditing standards, 

will continue to increase as more NPCs assume responsibility for non-VA Federal 

grants. According to reports submitted to VA in June 2008, nearly 80 percent of 

prior year NPC expenditures were subject to an A–133 audit and overall, 99.7 percent of NPC expenditures were subject to an audit of one type or another. These 

audits are comprehensive and provide a sound framework for examining an organization’s controls over funds as well as compliance with program requirements. 

CONCLUSION

In conclusion, NAVREF urges the Congress to enact title VI of S. 252 at the earliest possible opportunity. The NPCs are already a highly efficient means to maximize the benefits to VA of externally-funded research conducted in VA facilities, 

ably serving to facilitate research and education that benefit veterans. Additionally, 

they foster vibrant research environments at VA medical centers, enhancing VA’s 

ability to recruit and retain clinician-investigators and other talented staff who in 

turn apply their knowledge to state-of-the-art care for veterans. 

Twenty years after the VA-NPC public-private partnership was first authorized 

by Congress, this is a timely opportunity to update and clarify the NPCs’ enabling 

legislation. This legislation will accomplish those objectives. Experience working 

within the current statute has brought to light its many strengths, but also areas 

that will benefit from modification, enhancement and updating, particularly in light 

of the increasing complexity of both research and nonprofit compliance. We believe 

enactment of title VI of S. 252 will allow NPCs to better achieve their potential to 

support VA research and education while ensuring VA and congressional confidence 

in their management. 

NAVREF thanks the Senate Committee on Veterans’ Affairs and its staff members for their work on title VI of S. 252. We look forward to working with the Members of the Committee toward enactment of this bill. Please direct any questions you 

may have to NAVREF Executive Director Barbara West at 301–656–5005 or 

bwest@navref.org. 

PREPARED STATEMENT OF BARBARA COHOON, DEPUTY DIRECTOR, GOVERNMENT

RELATIONS, THE NATIONAL MILITARY FAMILY ASSOCIATION

National Military Family Association is the leading nonprofit organization committed to improving the lives of military families. Our 40 years of accomplishments 

161 

have made us a trusted resource for families and the Nation’s leaders. We have 

been at the vanguard of promoting an appropriate quality-of-life for active duty, National Guard, Reserve members, retired servicemembers, their families, and survivors from the seven uniformed services: Army, Navy, Air Force, Marine Corps, 

Coast Guard, Public Health Service, and the National Oceanic and Atmospheric Administration. 

Association Representatives in military communities worldwide provide a direct 

link between military families and the Association staff in the Nation’s capital. 

These volunteer Representatives are our ‘‘eyes and ears,’’ bringing shared local concerns to national attention. 

The Association does not have or receive Federal grants or contracts. 

Our Web site is: http://www.nmfa.org. 

Chairman Akaka and Distinguished Members of this Committee, the National 

Military Family Association would like to thank you for the opportunity to present 

written testimony for the record on ‘‘Family Caregiver Program Act of 2009.’’ We 

thank you for this legislation’s recognition of the integral role caregivers serve in 

managing both medical and non-medical care of our wounded, ill, and injured veterans. The proposed legislation ensures access to quality health care and mental 

health care for our wounded, ill, and injured veterans’ caregivers and provides them 

the opportunity for training, certification, and compensation. 

National Military Family Association applauds Chairman Akaka, Senator Burr, 

and Senator Rockefeller for this legislation. The intent of the legislation is to recognize the important role caregivers play in caring for our veterans. Research has 

shown the quality-of-life of our wounded, ill, and injured veterans can be directly 

linked to the level of caregiver involvement. It is because of the caregiver’s dedication our veterans get timely quality care and they are also strong advocates who 

oversee the rehabilitation process. 

The legislation addresses the special conditions and behaviors presented by veterans with a wide range of diagnosis. The definition of ‘‘severe injury’’ captures not 

only physiological conditions and psychological, but the inclusion of ‘‘an injury for 

which a veteran needs supervision or protection based on symptoms or residuals of 

neurological or other impairment.’’ This provision is key with our Traumatic Brain 

Injury (TBI) injured veterans and the individuals who care for them. 

We especially appreciate the fact this proposal has a more inclusive view for caregivers then other legislation previously introduced. Your legislation includes a provision for medical care, has a provision to expand coverage to other veteran caregivers 

in the future, and is more than a pilot study for a select few caregivers. 

However, there are some areas of the legislation with which we have concerns and 

believe need further clarification. 

Section 2 allows for ‘‘emergency’’ care for caregivers attending a VA facility; however, this is a ‘‘may’’ and not a ‘‘shall.’’ A true emergency must be addressed by a 

hospital when you are physically present on their premises. For example, Congress 

enacted the Emergency Medical Treatment and Labor Act (EMTALA) in 1986 to ensure the public access to emergency treatment regardless of ability to pay. Health 

care providers have an ethical requirement to ‘‘do no harm’’ and not providing care 

would cause harm. Hospitals are already allowed to provide emergency services and 

then bill if the individual has insurance. We understand co-pays and out-of-pocket 

expenses may be involved, but hospitals have the right to waive those fees. Another 

concern is what constitutes ‘‘emergency’’ care? Who will decide this, especially as the 

event is unfolding in real time? The National Defense Authorization Act for Fiscal 

Year 2008 (NDAA FY08) Section 1672 provides for medical care at Department of 

Defense (DOD) Military Treatment Facilities (MTFs) or Department of Veterans Affairs (VA) facilities on a space-available basis authorized for certain family members, not otherwise eligible for medical care, caring for a recovering servicemember. 

According to a briefing by General Elder Granger, Deputy Director and Program Executive Officer for TRICARE Management Activity, on April 13, 2009, DOD has implemented this Section of the NDAA FY08. This law allows for non-emergent care. 

How has the VA complied with this law in allowing access to care for caregivers? 

The long extensive list of ‘‘family members’’ is appreciative. Most individuals and 

government agencies recognize and understand the blood and marriage connection. 

However, the list left off ‘‘significant other’’ and ‘‘fiance ́e,’’ which we frequently hear 

are part of the caregiver structure. We see the added provision for the Secretary 

of the Department of Veterans Affairs to add additional people; however, we find 

that these additional caregivers are often not recognized by DOD as eligible. The 

difference between DOD and VA in regards to a caregiver definition and eligibility 

is important because the choice or self selection of the caregiver begins while the 

wounded, ill, and injured servicemember is still on active duty. According to the VA, 

162 

‘‘ ‘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.’’ We would like to make sure 

the definition of caregiver eligibility is broad enough to capture additional individuals. 

The provision regarding the date of enactment is confusing. We understand the 

intent to start with a certain population, Sept. 11, 2001, and then go back and possibly increase the population to earlier veterans’ caregivers, but it is hard to glean 

that information from the written language. We support the expansion of the program to cover all eligible veteran caregivers. 

The provision outlining additional instruction and allowing the caregiver to be 

certified as a personal care attendant is dependent on the Secretary. It states, the 

Secretary ‘‘may’’ provide these services. Caregivers are not guaranteed the opportunity to become certified and be eligible for additional instruction and training. 

Certification will be key in determining the level of care and the scope of practice 

the caregiver can provide and affecting the amount of compensation they could 

receive. 

The provision on certified personal care attendant versus designates needs further 

clarification. The legislation provides for a ‘‘certified’’ personal care attendant to receive technical support, counseling, and internet access and allows the ‘‘designated’’ 

personal care attendant to qualify for mental health services, respite care, medical 

care, and a stipend. We don’t understand why one qualifies for counseling and the 

other mental health? What would be the difference in services? Adding to the confusion is the fact the designated personal care attendant qualifies for health care, 

which should cover mental health services. We would appreciate further clarification 

on the eligibility sequencing. It is hard to determine if there are two levels of eligible caregiver services or if both caregiver categories can be eligible for one or the 

other. For example, must the caregiver first qualify for one in order to be eligible 

for the other? If so, then which category must they qualify for first? It would make 

more sense for there to be a lower level entry first, which would be your ‘‘designated’’ personal care attendant, and they would then be eligible for the higher 

level, the ‘‘certified’’ personal care attendant, and receive additional services. 

What constitutes ‘‘protection?’’ Is it physical protection from physical injury, such 

as someone who is prone to falls and is in need of bed rails? Or, does it encompass 

a much broader definition that would include overall safety concerns, such as crossing the street by themselves and navigating their way on public transportation? Our 

Association would support the adoption of a more expansive definition involving 

overall safety concerns for the veteran. 

National Military Family Association will also take the opportunity to discuss several issues of importance to wounded, ill, and injured servicemembers, veterans, and 

their families in the following subject areas: 

I. Wounded Service Members Have Wounded Families 

II. Who Are the Families of Wounded Service Members? 

III. Caregivers 

IV. Mental Health 

WOUNDED SERVICE MEMBERS HAVE WOUNDED FAMILIES

National Military Family Association 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, and injured servicemembers, veterans, and their families. DOD and the VA health care systems, along 

with State agency involvement, should alleviate, not heighten these concerns. National Military Family Association believes 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. 

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 Reserve 

almost 50 percent of the members are single. Having a wounded servicemember is 

new territory for family units. Whether the servicemember is married or single, 

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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, or sibling through the recovery process. Family members are 

an integral part of the health care team. Their presence has been shown to improve 

the servicemember and veteran’s quality-of-life and aid in a speedy recovery. 

National Military Family Association recently gathered information about issues 

affecting our wounded servicemembers, veterans, and their families through our Operation Purple® Healing Adventure Camp in August 2008 and a focus group held 

March 2008 at Camp Lejeune. Families said following the injury, they 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, they feel 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 

health care providers because they tend to the needs of the servicemembers and the 

veterans on a regular basis. Their daily involvement saves DOD, VA, and State 

agency health care dollars in the long run. 

Caregivers of the severely wounded, ill, and injured services members 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. National Military Family Association is pleased with the 

‘‘Family Caregiver Program Act of 2009’’ legislation that will provide for the training, certification, and compensation for injured servicemembers or veterans. 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 health care 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 

successful, should be implemented by the VA as soon as possible and fully funded 

by Congress. However, one program not addressed 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. Our Association 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. 

RELOCATION ALLOWANCE

Active Duty servicemembers and their spouses qualify through the DOD for military orders to move their household goods (known as a Permanent Change of Station (PCS)) when they leave the military service. Medically retired servicemembers 

are given a final PCS move. Medically retired married servicemembers are allowed 

to move their family; however, medically retired single servicemembers only qualify 

for moving their own personal goods. 

National Military Family Association is requesting the ability for medically retired single servicemembers to be allowed the opportunity to have their caregiver’s 

household goods moved as a part of the medical retired single servicemember’s PCS 

move. This should be allowed for the qualified caregiver of the wounded servicemember and the caregiver’s family (if warranted), such as a sibling who is married 

with children or mom and dad. This would allow for the entire caregiver’s family 

to move, not just the caregiver. The reason for the move is to allow the medically 

retired single servicemember the opportunity to relocate with their caregiver to an 

area offering the best medical care, rather than the current option that only allows 

for the medically retired single servicemember to move their belongings to where 

the caregiver currently resides. The current option may not be ideal because the 

area in which the caregiver lives may not be able to provide all the health care services required for treating and caring for the medically retired servicemember. Instead of trying to create the services in the area, a better solution may be to allow 

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the medically retired servicemember, their caregiver, and the caregiver’s family to 

relocate to an area where services already exist, such as a VA Polytrauma Center. 

The decision on where to relocate for optimum care should be made with the Federal Recovery Coordinator (case manager), the servicemember’s physician, the servicemember, and the caregiver. All aspects of care for the medically retired servicemember and their caregiver shall be considered. These include a holistic examination of the medically retired servicemember, the caregiver, and the caregiver’s family for, but not limited to, their needs and opportunities for health care, employment, transportation, and education. The priority for the relocation should be where 

the best quality of services is readily available for the medically retired servicemember and his/her caregiver. 

The consideration for a temporary partial shipment of caregiver’s household goods 

may also be allowed, if deemed necessary by the case management team. 

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 health care 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. National Military Family Association 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 other programs. 

National Military Family Association 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 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. Many isolated veterans and their families do not 

have the benefit of the safety net of services and programs provided by MTFs, VA 

facilities, Community-Based Outpatient Centers, and Vet Centers. Our Association 

recommends the use of alternative treatment methods, such as telemental health. 

Another solution is modifying licensing requirements in order to remove geographical practice barriers preventing mental health providers from participating in 

telemental health services outside of a VA facility. 

The VA must educate their health care 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. Our Association 

recommends spouses and parents of returning servicemembers and veterans need 

programs providing education on identifying mental health, substance abuse, suicide, and Traumatic Brain Injury. 

VA mental and health care providers must be able to deal with polytrauma—Post 

Traumatic Stress Disorder (PTSD) in combination with multiple physical injuries. 

National Military Family Association appreciates Congress establishing the National Center of Excellence and the Defense Center of Excellence. It is very important for DOD and VA to partner in researching TBI and PTSD. We believe the VA 

needs to educate their civilian health care providers on how to identify signs and 

symptoms of mild TBI and PTSD. As the VA incorporates Project Hero, they must 

educate civilian network mental health providers about our military culture. 

INFORMATION TECHNOLOGY (IT) INTEROPERABILITY

The DOD, VA, and State agencies, along with civilian providers, need to work together, creating a seamless transfer of medical record information regarding health 

care services received by our servicemembers, veterans, National Guard and Reserve members, retirees and their families and survivors. Interoperability, especially 

between DOD and VA, is crucial. A recent visit to the Naval Branch Medical Clinic 

Key West found servicemembers and their families utilizing a VA provider. This 

clinic is a joint facility. There are systems in place for sharing of data between the 

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two agencies’ electronic health servers, yet staff at the clinic were unable to access 

this option. Medical records were being hand carried and manually entered into the 

receiving health care server. As we move toward more joint facility operations, medical record information must be easily accessed and transferred between agency 

servers. This is especially important for our wounded, ill, and injured servicemembers who frequently transfer between the two agencies’ health care systems 

and, eventually, from active duty status to veteran status. We encourage Congress 

to adequately fund VA and DOD IT interoperability. 

SENIOR OVERSIGHT COMMITTEE

Our Association is appreciative of the provision in the NDAA FY09 continuing the 

DOD/VA Senior Oversight Committee (SOC) for an additional year. We understand 

a permanent structure is in the process of being established and manned. We urge 

Congress to put a mechanism in place to continue to monitor DOD and VA’s partnership initiatives for our wounded, ill, and injured servicemembers and their families, while this organization is being created. 

National Military Family Association proposes the top agenda items that would 

benefit veterans, wounded servicemembers, their families, and survivors are: 

• Coordination and collaboration of health care and behavioral health care services between the VA, DOD, and State and governmental agencies in sharing of resources; 

• Provision of sufficient, timely, and accurate funding for VA benefits and services; 

• Train, certify, compensate, and provide benefits to include health care for the 

caregivers of our severely wounded servicemembers and veterans; 

• Increased respite care for severely wounded veterans and their caregivers; 

• Increased access to behavioral health services for survivors, caregivers of 

wounded servicemembers and veterans, and their families; 

• Increased outreach to veterans, their families, and the communities they live 

in about available benefits and services, including education on the signs and symptoms of behavioral health conditions and available resources; 

• Continue to quickly and efficiently address the needs of our wounded servicemembers, veterans, and their families regarding transition, IT sharing, and joint facility operations; and 

• Inclusion of senior DOD and VA leaders, along with respective VSOs and MSOs 

regarding the discussion of a National health care agenda by Congress because of 

its potential impact on both health care systems and the veteran, servicemember, 

and their families. 

National Military Family Association would like to thank you again for the opportunity to present testimony for the record on the ‘‘Family Caregiver Program Act 

of 2009’’ for veterans and their caregivers. 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 health care in DOD 

and VA. 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 and DOD and VA to work together to create a seamless transition. We ask 

this Committee to assist in meeting that responsibility. 

We look forward to working with you to improve the quality-of-life for veterans 

and their families. 

PREPARED STATEMENT OF THE NURSES ORGANIZATION OF VETERANS AFFAIRS

Mr. Chairman, Ranking Member Burr and other Members of the Committee: The 

Nurses Organization of Veterans Affairs (NOVA) is the professional organization of 

the approximately 40,000 registered nurses employed by the Department Affairs. 

NOVA is committed to providing high quality care to our Nation’s veterans. 

S. 362

NOVA appreciates the opportunity to provide input into S. 362, legislation that 

would allow VA health care professionals to bargain over the issue of Clinical Competency, Clinical Conduct, Title 38 Compensation and Peer Review. NOVA is opposed to this legislation. 

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Summary: 

This bill would remove from the existing Title 38 collective bargaining statute the 

provisions that bar bargaining and grievances over issues relating to direct patient 

care, clinical competence, peer review, or Title 38 compensation. It would also repeal 

the statutory provision that authorizes the VA Secretary to determine whether a 

particular union proposal or grievance is subject to one of those subject matter exclusions. 

While proponents of the bill assert that it will ‘‘restore’’ collective bargaining 

rights for VA doctors, nurses, and other medical professionals, those employees have 

never had the right to bargain over the subjects excluded by the current statute. 

If this bill were to pass, VA would be required to bargain over patient care issues, 

clinical competence issues, peer review processes, and the discretionary aspects of 

Title 38 compensation (e.g. nurse locality pay and physicians’ market pay and performance pay) to an extent that is unprecedented and would represent an unwarranted intrusion into the way that VHA manages its clinical practices and adjusts 

pay for physicians and nurses. Quality of care delivered to patients should not be 

subject to negotiation. 

Background: 

1. The existing statute. 

An existing provision of the Title 38 personnel statute, 38 U.S.C. § 7422, was enacted in 1991 to authorize VA physicians, nurses, and other Title 38 medical professionals to engage in collective bargaining. Prior to 1991, VA physicians and nurses 

were not authorized to engage in collective bargaining because they were not covered by the Title 5 statute that authorizes bargaining for most Federal employees. 

a. What the existing statute says: 

Subsection (a) of section 7422 generally authorizes Title 38 medical professionals 

to engage in bargaining under the Title 5 collective bargaining rules that apply to 

other Federal employees. 

Subsection (b) of section 7422 excludes from Title 38 medical professionals’ bargaining rights (and from any grievance procedure provided under a collective bargaining agreement) three specific subjects: 

• professional conduct or competence (which subsection (c) of the statute defines 

to mean clinical competence or direct patient care); 

• peer review (the process by which Professional Standards Boards and other peer 

review entities review medical professionals’ clinical skills); and 

• the establishment, determination, and adjustment of Title 38 employee compensation (which in general means that VA doctors and nurses, like other Federal 

employees, can’t bargain over their pay, but for slightly different reasons). 

Subsection (d) of section 7422 authorizes the VA Secretary to determine whether 

a particular bargaining proposal or union grievance is subject to one of the exclusions set forth in 38 U.S.C. § 7422(b). The VA Secretary has delegated that authority 

to the Under Secretary for Health. 

Subsection (e) of section 7422 says that only the U.S. Court of Appeals for the 

District of Columbia Circuit can hear certain types of cases relating to collective 

bargaining for Title 38 medical professionals. 

b. The legislative history of the existing statute: 

The current version of 38 U.S.C. § 7422 was sponsored by Senator Alan Cranston 

(D-CA), the then-Chairman of the Senate Veterans’ Affairs Committee. Senator 

Cranston and his colleagues worked for several years, over several sessions of Congress, to craft a compromise bill that would extend collective bargaining rights to 

VA doctors and nurses under terms that were acceptable to all stakeholders, including labor unions, physicians’ and nurses’ professional associations, Veterans’ Service 

Organizations, and the Department. Senator Cranston’s remarks to the Senate 

when he introduced the new law indicate that the statute was intended to strike 

a balance between inherently conflicting interests, i.e., between the interests of VA 

physicians and nurses to engage in collective bargaining, and of the Department and 

its veteran patients to ensure patient care is not compromised by the collective bargaining process. 

2. Proposed bill. 

S. 362 proposes to amend title 38, United States Code, ‘‘to improve the collective 

bargaining rights and procedures for review of adverse actions of certain employees 

of the Department of Veterans Affairs.’’ If enacted, this bill would: 

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• Repeal the collective bargaining exclusions for professional conduct or competence, peer review, and employee compensation that are currently set forth in 38 

U.S.C. § 7422(b); • Repeal the provisions of 38 U.S.C. § 7422(c) and (d) that define the 7422(b) exclusions and authorize the Secretary to determine whether a particular union proposal or grievance is excluded; and • Modify certain provisions of 38 U.S.C. §§ 7462 and 7463 relating to Title 38 

medical professionals’ adverse action appeal rights. 

The effect of S. 362 would be to require VA to bargain over issues of clinical competence, patient care, peer review, and employee compensation that are currently 

excluded from bargaining. Moreover, the bill would allow arbitrators, through rulings on grievances filed through the negotiated grievance procedure, to substitute 

their own judgment for the judgment of VA managers and clinicians on these issues. 

Examples of issues that are currently excluded from union bargaining and grievances, but would be subject to bargaining and the negotiated grievance procedure 

under the Filner legislation, include the following: 

• Mandatory TB testing for employees • Professional Standard’s Board restricting a provider’s clinical privileges due to 

competency issues. • Work schedules for physicians and nurses, including alternative or compressed 

work schedules; • The amount of market pay recommended for a particular physician by a Physician Compensation Panel or approved for that physician by a VAMC Director; • The adjustment of locality pay for nurses at a particular VAMC or within a particular work unit; • The selection of a particular RN or physician for a specialized work assignment 

for clinical competence reasons; • A Professional Standards Board’s assessment of a provider’s clinical competence; • A Physical Standards Board’s assessment of a provider’s mental or physical fitness for duty; and • The decision of a VAMC Director to require staff psychiatrists to rotate weekend call duty, rather than relying on the Medical Officer of the Day to assess patients’ emergent mental health needs. 

Consider that without the Title 38 collective bargaining exclusions, the Department would be unable to respond expeditiously to changes in veterans’ health care 

needs. For example, as the need for expanded mental health services for returning 

OEF/OIF veterans became clear, the Department was able to quickly set up a dedicated Suicide Prevention hotline and to assign qualified medical professionals to 

staff the hotline on a 24/7 basis. In the first 60 days of the Suicide Prevention hotline’s existence, hundreds of veterans in critical need of mental health counseling 

called the hotline and received the care they needed. Absent the Title 38 collective 

bargaining exclusion for issues of direct patient care, the Department would have 

been required to bargain over the procedures by which employees would be assigned 

to the hotline before it could be implemented, resulting in unacceptable delays and 

potentially many lost lives. 

Finally, the Unions would have you think that the existing statute weakens the 

VA’s ability to recruit and retain an adequate work force. To the contrary, one of 

the draws for the VA in being able to recruit high quality clinical staff is the high 

level of ‘‘clinical competence’’ of its existing workforce. Allowing the Unions status 

to address competency issues will only erode the high level of clinical competence 

that exists. The VA’s current branding for recruitment is ‘‘The Best Care/The Best 

Careers.’’ Nurses are drawn to the VA because of the quality of care VA nurses provide to the Veterans. VA Nurses are proud of their reputation of providing the best 

care. 

The Secretary has not abused his discretionary authority in using 38 U.S.C. 

7422 to exclude issues relating to direct patient care, clinical competence, peer 

review, or Title 38 compensation. Of the issues that were decided by the Secretary in 2008, approximately 41 percent were held to be partially or fully negotiable. 

As is noted above, the current Title 38 statute was a carefully crafted compromise bill that empowers VA doctors and nurses to engage in collective bargaining while protecting from compromise VA clinicians’ patient care determinations and related peer review and compensation adjustment processes. 

S. 362 would upset that careful balance in a way that is unwarranted, unprecedented, and unwise at a time where responding quickly to the needs of our Veterans is imperative. 

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In conclusion, repeal of Title 38 Collective Bargaining exclusions would cripple 

VA’s patient care mission by: 

• Delaying critical changes in health care delivery and substituting the decisions 

of labor negotiators/arbitrators for clinician’s professional judgment; • Allowing the unions to decide whether or not it is appropriate if patient care 

needs dictate than an RN stay beyond their scheduled tour; • Substituting staff preferences for tours of duty in lieu of patient care needs; • Delay the detail of staff from one area of need to another until negotiations are 

completed; and • All other issues pertaining to the clinical needs of our Veterans. 

NOVA understands that provisions in S. 362 have been adopted by the Department of Defense (DOD); however we feel strongly that this policy cannot adequately 

be compared to the VA health care system. The unions have used the argument that 

Collective Bargaining within Walter Reed on issues of Clinical Competency, Clinical 

Conduct, Title 38 Compensation and Peer Review has not compromised patient care 

and should, therefore, also be adopted by VA. This is not a true comparison. DOD 

employs considerably fewer bargaining unit MDs and nurses than the VA does. 

DOD has approximately 500 bargaining unit physicians and 4,600 bargaining unit 

nurses while VA has 10,000 bargaining unit physicians and 50,000 bargaining unit 

nurses. If absolutely necessary, NOVA would agree to the reestablishment of Mandatory Labor/Management Councils at each VA Facility and alternative legislative 

language as proposed by VA. NOVA is dedicated to the safe, quality care of America’s heroes and thanks the Committee for considering NOVA’s position on S. 362. 

PREPARED STATEMENT OF DAVID J. HOLWAY, NATIONAL PRESIDENT, NATIONAL

ASSOCIATION OF GOVERNMENT EMPLOYEES, SEIU/NAGE LOCAL 5000 

On behalf of the National Association of Government Employees (SEIU/NAGE), 

and the more than 100,000 workers we represent, including 20,000 at the Department of Veterans Affairs (VA), I would like to thank you for the opportunity to submit written testimony regarding pending health care legislation. 

SEIU/NAGE strongly supports S. 362. This bill would restore a meaningful scope 

of bargaining for Title 38 health care providers at the VA, a critical necessity to 

boost morale and strengthen recruitment and retention at the agency. Giving health 

care providers a meaningful voice in their workplace will lead to better care for the 

American veteran. 

In 1991, Congress amended Title 38 to provide VA medical professionals with collective bargaining rights, which include the rights to use the negotiated grievance 

procedure and arbitration. Under Sec. 7422 of Title 38 (‘‘7422’’), covered employees 

can negotiate, file grievances and arbitrate disputes over working conditions, except 

for matters concerning or arising out of professional conduct or competence, peer review, or compensation. Increasingly, VA management is interpreting these exceptions very broadly, and refusing to bargain over virtually every significant workplace issue impacting medical professionals. The broad interpretation 7422 is leading to significant dissatisfaction among rank-and-file VA health care providers. 

We have heard from our local members across the country, who have urged our 

union to make passage of S. 362 our top legislative priority for legislation impacting 

the VA workforce in the 111th Congress. Their concern is that too many highly 

qualified, outstanding health care professionals have left the VA for other employment because they were unsuccessful in getting someone of authority at the agency 

to listen to or address legitimate concerns because the issue fell under the evergrowing umbrella of 7422. 

The agency has increasingly been unwilling to address those issues that are most 

important to Title 38 employees, including time schedules, shift rotations, evaluations, fair and equal opportunity to be considered for a different position within the 

facility, and fair treatment among colleagues. Rather than suffer under a system 

where they have no mechanism to provide input or air grievances, disenfranchised 

VA employees simply move on to other employment. It has gone on too long, and 

it has to stop. 

VA medical professionals have extremely limited collective bargaining rights in 

the first place, and the broad interpretation of 7422 is narrowing the scope of bargaining to the point that it is practically meaningless. As a result, RNs, doctors, and 

other impacted employees at the VA are experiencing increased job stress, low morale and burnout. This in turn exacerbates the VA’s well-documented recruitment 

and retention problems. Chronic short-staffing has been shown to adversely impact 

quality of care, patient safety, and workplace safety, leading to costly stopgap measures such as the overuse of contract nurses and doctors. 

169 

I want to share a good example of the kind of management abuse that occurs at 

the VA when management has the unfettered discretion to attain a 7422 ruling, and 

therefore, take a seemingly bargainable issue off the table. We witnessed a case 

where a staff RN position was posted for nurse on an acute medical/surgical unit. 

Four RNs applied for the position, one of which had far more experience and competence by any reasonable measure than the other three. This was meaningful because the local collective bargaining agreement provided that when two or more 

equally competent nurses request to fill an open position, preference will be given 

to the most senior competent nurse. When the more senior competent nurse was 

passed up for the position in favor of a nurse with substantially less experience, the 

union filed a grievance on behalf of the more senior nurse. In the first step of the 

grievance, which involved the unit manager, no settlement could be reached. In the 

second step of the grievance, which involved the acting nurse executive, the unit 

manager’s decision to hire the less experienced nurse was upheld. In the third step 

of the grievance, which involved the medical center director, our nurse’s case was 

heard, but management chose to use their allotted time to respond after hearing our 

case. But management never ended up responding. Instead, at this late stage of the 

grievance process, the director notified the union that the grievance was a 7422 

issue and was therefore not grievable. The union reminded the director that he did 

not have the authority to make that decision. The director then made a request for 

a 7422 ruling from the Under Secretary who did, in fact, render the grievance as 

a 7422 issue and therefore not grievable. This was extremely demoralizing to this 

nurse, who had spend years caring for the American veteran and rightfully deserved 

the position that was applied for. 

We see cases like this, and worse, every day at the VA. Our health care providers 

know that there is no use in even questioning management’s decisions when they 

can always fall back on 7422 as a way to trump the efforts of the union to give Title 

38 VA workers a fair shake. It is especially egregious that management can claim 

7422 very late in the grievance process. Our local union representatives report management threatening to seek a 7422 decision over practically any issue they do not 

want to bargain over, and the disturbing thing about that is, in most cases, those 

managers will be granted their 7422 claim if it is requested. 

Additionally, we have seen cases where RNs have been denied union representation during fact-finding for a potential disciplinary action; the agency claimed this 

was a competence issue. We have been prevented from bargaining over nurse-patient ratios, which has resulted in geriatric nurses having as many as 30 patients 

in their care because of poor staffing. We have seen nurses sent on mandatory temporary reassignments that required them to take a shuttle bus from one facility to 

another that was approximately 60 miles away. We have seen management spontaneously cancel annual leave requests that were granted months in advance, because 

of chronic understaffing. This causes nurses to scrap vacation plans that may have 

been several months in the making. 

Health care providers at the VA are very frustrated with the kind of management 

style that has been demonstrated in many VA facilities in recent years, and they 

end up leaving because they do not have to take it. Most nurses and other health 

care providers can find equal or even higher paying jobs in private sector medical 

facilities in the same city or town where they are currently living; places where they 

can have a meaningful voice in their workplace. This is a major reason why maintaining staffing has been such a major concern at the VA. VA workers are not willing to tolerate being disrespected by the agency when they can go down the street 

to a private facility, where they can probably make more money while getting treated with dignity. 

Passing S. 362 would help to address many of these concerns. This bill would restore a meaningful scope of bargaining for Title 38 VA professionals by eliminating 

the ‘‘7422 exceptions’’ (conduct, competence, compensation, and peer review) under 

the law. 

Eliminating these exceptions will provide health care providers with the same 

rights as other VA providers, including psychologists, LPNs, and pharmacists, as 

well as other Federal employees. Title 5 health care providers at the VA have full 

collective bargaining rights. Even nurses and doctors at Army Medical Centers such 

as Walter Reed, who perform the same exact function as nurses and doctors at the 

VA, have full collective bargaining rights. Most private sector health care providers 

have a meaningful voice in their workplace as well. Nowhere have we seen cases 

where collective bargaining has had a negative impact on patient care. There is no 

reason for Title 38 VA workers to have these critical rights taken away. 

Restoring meaningful bargaining rights will greatly increase morale at the VA. It 

will also serve to address recruitment and retention issues at the VA, which are 

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critical at this time, given the veterans returning home from conflicts abroad. All 

this will lead to better care for our Nation’s veterans. 

SEIU/NAGE greatly appreciates the Committee’s decision to hold a hearing on 

pending health-related legislation. I thank the Committee for the opportunity to provide testimony. 

PREPARED STATEMENT BY LUANNE LONG, RN, PRESIDENT, HAWAI’I NURSES

ASSOCIATION, UNITED AMERICAN NURSES, AFL–CIO 

I would like to thank Chairman Akaka, Ranking Republican Member, and Members of the Committee for the opportunity to provide testimony for the hearing on 

S. 362, legislation that will restore collective bargaining rights to registered nurses 

working in the Department of Veterans Affairs. My name is Luanne Long and I 

have been a registered nurse for over 21 years. I’m also the President of the Hawai’i 

Nurses Association and an 18 year Army veteran. 

I’m testifying today as a member of the United American Nurses AFL–CIO, a 

union representing registered nurses—6,000 of whom are VA nurses. I will give my 

testimony from the perspective of a nurse labor leader, as well as a veteran who 

has used the VA health care system. 

There exists a health care crisis in our country regarding the shortage of registered nurses. A 2002 report by the Health Resources and Services Administration 

states that, by 2020 hospitals will be short 808,416 RNs. In a 2002 survey by the 

United American Nurses, three out of every ten nurses said it was unlikely they 

would be a hospital staff nurse in 5 years. The VA health care system has by no 

means been immune to the shortage. 

As nurses leave the VA system, new nurses are not joining the VA at comparable 

rates, and patient load is increasing. In its own report, ‘‘A Call to Action,’’ the VA 

states that it must replace up to 5.3 percent of its RN workforce per year to keep 

up with RNs retiring. By all accounts, that is not happening. In its web site documentation of system-wide capacities, VA statistics show that between 1996 and 2002 

the number of full-time-equivalent RNs went down by 8.4 percent. During that same 

time period, the number of ‘‘unique patients’’ treated at the VA went up by 55 percent. 

Congress amended Title 38 to provide medical professionals who work at VA facilities with collective bargaining rights, which include the rights to use the negotiated grievance procedure and arbitration. Under 38 U.S.C., section 7422, covered 

employees can negotiate, file grievances and arbitrate disputes over working conditions except ‘‘any matter or question concerning or arising out of:’’ 

• professional conduct or competence (defined as direct patient care or clinical 

competence; 

• peer review; or 

• the establishment, determination, or adjustment of employee compensation. 

Increasingly, VA management has interpreted these exceptions very broadly, and 

has refused to bargain over significant workplace issues affecting medical professionals. Recent court decisions are upholding the VA’s broad reading of Section 

7422, even when management raises it after completion of the arbitration process. 

Congress recognized the benefits of collective bargaining rights in the VA and the 

merit of nurses’ input into workplace and quality of care issues. As a result, Congress passed a law in 1991 to strengthen collective bargaining rights for nurses 

working at the VA. The VA has also acknowledged the critical role that nurses have 

in improving quality of care. According to the VA Office of Nursing, ‘‘VA nurses 

have been widely recognized for their instrumental work in initiating, developing, 

implementing, and monitoring the practices and policies that made VHA one of the 

world’s foremost authorities in patient safety and quality outcomes evidenced by 

performance measures—an exceptional achievement by any assessment.’’ (DVA Web 

site, April 30, 2007) An excellent example of this can be seen in the development 

of VA’s health information technology system. Nurses and other health care providers worked with VA management on the design and implementation of VA’s 

health IT system. The VA’s health IT system is now well-recognized as one of the 

most effective and efficient systems in the world, a shining example for other health 

care systems. 

Unfortunately, VA nurses are experiencing an ever-shrinking role in workplace 

issues, quality assurance, and patient safety. Too often, the Human Resources staff 

is making health care decisions instead of nurses. The VA’s current 7422 policy goes 

directly against good medicine and Congressional intent. Congress needs to amend 

section 7422 of Title 38 to ensure that the VA complies with Congressional intent 

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and that registered nurses are able to care for veterans with dignity, respect and 

the basic bargaining rights they were intended to have. 

As an RN, I am proud to be a member and leader of the Hawai’i Nurses Association—the union representing nurses where I work. Because I have the protections 

of my union behind me, I am able to forcefully and effectively advocate for my patients every day, using the tools afforded me by my union, such as a grievance and 

arbitration procedure, to improve working conditions for nurses and quality for patients. Congress intended that VA nurses likewise have the benefits of union representation in all matters except those dealing with compensation, direct patient 

care, and clinical competence, but VA management has stepped in to change Congress’ intent, depriving VA nurses of the full benefits of union representation to 

which they are entitled. 

As a veteran whose sizable extended family uses the VA health care system, I 

fully support legislation that would restore the collective bargaining right of registered nurses. I am concerned about the nurse shortage in the VA health care system. This shortage has been exacerbated by the VA’s recent effort to restrict RNs’ 

collective bargaining rights through the use of section 7422 of Title 38. Nurses are 

becoming frustrated by the fact they have less rights than the LPNs and Certified 

Nursing Assistants that work in same units, just because these health care providers work under Title 5. As a result, registered nurses are leaving the VA to work 

at private sector hospitals right down the street, where they have full collective bargaining rights. 

As a veteran, I’m also concerned that VA RNs are not fully protected by their collective bargaining rights. RNs should be able to use the grievance process to challenge management when well established policies are being broken. For example, 

if a nurse is asked to complete assignments that regularly violate the VA’s safe patient handling policy, the RN should be able to file a grievance. This would make 

it safer the nurse as well as veteran patients. Unfortunately, VA’s use of section 

7422 unfairly prohibits the grievance of most any issue. 

To address the problems with section 7422 of Title 38, Senate Rockefeller has introduced S. 362, a bill that would improve collective bargaining rights of registered 

nurses in the Department of Veterans Affairs. Congress needs to pass S. 362 to increase RN recruitment and retention, as well as protect RN’s and veteran patients 

they take care of. The UAN and HNA strongly urge Members of the Committee to 

support and work for the passage of this important legislation. 

Thank you again for opportunity to provide testimony regarding this important 

issue. 

Æ