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41–535 PDF 2008

S. HRG. 110–346

VETERAN’S HEALTH: ENSURING CARE FOR OUR

AGING HEROES

HEARING

BEFORE THE

SPECIAL COMMITTEE ON AGING 

UNITED STATES SENATE

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

WASHINGTON, DC

OCTOBER 3, 2007

Serial No. 110–15

Printed for the use of the Special Committee on Aging

(

Available via the World Wide Web: http://www.gpoaccess.gov/congress/index.html 

SPECIAL COMMITTEE ON AGING 

HERB KOHL, Wisconsin, Chairman 

RON WYDEN, Oregon 

BLANCHE L. LINCOLN, Arkansas 

EVAN BAYH, Indiana 

THOMAS R. CARPER, Delaware 

BILL NELSON, Florida 

HILLARY RODHAM CLINTON, New York 

KEN SALAZAR, Colorado 

ROBERT P. CASEY, Jr., Pennsylvania 

CLAIRE McCASKILL, Missouri 

SHELDON WHITEHOUSE, Rhode Island 

GORDON H. SMITH, Oregon 

RICHARD SHELBY, Alabama 

SUSAN COLLINS, Maine 

MEL MARTINEZ, Florida 

LARRY E. CRAIG, Idaho 

ELIZABETH DOLE, North Carolina 

NORM COLEMAN, Minnesota 

DAVID VITTER, Louisiana 

BOB CORKER, Tennessee 

ARLEN SPECTER, Pennsylvania 

DEBRA WHITMAN, Staff Director 

CATHERINE FINLEY, Ranking Member Staff Director 

(II) 

C O N T E N T S 

Page 

Opening Statement of Senator Gordon H. Smith ................................................. 1

Opening Statement of Senator Herb Kohl ............................................................. 3

Opening Statement of Senator Ron Wyden ........................................................... 4

Opening Statement of Senator Susan Collins ....................................................... 5

Opening Statement of Senator Bob Corker ........................................................... 6

Opening Statement of Senator Claire McCaskill .................................................. 6

Opening Statement of Senator Norm Coleman ..................................................... 7

Opening Statement of Senator Ken Salazar ......................................................... 8

Opening Statement of Senator Blanche Lincoln ................................................... 18

Opening Statement of Senator Sheldon Whitehouse ............................................ 20

PANEL I 

Robert Dole, Former United States Senator, Washington, DC ............................ 9

PANEL II 

Michael Shepherd, senior physician, Office of Healthcare Inspections, Office 

of Inspector General (OIG), Department of Veterans Affairs, Washington, 

DC .......................................................................................................................... 24

Larry Reinkemeyer, director, Kansas City Office of Audit, Office of Inspector 

General, Department of Veterans Affairs, Washington, DC ............................ 32

PANEL III 

Steven R. Berg, vice president for Programs and Policy, National Alliance 

to End Homelessness, Washington, DC ............................................................. 48

Fred Cowell, associate director of Health Policy, Paralyzed Veterans of America, Washington, DC ............................................................................................ 60

Mark S. Kaplan, professor of Community Health, Portland State University, 

Portland, OR ......................................................................................................... 74

APPENDIX 

Prepared Statement of Robert P. Casey ................................................................ 97

Responses to Senator Smith’s Questions from Dr. Shepherd .............................. 98

Responses to Senator Smith’s Questions from Larry Reinkemeyer .................... 99

Responses to Senator Smith’s Questions from Mark Kaplan .............................. 100

Letter from Department of Veterans Affairs, Washington, DC ........................... 102

(III) 

(1)

VETERANS’ HEALTH: ENSURING CARE FOR 

OUR AGING HEROES 

WEDNESDAY, OCTOBER 3, 2007 

U.S. SENATE, 

SPECIAL COMMITTEE ON AGING, 

Washington, DC. 

The Committee met, pursuant to notice, at 11:48 a.m., in room 

325, Russell Senate Office Building, Hon. Gordon H. Smith (ranking member of the committee) presiding. 

Present: Senators Kohl, Wyden, Lincoln, Salazar, McCaskill, 

Whitehouse, Smith, Collins, Coleman, and Corker. 

OPENING STATEMENT OF SENATOR GORDON H. SMITH, 

RANKING MEMBER 

Senator SMITH. Good morning, ladies and gentlemen. We welcome you all to this hearing of the Senate Special Committee on 

Aging. 

Our Chairman is the senator from Wisconsin, Herb Kohl. The 

way that he and I have operated is he is the boss. I was in the last 

Congress, but we don’t, frankly, much see that distinction. Each of 

us are able to call hearings. 

Our tradition is to work in a bipartisan way and focus on issues 

critical to aging Americans. Today we are going to focus on the ongoing and critical needs of our new and of our aging veterans and 

their physical and mental health needs. 

So to that end, we will begin. I will offer an opening statement. 

Our Chairman will do that, as well. We will have 5-minute opening 

statements for others who wish to give them. 

There is no greater obligation than caring for those who have 

served this country with their military service. We would be remiss 

if we did not ensure that the health care of our heroes in arms is 

the finest medicine has to offer. 

While much of the focus in the media has been centered on the 

state of health care for our returning vets, it is the responsibility 

of this Committee to not forget those who have served in wars past. 

It was exactly 3 months ago today when, in Oregon, Senator 

Wyden and I chaired a hearing on the topic of veterans’ health. At 

that time, we looked at the provision of mental health services for 

aging veterans. While that will remain a focus of today’s discussion, we will also look forward to hearing testimony on all aspects 

of veterans’ health care. 

As I made clear in July, we must ensure that our aging veterans 

are not left behind. 

2

In our Nation today, we have nearly 24 million veterans, about 

40 percent of whom are 65 years and older. 

I think many of us have probably watched the Ken Burns series 

‘‘The War.’’ If you have, you have a fuller understanding of just 

how much we owe to the greatest generation. Our first witness is 

more emblematic of that generation than perhaps any American 

that I know. 

The Veterans Health Administration serves about 5.5 million of 

them each year and employs 247,000 employees to attend to their 

care. I draw attention to these numbers to emphasize not only the 

scale of the system and, therefore, the noted difficulties in meeting 

all the needs at all times in such a large system, but also to reiterate that there are large numbers of veterans to whom we owe an 

enormous debt. 

We also know that too many veterans are falling through the 

cracks. 

Today, we will hear from the Department of Veterans Affairs Office’s inspector general that wait times for outpatient care are actually longer than have been reported by the department. This report 

is important as we work to ensure that veterans, particularly those 

with time-sensitive health needs, are seen quickly. 

Today, we will also hear about the numbers and needs of homeless veterans in our Nation. We know that nationally 23 percent 

of all homeless persons are veterans. In Portland, OR, that number 

could be as high as 30 percent. They suffer disproportionately from 

poor health, including mental health and substance abuse challenges. 

We are fortunate to have wonderful community-based groups, 

such as the Central City Concern, in Portland working to help 

those who are homeless to get the help and support they need. But 

we must do more. 

We will also hear today about the risks of suicide for our Nation’s 

veterans. 

As reported earlier this year by Dr. Kaplan from Portland State 

University, and subsequently in various news reports, veterans in 

our Nation are at twice the risk of suicide as nonveterans. With the 

number and needs of our veterans ever-increasing in our Nation, 

we must ensure that our mental health infrastructure is prepared 

to handle their unique needs. 

I will continue to work with the Department of Veterans Affairs, 

the Department of Defense, the Substance Abuse and Mental 

Health Services Administration, and our community-based mental 

health network to ensure that the needs of our veterans are met. 

I know that SAMHSA and the VA earlier this year worked to address the unique needs of veterans who call the National Suicide 

Hotline. For instance, when veterans call the hotline, they will be 

linked to professionals who specialize in the needs of veterans. 

Since the implementation in July, there have been nearly 8,000 

calls made by veterans looking for a lifeline, including 177 from my 

home State of Oregon. 

I also look forward to hearing testimony on the needs of our 

aging veterans as it relates to long-term care. 

3

We know that in our Nation almost two-thirds of people receiving 

long-term care are over age 65, many of whom are veterans. We 

also know that this number is expected to double by 2030. 

There are many demands and constraints on the VA system, as 

well as Medicare and Medicaid, to ensure that aging veterans’ 

health needs are being met. To better understand this need, we 

will first hear from Senator Bob Dole after my colleagues give their 

opening statements. 

Bob Dole is a friend of mine and a great American patriot. Senator Dole served and was injured twice in World War II while serving in Italy. For those injuries, he was hospitalized for more than 

3 years. 

He was a distinguished legislator in this body and in the House 

for many years, where he was a strong supporter of veterans’ 

issues, including a pivotal role in the creation of the World War II 

Memorial on our National Mall. Most recently, he served as CoChair of the President’s Commission on the Care for America’s Returning Wounded Warriors. 

I have only known Senator Dole to speak from his heart on these 

issues. I look forward today to hear his personal story and recommendations on how we on the Aging Committee can do a better 

job to facilitate in this great effort. 

With that, our Chairman, Senator Kohl. 

OPENING STATEMENT OF SENATOR HERB KOHL, CHAIRMAN 

Senator KOHL. I thank you, Senator Smith, for holding this important hearing. Ensuring quality care for our Nation’s veterans 

both young and old is of great importance to everybody. So we welcome our witnesses and look forward to your testimony. 

In combat our veterans sacrifice their physical and mental 

wellbeing in order to defend our Nation and its values. In return 

they deserve the highest standard of care from our government. 

The war in Iraq is creating a new generation of veterans, many 

of whom are in need of critical care. They are joining the ranks of 

older veterans who have survived wars of the past and are still in 

need of, and certainly deserving of, our attention. Unfortunately, 

some of them are simply not getting the care they need. 

Scandals such as the deteriorating conditions at Walter Reed 

Army Medical Center demonstrate just part of the problem. We 

must also consider the broader faults in the system of veterans’ 

health care. 

Recent reports—notably, the President’s Commission on Care for 

America’s Returning Wounded Warriors and the DOD Task Force 

on Mental Health—have documented complex bureaucratic processes and limited communication between government agencies 

that have allowed too many veterans to fall through the cracks. 

These problems have been around for a long time. They will not 

yield to easy fixes. 

While we work to improve treatment and health care for our veterans’ bodies, we have also learned that it is just as important to 

treat their minds. Too many of our bravest men and women are 

suffering silently from mental health problems which can lead to 

personal struggles, homelessness, and even suicide. 

4

We have heard a great deal about how these problems affect the 

veterans returning now from Iraq and Afghanistan. But we certainly should not forget that for many of our older veterans time 

has not erased their mental battle scars. Our hope is that it is certainly not too late to help them. 

We are very pleased that our former Senate colleague, Senator 

Bob Dole, is here to share his thoughts on these issues. 

We welcome you back, Senator Dole. I have the fondest recollections of the time that we spent together. As I told you, I have the 

greatest respect for your service. We are very pleased that you 

could join us. 

We thank also of our witnesses for participating. 

I would like to remain for the entire hearing, Senator Smith, but 

I am Chairman of the Antitrust Subcommittee, which is having a 

hearing as we speak. So I am going to have to——

Senator SMITH. We will carry on in a bipartisan fashion. In that 

spirit and with your permission, we will go in this order: Senator 

Wyden, Senator Collins, Senator Corker, Senator McCaskill, Senator Coleman, Senator Salazar. I think that is the order of arrival. 

Senator Wyden. 

OPENING STATEMENT OF SENATOR RON WYDEN 

Senator WYDEN. Thank you, Senator Smith. I want to commend 

you for this follow up on the very important hearing we held at 

home. I especially appreciate the bipartisan cooperation we have 

always had on this Committee with Senator Kohl. 

In our home state, from the woods of central Oregon to the 

streets of downtown Portland, older veterans are needlessly suffering because the veterans’ health system has let them down. 

In the woods in our state, the veterans have had to establish 

camps trying to find a way in the woods to get by. I don’t see how 

anyone can argue that having veterans try to get these kinds of 

services through camps in rural Oregon is acceptable in 2007. 

In the city, my state has worked with a number of older veterans 

who have drug problems. They have been able to get clean. But 

then they go into these extraordinarily long waiting lines for housing, which is representative of the bureaucratic water torture that 

our veterans are submitted to. 

Senator Dole is with us here today. He has really been a role 

model for a lot of us because he has shown on these key kinds of 

health issues that it is possible to bring together your head and 

your heart and to think sensibly about how to tackle the issues. 

Senator Dole, your report, as is always the case with your work, 

is chock full of useful recommendations. But I am especially 

pleased that you and Secretary Shalala have come up with this 

idea of a care coordinator. I think that is going to be especially 

helpful for the older veteran because, as Gordon and I got about 

the state and listened to veterans, we especially found the older 

veteran getting lost in this health care system. 

So your suggestion about the idea of a care coordinator, where 

somebody would actually be held accountable and the veteran 

wouldn’t just be jostled from one place to another, is especially sensible. 

5

So we thank you, once again, for your contributions, something 

you have done again and again throughout your time in public 

service. I am just glad to have you here. 

I am an Oregonian now, but you and I will always have our Kansas roots. I thank you. 

Senator SMITH. Thank you, Senator Wyden. 

Senator Collins. 

OPENING STATEMENT OF SENATOR SUSAN COLLINS 

Senator COLLINS. Thank you, Mr. Chairman. First, let me thank 

you for calling this hearing to examine the many challenges facing 

our Nation’s older veterans and to consider possible policy changes 

that are necessary to ensure that veterans receive high-quality 

health care. 

Like the rest of my colleagues, I am absolutely delighted that 

Senator Dole is our leadoff witness today. He not only knows from 

personal experience the challenges that our veterans face, but I 

can’t think of someone who has a greater knowledge of how the 

Congress works, plus how the veterans’ health care system works, 

than Senator Dole. 

So he is indeed the ideal leadoff witness for this hearing. He is 

a person for whom all of us have the greatest admiration. 

So it is great to welcome you back, Senator Dole. 

My work on the Senate Armed Services Committee has only 

served to heighten my personal admiration for the men and women 

who wear the uniform of this country. 

Throughout our history, our Nation’s veterans have done their 

duty with honor and with great dedication. For their sacrifices, we 

can never fully repay that debt that we owe them. 

But I also have a very deep personal connection to our veterans. 

My father is a member of the greatest generation. He is a World 

War II veteran who fought in the Battle of the Bulge. He was 

wounded twice and has a Purple Heart, Bronze Star, and Oak Leaf 

Cluster. 

Like so many veterans of his generation, he never talked much 

about the service that he rendered to our country. It was only now, 

as he has gotten older, that he has begun to share those stories 

with us and with his fellow veterans. But he was always very 

proud of that service. 

As I have gotten older I have appreciated even more his sacrifice 

and patriotism, so typical of those of that generation, so typical of 

those like Senator Dole. 

In the State of Maine, which is a large, rural state, we face two 

particular challenges in providing health care to our veterans. They 

both really have to do with access to health care. 

The first is transportation so that our elderly veterans are able 

to get to the one veterans’ hospital that we have in our state. It 

is the Togus Hospital in Augusta. It is an excellent facility. But for 

some of our veterans, it is as far as 5 hours away. 

The second challenge has been funding, funding not only for 

Togus to ensure that it has the specialists that many of our veterans need so that they don’t have to travel even further to the 

Boston area to get the care they need, but also funding for community-based outpatient clinics. These clinics are enormously successVerDate 0ct 09 2002 12:25 Apr 11, 2008 Jkt 000000 PO 00000 Frm 00009 Fmt 6633 Sfmt 6633 H:\DOCS\41535.TXT SAGING1 PsN: JOYCE
6

ful because they provide much closer access to health care for our 

veterans. 

The ones that have been established work very well. But there 

are many that have been on the drawing board for a long time, delayed from opening due to funding constraints. 

I noticed Senator Salazar is here today. I was very pleased to cosponsor last year a Veterans’ Ride Bill that he developed to establish a grants program to help veterans travel to appointments at 

our VA clinics and our VA hospital. 

But I think transportation and funding are the two biggest challenges that I see for providing this care. 

So again, thank you, Mr. Chairman, for holding this hearing. 

Senator Dole, what an honor it is to have you here today. 

Senator SMITH. Thank you, Senator Collins. 

Senator Corker. 

OPENING STATEMENT OF SENATOR BOB CORKER 

Senator CORKER. Mr. Chairman, thank you for holding this hearing. 

We are honored to have Senator Dole, who can help us with this 

issue, help introduce it, help us be focused on it the right way. 

He also, I think, can help us with civility in the Senate in general. We were talking a little bit about that before we began. 

But in order to be able to hear him today, I am going to withhold 

any comments and questions until after the testimony, but thank 

you. 

Senator SMITH. Thank you, Senator Corker. 

Senator McCaskill. 

OPENING STATEMENT OF SENATOR CLAIRE MCCASKILL 

Senator MCCASKILL. Thank you, Mr. Chairman. 

I am always self-conscious when we all talk before a witness testifies, but somehow I have a feeling you understand, Senator Dole, 

about the need of all of us to say a few words before we begin. I 

want to welcome you and thank you for all you have done for our 

country. 

As you well know, I am your neighbor. I will tell you one thing. 

When I was being brought up in Columbia, MO—both of my parents being graduates of Mizzou—my father told me, without a 

smile on his face, that I could go to college anywhere I wanted to 

go, but if I went to KU I had to pay for it myself. [Laughter.] 

So with the one exception of the rivalry between the Jayhawks 

and the Tigers, I am a big fan of yours and welcome you here 

today. 

When I did my veterans tour back on the week after Memorial 

Day, I traveled all over the state. I was blessed to have the opportunity to visit with hundreds and hundreds and hundreds of Missouri veterans of all ages. I was struck by that when I went to Iraq 

about a month later because in every unit I visited, I saw some 

variation of the theme leave no fallen comrade behind. 

I reflected on the ethic that imbues our military about taking 

care of one another; taking care of your unit. I realized what an 

incredible lonely and solitary journey it must be, particularly for 

those men and women who come home with mental health issues. 

7

After you have been surrounded by this all-enveloping culture 

that it is about taking care of one another, you all of a sudden are 

facing an incredibly lonely time. The stigma associated with it can 

be almost as paralyzing, I think, as a physical paralyzation. 

I think it is so important as we move forward that we be very 

aggressive reaching out in giving these men and women the kind 

of moral support and the kind of bureaucratic support within this 

bureaucracy that removes the loneliness from that journey and 

works very hard on the stigma. I think so much of your work on 

the commission will go toward that end. 

I am also anxious to hear from the other witnesses today, particularly the IGs, about some of the internal problems we have 

within Veterans Affairs in terms of the bureaucracy. I am particularly offended by this game they are playing with waiting lists. 

You know, we owe our veterans a lot, but we sure owe them a 

straight shot in being truthful with them about how long they are 

going to have to wait to see a doctor. This idea that we are playing 

games with waiting lists to try to make us look better is so offensive, I think, to the military and what they mean to our country. 

So I thank you for being here today. I look forward to your testimony and the testimony of the other witnesses. 

Senator SMITH. Thank you, Senator McCaskill. 

Senator Coleman. 

OPENING STATEMENT OF SENATOR NORM COLEMAN 

Senator COLEMAN. Thank you, Mr. Chairman. 

Mr. Chairman, I would like my full statement to be entered into 

the record and——

Senator SMITH. Without objection. 

Senator COLEMAN. Let me just say one brief comment, because 

I look forward to hearing Senator Dole’s testimony. 

I recently buried my dad in Arlington Cemetery just less than a 

couple of months ago. He was a veteran of World War II, on the 

beach in the early morning hours of D-day at Normandy; like Senator Collins’ dad, was at the Battle of the Bulge, wounded, received 

his Purple Heart there. 

My dad and his generation—and, Senator Dole, your generation—experienced the Depression, world war, holocaust, defeated 

two isms—fascism and communism—and came back with this unbridled optimism that has given us the opportunity to have all that 

we have. 

For that, we say, ‘‘Thanks.’’ For that, we owe you and those who 

have served a debt of gratitude. We owe you and those who you 

speak for a system in which there aren’t waiting lines, in which 

there is adequate mental health facilities. 

I just want to thank you for being a voice for so many whose 

voices have been stilled by time and circumstance. 

Senator Dole is a patriot. He is a great American. 

Senator, I thank you for your service. I look forward to your testimony. 

Senator SMITH. Senator Salazar. 

8

OPENING STATEMENT OF SENATOR KEN SALAZAR 

Senator SALAZAR. Thank you very much, Senator Smith. I just 

want to thank Chairman Kohl for also holding this hearing on veterans’ issues. 

I will just change chairs. [Laughter.] 

Let me just begin first by thanking both Senator Kohl and Senator Smith for holding this hearing. It is truly an example of bipartisanship here in the Senate that I am very proud of. 

Second, to you, Senator Dole, we are all very, very proud of you. 

I think, when we look at you, most of us are in that generation 

where we know that we have stood on your shoulders and the 

shoulders of our parents. In the same way that Senator Coleman 

and Senator Collins were talking about their parents, I, too, could 

talk about both my father and my mother and their efforts in 

World War II. So we appreciate your service to our country. 

The issues of veterans for us are very important. It is not a 

Democratic or a Republican issue. It is an American issue. 

For me and my service on the Veterans’ Committee for the first 

2 years that I was in the Senate, there were a number of issues 

that I was very concerned about. Hopefully, during your testimony 

you might address a few of those issues. 

The first of those had to do with rural veterans and the disparity 

of health treatment and health care availability to veterans in 

rural areas in comparison to those in urban areas. Then-Undersecretary Perlin had done a very comprehensive study that demonstrated the huge disparity that existed in terms of health care 

treatment for veterans in far-away places in rural areas and those 

in urban areas. 

In my state, we have tried to address some of those issues over 

the last several years with community-based outreach clinics and 

have had some success there. But I continue to believe that that 

disparity still exists. 

Second, there is an issue of long-term care. In my view, I do not 

believe that the VA has done an adequate job in terms of putting 

together a long-term care plan for our veterans, for our Nation. It 

is something that I have legislation which has been passed which 

has directed the VA to develop a plan with respect to long-term 

care. 

Then third, an issue which has been very hot here in Washington, DC, but it is a very real issue that some of my colleagues 

have addressed, and that is the issue of mental health. Especially 

now with the bulge of veterans that we will see from Operation 

Iraqi Freedom and Operation Enduring Freedom, it is going to be 

important for us to make sure that we are doing what we have to 

do with mental health care. 

Finally, let me just once again echo my thanks to you and the 

pride that we have in people like you who have really shown us 

the way here in America. Thank you. 

Senator SMITH. Thank you, Senator Salazar. 

Senator Dole, I have been given a long introduction, but I don’t 

think you want to hear it. We all are here in part as a reflection 

of the esteem in which we hold you. We thank you for being here 

and for being patient to hear us out, as well. We are anxious to 

receive your testimony. 

9

STATEMENT OF FORMER SENATOR ROBERT DOLE, 

WASHINGTON, DC 

Senator DOLE. Well, thank you very much. Herb had to leave. 

Mr. Chairman had to leave, but I appreciate all your statements. 

I know all of you. You are all doing a great job. This is one Committee where you can come in and have a bipartisan meeting and 

agreement and everybody leaves thinking, you know, we have done 

the right thing. 

I think before I—I don’t have a very long statement, which I read 

to Elizabeth last evening. She is a member of the Committee, and 

she approved it. I said, ‘‘Well, you don’t have to come then,’’ so—— 

[Laughter.] 

Senator DOLE [continuing]. I gave her an excuse. 

But the one thing that I think—there are a lot of problems. Secretary Shalala, I must say, is the original Energizer bunny. I mean, 

she is doing something every second. 

We work very well together and never got into any political differences. We didn’t even know the politics of the other seven of 

members. 

Of the other 7 members, 2 were Iraq veterans—1 who lost an 

arm, 1 who had a badly damaged leg—another was the wife of a 

husband who had burns on 70 percent of his body, and then the 

other was Ed Eckenhoff, who directs the National Rehabilitation 

Center, who has a very difficult problem. 

So there are 5 out of the 9 with disabilities. So we understood 

a little about what we were supposed to do. We relied a lot on 

these younger veterans. 

But the point I want to make right up front—I mean, there are 

so many negative stories about DOD and Walter Reed and the VA. 

The one thing that we found almost without exception is that these 

patients—young, old, men, or women—would brag about their doctors, brag about their nurses, brag about their therapists. The care 

was good or excellent. It was after you get into the outpatient category, when you start trying to make appointments and things of 

that kind, that we found difficulties. 

Now, Walter Reed is a great hospital. I have been going there for 

30-some years as a patient and to visit other patients. 

Building 18 was a facilities problem, but it was a disaster. The 

Washington Post story kind of was a wakeup call. Certainly everybody is focusing on veterans and veterans’ health care, which is a 

good thing. 

But I think the morale sometimes of these hardworking people 

in the VA hospitals—I know at Walter Reed because I have talked 

to some of the professionals—is sort of down because they read the 

stories and they watch television. The inference is that, ‘‘I am not 

taking care of this young man or this older man or this older 

woman or young woman.’’ That is certainly not the case. I know 

none of you—I think you all agree that it is not the case. 

The individuals, for the most part, in the Veterans Administration and all the DOD facilities are just good, hardworking men and 

women doing a job, trying to help our veterans. 

That doesn’t mean there aren’t some mistakes or bureaucracies. 

You go out to Walter Reed or you go to a VA hospital for a better 

example and you see people lined up for hours waiting for their 

10

drugs. They like the program. The formulary is not really—could 

be bigger—but it is a great program. 

So we traveled all over the country. We only had 4 months. We 

went to the different VA and DOD facilities and talked to the patients away from the doctors so there wouldn’t be any intimidation—perceived intimidation. I want to report to this group that 

there may be some—obviously there are some—but very few would 

say anything but good things about their treatment. 

We wanted to make certain that Walter Reed was in A–1 condition until somebody finally turned off the lights 3 or 4 years from 

now. So one thing we did is to urge Congress to offer incentives to 

contract doctors or other staff, military or whatever, to keep them 

there until Walter Reed finally closes, because 27 percent or 28 

percent of those who come from Iraq or Afghanistan, their first stop 

is Walter Reed. So it has got to be kept an A–1 facility. We can’t 

let it diminish to any extent at all. 

Well, anyway, I feel at home here before the Aging Committee. 

I know I am the oldest one here. Every day I feel more qualified 

to be here. 

But I am reminded this morning of the words of General George 

Marshall who, during World War II, was asked if America had a 

secret weapon that would ensure a victory. ‘‘Yes,’’ he said, ‘‘America 

does have a secret weapon. It is the best darn kids in the world.’’ 

What was true in World War II has been true ever since in places 

like Korea and Vietnam and Afghanistan and Iraq and the Gulf 

crisis. 

So we remain free and we remain strong because there are always the young men and women out there willing to make sacrifices for the rest of us. Today, most of us the only sacrifice you 

make is getting on an airplane and that is about it. But the families make sacrifices and obviously the young men and women who 

are injured or wounded make sacrifices. 

I think whatever you think of President Bush and whatever you 

think of war—we didn’t get into that in our Committee—but the 

President told us—told me and Secretary Shalala—he said, ‘‘Do 

whatever it takes.’’ We never had raised any question about the 

cost. 

Now, I don’t think our recommendations are perfect. We have 

only had 4 months. We are already getting a little push back in 

certain areas from certain veterans’ groups, and that is to be expected. But we think overall, you know, it is a good, balanced program. 

One thing that Ron mentioned—excuse me, Senator Wyden mentioned—was the care coordinator. 

Now, you know, we were limited to Iraq and Afghanistan in our 

charter. But I think it is a good idea to expand it to the older veterans. That program is already started. 

They already started training these care coordinators on October 

1. So the Administration is moving quickly in the areas where they 

should move quickly. 

I met a young man on our commission, Jose Ramos, who lost an 

arm above the elbow. He did a lot of work in the disability area. 

He had so many caseworkers he couldn’t remember their names. 

11

That is where, you know, if somebody meets you at the door at 

Walter Reed when you come here, whether you are wounded, sick, 

whatever, and if you are in serious condition and a care coordinator 

meets you at the door and follows you all the way through—they 

may have two or three others, too—but they follow you all the way 

through to the time you go back to your unit or the time you go 

back to the farm or back over to the VA or wherever it may be. 

That will make a big, big difference when it comes to efficiency. 

Most of our complaints were people waiting for appointments and 

then having them delayed. 

Another thing that Ken mentioned, the fact that—the rural 

areas—I think it is very important. One thing we stress in this—

and you have, I think Norm mentioned, too—rural areas. 

You know, it is a long way to a VA hospital in states like Colorado, Minnesota, even my State of Kansas, Missouri, wherever. We 

stress that there should be available to this person private-sector 

care. 

If there is someone, you know, in a city, not Denver, but some 

smaller place closer to this person’s home that can provide adequate high-quality care, then they ought to have it. They shouldn’t 

have to travel 300 or 400 miles to go to a VA hospital. 

You know, there may be some in the VA who think, ‘‘Well, that 

may mean we will have fewer patients.’’ But we had a patient-centered commission. 

We were only concerned about the patient. We were concerned 

about the DOD facilities and the VA facilities. But our primary responsibility was what can we do for the patient? 

The care coordinator is a little thing, but it is a very, very important thing. I think you have a great idea, if Congress will expand 

it, because there are some older people—and I said before this 

hearing started, I visit a lot of VA hospitals. I have been to the 

Portland VA hospital, for example, and I have been to a lot of hospitals. 

But you got to think of these men in their 1980’s—and we are 

down to about 4.5 million out of 16.5 million—and if they are hospitalized, you know, maybe their family’s a couple hundred miles 

away. They probably see the person who mops the floor and brings 

in their food and that is about it. 

You know, it is a pretty lonely life. I know there are a lot of activities and a lot of people come, but it is still a pretty lonely life. 

Anything you can do in those areas to sort of give them a life—

and there is a little program going on right now that I think some 

of your states are participating in. But it is something each of you 

could start. It is called Honor Flight. 

They would go to Portland, ME, for example, and raise say 

$50,000, charter an airplane, put people like your father on this 

airplane early in the morning. They would fly to Washington, visit 

the memorials, have a boxed lunch at the World War II Memorial, 

and just spend a couple or 3 hours there. 

Let us see, I think we have had a group from Missouri. I don’t 

think any other—maybe a group from Minnesota. Right. We had a 

group from Minnesota. 

But anyway, it is a great program. 

12

You ought to see the faces of these 80-, 85-, 90-year-old men 

when they get off that bus or somebody pushes their wheelchair 

and they get into that memorial. Suddenly they are thinking about 

what? I don’t know. When they were young, where they were in the 

service? 

You know, it is just a great thing. It doesn’t cost them one cent. 

Many could never make the trip because of the cost or because of 

their disability. They can’t get on a plane, if, you know, they are 

in bad shape and in a wheelchair. 

So get it on the Web site. It is Honor Flight. Look into it. It is 

a great program. 

It is now in about 18 States. Some fellow who ran a laundromat—well, he had several—in North Carolina came up with 

this idea because of his father. 

You know, you talk about making the day for this World War II 

vet, it makes his whole life in some cases. 

Well, I didn’t mean to get off on that. 

But we are going to testify before our—Secretary Shalala and I—

before the Senate Veterans’ Committee on the 17th of this month. 

I think the purview of this Committee—I know it deals with people 

what, a little older than the Iraq and Afghan veterans? But I think 

it is important because a lot of these things that we recommend 

will also affect older veterans. 

One thing we do that I think is very important, that applies to 

the Iraq and Afghan veterans, for the first time we have a quality 

of life payment. You know, when you get your VA rating somebody 

may say, ‘‘Well, the quality of life may be different,’’ but it has 

never been explicit. 

So there is going to be—when they add up your total check, there 

is going to be a little box there: quality of life. Now, if you lose your 

sight, your quality of life has gone from a 10 to what, 1, 2, 3? Or 

any loss of limb or whatever, burns, whatever the injury might be. 

We also think it is important when some person leaves the service that they have a transition payment, maybe 3 months paid, to 

get back home and get settled and get back to work and, you know, 

get the kids in school; little things. 

We also believe that where you have got a seriously injured 

spouse, the other spouse should have educational benefits, aid and 

attendant care, and respite care so they can take a break. 

These are all things that we didn’t apply to Vietnam or World 

War II or Korean veterans or Gulf veterans but, you know, they 

are available. 

The toughest part is in the benefits section. That will be the area 

that I think we need to work out with Congress and the veterans’ 

groups. 

But you have got to keep in mind that you are dealing with a 

group that probably hasn’t had a uniform on in 60 years. That is 

a long time. 

Now, a few of these guys that come on these Honor Flights still 

can wear their original uniform. They are very proud of it, that 

they haven’t changed that much. 

But we just can’t diminish our commitment to our veterans, 

whether 24 million, 25 million. Not all of them have a problem. 

13

I still get a lot of mail from veterans. I spend, I think, about 2 

hours—I think I can say maybe an hour-and-a-half a day answering emails from veterans across the country. Some because they 

have read about the commission or the World War II Memorial or 

they think I am still here. [Laughter.] 

So, you know, we try to send it on to whoever we can, probably 

one of you. 

But there is no doubt about it. The VA can be bureaucratic. I am 

sure that has always been the case. 

We went way back to a commission chaired by General Omar 

Bradley in 19—what, what, 50—I don’t know—early 1950’s. We 

haven’t really changed the system since then. We just believe—

and, again, it is a little beyond the purview of this Committee—

that it is time to simplify and update this system. 

The young men and women today are going to be the seniors of 

tomorrow. They want to be compensated, don’t misunderstand me. 

But they want a life. They want an education. They want an opportunity. 

So we sprinkled the educational part with incentives to keep people in the program. If you stayed a second year, you get a 10 percent increase; a third year, 10 percent more; a fourth year, 10 percent more, plus a stipend. So they would be able to, you know, really make a contribution. 

But I know you have got some great panels coming up to deal 

with long-term care and homeless veterans and paralyzed veterans. 

The PVA does a great job for paralyzed veterans. I do a lot of 

work with the PVA. They are just a great group, as are the other 

VSOs. But obviously they are going to tell you things that we didn’t 

get into. 

But the thing we don’t want to forget, that somebody—I think, 

Gordon, you said or Herb—just because we are getting old, don’t 

forget us. You know, we are still here. We are still breathing. We 

are still watching ‘‘Law and Order’’—I know I do, or whatever—and 

things like that. We are still making contributions. 

You see some of these fellows at the World War II Memorial who 

are in a wheelchair, and they are in their nineties. The fellow yesterday I met from Findlay, OH, 92 years old. I said, ‘‘Well, you just 

stay in the chair, and I will get—’’ ‘‘Oh, no, I am going to stand 

up.’’ He stood up straight as a string. He said, ‘‘I am the smartest 

guy in this group.’’ He probably was. He had been around longer. 

So that is sort of where we come from. 

We had a good commission. We worked hard. We know it is not 

perfect. We didn’t try to overhaul the whole system. 

But we do understand the importance of this Committee hearing 

and what it may mean to, you know, senior veterans, because you 

have got these baby boomers coming along, and we are going to 

have to get ready for them. I think we have got a lot of good people 

on this Committee who put the patient ahead of anything else. 

That is what it is all about. 

If anybody has any questions, I will be——

Senator SMITH. Thank you, Senator Dole. 

To your last point, obviously the focus of this Committee is on 

our older veterans. 

14

Clearly, we are doing a lot to take care of those coming home 

from Afghanistan and Iraq. We need to do more. But is it your 

view that we will, by taking care of them, the older ones will automatically be included, or do we need to put a special focus and emphasis that they not be forgotten? 

Senator DOLE. I think what you may want to do, if I were up 

here, is go through this recommendation, maybe do a little cherry 

picking, and say, ‘‘Oh, that would be great for, you know, World 

War II veterans.’’ It is going to cost money, but that is—I have a 

view that if we spend billions to get them there in harm’s way, we 

ought to spend whatever it takes to, you know, get them back to 

as normal as possible. 

But I think there are some of the recommendations, even though 

they are now limited to, I think, people who entered the service 

after 2001, the others can stay in the old system so we don’t touch 

the old system. But I think you may find some things in there that 

you might want to apply to World War II, Korea, certainly Vietnam. 

Senator SMITH. Senator, I have never been in battle. I can only 

imagine its horrors from watching documentaries like many Americans have just finished watching about the second world war. 

But as a student of history, I am aware that there have been 

many ways to describe post-traumatic stress syndrome. It has been 

called soldier’s heart, soldier blues, shell shock, battle fatigue. All 

of these relate to mental health issues. 

Now, we know that, you know, General Patton used to go 

through and slap a soldier occasionally. Clearly, we have come a 

long way since then. 

But I wonder if you can speak to at least your impressions as to 

how we are dealing with battle fatigue now. Are we doing it adequately? Does it enjoy——

Senator DOLE. Oh, we spent a lot of time on PTSD and TBI. 

They are different stages of traumatic brain injury. Right now, 

we have four VA polytrauma centers in Richmond and Tampa and 

Minneapolis and Palo Alto, CA, where they sort of specialize in TBI 

treatment. 

They are about 250 severe TBI cases from the present conflict. 

The rate of PTSD claims is probably going to reach 15, 20 percent. 

I would always ask the question, when we had these people in 

front of the mental health experts, ‘‘If I brought somebody in who 

had PTSD symptoms, would you all reach the same conclusion?’’ 

They always told me yes. But I don’t know how they do that because they are—there may be guidelines that I am not aware of 

you can follow. 

But another thing we recommend is that every 3 years this person ought to have a checkup by the VA. That anybody who has 

PTSD symptoms, the VA is obligated to take them whenever it 

happens, if it is 3 years from now, 5 years from now, whatever. We 

think a 3-year review is good because you might find some other 

things the veteran needs help for. 

But we did spend a lot of time on that. It is a big, big problem. 

In our generation, it was battle fatigue or see your chaplain or 

whatever. But now it is real. It is out there. People have, you 

know, nightmares and all kinds of experiences. 

15

Senator SMITH. Do you believe that enjoys an equal legitimacy 

with physical wounds? 

Senator DOLE. Oh, yes, in the VA. 

Senator SMITH. OK. 

Senator DOLE. I think our commission was not properly named. 

It was called Wounded Warriors. But you don’t have to be shot, you 

know, to be the line of duty, combat-related, whatever-injured. 

Senator SMITH. Yes. 

Senator DOLE. You don’t have to get shot. So I thought the name 

of our commission was a little too narrow. But we didn’t really 

worry about the title. 

Yes. It is equivalent. 

Senator SMITH. OK. That is a very important answer for me. 

Senator DOLE. Oh, I mean, what is the difference? I mean——

Senator SMITH. Yes. 

Senator DOLE [continuing]. If somebody, you know, well, you 

know what—if somebody experiences that, it ought to be treated 

just the same as if it was combat-related, line of duty. It ought to 

be compensable. 

Senator SMITH. Nobody says to them, ‘‘Look, you buck it up. Get 

over it.’’ 

Senator DOLE. Yes. Well, that might have been—I think there 

are some who might game the system. Let us be very honest about 

it. You need to caution it. But that is a very small number. 

Senator SMITH. Yes. 

Senator DOLE. It is hard—I am not an expert so I couldn’t detect 

it, but the experts can detect it. You may have members on the 

other panels who are experts in that area. 

It is out there. We need to deal with it. The people who suffer 

from it need to be compensated and entitled to all the benefits the 

same as anybody who may have lost an arm or been burned or 

whatever. 

Senator SMITH. I just have one other question. 

You mentioned that there are some veterans’ groups that are disagreeing with some of the recommendations. I wonder if one of the 

disagreements would be the idea of a care coordinator that would 

coordinate——

Senator DOLE. They like that——

Senator SMITH [continuing]. Care in the private sector. They like 

that? 

Senator DOLE. Well, they didn’t like—initially, we were going to 

have the Public Health Service—Secretary Shalala had done a lot 

of work with Public Health Service, and she thought, instead of the 

VA or DOD doing it, let us get some third party that doesn’t have 

any bias. I think VSOs thought that wasn’t a good idea, thought 

it would be another layer of bureaucracy. They may be right. 

So we decided the PHS would help train the coordinator, but it 

would be a VA person. 

Senator SMITH. OK. 

Senator DOLE. But you have got to give that person some authority, otherwise some colonel’s going to come along and say, ‘‘You 

know, get out of here.’’ They have got to have authority to cut 

through the——

Senator SMITH. The bureaucracy. 

16

Senator Wyden. 

Senator WYDEN. Let me pick up there, Senator Dole, and as always, when we listen to you, you always get the sense Senator 

Dole’s being too logical for Washington—— [Laughter.] 

—just coming in here and offering unvarnished common sense. 

One of the reasons that I came up with this thought about having a care coordinator for older people is that I thought that you 

logically said it is useful for the Iraq and Afghanistan veterans. 

What we have seen in Oregon is that it is usually the older veteran 

who is least equipped to kind of navigate all these various, bureaucracies and systems. 

I wanted to get your sense on one point with respect to the idea 

of a care coordinator for older veterans. 

I don’t get the sense that this is primarily going to be a big ticket 

financial item. It is primarily an organizational challenge, because 

right now the veteran is supposed to have a case manager and, as 

we heard, various other people to help. But it seems so often that 

one of these systems doesn’t communicate with the other and then 

the veteran ends up being sort of lost somewhere in the bureaucracy. 

So my thought was, if we could take your idea as it relates to 

Iraq and Afghanistan veterans, apply it to the older, person, make 

sure that there would be one person accountable, one person to be 

the care coordinator, all you would be talking about is reorganizing 

most of what is going on today so that somebody would be accountable. 

I think it would be helpful to have your sense about whether this 

is going to be a big expense item because I don’t get the sense it 

will be. 

Senator DOLE. You know, I hadn’t thought of this. But, you 

know, some of these senior men and women have maybe Alzheimer’s. They really need help. 

I certainly do not denigrate the case workers. I think in most 

cases they do—. 

Senator WYDEN. Right. 

Senator DOLE. But they get transferred or they——

Senator WYDEN. Right. 

Senator DOLE [continuing]. Leave or something, so somebody has 

to pick it up. 

We are not talking about—we think 50 care coordinators is what 

we need right now, 50. I mean, that is not a lot of people. 

You can extend that to certain VA cases. You know, most of 

these people they don’t need it. They are only hospitalized for a 

while. 

But some are there for 1 year, 2 years, 3 years, 6 months. They 

need help; the families who are there, the spouse or the mother. 

Then you also work with them. 

So, yes, I think it just makes sense that when I go to the hospital 

that somebody is going to watch out for me, not 10 somebodies, but 

one person. That doesn’t mean that there might be cases where 

they have to move on or something, but rarely. 

Senator WYDEN. If I have a——

Senator DOLE. That was Secretary Shalala’s thought. She just 

thought it would be a good move, and she was right. 

17

Senator WYDEN. If I am in trouble on the floor of the Senate, I 

am going to bring you and Secretary Shalala out so we get this 

done. 

Senator DOLE. Well, we think they need a coordinator for the 

Senate, too. [Laughter.] 

Senator WYDEN. Well, there, again, getting logical. [Laughter.] 

Thank you for all you have done, Senator Dole. 

Senator SMITH. Senator Collins. 

Senator DOLE. I don’t mean that. You know, I am only kidding. 

[Laughter.] 

Senator COLLINS. Actually, Mr. Chairman, when Senator Dole 

made that comment, I thought it would take way more than one 

coordinator for the Senate, probably per senator, in order to coordinate things. 

Senator Dole, I mentioned in my opening statement my concern 

about access to care in a large rural state like mine. 

I realize that your commission was looking more at the problems 

of the recently returned younger veterans from Iraq and Afghanistan. But are there any lessons that you learned from looking at 

that population on how we could improve access to care for elderly 

veterans or senior veterans for whom transportation may be much 

more of an issue? 

Senator DOLE. You are exactly right. I mean, when you are 80, 

85 years old, you are not driving. You may not have a spouse. Your 

children may be somewhere. You know, how do I get to the VA hospital? We didn’t deal with that because we are dealing with this 

younger generation. 

But the thing we did deal with, which should apply to any veteran, that if you have a facility say much, much closer to you than 

the VA hospital, that you ought to be able to use it. There ought 

to be authority to use it. That is happened in some cases in Afghan 

and Iraqi veterans. 

The National Rehabilitation Hospital here in Washington, DC, is 

one of the finest in America. They have treated, I think, about a 

dozen Iraq-Afghanistan veterans. 

The Rehab Institute of Chicago, they have had veterans who—

because they get really excellent care. 

So, yes, the answer is that ought to be available to—you know, 

we don’t want to forget these people just because they are getting 

older and say, ‘‘Well, we don’t really care about them. Let them figure it out.’’ If we have to send a taxi, I guess that would be all 

right with me, too; maybe a limo. Why not a limo? Yes. 

Senator COLLINS. Thank you. Thank you for your excellent service and your testimony. 

Senator DOLE. Thanks a lot. 

Senator SMITH. Senator Dole, I just wanted to follow up. 

What are the veterans’ groups objecting to so far in your commission’s recommendations? 

Senator DOLE. Well, I am hoping we are going to be able to work 

it out. But one group said we didn’t go far enough. We didn’t go 

back over the whole system. 

We only had 4 months. So we did limit it to Iraq and Afghanistan because that seemed to be where the focus was, based on, you 

know, different stories. 

18

There is a benefits commission going to report—I thought last 

week; maybe this week—but they pretty much agree with ours. 

I think it is when you start dealing with benefits and somebody 

thinks they are going to get a dollar less, that is not a good program. Our view was, we don’t want anybody to get any less, but 

we also want to stress that we are dealing with outcomes where 

people can be prepared. We had these two young men on our commission, both Iraqi-wounded veterans, who worked on the benefits 

section. 

But hopefully we can work it out. We are meeting with all the 

different groups and——

Senator SMITH. So it is nothing we need to be alarmed about 

or——

Senator DOLE. No. But before you introduce a bill, I think I 

would——

Senator SMITH. OK. 

Senator DOLE [continuing]. Read it carefully, so—— [Laughter.] 

Senator SMITH. I apologize, Senator Lincoln. I didn’t see you 

come back in. Do you have questions for Senator Dole? 

OPENING STATEMENT OF SENATOR BLANCHE LINCOLN 

Senator LINCOLN. A special thanks to you, Chairman Smith, for 

having this discussion today. We do think it is so important. 

I am the daughter of an infantryman from the Korean War and 

was taught certainly at a young age how important it was to have 

the respect and appreciation for our servicemen and women. 

I want to thank you, Senator Dole, for coming to speak to Arkansans that were in town. What a treat that was when our World 

War II veterans were here and you came down and spoke. They 

had a wonderful——

Senator DOLE. Well, I was just bragging about that program. You 

have been there. You know how the veterans feel after they have 

been here. 

Senator LINCOLN. Oh, they are just—it is incredible for them to 

be with one another and to be with fellow servicemen like you. It 

is a wonderful thing. 

Arkansans, and certainly brave men and women all across our 

country, they continue to make these tremendous sacrifices today. 

In my State, thousands, both active duty and reserve, have served 

honorably in Iraq and Afghanistan. Tragically, 74 have given their 

lives. I received word of our latest fatality just 2 days ago. 

So it is ongoing, and it is heavy on the hearts of the families, and 

in States like Arkansas and all across this Nation. My heart grows 

heavier by the day as nearly 3,200 Arkansans from our Guard and 

Reserve will deploy to Iraq probably December or right after the 

first of the year. 

So providing for our men and women in uniform is essential 

when they are in harm’s way. But undoubtedly, when they return 

home, it is absolutely our responsibility to provide for them. 

So we thank the Chairman for having this hearing, and, Senator 

Dole, to you for your incredible service, not only serving our Nation 

honorably in uniform, but here in the U.S. Senate and yet again 

your work here with Secretary Shalala. 

19

My one question to you, sir, would be one of your recommendations was to shift more responsibility for awarding benefits from 

DOD to the VA. I share your belief in this that it would help 

streamline the process that has become so cumbersome in terms of 

the bureaucracy for our veterans who are applying for disability 

benefits. 

We are trying to do the same thing here in shifting that responsibility for the educational benefits of our Guard and Reservists because we are finding that when they come home they don’t have 

the time to access. 

I noticed you mentioned that looking for benefits for spouse for 

educational purposes was another recommendation. But just making sure that they can get those benefits and having them delivered through the VA, as opposed to DOD, particularly I would 

think these disability benefits, but also the educational benefits, 

which we are. 

But as you also well know, in this place and in this city the battle for jurisdiction is a great one. 

Have you experienced any pushback on this recommendation? Do 

you have any advice for those of us that are trying to kind of circumvent some of that territorial bureaucracy? 

Senator DOLE. What we do is get the DOD out of the disability 

business, and they do what they should do. They decide whether 

Gordon Smith is fit for duty. 

But we want to make certain whoever makes that examination 

also—because you can have certain things wrong with you and still 

be fit for duty, which might be compensable under a VA rating. So 

whoever examines Mr. Smith, once he finds he is unfit, we are 

going to have a little checklist to make sure that all those things 

he finds wrong is given to the VA so when they make the rating 

it is based on, you know, accurate information. 

There is not much pushback there. I think most veterans, I 

think, feel the VA is a little more generous in their rating system. 

Of course, you have the right of appeal and all the other things. 

But I don’t think that is a difficult point. 

But you made another thing that made me realize, which probably doesn’t come within the purview of this Committee. But the 

hardest thing for the younger generation, the seriously injured—

and there are about 3,000 in that category, seriously injured—is 

when they leave the hospital and go back to Russell, KS, or wherever it is and there are no nurses around or doctors or somebody 

to do this. 

You know, it takes a while for, you know, to really understand 

what you are going to have the rest of your life. You can’t compensate for that. But we have to do everything we can to make, you 

know, to make it as normal as possible. 

Senator LINCOLN. Well, the rural centers that we are setting up 

with the VA are doing a good job at helping in that outreach. We 

just need a few more of them. 

But you are right. That transition is critical. When you are going 

back to rural America, it is hard. You have got to have somebody 

there to help you. 

Thank you. 

20

Senator DOLE. Well, we do a lot more for the—when I was 

wounded and in the hospital, my mother came and nobody—we 

didn’t have any money. But somehow she was able to stay there 

and take care of me day after day and even held cigarettes, which 

I shouldn’t have been doing and she didn’t think was a good idea, 

but I couldn’t use my arm, so—but now we make certain that person gets there—the spouse or the mother—and we relocate them 

and we take care of them. 

You know, we really do a lot of good things. It is just those cases 

that fall through the cracks. I guess when 25 million people are involved, that is going to happen. It just happens. 

I always tell people who send me emails, if everything else fails, 

and I say this very seriously, you need to contact your senator or 

your Member of Congress because they can sometimes work these 

things out. So——

Senator LINCOLN. Thank you. 

Senator SMITH. Thank you, Senator Lincoln. 

Senator DOLE. Thank you very much. I appreciate it. 

Senator SMITH. Senator Whitehouse has rejoined us. 

Senator DOLE. Oh, excuse me. 

Senator SMITH. Do you have a question? Or do you have a statement you want us to put in the record? 

OPENING STATEMENT OF SENATOR SHELDON WHITEHOUSE 

Senator WHITEHOUSE. One of the things that is notable about the 

Veterans Administration and that it often gets great credit for is 

the extent to which it has adopted modern technologies: electronic 

health records, internal electronic physician order entry, and other 

such technologies. Throughout the American health care system, 

we are way, way, way, way, way behind on the adoption of those 

technologies. 

Not too long ago, The Economist magazine reported that the 

American health care system is second only to the American mining industry in being at the bottom of adoption of these information 

technologies. 

It is a little bit peculiar because if you look at the diagnostic side, 

we have the best equipment in the world. We have the most astonishing radiology, MRI, other devices. Yet when you go to the information management side, we fall to the very bottom of all American industries. 

I am wondering if you have any comment on, first of all, how effective this investment has been for the Veterans Administration, 

and second, why you think the Veterans Administration has shown 

such leadership in this area and what we, as senators, might take 

from that experience in terms of trying to improve the adoption of 

health information technology in other areas. 

Senator DOLE. Well, we recognize that IT electronic recordkeeping was—the VA probably has the best system in the country. 

I mean, it is the envy of all the private hospitals. 

We had a Dr. Harris in the Cleveland clinic who that is his sole 

responsibility. He came back there and met with Members of Congress, with the VA, with the DOD. 

So you can get these—at my age, I don’t understand all the stuff 

like you do—but you can get these computers talking to each other. 

21

If you leave Walter Reed, you leave with a half a bushel of paper. 

If you leave the VA hospital, you have got a little tape, I guess. 

But the DOD is doing better. There is improvement. That is one 

of our 6 strong recommendations that we improve electronic recordkeeping because we are behind. It means so much if I am out in 

Phoenix somewhere and I get sick and somebody can just push a 

button and they have got everything. 

Yes. We have got a provision. We don’t know what it costs. But 

that, again, that wasn’t—we didn’t have any restraints, so that, we 

think, will bring us up into this century. 

Senator WHITEHOUSE. I thank you, Senator. 

I just want you to know, as a new Senator it is an honor to be 

with somebody who served this institution so proudly and so long 

as yourself. 

Thank you. 

Senator DOLE. Thank you. I appreciate it. 

Senator SMITH. Senator Dole, before we let you go, for my colleagues’ benefit and for the record, I’d like to read a couple of statements, a couple of paragraphs, from your book, ‘‘One Soldier’s 

Story.’’ 

Senator DOLE. Oh, yes. 

Senator SMITH. Senator Dole wrote: 

I once said that I was the most optimistic man in America. It 

was a phrase reminiscent of Franklin D. Roosevelt, who undoubtedly was the most optimistic man in America during his lifetime. 

Deprived of the use of his legs, he had been brought through his 

own personal hell yet continued to hope for the best. I could relate 

to that. 

Today, I am still an optimist. I believe that the greatest generation is today’s generation. My optimism is based on the belief that 

anyone in America, whatever your race, age or status, whatever 

your strengths, weaknesses or disabilities, deserves an equal opportunity to succeed. You can find that opportunity in America. 

That is what we fought for in World War II. That is why I 

charged uphill 9–13. That is what some of my friends bled and died 

for. That is what I lived for ever since. 

Thank you, Senator Dole. 

Senator DOLE. Thank you. Good luck. 

[The prepared statement of Senator Dole follows:]

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Senator SMITH. We will now call up our second panel. 

We are pleased to be joined by Dr. Michael Shepherd from the 

Office of Inspector General of the Department of Veterans Affairs. 

Today, Dr. Shepherd will discuss the Veterans Affairs Office of Inspector General’s review of the VA’s suicide prevention initiatives 

implementation. 

Also on the panel are Mr. Larry Reinkemeyer, who is the director 

of the Kansas City Audit Operations Division for the Office of 

Inspector General. Today, he will discuss with us the Veterans Affairs Office of Inspector General’s report on outpatient waiting 

times for care through the Veterans Health Administration. 

Why don’t we start with you, Doctor, and then we will go to 

Larry. 

STATEMENT OF MICHAEL SHEPHERD, SENIOR PHYSICIAN, 

OFFICE OF HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR GENERAL (OIG), DEPARTMENT OF VETERANS AFFAIRS, 

WASHINGTON, DC 

Dr. SHEPHERD. Mr. Chairman and members of the Committee, 

thank you for the opportunity to testify today on the issue of suicide and veterans in our Nation. Thank you for the opportunity and 

the honor to hear Senator Dole testify today. 

Suicide is an unequivocally tragic and often incomprehensible 

event. 

CDC data indicate there were more than 30,000 known suicides 

in 2004, making suicide the 11th leading cause of death in the 

United States. Although older adults comprised roughly 12 percent 

of the population, those 65 years and older represented 16 percent 

of suicides, with men accounting for 3 out of 4 suicides in this age 

range. 

Between 1 percent and 5 percent of older adults living in the 

community are estimated to have major depression. The incidence 

increases among those older adults requiring home health care or 

residing in long-term care settings. 

Although many older adults prefer treatment for depression in a 

primary care setting, geriatric depression is often inadequately 

treated in this setting. Between 50 percent and 75 percent of older 

adults who die by suicide have had contact with a primary care 

provider within a month prior to their death. 

There are approximately 25 million veterans in the United 

States, and 5 million receive care within the VA. In 2005, 45 percent of veteran enrollees were ages 65 or over. 

In November 2004, VA finalized the 5-year Mental Health Strategic Plan. Among the action items were a number specifically 

aimed at the prevention of suicide. 

In May of this year, the OIG published an assessment of the extent to which VA has implemented these suicide prevention initiatives. Although we found that most facilities reported availability 

of 24-hour mental health care in person or through a crisis hotline, 

this was not universal throughout the system. 

On July 25 of this year, VA subsequently began operation of a 

national suicide prevention hotline. Through the end of August, 56 

veteran calls have resulted in emergency rescues, and 165 calls resulted in VA hospital admission. 

25

One of the more extensive efforts that began implementation 

during the last year is the Primary Care-Mental Health Integration 

Program. Two models for primary care-mental health integration 

include co-located collaborative care and a case management model. 

The program, in which implementation began last winter, was at 

a handful of sites at the start of our inspection and is now presently running at 92 sites. It is hoped that the program will reduce 

stigma and enhance continuity of mental health treatment, especially for older adult veterans. 

In terms of referral, although 95 percent of facilities reported 

that patients with moderate depression referred to Mental Health 

by primary care providers are evaluated within 4 weeks, approximately 5 percent of facilities reported a significant 4- to 8-week 

wait. 

Prior suicide attempts are one of the better predictors of at-risk 

patients. An electronic registry of suicide attempts has been piloted 

in 2 VA health care networks. The aim of the registry is to enhance 

follow up for at-risk veterans and to help identify potential VA system issues. 

On a national level, VA has been in the process of implementing 

suicide prevention coordinators at all VA medical centers to case 

manage at-risk veterans. At present, dedicated staff are reportedly 

in place at approximately 85 percent of facilities. 

In terms of initiatives related to education, we found that half of 

facilities provide training for first contact nonclinical personnel 

about crisis situations involving at-risk veterans. But only one-fifth 

of these facilities include mandatory presentation of suicide response protocols. Likewise, though most facilities provide education 

to health providers on best practices for suicide, these programs 

were mandatory at only a small percentage of facilities. 

Included in the recommendations were that VA facilities should 

provide for 24-hour crisis and mental health care availability either 

in person or via a functioning crisis line; that all nonclinical staff 

who interact with veterans should receive mandatory training that 

includes suicide response protocols; three, that all health care providers should receive mandatory education on identifying and addressing suicide risk; and four, that VA should establish a centralized mechanism to select among the emerging best practices for 

screening, assessment, referral, and treatment. 

Preventing suicide is a complex, multifaceted challenge to which 

there is not one best practice but several promising but not proven 

approaches and methods. 

VA has made ongoing progress toward implementation of the 

strategic plan initiatives for suicide prevention. However, more 

work remains to ensure a coordinated effort in achieving systemwide implementation. 

Mr. Chairman, thank you again for this opportunity to testify. I 

would be pleased to answer any questions that you or other members of the Committee may have. 

[The prepared statement of Dr. Shepherd follows:]

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Senator SMITH. Before we go to Larry, Doctor, I was curious. 

Your final comments there—there is no one specific treatment for 

someone susceptible to suicide. 

Dr. SHEPHERD. I think there are many determinants. For instance, an older adult with major depression may have a certain 

set of needs compared to a young female with borderline personality disorder. 

So, there is not one answer for everyone. But it is an issue of 

finding what is considered to be the best possible modes and initiatives out there. 

Senator SMITH. There are many avenues that work, but for different people. 

Dr. SHEPHERD. Right. 

Senator SMITH. Is the reason there isn’t one is because we 

haven’t discovered it or because people are just different? 

Dr. SHEPHERD. I think it is a mix of both. People are different 

and have different determinants in what ultimately leads to suicide. 

Also, for some of these things, what would be an ideal screening 

tool are in the process of being developed at the Rocky Mountain 

Network in the VA system. The researchers there are doing a lot 

of work developing innovative tools. So they are having to essentially come up with those things from the start. 

I think the next step is going from there to getting those things 

in place system-wide. 

Senator SMITH. Very good. 

Larry. 

STATEMENT OF LARRY REINKEMEYER, DIRECTOR, KANSAS 

CITY OFFICE OF AUDIT, OFFICE OF INSPECTOR GENERAL, 

DEPARTMENT OF VETERANS AFFAIRS, WASHINGTON, DC 

Mr. REINKEMEYER. Mr. Chairman and members of the Committee, I also thank you for the opportunity to testify on our audit 

of the VHA’s outpatient waiting times that we issued on September 

10, 2007. 

Within the Department of Veterans Affairs, the Veterans Health 

Administration, commonly known as the VHA, has the mission to 

provide quality medical care on a timely basis to all authorized veterans. 

We performed this audit at the request of the U.S. Senate Committee on Veterans’ Affairs. Our objective was to follow up on our 

July 2005 audit, where we reported that VHA did not follow established procedures when scheduling medical appointments, resulting 

in waiting times and waiting lists that were not accurate. 

VHA agreed with the findings and the 8 recommendations contained in our July 2005 report. 

The objectives of this audit were to determine whether established scheduling procedures were followed and outpatient waiting 

times reported by VHA were accurate, whether waiting lists were 

complete, and whether prior OIG recommendations were fully implemented. 

Our results showed the schedulers were still not following established procedures for making and recording medical appointments. 

As a result, the accuracy of VHA’s reported waiting times could not 

33

be relied on and the waiting lists at those medical facilities were 

not complete. 

Also, to date, VHA has not taken the necessary actions to implement five of the eight recommendations from our July 2005 report. 

In the Department of Veterans Affairs Fiscal Year 2006 Performance and Accountability Report, VHA reported that veterans were 

seen within 30 days of their requested appointment date for 96 percent of primary care and 95 percent of specialty care appointments. 

To test the accuracy of VHA’s reported waiting times, we selected 

a nonrandom sample of 700 appointments where VHA reported the 

veteran waited 30 days or less. We found that only 524 of the 700 

veterans were seen within 30 days of their requested appointment 

date, for an error rate of 25 percent. This included 78 percent of 

veterans seeking primary care compared to VHA’s reported 96 percent, and 73 percent of veterans seeking specialty care, compared 

to VHA’s reported 95 percent. 

These error rates occurred because schedulers were not following 

established procedures when scheduling appointments. 

For example, VHA calculates a veteran’s waiting time from the 

requested appointment date, which could either be requested by 

the medical provider or by the patient, to the actual appointment 

date. We found that instead of recording the requested appointment date, some schedulers would identify the date of the first 

available appointment and then record that as the patient’s requested appointment date. This resulted in a waiting time of zero 

days. 

We also found that some schedulers were not following procedures for placing veterans on the waiting list. The most significant 

underreporting we identified involved referrals from one clinic to 

another. 

For example, if a veteran’s primary care doctor refers him to the 

eye clinic, the eye clinic scheduler has 7 days to act on that referral 

by either scheduling the appointment or placing the veteran on the 

waiting list. This 7-day requirement prevents schedulers from creating unofficial waiting lists by holding on to referrals for extended 

periods until an appointment slot becomes available. 

Although the 10 medical facilities we reviewed listed a little over 

2,600 veterans on their specialty care waiting lists, we identified 

over 70,000 veterans who, according to VHA’s records, had been 

waiting more than 7 days, did not have an appointment, and were 

not on the waiting list. 

Part of the cause for these error rates was that medical facility 

schedulers were still not getting the necessary training to fully perform their job. 

Although we did not investigate whether schedulers were intentionally gaming the system, we did find that schedulers at some facilities were interpreting guidance from their managers to reduce 

waiting times as instruction to never put the veterans on the waiting list. 

Had VHA taken timely action to implement recommendations 

from our July 2005 report, they may have precluded some of these 

same conditions from occurring again. 

The VHA agreed with four of our five recommendations on this 

audit, including routinely testing the accuracy of waiting times and 

34

the completeness of waiting lists; ensuring consult referrals are 

acted on timely; ensuring all schedulers receive required annual 

training; and assessing alternatives to the current process of scheduling appointments and reporting waiting times. 

The VHA did not agree to our recommendation to either create 

appointments within 7 days or use the desired date to calculate the 

waiting time for new patients. 

In closing, we maintain that full compliance with established 

scheduling procedures is critical to ensuring patients are seen in a 

timely manner and that no one falls through the cracks. In addition to compliance, VHA management needs to establish effective 

mechanisms to ensure data integrity. VA and Congress must have 

accurate, reliable, timely information for budgeting and other decisionmaking purposes. 

Mr. Chairman, I thank you again for the opportunity to testify. 

I would be pleased to answer any questions you may have. 

[The prepared statement of Mr. Reinkemeyer follows:]

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Senator SMITH. Thank you, Mr. Reinkemeyer. 

Dr. Shepherd, in your testimony, you state that approximately 3 

out of 4 veterans seeking mental health treatment are Vietnam 

veterans. Why? 

Dr. SHEPHERD. You know, everywhere I have gone in the last 

year in terms of VA facilities, I ask the clinicians their take on 

that. I have talked to the people at the National Center for PTSD. 

You get a list of theories, among which would be that one might 

be that since the VA instituted universal screening for depression 

and PTSD at primary care appointments, people are being picked 

up who would not have been picked up prior. 

Some people say that perhaps the present war has reawakened 

anxiety or stress that had been dormant. 

Some have mentioned emergence of symptoms in people who essentially were workaholics all their lives and just kind of lived with 

their symptoms, they now retire or slow down and the symptoms 

take on a lot more bothersome role in their lives. 

With many aging adults, the co-morbid effect of the onset of new 

physical problems and functional impairments also adds to the 

mental health burden. 

So that is 3 or 4 of among probably a list of 10 theories I have 

heard. 

Senator SMITH. Interesting. OK. 

Mr. Reinkemeyer, I want to applaud part of your report which 

notes that approximately 85 percent of VA facilities now have an 

acting suicide prevention coordinator. Is that correct? 

Mr. REINKEMEYER. That wasn’t my report. That might have been 

Dr. Shepherd’s. 

Senator SMITH. I am sorry. That is Dr. Shepherd’s. 

Dr. SHEPHERD. Yes. As of a conversation I had last week, approximately 85 percent have suicide prevention coordinators in 

place. 

Senator SMITH. What is the next step? How do we get 100? Do 

these coordinators—is it working? 

Dr. SHEPHERD. From what I understand, for the other 15 percent 

of the facilities, they have acting coordinators in place. I think they 

have ongoing recruitment for those positions. 

In terms of people I have spoken to at the hotline, the coordinators are having an impact. The hotline staffers follow up with the 

suicide prevention coordinator at the facility to make sure that the 

veteran actually did get seen and evaluated. Then they are initiating and following up again at 2 weeks to see whether the patient 

got evaluated and then kind of was lost to further treatment or has 

stayed in treatment. 

So I think it is starting to show some benefit. I think time will 

tell. 

Senator SMITH. Thank you very much. 

Senator Wyden. 

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

I think Senator McCaskill identified a real priority on this wait 

issue and the question of sort of gaming the numbers. I think what 

I want to do is take it in a little bit different direction, although 

I think what Senator McCaskill has contributed is extremely important. 

42

You IGs talk, has been my experience, Mr. Reinkemeyer. That 

IGs around the country talk. How widespread do you think this 

problem is based on the fact that you looked at a handful of facilities? 

Mr. REINKEMEYER. Within the VA——

Senator WYDEN. Yes. 

Mr. REINKEMEYER. I think it is probably pretty prevalent. 

This effort was a short-timeframe audit requested by the Senate 

Committee on Veterans’ Affairs in January. So we did not do a lot 

of interviews and questioning on the intentional gaming part. 

Having said that, I can tell you that, back in July 2005 when we 

did the first report, we did extensive work in this area. We sent 

out a questionnaire to 30,000 schedulers. We had 15,000 responded. We asked questions such as, ‘‘Have you ever been directed 

by your supervisor to do this?’’ Or, ‘‘How would you schedule an appointment this way?’’ 

The first question, if my memory serves me correctly, we had 

about 7 percent or 8 percent of schedulers nationwide that said 

that they were directed by their supervisors to circumvent the 

scheduling process to make sure that waiting times looked good. 

So, although I can’t answer that now, just by the scope of the 

audit that we just did, I can tell you that procedures have not 

changed all that much. We still found problems with schedulers following procedures. So we have no indication that some of this is 

still not going on. 

Senator WYDEN. So you find these problems. You think they are 

fairly prevalent. You bring them to the VA. They say what? We 

don’t agree with you? What is their response when you bring it to 

them? 

Mr. REINKEMEYER. Well, on the first audit back in July 2005, we 

made 8 recommendations. They agreed with the findings and all 8 

recommendations. 

However, as I said in my statement, five of those have not been 

acted on or have not been implemented yet. You would have to talk 

to the department as to why. 

Senator WYDEN. We are going to have to have some spirited discussions with them to make sure that they get those 5 done. 

Mr. REINKEMEYER. I can tell you, for this audit they did not 

agree with some of our findings, primarily having to do with the 

methodology. It was not a statistical sample we didn’t do a nationwide sample for this audit intentionally because of the short timeframes. 

But, they have agreed with 4 of the recommendations. 

Senator WYDEN. Let me ask you one other one. 

My understanding is that there aren’t a lot of statistics or good 

information on some of the groups that have really lost services in 

the past, like priority eight and priority seven. Is that your understanding? 

Mr. REINKEMEYER. Yes. I really don’t know, the extent of the 

number of priority eight veterans out there. 

Senator WYDEN. Yes. 

My sense is that there isn’t a lot of good information about priority eight and priority seven folks who are being turned away. The 

statistics we have that several million veterans, 2 million veterans, 

43

can’t access care at all may not even be reflected in the VA statistics. We may not even have our arms around an accurate number 

of veterans who we ought to be thinking about. 

Is that generally a point that you would share? 

Mr. REINKEMEYER. I really couldn’t speak to that. I think the department could probably address that. 

I know we have not done any work looking at——

Senator WYDEN. You have not done any work. 

Mr. REINKEMEYER. We have not done any work looking at the 

number of priority eights, for example, that are out there and not 

receiving treatment. 

Senator WYDEN. Well, I am going to let Senator McCaskill continue to prosecute this cause of making sure the gaming issue gets 

addressed because my sense is one, it is pretty prevalent, and two, 

based on some issues relating to whether we are getting numbers 

on priority seven and priority eight. If anything, I think we are underestimating the number of folks that are getting lost and getting 

denied services. 

So I thank both of you for your good work. 

Doctor, we will spare you because I think Senator Smith covered 

it very well. 

We appreciate both of you and your professionalism. 

Senator SMITH. Senator McCaskill. 

Senator MCCASKILL. Thank you, both, for being here. It doesn’t 

get much better than an auditor from Kansas City, Mr. 

Reinkemeyer. 

Mr. REINKEMEYER. Especially one from Jefferson City, so I was 

a Tigers fan. 

Senator MCCASKILL. Two near and dear things to my heart. 

I have reviewed an awful lot of GAO reports in preparation for 

this hearing. I want to take a minute to reference one of them that 

really got my attention from both of your perspectives within the 

IG system, within Veterans. That is a GAO report dating back from 

2001 concerning the VA nursing homes and the reality that the 

nursing home inspections of the VA-operated nursing homes, unlike any other nursing home inspections done by CMS, are not 

available to the public. 

I wondered if you all were aware of that, and if that is something 

that internally has been discussed in the IG community. 

The interesting thing in this audit back in 2001, the VA said, oh, 

they had a plan to begin to look—you know, there are three different types of nursing homes that VA uses. One is the community 

nursing homes they contract with, one is the state-owned nursing 

homes that are owned by the various states, and then the vast majority of the average daily census in these veterans’ nursing homes 

are actually VA-operated nursing homes. 

Now, understanding that the community-based and the—in most 

instances—and the state-based are getting very thorough CMS inspections for quality of care issues, and all of those inspections are 

public records. The state facilities are also getting—and the community facilities—are also getting state surveys and inspections. 

Those are indeed public records. 

But for some reason, the VA nursing homes do not have any public review of the inspections of these homes. 

44

I know that there are waiting lists for them. I know the kind of 

pressure that is on health care workers in that particular segment: 

long-term care. That the quality issues are a real problem in terms 

of care. 

I was wondering, you know—and the thing that is really frustrating is, like so many of the GAO reports, you know, the response 

from the agency is, ‘‘Oh, we are on it. We are planning that. We 

are fixing all that.’’ Of course, here were are in 2007 and my staff 

made inquiry and nothing has changed. That, in fact, they still are 

not using the CM—and, by the way, they should be relying on 

these CMS inspections. 

They should allow—I mean, this system is very thorough, and it 

is, you know, public. People who are putting people in nursing 

homes, loved ones, can look at these reports and determine whether they believe this is a quality facility. 

I was curious if either one of you are aware of this or if there 

has been any discussion within the IG community to take a more 

in-depth look at this in the near future. 

Dr. SHEPHERD. I was unaware of that. If I may, I would like to 

respond in the record after I educate myself more on to what extent 

VA does look at its own nursing homes and not just the extent but 

with what quality. 

Senator MCCASKILL. Well, I would—Mr. Reinkemeyer? 

Mr. REINKEMEYER. Yes. 

From an audit perspective, we have looked at nursing homes in 

the past but typically it would have to do with rates. What are we 

paying? What are we getting? Those aspects. 

I know health care, which Dr. Shepherd is a part of, they will 

look at the quality of care aspect and maybe have looked in the 

past at why inspections are not visible. Certainly, as Dr. Shepherd 

indicated, he can, prepare a statement for the record later. 

I just have not been the—Office of Audit typically will look at the 

contract side of it. 

Senator MCCASKILL. Well, I would appreciate a response for the 

record. 

I will follow up with that, Mr. Chairman, because I think this 

Committee would be a good place to look at that issue, particularly 

if we look at why in the world will they not make these reports 

public? I can’t imagine what a good answer would be. 

It seems to me that ought to be something—we are always looking for something we can actually get done around here. You know, 

because we can talk about things until we are blue in the face, but 

getting things done is a whole other matter. 

It seems to me this ought to be low-hanging fruit that we ought 

to get accomplished for the veterans and their families. They ought 

to be able to look at the quality of care in these homes based on 

thorough inspections that are done on an ongoing basis. 

I would hope that if you determine that what I have stated today 

is, in fact, accurate, that the IG’s office would also take a look at 

this issue. Maybe between the IGs and this Committee, we can 

change that on behalf of the veterans and their families that are 

looking at nursing home care. 

Thank you, Mr. Chairman. 

Senator SMITH. Thank you, Senator McCaskill. 

45

Senator Lincoln. 

Senator LINCOLN. Thank you, Mr. Chairman. 

Dr. Shepherd, as I mentioned earlier with Mr. Dole, we have got 

about 3,200 Arkansas National Guard and Reservists which will be 

deploying for Iraq after the first of the year. It will be their second 

deployment in 3 years. 

One of the issues we have brought up in the debate under 

SCHIP is the kind of care that these Guard and Reservists look to 

for health care when they return home and after they have been 

home. We have a number that depend on SCHIP for their children. 

I was disappointed to see the president’s veto of that. 

But given that the National Guard soldiers only have access to 

TRICARE for a limited time upon their return from service, and 

given that some of the symptoms of PTSD and TBI may not become 

apparent right away, maybe you can let us know what safeguards 

are in place to provide for the mental health care needs of our citizen soldiers, as well. 

Do you feel that our military and veterans’ health care system 

are properly taking into account the increased service of our reserve components? we are seeing a tremendous number of our 

Guard and Reserve, and, of course, coming home, having had an 

experience in many instances very different than what they expected. Are there any unique challenges that we are confronted 

with in providing for them? 

Dr. SHEPHERD. In terms of Guard and Reservists, beside the window for TRICARE, I believe there is a 2-year window to enroll in 

VA care. 

One of the efforts I know that VA’s making is that I think is one 

of the key things—is continuing to outreach to Guard and Reservists units to let people know that even if you are not having symptoms now, that with this type of problem, you can develop symptoms 6 months from now, 5 years from now, and the importance 

of when you are 22 or 24 of not thinking, ‘‘I am fine today. I don’t 

need anything.’’ But really encouraging, through outreach at Guard 

and Reservists bases, returning veterans to enroll in VA in case 

they do need this care down the line. 

Senator LINCOLN. So they are able to apply for the VA services 

early. 

Do they need detection? I mean, do they need to be tested, if it 

is going to be service connected, in order to get that benefit? I 

mean, is it something you would encourage them to do when they 

return before they have to—I mean, they have a limited window 

when they can apply for that, is that not right? 

Dr. SHEPHERD. Right. 

I know that the DOD and the VA do these post-deployment 

health assessment screenings and are supposed to do them, not 

just on deactivation but at 3 months and at 6 months, to try to capture some veterans who may not have been showing symptoms immediately post-deployment but are starting to show symptoms at 

3 and 6 months. 

Again, I think it is very important that the word keeps getting 

out there that, even if you are not having symptoms now, you may 

develop them. To get in, get enrolled. 

46

If people do get in the system and do get seen during the window 

where they can be seen without having to have a service obligation 

connection, the primary care providers at their appointments 

should be mandatorily doing a PTSD and depression screen. So 

hopefully in that 2-year window some of these people, if they can 

be engaged to get into the system, will get picked up. 

Senator LINCOLN. Are there recommendations of how we get that 

word out there in a better—or do you see us getting that word out 

in an efficient and effective way? Are we being effective about that? 

Or is there some recommendation of how we do a better job of getting that word out to these Guard and Reservists? 

Dr. SHEPHERD. I don’t have a specific recommendation or a specific sense of how well that effort is. 

In terms of some vignettes that have been pointed out to me, one 

of the suicide prevention researchers goes out to Guard and Reservists bases pre-deployment and talks to Guard and Reservists about 

symptoms they may experience post-deployment. 

I think that is an important consideration because if I was returning home, I am a young guy, I want to get home to my family. 

I might not be listening too much and be interested in getting 

home. Whereas I might have a lot more attention to what I am 

hearing pre-deployment when someone, you know, discusses possible mental health issues I may develop later and also ways to access the system. 

I thought that was a very good initiative. 

Senator LINCOLN. Well, that is a good suggestion. Doing it predeployment instead of, you are right, the anxiousness. 

Just last question, Mr. Chairman. 

We are certainly grateful to your work in the area of veterans’ 

mental health and particularly the suicide prevention. It is such a 

crucial issue. You have done an important job in bringing about a 

greater awareness. 

Senator Snowe and I recently introduced legislation that, among 

other provisions, seeks to increase the number of mandatory mental health assessments. It would include comprehensive screenings 

for mild, moderate and severe cases of TBI. 

Kind of similar to my previous question, maybe you might briefly 

describe the way that we attempt to screen and detect those symptoms of PTSD and TBI in its early stages. 

What is the methodology there that is used? How do we address 

and detect the instances of later occurring symptoms? If they are 

going to go in for these screenings, or they are going to go in, what 

is the methodology or the questions that we are using to try and 

have that early detection? 

Dr. SHEPHERD. The screening questionnaires they use have about 

four or five questions about PTSD. So they are not extensive, comprehensive questionnaires or interviews. 

If someone scores I forgot whether the number is 3 or 4 positives, 

then they are supposed to be referred for a more extensive evaluation. So that is the present methodology. 

I think in terms of trying to detect PTSD in the presence of TBI, 

it is a very clinically challenging situation. I think, again, keeping 

the awareness among the clinicians that these things can co-exist 

and that they are not mutually exclusive, and that people can have 

47

PTSD in the setting of TBI, and that the symptoms you see may 

not be ascribable to just one. 

So I think basically more disseminated education regarding that 

is needed. 

Senator LINCOLN. How much early information do they go back 

to? 

I just remember reading an account in the news several months 

ago. A woman who was concerned that her husband—too much 

early background information, high school grades were used. She 

said, ‘‘Well, you know, if he was competent enough for the military 

to take him and send him off, you know, then why is it now a question as to whether his capacity or his mental health is at risk or 

is a problem because of those early grades?’’

I thought that was interesting. How far back do they go? 

Dr. SHEPHERD. I really couldn’t answer that. 

Senator LINCOLN. No? 

Dr. SHEPHERD. I just don’t know. That was not the focus of our 

review. 

Senator LINCOLN. OK. 

Thank you, Mr. Chairman. 

Senator SMITH. Gentlemen, thank you for the work you have 

done, the work you are doing, and for adding so much to our hearing this morning. 

We will now call up our third panel. They consist of Mr. Steven 

R. Berg. He is the vice president for programs and policy at National Alliance to End Homelessness. Today, Mr. Berg will testify 

on the unique needs of homeless veterans, including their complex 

health care needs. 

He will be joined by Mr. Fred Cowell, who is the senior associate 

director of the health analysis program at Paralyzed Veterans of 

America. He is a veteran of the U.S. Navy and served two tours 

of duty in Vietnam assigned to the Naval Security Group. Mr. 

Cowell will testify on the long-term care needs of our veterans. 

Finally, last but certainly not least, Dr. Mark Kaplan. He is a 

professor of community health at Portland State University and 

holds adjunct appointments in psychiatry and family medicine at 

the Oregon Health Sciences University and epidemiology and community medicine at the University of Ottawa. Today, Dr. Kaplan 

will testify on the study he published earlier this year on the rate 

of suicide for veterans, which garnered national attention. 

Gentlemen, a vote has just started. With your indulgence so as 

not to shortchange you, I will rush real quickly, vote, and be right 

back, so that we in no way lose what you have to present to us. 

So, if you have no objection, we will take a very brief recess and 

be right back. [Recess.] 

Thank you, gentlemen, for your understanding. I just simply note 

that the leaders on the Senate floor don’t often check with the 

Aging Committee as to when they time the votes. But we do want 

to make sure we give full consideration to your testimony. 

So, Steven, why don’t we start with you. 

48

STATEMENT OF STEVEN R. BERG, VICE PRESIDENT FOR PROGRAMS AND POLICY, NATIONAL ALLIANCE TO END HOMELESSNESS, WASHINGTON, DC 

Mr. BERG. All right. 

Thank you, Senator Smith, for having us at this hearing. I am 

with the National Alliance to End Homelessness, as you know. 

Thank you, also, for the work you have done personally, I know, 

and your staff has done, on this issue in a whole range of different 

ways. 

Part of the homelessness issue that is particularly vexing, particularly infuriating, is the high rates of homelessness among veterans. We are in the middle of a major research project to try to 

put some numbers on that problem, look at some of the factors that 

go into it. That is research that will be released in early November, 

but I would like to share some of our preliminary findings today 

that I think are worth noting. 

First of all is just that it is a sizable problem. Our estimate is 

that over 195,000 veterans are homeless on any given night in the 

United States, which is—there are different ways to look at it. It 

is like a whole medium-sized city. You cleared everyone out and 

filled the whole city up with homeless veterans. That is the size of 

the problem. 

Of particular relevance to this Committee is that many homeless 

veterans are older and have disabilities. It is sort of a commonplace 

within the homeless services field that homeless veterans are older 

and sicker than homeless people generally. That is particularly 

seen among homeless veterans who are considered chronically 

homeless. 

That is a term the Federal Government uses to describe homeless people who are on their own, have severe disabilities, have 

been homeless for a long time, for a year or more. Our estimate is 

that between 44,000 and 64,000 veterans fit that definition of 

chronic homelessness, which makes this very much a health care 

issue because besides housing those are all people who need treatment, many times for mental health conditions accompanying substance abuse conditions and a whole range of physical ailments. 

Veterans are disproportionately represented among homeless 

people. In other words, veterans in the United States are more 

likely to be homeless than are Americans who are not veterans. 

There has been a whole range of theories put forward as to why 

that should be the case. We are trying to address some of those in 

this research that we are doing. 

One of the key contributors to homelessness among veterans and 

anyone else is housing affordability and high housing costs. 

Most veterans do pretty well in terms of incomes, in terms of 

their ability to afford housing. In fact, for veterans in general their 

incomes and their ability to afford housing are better than nonveterans. 

But there is a subset of veterans who don’t do as well, who have 

high housing cost burdens, who are paying a disproportionate percentage of their income in rents. That is particularly the case 

among women veterans, among veterans who have a disability, and 

also among veterans who are older. The sort of World War II and 

49

Korea-era veterans are far more likely to have a high housing cost 

burden than veterans who are younger. 

So it is a sizable problem. But we view the problem of homelessness—and particularly homelessness for veterans—as a problem 

with a solution. 

Several years after sort of the Federal Government and Congress, we like to, you know, we hope we had some small part to 

play in this, announced new initiatives to try to get communities 

to work less at managing the problem of homelessness and more 

at ending homelessness. 

We see communities around the country who are undertaking 

local plans to end homelessness a lot of times with the participation of the VA. We have good models all around the country. 

You mentioned Central City Concern in Portland. There are similar kinds of programs all over the country that are doing similar 

kind of work. 

The most important thing is we are starting to see results. In a 

small handful of cities that have undertaken some of these best 

program models, we are seeing the number of homeless people decline. 

People in the homeless services field, I will say, talk about the 

Portland miracle, based on the reductions in the number of people 

who are homeless in Portland. 

I lived in Portland back in the 1970’s, and even then there were 

lots of people living on the street and had been for a long time. In 

recent years, those numbers have really demonstrably declined because of work that people like Central City Concern, people with 

the city are doing to adopt a range of strategies that we know really work. 

Now, our feeling is that this should be easiest for veterans for 

a number of reasons. One, because one of the key components of 

the strategy that works is health care. Veterans have a system of 

health care that other Americans don’t have access to that should 

work to deal with mental health problems, to deal with substance 

abuse problems. 

The VA keeps a lot of information about veterans. They do a 

good job of knowing which people that their health care system 

serves are homeless at the time they are being served. So it is a 

matter of identifying people who are experiencing the problem. 

Now, they have some tools there to deal with even things like the 

numbers. 

I mean, in Wisconsin, for example, the work the VA did to identify the number of homeless veterans came up with the number 

828 veterans in the State of Wisconsin. You can fill this room pretty well with 828 people. 

But in a State that size, it gives people an understanding of what 

they are up against. That is the kind of number where sort of one 

big push could make a significant impact on that problem. Knowing 

that, having the VA able to tell you that number, I think, helps 

people on the ground adopt strategies that are going to work. 

Finally, the VA exists as a mechanism for ongoing support for 

veterans. 

50

I mean, Senator Dole and Senator Wyden talked about the idea 

of a care coordinator. The idea that there is a system in place that 

could adopt that kind of intervention is a big plus for veterans. 

Yet despite all these sort of advantages that veterans have in 

terms of dealing with homelessness, still it is a problem that disproportionately affects veterans. So there needs to be—we have a 

lot of work to do in this area. 

We have some recommendations for Federal policy. In my written testimony, I have gone through a number of those. 

The basic ideas are to provide funding and incentives for some 

of these key strategies that we know work: for discharge planning 

so that people have—the risks of homelessness are identified early 

on at the time people leave the military; emergency prevention; 

rapid re-housing so that when people do experience homelessness 

or are on the verge of experiencing homelessness, it is treated as 

a true emergency, intervention is in place. 

We know the kind of intervention that works. There just needs 

to be systems set up so that those interventions are applied to people who need it right at the time they need it. 

Another key element is permanent supportive housing, particularly for the older veterans who have the chronic health care problems and have been homeless a long time. 

Low-cost housing, combined with treatment, combined with case 

management, this is a very cost effective intervention that we 

know works. I know we have talked to you and your staff about 

this. 

There are a number of specific things that Congress could do 

that I have mentioned there. One thing I just want to mention, because it is sort of a hot item right now, is something called the 

HUD-VASH Program, HUD-VA Supportive Housing Program. 

This is a program that matches rent subsidies from HUD with 

supportive services, treatment, and sort of case coordination provided by the VA. It has been put into effect in the past. 

There haven’t been new HUD-VASH vouchers put in place for a 

number of years. But in this year’s appropriations bill for HUD, 

particularly the Senate bill, there is a substantial investment in 

the HUD bill for new HUD-VASH vouchers. In the Senate bill, 

there is probably enough to do 8,000 new vouchers. 

So two aspects of that. One, it is very important that as that bill 

goes through the process—I know the whole appropriations process 

is very uncertain this year—but as that bill goes through, it is important that the funding for HUD for those VASH vouchers stay 

in there. 

Two, it is incredibly important that the VA understand that it is 

Congress’ intent and expectation that the VA will do their part in 

putting this program into effect. 

The VA services are paid for by the regular health care program. 

There isn’t a need for a special appropriation for the VA share of 

this. 

But it is important—again, as Senator Wyden mentioned—this is 

an organizational challenge issue to ensure that in every city 

where the Housing Authority gets funding for some of these VASH 

vouchers, that the VA hospital is coordinating with the Housing 

Authority, making sure that the veterans who need the help the 

51

most are referred for the vouchers, making sure that the case manager and that the VA is part of that is put into place. 

We can house thousands of veterans with what is in the appropriations bill now. But everybody needs to do their part. 

So thank you, once again, for inviting me. I am happy to answer 

any questions. 

[The prepared statement of Mr. Berg follows:]

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Senator SMITH. Steven, for the record, I have your testimony 

here. But can you list 3 or 4, maybe 5 features of the best practices 

models? What is working? 

Mr. BERG. Right. I think——

Senator SMITH. It is affordable housing, access to health care, 

what else? 

Mr. BERG. Yes. 

I think that some of the key models—I mean, I mentioned permanent supportive housing, which is affordable housing combined 

with the health care, the case management, particularly treatment 

for mental health and substance abuse issues closely targeted to 

veterans with the worst health care needs and who have been on 

the street the longest, has very good results in terms of taking people who really are, you know, most people would have given up a 

long time ago, and getting them into housing. They tend to stay in 

the housing. They tend to get better, when they hadn’t gotten better while they were living on the street. 

Senator SMITH. So affordable and permanent housing. 

Mr. BERG. Permanent. Yes. 

Senator SMITH. Any other feature? 

Mr. BERG. Other features that work well are the idea of sort of 

a rapid re-housing program, having people available who know the 

local rental market, who know landlords who are willing to rent to 

tenants who might not sort of on paper look like the best risks in 

the world, and who have sort of short-term flexible resources available to deal with things like security deposits, deal with things like 

a bad credit history. 

These kind of programs have been very effective in a number of 

places and it is the kind of thing that, you know, if you had a care 

coordinator at the VA, that that kind of person could help make 

sure people have access to either as soon as they find out they are 

homeless or preferably before they ever become homeless but when 

they are experiencing a housing crisis. 

Those are some of the real best practices——

Senator SMITH. You know, I was struck, Steve, that according to 

your testimony, 2 percent of all Oregon veterans are homeless? 

Mr. BERG. Yes. 

Senator SMITH. If this is accurate, Oregon appears to be fifth in 

the Nation for the percentage of veterans in a state who are homeless. That is pretty high. 

Mr. BERG. It is pretty high. I mean, and——

Senator SMITH. We don’t have any active duty military bases, so 

why Oregon? 

Mr. BERG. Right. 

Senator SMITH. Why Oregon? 

Mr. BERG. Right. 

Well, we are trying to figure—one of the reasons it is taking us 

so long to get this report out, as I was just speaking to someone 

else, is that we are trying to figure out what some of the factors 

are behind some of those differences. 

Some of it is just some people do—I mean, as you probably know, 

the VA is a fairly decentralized agency. These numbers are all 

based on local VA counts. Each local VA does it a little differently 

so some of it is just counting. 

60

But it is also the case we know that, for example, veterans in Oregon are more likely to have a higher housing cost burden. That 

we know based on census data that is done the same in every 

State. It is part of just a housing affordability issue that varies 

State to State. 

Senator SMITH. Is that an unintended consequence of urban 

growth boundaries? 

Mr. BERG. That is something you would know more about than 

I would. 

Senator SMITH. I know I shouldn’t get into that. But, I mean, 

don’t they, as part of land use planning, require certain amounts 

of affordable housing to go in to deal with that issue? 

Mr. BERG. That is a matter of State law. 

I know Oregon has been a leader in that for a long time. But it 

is, I mean, it is also the case housing costs—there are a whole 

range of factors behind housing costs. 

I think it is the case that Oregon has seen sort of rents grow 

faster than a lot of parts of the country just because of population 

changes. It is a good place to live and people want to live there. 

It is supply and demand. There are a lot——

Senator SMITH. Well, it is strange to me that, without an active 

military base, which you would think would be something of a magnet to veterans who are, you know, when they go home, that the 

homelessness would correlate to where those exist. But Oregon is 

obviously an exception to that. 

Mr. BERG. That is true. We are trying to get some answers to 

that. It is a range of different factors. 

Senator SMITH. Well, when you get those answers, please share 

them with us. 

Mr. BERG. Absolutely. 

Senator SMITH. I am very interested. 

Mr. BERG. Absolutely. 

Senator SMITH. Thank you, Steve. 

Fred Cowell. 

STATEMENT OF FRED COWELL, ASSOCIATE DIRECTOR OF 

HEALTH POLICY, PARALYZED VETERANS OF AMERICA, 

WASHINGTON, DC 

Mr. COWELL. Thank you, Mr. Chairman. 

Before I begin my oral testimony, I would just like to take a second, with your indulgence, on behalf of the Paralyzed Veterans of 

America, I would like to express our sincere gratitude and profound 

respect that we have for Senator Dole for his service to our country, our Nation’s veterans, and all Americans with disabilities. 

Senator SMITH. Thank you. 

Mr. COWELL. It was a real honor to be on the same panel with 

him today. 

Mr. Chairman and members of the Committee, the Paralyzed 

Veterans of America is pleased to present its views concerning access to, and availability of, quality VA long-term care services for 

our Nation’s veterans. 

In the interest of time, PVA’s oral testimony will briefly focus on 

five long-term care issues of importance to America’s veterans. 

61

More detailed information on these and additional topics is contained in our written testimony. 

The long-term care needs of younger OIF-OEF veterans. 

Mr. Chairman, PVA believes that age-appropriate VA institutional and non-institutional programming for younger OIF-OEF 

veterans must be a priority for VA and your Committee. New VA 

institutional and noninstitutional programs must come online and 

existing programs must be re-engineered to meet the various needs 

of a younger veteran population. 

Changes to VA’s noninstitutional long-term care programs will be 

required to assist younger veterans with catastrophic disabilities 

who need a wide range of support services, such as personal attendant services, programs to train attendants, family caregiver 

training, peer support programs, assistive technology, and hospitalbased home care teams which are trained to treat and monitor specific disabilities. 

VA’s institutional programs must change direction, as well. Nursing home services created to meet the needs of aging veterans will 

not serve younger veterans well. VA must make every effort to create an environment that recognizes younger veterans have different needs. 

These younger veterans must be surrounded by forward-thinking 

administrators and staff that can adapt and design programs to 

meet youthful needs and interests. For example, therapy programs, 

living units, meals, recreational programs and policies must be 

changed to accommodate younger veterans entering the VA longterm care system. 

Veterans with spinal cord injury or disease. 

PVA is concerned that many aging veterans with spinal injury 

and disease are not receiving the specialized long-term institutional 

care they require. 

Today, VA’s SCI-D long-term care capacity cannot meet current 

or future demand. Waiting lists exist at the 4 existing designated 

SCI-D long-term care facilities, which only have a total of 125 beds 

nationwide and geographic accessibility is a major problem because 

none of these 4 existing facilities are located west of the Mississippi 

River. 

VA data projects an SCI-D long-term care bed gap of 705 beds 

in 2012 and a larger bed gap of 1,358 for the year 2022. 

Currently, VA’s construction budget submission for 2007 includes 

provisions for new VA nursing homes in Denver, CO, Las Vegas, 

NV, and Des Moines, IA. A 15 percent bed allocation at each of 

these new facilities would be a good first step toward closing the 

looming long-term care bed gap for veterans with SCI-D. 

Mr. Chairman, PVA needs the Committee’s support to ensure 

that new VA nursing home construction planning includes a 15 

percent bed allocation for SCD-D residents. 

Waiting lists for VA noninstitutional long-term care. 

PVA is concerned about reports from our members and from VA 

health care professionals that long waiting lists exist for aging veterans who need access to certain segments of VA’s noninstitutional 

care program list. PVA calls upon Congress to review the demand, 

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based primary care program. Recommendations for appropriate 

funding would then depend on the outcome of the program review. 

Assisted living. 

VA conducted an assisted living pilot project mandated by the 

Millennium Benefits and Health Care Act between January of 2003 

and June 2004. VA’s subsequent report on the pilot project was forwarded to Congress by then-VA Secretary Principi in November 

2004. 

The report revealed a number of positive findings, including information on cost, quality of care, and veteran satisfaction. 

The authors of the independent budget have called on VA’s assisted living project to be replicated in at least three VA networks 

with high concentrations of elderly veterans to determine if the 

findings of the original pilot are valid. 

Finally, VA’s strategic plan for long-term care. 

Mr. Chairman, Congress recently passed a comprehensive package of veteran proposals which became Public Law 109–461. Section 206 of the law mandated the secretary of Veterans Affairs to 

publish a strategic plan for the provision of long-term care within 

180 days of enactment. To date, VA has not complied with the law. 

The aging of the veteran population and the subsequent increasing demand for long-term care services has been well documented 

for over a decade by both VA and the General Accountability Office. 

Mr. Chairman, PVA calls upon members of this Committee to investigate VA’s delay in publishing its urgently needed strategic 

plan for long-term care as soon as possible. 

Mr. Chairman, that concludes my remarks. I will be happy to answer any questions. 

[The prepared statement of Mr. Cowell follows:]

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Senator SMITH. Thank you very much, Fred. 

In your testimony you mentioned that there are many veterans 

who are denied admission or care through the VA or through community nursing homes due to high acuity needs, spinal cord injuries specifically. What happens to them? 

Mr. COWELL. Well, many times they are not able to get the proper care they need. They are relegated to stay at home with caregivers that are also aging. 

This is probably the first time in our Nation’s history that we 

have a generation of aging veterans that have survived with spinal 

cord injury. So they heavily depend on those specialized services 

the VA can provide. 

VA currently only has a current capacity of 125 beds for trained 

staff to meet the needs of this aging population. 

These veterans are staying home longer than they need to be or 

should be. They are not receiving the proper care they do. Many 

of them wind up in VA acute care hospitals for long periods of time 

because there are no nursing homes that can treat them. 

Senator SMITH. Obviously, the point you are making is, in previous wars, those with these kinds of injuries would simply die. 

Mr. COWELL. That is right. 

Senator SMITH. Clearly, they are performing miracles on the battlefield now. They are not dying. But I think you are highlighting 

a real shortcoming in our VA capacity. 

Mr. COWELL. Yes, sir. It is absolutely true. 

Senator SMITH. In a nutshell, that is the problem. So we have 

got to ramp that up. 

Is this something you see a lot of or a growing amount of because 

of the survivability rates now? 

Mr. COWELL. It is an increasing issue for PVA. 

We are a member organization with an aging membership. More 

and more of our members are in their sixties, seventies, and some 

are reaching their eighties. They are just simply not able to live 

independent lives any longer. 

Senator SMITH. Yes. 

Mr. COWELL. Even with the advent of many breakthrough programs in a noninstitutional care, they are designed to keep veterans at home as long as possible, and we certainly support all of 

those programs. There is just an increasing demand. 

VA’s own data shows a lack of capacity to treat these aging veterans. There really needs to be more work done in this area. 

We have brought this attention to the Strategic Group of Spinal 

Cord Injury in the VA. We are trying to work to get new long-term 

care beds created that can meet the needs of this population. It has 

just been an uphill battle, to be quite frank. 

Senator SMITH. So if I understand your other point about—I 

think you were speaking of authorizations and appropriations for 

new veterans nursing homes, you are saying they should have a 15 

percent bed requirement——

Mr. COWELL. Yes, sir. 

Senator SMITH [continuing]. To deal with high acuity cases. 

Mr. COWELL. Most of these new facilities that are in VA’s 2007 

construction budget were located west of the Mississippi. Currently, the 4 facilities the VA has for our members today are all 

74

on the East Coast. There is nothing west of the Mississippi for this 

membership. 

So they are relegated to nursing homes, community nursing 

homes, state veterans’ homes, if they can get in. They don’t have 

the trained staff to meet their needs. So it is a major problem. 

Senator SMITH. Is 15 percent the right percentage, or is it——

Mr. COWELL. We would be happy to talk about that with VA. 

When we look at only 125 beds being available nationwide, we 

think 15 percent is a good first step. We could step back from these 

original facilities, these new proposed facilities and see how that is 

working and try to get a handle on, ‘‘Is it meeting the demand or 

is there a greater need for a higher percentage?’’ Senator Smith. 

Thank you very much, Fred. 

Mr. COWELL. Absolutely. 

Senator SMITH. Dr. Kaplan, thank you for your patience. 

STATEMENT OF MARK S. KAPLAN, PROFESSOR OF COMMUNITY HEALTH, PORTLAND STATE UNIVERSITY, PORTLAND, 

OR 

Dr. KAPLAN. Thank you. 

Good afternoon, Mr. Chairman. I am Mark Kaplan, professor of 

community health at Portland State University. 

I want to thank you and the Committee for the invitation to testify before this Committee on this critical public health issue affecting the aging veteran population. 

I should note, interms of the demographics that today approximately 70 percent of older males are veterans. 

I applaud the Committee for embracing the critical issue of veterans’ mental health and particularly the emphasis on suicide risk 

and prevention. 

I should point out here that I have been an active suicide researcher since 1992. Most of my work has focused on late life suicide. I am an elected member of the American Association of 

Suicidology Council of Delegates, as well as a member of SPAN 

USA National Scientific Advisory Council. 

Before I move on to my presentation, let me just take this opportunity to thank you, Senator Smith, for your leadership on these 

important issues. 

Senator SMITH. Oh, you are welcome. 

Dr. KAPLAN. As you know, Mr. Chairman, suicide remains a serious public health problem. Reducing suicide is a national imperative. 

To the best of our knowledge, more than 30,000 people in the 

United States take their lives every year. Approximately 1 million 

make an attempt on their lives, as well. Veterans are particularly 

vulnerable to suicide compared to their civilian counterparts. 

So what I want to do in my testimony today is review some of 

the research that I have done with my colleagues back in Oregon 

and highlight some of the key findings and then end with some policy-oriented recommendations for the Committee. 

To start, in Oregon veterans are more than twice as likely to die 

of suicide than their nonveteran peers. The age-adjusted suicide 

rates among male veterans was 46.05 per 100,000 and for nonVerDate 0ct 09 2002 12:25 Apr 11, 2008 Jkt 000000 PO 00000 Frm 00078 Fmt 6633 Sfmt 6633 H:\DOCS\41535.TXT SAGING1 PsN: JOYCE
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veteran males, the rate was 22.09 per 100,000. So the rate is twice 

as high as the nonveteran population. 

Senator SMITH. Mark, can I stop you there——

Dr. KAPLAN. Sure. 

Senator SMITH [continuing]. Can I ask you this question? It sort 

of relates to what I was asking Steven. 

Dr. KAPLAN. Of course. 

Senator SMITH. Because they are veterans and they have access 

to other resources, why is the suicide rate higher? 

Dr. KAPLAN. Well, I don’t think anyone really has an answer on 

that. As we noted in the publication that you alluded to, that the 

risk of suicide was twice as high as their non veteran peers. 

We did a slightly different analysis where we looked at vets who 

use and don’t use VA facilities. There is not a whole lot of information out there on the vets who are not part of the VA system. 

According to a veteran survey done in 2001, only about one out 

of every five uses the VA. Most don’t. So there is a gap in our 

knowledge in our understanding of why veterans might be at risk. 

But the fact is that independent of the era they served in, veteran status alone is an independent predictor of suicide. 

Senator SMITH. Does it relate to combat experience? 

Dr. KAPLAN. We don’t really know. It might relate to combat. In 

studies that have been done within the VA system, obviously combat experience is a key factor. PTSD, depression, and a whole host 

of other forms of psychiatric morbidity have been linked to suicidal 

behavior. 

Senator SMITH. Does combat experience increase the likelihood of 

substance abuse, alcohol——

Dr. KAPLAN. The two are correlated. 

Senator SMITH. They are correlated. OK. 

Dr. KAPLAN. Absolutely; substance abuse and co-morbid conditions. Rarely do you find a case of somebody simply having a substance abuse but it often goes hand in hand with a variety of other 

psychiatric conditions. 

Senator SMITH. It may or may not be triggered—that substance 

abuse may or may not be triggered by combat experience, but combat experience does seem to have some linkage——

Dr. KAPLAN. Exactly. 

Senator SMITH [continuing]. Then, of course, substance abuse 

leads to suicide. 

Dr. KAPLAN. Exactly. 

Well, we already heard about the risk for homelessness that is 

a big factor. So people who experience downward mobility, unemployment, a breakup in their relationships, and a whole host of 

other circumstances that may trigger suicidal behavior. So it is a 

very complex problem—remarkably, we know very little. 

Senator SMITH. Yes. Sorry for the interruption——

Dr. KAPLAN. That is fine. 

Senator SMITH [continuing]. But I am trying to learn from you. 

Dr. KAPLAN. That is fine. 

Veterans tend to have—along with what has already been said—

veterans tend to have more disabilities that limit their ability to 

function, which in turn may lead to social isolation and depression. 

Disabilities that limit functioning are an important suicide risk facVerDate 0ct 09 2002 12:25 Apr 11, 2008 Jkt 000000 PO 00000 Frm 00079 Fmt 6633 Sfmt 6633 H:\DOCS\41535.TXT SAGING1 PsN: JOYCE
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tor among veterans compared to nonveterans in the general population. 

Again, referring to the study that we published over the summer, 

one of the key predictors of suicide over a 12-year period was disability. That is, in male veterans who reported at baseline some 

form of disability were at an elevated risk of completing suicide. 

Veterans are also more likely than their civilian counterparts to 

use firearms as their primary mode of suicide. This is also an important factor. I will say a little bit more about this. I will also address this in my recommendations. 

The National Violent Death Reporting System data reveals that 

the proportion of suicides involving firearms was significantly higher among veterans than their nonveteran peers. This is remarkable. 

Seventy-two percent of veterans use guns to complete suicide, 

while their nonveteran peers, the percentage there was only 56 

percent. Equally ominous, female veteran suicide decedents were 

also significantly more likely than other nonveteran counterparts to 

use guns. Here again, female veterans, nearly 50 percent of them 

used guns to complete suicide, while their nonveteran counterparts, 

the rate there was only 33 percent. 

I should note here, and this might surprise you, we reported 

some years ago that the most common method used among elderly 

women happens to be firearms, 40 percent. More elderly women 

use guns than poison. 

Senator SMITH. Is it generational or what is——

Dr. KAPLAN. Well, it might—I have often looked at that as sort 

of the masculinization of suicidal behavior. We are seeing that 

crossing generations. It is becoming the most common method 

across ages. But remarkably, we found that to be the case among 

elderly women. 

Male and female veteran suicide decedents are respectively 47 

percent and 76 percent more likely than their nonveteran peers to 

use guns. These statistics are important because what we did, we 

tried to statistically control for confounding factors. So, again, it 

seems to be a little higher for females. 

Similarly, older male and female veterans were also significantly 

more likely than their younger veterans to use firearms. This is 

based on the National Violent Death Reporting System. 

So we did some analysis where we tried to address some factors 

and found that the older vets, male and female, were more likely 

to use guns than their younger counterparts. 

So, again, one can look at guns as not just a method of completing suicide, but it also sends a message that there is a determination to end their lives and that there is very little that one can 

do. That window of opportunity to intervene, to prevent, is almost 

shut. 

So we need to begin thinking about ways of intervening with people who are going to attempt suicide with a gun as opposed to what 

some might characterize as a cry for help with some other less lethal methods. 

The rate of lethality is extremely high with guns. Ninety-five 

percent plus, maybe close to 99 percent. 

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I would like to conclude my testimony today with several policyoriented recommendations. The first one is—and I think this touches on what some of the other witnesses have said today—No. 1, 

clinical and community interventions directed toward patients in 

both VA and non-VA care facilities will be needed. I want to underscore the word both here because I think we know a lot more about 

those users of VA than we do about the nonusers. 

Second, Congress should direct the Department of Veterans Affairs to provide reimbursement for primary care depression detection and management for veterans unable to be served within the 

Veterans Affairs system for a variety of reasons that we have discussed today, including geographic issues. 

I remember being on call-in shows during the summer in response to my piece. Many veterans called in and were—very dissatisfied with the quality of care in the VA system. Many thought of 

it as just an extension of the military and did not feel very comfortable in that culture. 

So there were a lot of reasons, but I heard that a lot. As I said, 

there is a survey of veterans done in 2001 that showed that only 

one out of every five was using the VA. Others were not for many 

different reasons. 

Another recommendation is training primary care physicians in 

suicide assessment, management and referral within the VA and 

outside. 

An interesting statistic here is that there has been a declining 

rate of primary care physicians in this country. Unlike other advanced industrialized countries, we are seeing a rise in specialists 

and a decline in primary care physicians. 

Senator SMITH. Isn’t that about compensation and all of that? 

Dr. KAPLAN. Excuse me? Compensation. Right. Right. Absolutely. 

I spent some time in Canada as a Fulbright Scholar a few years 

ago. I studied the Canadian public health system. But what impressed me was the fact that over 50 percent of their physicians 

are primary care providers. 

Senator SMITH. When you go to medical school—and I am not a 

medical doctor—but is there a real hierarchy of specialties and the 

social pressure to go into one of those as opposed to somehow a primary physician being a lesser professional? 

Dr. KAPLAN. I am not a physician, but I have studied physicians. 

I must say that, at least anecdotally, you do hear that. 

Senator SMITH. Yes. That is what I figured. That is how it is 

in——

Dr. KAPLAN. That would be an interesting project, actually. Medical sociologists do that kind of thing. 

Another recommendation is that there is a critical need to collect 

more comprehensive epidemiological information on the proximal 

and distal circumstances surrounding suicide morbidity and mortality. 

Here I want to make the point that I think we have looked at 

suicide in very narrow ways. We tend to focus on the immediate 

risk factors. But sometimes these are more distal, both in time and 

in space, such as homelessness. 

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tion, a more community-oriented approach as opposed to the reactive. 

Quite often the system is geared up to respond to people who call 

in, for instance. An interesting side note here is that most elderly 

people who are suicidal don’t call up, do not use crisis lines. 

Another recommendation is that currently there are only funds 

to operate the National Violent Death Reporting System, run by 

the Centers for Disease Control, in 17 states. This is important in 

terms of developing a better database. At least $20 million is required to fully implement and maintain 

the NVDRS in all 50 states. It is now running in just a handful 

and, as I said, in 17 states. Oregon happens to be one of those. However, congressional funding has remained flat at about $3.3 

million. So there is a real need to increase that budget, as I see 

it. 

Senator SMITH. We are going to do that. 

Dr. KAPLAN. Thank you. 

Another recommendation: Firearms are responsible for significant suicide mortality in the older veteran population. Many studies offer evidence linking accessibility of firearms to suicide with 

guns. 

More research is needed to study the interaction between firearm 

usage and suicidal behavior in the older adult population. We know 

so little about that. 

I had this conversation earlier today. Quite often we refer to it 

as suicide, but in many cases with older adults, 80 percent of older 

men, men over the age of 65, white men in particular use guns to 

complete suicide. The firearm issue, and I know it is a highly 

charged question, but it is the elephant in the room when we talk 

about reducing suicide in the U.S. 

Senator SMITH. It is actually something that, while I haven’t 

seen legislation, it is one of the first issues after Virginia Tech that 

actually has gotten the NRA and gun opponents or mental health 

advocates actually talking constructively because I think even the 

gun advocates——

Dr. KAPLAN. Right. 

Senator SMITH [continuing]. NRA and others——

Dr. KAPLAN. Right. 

Senator SMITH [continuing]. Understand that gun ownership 

comes with gun responsibility. When people have diminished capacity, there needs to be some kind of a standard whereby we help 

them by removing guns from their proximity. 

Dr. KAPLAN. One additional recommendation related to that is 

that unfortunately for too long we have looked at the gun issue, 

gun violence as a criminal justice, as opposed to a public health 

problem. 

Senator SMITH. Yes. 

Dr. KAPLAN. I think we need a paradigm shift in that regard. 

A couple of other points that I just want to run through quickly. 

I would like to see a congressional mandate for studies on the 

role of firearms in suicide specifically. Funding should be increased 

at the Centers for Disease Control and Prevention and other Federal agencies, such as NIMH, for research involving this type of 

firearm violence. 

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Health care providers—another recommendation—need to be 

more attentive to the critical role that firearms play in suicidal behavior among veterans. Many physicians find it difficult to ask patients directly about suicide, fearing that they might prompt a case 

of suicide. 

Some years ago, my colleagues and I studied primary care physicians and found that only half of primary care physicians who identified an elderly patient as suicidal would inquire about their access to firearms. However, 70 percent asked about their misuse of 

medications. 

So there is an unwillingness or reluctance to probe with patients 

who are at risk about their access to guns. 

Another point: It is very important for medical providers to ask 

people if they have been in the military and then screen for health 

problems, mental health issues, and suicide in this population. This 

relates to this question of veterans who are not using the VA. 

There is also a need—and this is important—to incorporate more 

geriatric and gender-specific content into the programs in the VA. 

By that I mean, quite often we don’t—when we look at suicide prevention programs, we haven’t incorporated male-specific content, 

even though most individuals who complete suicide are males, particularly older males. 

Finally, according to the American Psychiatric Association, men 

in psychological distress face appreciable stigma and barriers and 

are less likely to seek help than are equally distressed women. 

Thank you for the opportunity to testify before you today. I 

would be happy to respond to any questions you may have and look 

forward to working with you in the future. 

[The prepared statement of Mr. Kaplan follows:]

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Senator SMITH. Thank you very much, Mark. 

We will leave the Senate record open for a period. 

I apologize. My colleagues are gone. It is not any reflection on 

you. That is how life is around here. 

You have all contributed importantly to the Senate record and to 

our understanding. There may be written questions submitted. If 

there are, if you can answer them, great. We appreciate that. 

But you have come a long way. We value your work. That is why 

it was important to me that we not in any way shortchange your 

testimony and the contribution you have made here today. 

So thank you. I don’t know how to say it better than just thank 

you. 

Keep it up. We need you to keep succeeding at what you do. 

With that, we are adjourned. 

[Whereupon, at 12:40 p.m., the Committee was adjourned.] 

(97)

A P P E N D I X 

PREPARED STATEMENT OF SENATOR ROBERT P. CASEY

I want to thank my colleague, Senator Gordon Smith, for chairing this important 

hearing to address health care for aging veterans. I look forward to continuing our 

work through this committee to meet their needs and ensure that the services this 

nation promised them are delivered. 

The 110th Congress is focusing a good deal of attention to veterans’ health care 

and with good reason. Those who have sacrificed so much for America’s security and 

freedom deserve the most advanced medical care and comprehensive benefits our 

country has to offer, and the government is obligated to guarantee them. It is troubling, however, that it takes events like those of the past year at Walter Reed and 

throughout the Department of Defense and the Veterans’ Administration health 

care systems to propel this issue to the forefront of our concerns in Washington. 

As the wars in Iraq and Afghanistan continue, we can only expect more casualties. Thanks to brilliant medical advances, many of these casualties will be survivors returning home to cope with debilitating physical and mental injuries and illness. The VA will face the challenge of caring for these veterans. Modern medicine 

has found a way to keep them alive, but our government bureaucracy has not kept 

pace with serving their increased needs. 

While our efforts to expand our health care system to accommodate these young 

men and women are crucial, it is equally imperative that we not neglect our older 

veterans who have fought valiantly in combat in previous wars. In addition to the 

problem of obtaining their health care and other benefits, older veterans also confront the issues of long term care and, in the most tragic cases, homelessness. Combat veterans from World War II and the Korean War are now in the ranks of our 

older citizens. Many of those who served in Vietnam have retired, adding thousands 

to the Veteran Administration’s health care rolls. Men and women who fought in 

the Gulf War of 1991 have unique physical and mental health care concerns, the 

evidence of which has appeared in the years following the end of that war. With 

a quarter of the nation’s population potentially eligible for VA benefits and services, 

we cannot cast our older veterans aside in our urgency to devote health care resources to veterans of the wars in Afghanistan and Iraq. 

I have met with members of the Pennsylvania chapter of the American Legion 

twice this year. I asked these distinguished gentlemen about their experiences with 

the VA hospitals in Pennsylvania. The response was almost unanimous: the VA hospital consistently offers the finest health care they could hope for—if they could 

manage to get an appointment. While this evidence is anecdotal, it illustrates the 

greatest problem the VA faces: its own bureaucracy. The numbers are staggering: 

the VA operates 155 medical centers, over 1,400 sites of care, including 872 ambulatory care and community-based outpatient clinics, 135 nursing homes, 45 residential 

rehabilitation treatment programs, 209 Veterans Centers and 108 comprehensive 

home-care programs. Despite the challenges of managing such a sprawling system, 

technology and good planning would streamline VA health care and benefits administration and deliver comprehensive services to our aging veterans promptly. 

In fiscal year 2006, the VA reported that nearly 1.1 million veterans reside in 

Pennsylvania. Over 480,000 were 65 or older. In 2004, the VA spent $2.5 billion on 

health care for veterans in Pennsylvania, and that number continues to increase 

year by year. 

I am grateful to Senator Smith for calling attention to these critical issues and 

I look forward to the testimony of our witnesses. We must do whatever is necessary 

to meet the physical, psychological and emotional needs of our veterans and ensure 

that America keeps its promise to our aging heroes. We owe them our services, as 

we still enjoy the freedoms that they served to protect many decades ago. 

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REPONSES TO SENATOR SMITH’S QUESTIONS FROM DR. SHEPHERD

Question. In your testimony you mention that approximately three out of four veterans seeking mental health treatment for the first time through the VA are Vietnam era veterans; many of whom are in the 55–64 year-old age group. Why do you 

think this is the case, and are these numbers growing from years past? 

Answer. There are many hypotheses offered to explain the influx if aging veterans 

into the VA mental health system over the past few years. All of the following rationales can account for some portion of increase in the numbers of these veterans: • Universal screening for depression and PTSD by primary care physicians. 

• As a result of educational initiatives, media coverage, and mental health outreach efforts following the attacks of September 11, 2001, and/or related to the current Global War on Terror, veterans have gained a heightened awareness of PTSD 

and have recognized symptoms described in the media as akin to their own experience. 

• Some veterans in this group successfully suppressed and avoided their PTSD 

symptoms through the years by overachievement and sublimation to their work 

identity. As the specter of retirement and idle time becomes more apparent, they 

experience a decreased ability to evade symptoms, which then begin to impair their 

quality of life. 

• Veterans experience subsequent traumas, such as death of a spouse, career 

change, criminal victimization, etc., which causes emergence or reemergence of mental health symptoms. 

• Veterans progressing in the life cycle may begin to experience physical decline, 

functional impairments, and illness which, in turn, diminish their overall reserve 

and capacity to function. This co-morbid effect may impact vulnerability to onset of 

mental health problems or may decrease resiliency and coping with mental health 

symptoms that were already present at a sub-clinical level. 

•There are a small, but reported number of cases of patients experiencing PTSD 

symptoms for the first time years after the military exposure event. 

• Ongoing changes and reductions in employer provided health care benefit plans 

and/or the specter of having to provide for one’s own health care coverage upon retirement may contribute to a decision by eligible veterans to shift to VA care. 

Follow up a. We know that overall, older males have increased risk for depression 

and suicide. We also know that being a veteran increases those risks. What do you 

think this means for the VA Mental Health system as these veterans continue to 

age and increase in number? 

Answer. In light of the ongoing Global War on Terror, the mental health needs 

of Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans are in 

the forefront of our public consciousness. At present, the number of OIF/OEF veterans seeking mental health treatment is approximately 15 percent. Over time, we 

do not know whether this rate will remain steady, whether and when it will change, 

and if so, at what velocity this change will occur. Simultaneously, increasing numbers of aging veterans are seeking mental health treatment in VA, and other aging 

veterans represent potential influx. We also do not know whether this trend will 

plateau, continues at present rate, or accelerate. I believe that the ability to adequately assess, plan for, and make ongoing adjustments to meet the access and programmatic needs at both ends of the age spectrum will be a primary challenge facing the VA mental health system. 

Follow up b. Is the VA prepared to adequately respond to the needs of these veterans? 

Answer. This will, in part, depend on VA’s ability to simultaneously meet the 

needs that may arise from the increase in veteran utilization at both ends of the 

age spectrum described in the response to part A. Recruitment of mental health professionals, especially in rural areas, is a challenge in all sectors, public and private. 

I believe that a related consideration will be the ability for VA to recruit and/or efficiently match clinician skill sets with regional patient sub-populations. For example, 

it will be an advantage to have a higher density of clinicians particularly skilled and 

adept at treating geriatric depression and dementia related issues at VA facilities 

where there are a high concentration of patients with these mental health problems; 

likewise, having an increased density of clinicians adept at cognitive behavioral 

therapy such as prolonged exposure therapy is especially important in areas with 

high concentrations of returning OIF/OEF veterans. 

Question. In your testimony you discuss the recent effort by the VA Office of Mental Health Services to ensure each VA medical center had a suicide prevention coordinator. You also mention that approximately 85 percent of facilities have at least 

an ‘‘acting’’ suicide prevention coordinator at this point—which I applaud. However, 

I am wondering about the next step—do you think that once a problem is identified 

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that there are appropriate numbers of mental health care professionals in the VA 

system or affiliated with to ensure timely follow-up and treatment? 

Answer. In our work, we have found that over the past year, VA efforts at systematic suicide prevention have been more aggressive. VA Clinician researchers, especially in the Rocky Mountain Network, VA Stars and Stripes Network (Pennsylvania region), and New York/New Jersey Network have piloted or implemented 

some innovative programs. In our report, we encouraged VA to choose among 

emerging best practices for identifying, assessing, referring, tracking, and treating 

veterans at risk and for system-wide implementation with ongoing evaluation and 

modification. In our inspection, we did not look at access to mental health care. Access can be thought of in terms of multiple domains including waiting times, geographic location, patient eligibility, provider availability, and programmatic availability, among others. This would be a relevant topic for future examination by VA 

and our office. 

Question. In your testimony you talk about the implementation of a new hotline 

through the VA, and in cooperation with SAMSHA, to help respond to the emergency mental health needs of veterans. I applaud the VA and SAMSHA for their 

efforts and hear that since the end of July when the hotline went into effect; more 

than 170 Oregon veterans have been helped. Do you know how the training for 

those who answer the calls from veterans differs from the training for those who 

help on the nationwide hotline that SAMSHA runs for the general population? 

Answer. The primary difference between training for the VA suicide hotline and 

training for other major suicide hotlines is the specific focus on veterans and their 

issues. VA hotline officials reported that the phones are staffed with 9 social workers, 7 psychiatrically focused registered nurses, and 4 addiction therapists. Prior to 

taking calls, clinical staffers receive approximately 40 hours of suicide prevention 

training, which initially is general in nature but then moves to veteran specific 

issues with role plays based on actual calls from veterans. 

Question. In your testimony you mention that the VA does not adequately tap into 

the linkages in communities that serve older veterans such as the aging network, 

including senior centers, as well as faith-based organizations and other groups that 

work with or serve seniors who are veterans. Why do you think this is the case and 

how can we encourage the VA to reach out more frequently and consistently to 

groups we know can help identify needs for aging veterans? 

Answer. One of the initiatives in the Veterans Health Administration Strategic 

Plan concerns using the VA Chaplaincy service to facilitate community outreach. As 

of the time of our inspection, no central action had taken place on this initiative, 

although some individuals facilities had implemented innovative outreach programs 

on a local level. I do not know why VA has not optimized community linkages for 

reaching out to aging veterans. I believe that it would benefit VA to look at and 

evaluate the more promising of these pockets of innovation and community outreach 

as applicable to aging veterans and to consider implementing similar efforts on a 

system wide basis. 

RESPONSES TO SENATOR SMITH’S QUESTIONS FROM LARRY REINKEMEYER

Question. In your testimony you mention that more than 70,000 veterans in the 

10 VA medical facilities you audited had consult referrals from their doctors that 

were more than seven days old and that, according to VA policy, they should have 

been included on the VA wait list. However, you later mention that these facilities 

actually had a combined wait list of only 2,600. Does this mean that these 10 facilities alone are excluding more than 67,000 veterans from their wait list and therefore vastly under-reporting need? 

Answer. The facilities were under-reporting the number of veterans on their waiting lists but the exact number is unknown and because our review was based on 

a non-random sample, we cannot project our conclusion across the entire 70,000 

consults. VHA’s data (consult tracking report) identified over 70,000 consults for veterans who did not have an appointment and were not on the facilities waiting list. 

According to medical facility personnel, the consult tracking report did not always 

reflect the actual consult status because clinic personnel did not always update the 

consult after action was taken. To substantiate VHA’s data, we reviewed a non-random sample of 300 consult referrals and found that 61 percent of the associated veterans should have been on the waiting list and more than half of those had been 

waiting more then 30 days. The remaining referrals had already been acted on but 

facility personnel had not updated the records to reflect the true status (for example, completed or discontinued). 

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Follow up a: What impact do these huge discrepancies have on the VA’s budgeting 

and planning processes? 

Answer. A basic premise to budgeting and planning is that budgeting should meet 

demand. If the demand is under-reported, then information relied upon for budgeting and planning decisions are potentially flawed and could result in insufficient 

allocation of staff and other resources. 

Follow up b: Is Congress getting accurate information with which to make decision? 

Answer. No, our report clearly shows that waiting times and waiting lists are not 

reliable. 

Question. In your testimony you discuss your audit findings that many of the veterans who were waiting on a consult request to actually be scheduled, had no action 

on that request by schedulers for more than 30 days. You mention many factors that 

could contribute to this, including a shortage of scheduling staff, but one you don’t 

really mention is physician availability. Did you look into the possibility that they 

are not putting veterans on waiting lists or even attempting to schedule appointments because of a lack of time for existing physicians to see them? 

Answer. We did not determine the impact of physician availability on waiting lists 

during this review. 

Follo up: Does the VA need more medical professionals? 

Answer. The focus of our audit was on waiting times and not on staff resources. 

Question. Your testimony mentions the fact that schedulers may have been incorrectly interpreting the guidance from their managers to reduce wait times and 

therefore were essentially gaming the scheduling process. Do you think that this 

gaming was unintentional or do you think there are incentives for managers and 

facilities in place that would encourage some of these practices? 

Answer. Because of the audit’s short timeframe, we did not address the intentional gaming of the system on this audit. However, we did find indications that this 

was happening in our July 2005 audit and, based on results of this audit, it is possible that it is still occurring. 

In 2005 we conducted a nation-wide survey of schedulers where over 15,000 

schedulers responded and found that: 

• 7 percent were directed by their supervisors or managers to schedule appointments contrary to policy. 

• 41 percent were directed to find the first available appointment slot and then 

use that as the desired date of care effectively reducing the waiting time to 0 days. 

• 10 percent felt pressure from leadership to keep waiting lists short which caused 

them to circumvent established scheduling procedures. 

The visibility and the emphasis to reduce waiting times and waiting list would 

certainly provide an incentive to some managers to manipulate the system in order 

to show better performance. 

RESPONSES TO SENATOR SMITH’S QUESTIONS FROM MARK KAPLAN

Question. What do you feel are the most important characteristics of veterans that 

make more at risk for suicide than the general population? 

Do you feel that there are other factors that are unique or more acute for veterans 

that put them at greater risk for suicide such as the fact that they served in a war, 

that there is greater stigma in the military, or perhaps there is a difference between 

access to treatment through the VA system versus other community-based mental 

health systems? 

Answer. Indeed, there are several factors that put veterans at a higher risk for 

suicide compared to their nonveteran counterparts. In a national study of more than 

320,000 men, we showed that those who served in the military, regardless of age 

or era of service, were twice as likely as their nonveterans to complete suicide. Although we did not draw firm conclusions about what makes veterans more at risk 

for suicide than the general population, we did find that that veterans with disabilities that limited their ability to function in their daily activities was one of the 

highest suicide risk factors. With the projected increase in veterans with disabilities 

among those who served in the Afghanistan and Iraq conflicts, there will be a need 

for more interventions by both VA and community-based mental systems. Furthermore, I noted in my testimony that men in psychological distress face stigma and 

barriers and are less likely to seek treatment than equally distressed women. 

Question. What do you feel is the best way to help these veterans and to ensure 

that the doctors who are seeing them, whether they are mental health specialists 

or their general physician, are appropriately trained on the specific needs of veterans? 

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Answer. According to my colleague and co-author, Dr. Bentson McFarland, Professor of Psychiatry at the Oregon Health and Science University, primary care physician assessment and management of depression and suicide prevention for veterans could be encouraged by expanding reimbursement so that primary care providers can implement and sustain evidence-based procedures aimed at detection and 

treatment of veterans with major depressive disorder. Federally funded research 

projects over the past twenty years have shown that primary care providers can do 

an excellent job at detecting and treating people with major depressive disorder. The 

key to success is inclusion in primary care practices of ‘‘care managers’’ who have 

expertise in mental health. Care managers are nurses or counselors (usually with 

masters degrees) who follow protocols for detection and treatment of people with depression. Primary care providers facilitate treatment by prescribing medication as 

needed. This care management approach has been well studied and shown to be effective. Unfortunately, this model has rarely been sustained owing to lack of reimbursement. Primary care providers nowadays are notinfrequently in financial difficulty and are unable to sustain evidence-based practices such as care management. 

Congress should direct the Department of Veterans Affairs to provide reimbursement for primary care depression detection and management for veterans unable to 

be served within the Veterans Affairs system.

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