```

[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]

 
              LEGISLATIVE HEARING ON H.R. 1293, H.R. 1197, 
              H.R. 1302, H.R. 1335, H.R. 1546, H.R. 2734, 
                  H.R. 2738, H.R. 2770, H.R. 2898 AND 
                      DRAFT DISCUSSION LEGISLATION 

=======================================================================

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                             JUNE 18, 2009

                               __________

                           Serial No. 111-29

                               __________

       Printed for the use of the Committee on Veterans' Affairs

                               ----------
                         U.S. GOVERNMENT PRINTING OFFICE 

51-868 PDF                       WASHINGTON : 2009 

For sale by the Superintendent of Documents, U.S. Government Printing 
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; 
DC area (202) 512-1800 Fax: (202) 512-2250 Mail: Stop SSOP, 
Washington, DC 20402-0001 

                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     HENRY E. BROWN, Jr., South 
Dakota                               Carolina
HARRY E. MITCHELL, Arizona           JEFF MILLER, Florida
JOHN J. HALL, New York               JOHN BOOZMAN, Arkansas
DEBORAH L. HALVORSON, Illinois       BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia      DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico             GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas             VERN BUCHANAN, Florida
JOE DONNELLY, Indiana                DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia

                   Malcom A. Shorter, Staff Director

                                 ______

                         Subcommittee on Health

                  MICHAEL H. MICHAUD, Maine, Chairman

CORRINE BROWN, Florida               HENRY E. BROWN, Jr., South 
VIC SNYDER, Arkansas                 Carolina, Ranking
HARRY TEAGUE, New Mexico             CLIFF STEARNS, Florida
CIRO D. RODRIGUEZ, Texas             JERRY MORAN, Kansas
JOE DONNELLY, Indiana                JOHN BOOZMAN, Arkansas
JERRY McNERNEY, California           GUS M. BILIRAKIS, Florida
GLENN C. NYE, Virginia               VERN BUCHANAN, Florida
DEBORAH L. HALVORSON, Illinois
THOMAS S.P. PERRIELLO, Virginia

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.

                            C O N T E N T S

                               __________

                             June 18, 2009

                                                                   Page
Legislative Hearing on H.R. 1293, H.R. 1197, H.R. 1302, H.R. 
  1335, H.R. 1546, H.R. 2734, H.R. 2738, H.R. 2770, H.R. 2898 and 
  Draft Discussion Legislation...................................     1

                           OPENING STATEMENTS

Hon. Deborah L. Halvorson........................................     1
Chairman Michael Michaud, prepared statement of..................    15
Hon. Gus M. Bilirakis............................................     2
Hon. John Boozman................................................    13

                               WITNESSES

Halvorson, Hon. Deborah L., a Representative in Congress from the 
  State of Illinois..............................................     9
Hare, Hon. Phil, a Representative in Congress from the State of 
  Illinois.......................................................     3
McNerney, Hon. Jerry, a Representative in Congress from the State 
  of California..................................................     5
Mitchell, Hon. Harry E., a Representative in Congress from the 
  State of Arizona...............................................     4
Paralyzed Veterans of America, Fred Cowell, Senior Health Policy 
  Analyst........................................................    10
    Prepared statement of Mr. Cowell.............................    16
Perriello, Hon. Thomas S.P., a Representative in Congress from 
  the State of Virginia..........................................    12
Teague, Hon. Harry, a Representative in Congress from the State 
  of New Mexico..................................................     8
    Prepared statement of Congressman Teague.....................    15

                       SUBMISSIONS FOR THE RECORD

U.S. Department of Veterans Affairs, Robert A. Petzel, M.D., 
  Acting Principal Deputy Under Secretary for Health, Veterans 
  Health Administration..........................................    20
American Academy of Physician Assistants, statement..............    24
American Legion, Joseph L. Wilson, Deputy Director, Veterans 
  Affairs and Rehabilitation Commission, statement...............    26
Buyer, Hon. Steve, Ranking Republican Member, Committee on 
  Veterans' Affairs, and a Representative in Congress from the 
  State of Indiana, statement....................................    27
Disabled American Veterans, Joy J. Ilem, Deputy National 
  Legislative Director, statement................................    28
Moran, Hon. Jerry, a Representative in Congress from the State of 
  Kansas, statement..............................................    37
National Association of Veterans' Research and Education 
  Foundations, statement.........................................    37
National Military Family Association, Barbara Cohoon, Government 
  Relations Deputy Director, statement...........................    41
Veterans of Foreign Wars of the United States, Christopher 
  Needham, Senior Legislative Associate, National Legislative 
  Service, statement.............................................    44
Vietnam Veterans of America, Bernard Edelman, Deputy Director for 
  Policy and Government Affairs, statement.......................    47
Wounded Warrior Project, statement...............................    49

                   MATERIAL SUBMITTED FOR THE RECORD

Post-Hearing Questions and Responses for the Record:
    Hon. Michael H. Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs, to Hon. Eric K. Shinseki, 
      Secretary, U.S. Department of Veterans Affairs, letter 
      dated June 22, 2009, and VA responses......................    52
    Hon. Henry E. Brown, Jr., Ranking Republican Member, 
      Subcommittee on Health, Committee on Veterans' Affairs, to 
      Hon. Eric K. Shinseki, Secretary, U.S. Department of 
      Veterans Affairs, letter dated June 24, 2009, and VA 
      responses..................................................    61
    Hon. Michael H. Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs, to Joseph L. Wilson, Deputy 
      Director, Veterans Affairs and Rehabilitation Commission, 
      American Legion, letter dated June 22, 2009, and the 
      American Legion responses..................................    70
    Hon. Michael H. Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs, to Joy J. Ilem, Deputy 
      National Legislative Director, Disabled American Veterans, 
      letter dated June 22, 2009, and Ms. Ilem's responses.......    71
    Hon. Michael H. Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs, to Fred Cowell, Senior 
      Health Policy Analyst, Paralyzed Veterans of America, 
      letter dated June 22, 2009, and Mr. Cowell's responses, 
      letter dated July 28, 2009.................................    73
    Hon. Michael H. Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs, to Christopher Needham, 
      Senior Legislative Associate, National Legislative Service, 
      Veterans of Foreign Wars of the United States, letter dated 
      June 22, 2009, and VFW's responses.........................    75
    Hon. Michael H. Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs, to Bernard Edelman, Deputy 
      Director for Policy and Government Affairs, Vietnam 
      Veterans of America, letter dated June 22, 2009, and Mr. 
      Edelman's responses, letter dated July 23, 2009............    77

              LEGISLATIVE HEARING ON H.R. 1293, H.R. 1197,
              H.R. 1302, H.R. 1335, H.R. 1546, H.R. 2734,
                  H.R. 2738, H.R. 2770, H.R. 2898 AND
                      DRAFT DISCUSSION LEGISLATION

                              ----------                              

                        THURSDAY, JUNE 18, 2009

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice, at 10:03 a.m., in 
Room 334, Cannon House Office Building, Hon. Deborah Halvorson 
presiding.

    Present: 
Representatives Teague, McNerney, Halvorson, Perriello, 
Boozman, and Bilirakis.

  OPENING STATEMENT OF CHAIRMAN MICHAUD, AS PRESENTED BY HON. 
                      DEBORAH L. HALVORSON

    Mrs. Halvorson [presiding]. This hearing will now come to or
der.
    Before I go into my opening statement, I would like to 
welcome to the hearing today a distinguished group of law 
students who are spending the summer with the Board of 
Veterans' Appeals. Many fine law schools are represented and 
there are veterans, members of the National Guard, and a Marine 
spouse among the group.
    So, again, welcome to the hearing today. If you would like 
to stand up, I would like to welcome you, if anybody is here in 
the audience today. Thank you.
    [Applause.]
    Mrs. Halvorson. Thank you for being with us today. I would 
like to thank everyone for coming.
    Actually, before I start on my opening remark, I want to 
tell the audience that we are scheduled for votes somewhere 
between 10:15 and 10:30. And it is not like there will be one 
or two votes. There will be about 27 of them. What we do not 
get done, I am going to ask all the panelists to submit their 
testimony for the record. And anybody else, any questions that 
they have will be answered by staff.
    Today's legislative hearing is an opportunity for Members 
of Congress, veterans, the VA, and other interested parties to 
provide their views on and discuss draft legislation as well as 
recently introduced legislation within this Subcommittee's 
jurisdiction in a clear and orderly process.
    So I do not necessarily agree or disagree with the bills 
here today, but I do believe that this is an important part of 
the legislative process.
    So I welcome frank, open discussions from all parties that 
this legislation would affect.
    We have 11 bills before us today. And obviously we will 
probably be submitting most of them for the record. And each of 
the bills addresses important issues affecting our veterans and 
their families.
    These bills address a wide range of issues including help 
for family caregivers of wounded veterans, improving the 
nonprofit research and education corporations, establishing a 
position of Director of Physician Assistant, and creating a 
Committee on Care of Veterans with Traumatic Brain Injury.
    [The prepared statement of Chairman Michaud appears on p. 15
.]
    Mrs. Halvorson. We will also consider a lot of other 
important bills. But at this time, I would like to allow Mr. 
Hare a chance--oh, I am sorry. Mr. Bilirakis, would you like to 
give an opening remark, please?

           OPENING STATEMENT OF HON. GUS M. BILIRAKIS

    Mr. Bilirakis. Just very brief. Thank you very much, I 
appreciate it, Madam Chair.
    I appreciate you holding this legislative hearing and 
welcome the opportunity to discuss the 11 legislative proposals 
before us today.
    Knowing we have a full schedule, and of course votes coming 
up this morning, I will keep my remarks very brief.
    Our Ranking Member, Steve Buyer, is a sponsor of one of the 
bills on the agenda, H.R. 1293, the ``Disabled Veterans Home 
Improvement and Structural Alteration Grant Increase Act of 
2009.''
    Unfortunately, Steve is unable to be here this morning, and 
I ask unanimous consent, Madam Chair, that his statement be 
included in the record.
    Mrs. Halvorson. So ordered.
    [The prepared statement of Congressman Buyer appears on 
p. 27.]
    Mr. Bilirakis. Thank you.
    In his absence, I would like to take a few moments to 
explain this bill.
    H.R. 1293 would increase the amount available for grants 
under the Home Improvement and Structural Alteration (HISA) 
Program. The HISA program provides grants as part of the U.S. 
Department of Veterans Affairs' (VA's) Home Health Services to 
make home improvements that are necessary to continue care in 
the veteran's home.
    Both veterans with service-connected and nonservice-
connected disabilities are eligible to receive this benefit.
    H.R. 1293 would raise the authorized grant amount from 
$4,100 to $6,800 for service-connected veterans and from $1,200 
to $2,000 for nonservice-connected veterans.
    It is a good, bipartisan bill and I urge my colleagues to 
support it.
    In closing, I want to thank all the Members who have 
introduced the bills we will consider today and all of our 
witnesses for taking time to provide their views. I look 
forward to a productive discussion and I yield back.
    Thank you, Madam Chair.
    Mrs. Halvorson. Thank you, Mr. Bilirakis, for being here 
and for being a part of this.
    So we will start with Mr. Hare and then we will go to Mr. 
Mitchell.

STATEMENTS OF HON. PHIL HARE, A REPRESENTATIVE IN CONGRESS FROM 
     THE STATE OF ILLINOIS, AND HON. HARRY E. MITCHELL, A 
      REPRESENTATIVE IN CONGRESS FROM THE STATE OF ARIZONA

                  STATEMENT OF HON. PHIL HARE

    Mr. Hare. Thank you, Madam Chair. Good morning.
    And let me just say before I give the testimony how very 
much I appreciate having the opportunity to be here today. I 
miss this Subcommittee and I miss the full Committee. It is an 
incredible Committee and it works in a very wonderful, 
bipartisan way.
    So thank you for having me.
    Ranking Member Bilirakis, thank you, too, for allowing me 
to be here today.
    I am very pleased to provide testimony in support of H.R. 
1302, a bill that I introduced to elevate the current physician 
assistant (PA) Advisor, also known as the PA Advisor, to a 
full-time Director of PA services in the VA's Central Office.
    I would like to thank my colleagues, Representative Jerry 
Moran for his leadership with me on this bill as well as 
Chairman Filner, Chairman Michaud, Ranking Member Buyer and 
Brown and many other VA Committee colleagues joining us as co-
sponsors.
    PAs have long been a key component in the Veterans Health 
Administration, with over 1,800 PAs currently employed there, 
roughly 30 percent of whom are veterans.
    While the PA Advisor position established by Congress in 
the year 2000 has been valuable, many problems still exist.
    For example, as the AAPA explained in their written 
testimony of October 18, 2007, ``In one case, a local facility 
decided that a PA could not write out patient prescriptions 
despite licensure in the State allowing prescriptive authority. 
In other facilities, PAs are told that the VA facility cannot 
use PAs and will not hire PAs.''
    These inconsistencies and restrictions not only hinder PAs 
currently employed by the VA, but also discourage PAs from even 
entering the VA system. Quite simply, this is a position that 
needs to be made permanent and based at the VA Central Office.
    The lack of a Director of PA services at the VA prevents 
necessary recruitment and retention of the PA workforce in the 
VA, all at a time when the Veterans Administration needs more 
health care professionals to provide medical care for our 
veterans.
    Considering the fact that nearly 40 percent of all VA PAs 
are projected to retire in the next 5 years, the VA is in 
danger of losing its PA workforce unless some attention is 
directed toward recruiting and retention of this critical group 
of people.
    PAs are the fourth fastest-growing profession in the 
country, yet the VA is simply not competitive with the private 
sector for new PA graduates and is missing an opportunity to 
improve the quality of veterans' health care.
    One of the biggest challenges facing current and future PAs 
in the VA system is their exclusion from recruitment and 
retention efforts and benefits.
    The VA designates physicians and nurses as critical 
occupations and so priority, scholarships and loan repayment 
programs to those critical occupations.
    However, the PA profession has not been determined to be a 
critical occupation at the VA despite the fact that the VA has 
determined that PAs and Nurse Practitioners (NPs) are 
functionally interchangeable and that they perform equal work.
    A permanent Director at the Veterans Affairs Central Office 
(VACO) would serve as an advocate on behalf of the physician 
assistants and work to ensure their fair treatment.
    Additionally, VA medical facilities at times post vacant 
positions for NPs only, excluding physician assistants. There 
is also a hiring trend in the VA of NPs outpacing PAs nearly 
three to one, again despite the interchangeability between the 
NPs and the physician assistants.
    Finally, PAs are not included in any of the VA's special 
locality pay bands, so PAs' salaries are not regularly tracked 
and reported by the VA. There is evidence that this has 
resulted in lower pay for physician assistants employed by the 
VA compared to other health care professionals. This only 
serves as yet another deterrent to PAs to enter the VA system.
    The physician assistant profession is invaluable to the VA 
and it is time for the VA to devote some serious attention to 
the profession's recruitment and retention.
    Enactment of my bill, H.R. 1302, is a very good start. 
There is no significant cost to elevating and relocating the 
position. This change is common sense and it promotes quality 
medical care for our veterans.
    H.R. 1302 is nearly identical to a bill that was reported 
by your Committee in the 110th Congress, which passed the House 
by a unanimous voice vote.
    This bill, which also has been endorsed in the Senate by 
Senator Susan Collins of Maine and Daniel Inouye of Hawaii, is 
supported by the Veterans Affairs Physician Assistant 
Association, the American Academy of Physician Assistants, and 
the Blinded Veterans Association.
    Madam Chairman and Ranking Member, thank you again for 
allowing me to testify on the importance of physician 
assistants in the VA health care system. I appreciate your 
giving me the time and would be happy to answer any questions 
you may have.
    Thank you again very much for having me this morning.
    Mrs. Halvorson. Do the Members have any questions?
    [No response.]
    At this time, we will go to Mr. Mitchell for his 5 minutes.

              STATEMENT OF HON. HARRY E. MITCHELL

    Mr. Mitchell. Thank you, Madam Chair. And I want to thank 
you for inviting me to speak this morning in support of H.R. 
1197, the ``Medal of Honor Health Care Equity Act of 2009.''
    The Congressional Medal of Honor is awarded for conspicuous 
gallantry and intrepidity at the risk of life above and beyond 
the call of duty. It is the military's highest honor. Today 
there are only 98 living recipients.
    Last year, a medal recipient was injured in Chandler, 
Arizona. This veteran, Fred Ferguson, was awarded the Medal of 
Honor for flying his helicopter into enemy fire over Hue' 
Vietnam. Despite his valor, which saved the lives of five 
fellow soldiers, he was ineligible for health care through the 
VA when he was injured.
    The VA uses a priority scale to determine eligibility for 
health care services. Top priority is given to veterans with 
service-connected disabilities, former prisoners of war, and 
Purple Heart recipients. Priority is also given to those who 
have rendered special service or who demonstrate financial 
need.
    Each of these categories of veterans should be ensured 
priority access to health care. Unfortunately, Medal of Honor 
recipients do not automatically fall into any of these priority 
categories and some of them fall through the cracks.
    Now Fred Ferguson may not need medical care from the VA. In 
fact, he received excellent care at Scottsdale Healthcare 
Osborn's Hospital.
    But in order to ensure that the 98 living Medal recipients 
and all future Medal of Honor recipients have guaranteed access 
to high-quality health care, Dr. Roe, my Republican counterpart 
on the Oversight and Investigation Subcommittee, joined me in 
introducing the ``Medal of Honor Health Care Equity Act.''
    We are not talking about a large population of veterans, 
but they deserve access to medical care from the VA no matter 
what.
    H.R. 1197 has been endorsed by the Disabled American 
Veterans (DAV) and I appreciate your support for this bill.
    Madam Chair, thank you again for permitting me to appear 
before the Subcommittee today and I will be very glad to answer 
any questions. Thank you.
    Mrs. Halvorson. Are there any questions?
    [No response.]
    At this time, I would like to bring up panel two, which 
includes myself, Mr. McNerney, Mr. Perriello, and Mr. Teague.
    Thank you for not waiting for me to dismiss you. You would 
have been sitting there for a while.
    Gentlemen, since I am here, I will go last.
    Mr. McNerney, if you would like to proceed with your 5 
minutes.

STATEMENTS OF HON. JERRY MCNERNEY, A REPRESENTATIVE IN CONGRESS 
      FROM THE STATE OF CALIFORNIA; HON. HARRY TEAGUE, A 
 REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW MEXICO; AND 
 HON. DEBORAH L. HALVORSON, A REPRESENTATIVE IN CONGRESS FROM 
                     THE STATE OF ILLINOIS

                  STATEMENT OF JERRY MCNERNEY

    Mr. McNerney. Thank you, Chairwoman Halvorson.
    I would like to thank the Chairman of the Committee, Mr. 
Filner, the Ranking Member, Mr. Buyer, leadership from Mr. 
Boozman, and Mr. Michaud for their hard work on behalf of our 
veterans and all Members of the Committee for being on the 
Committee and working hard and looking out for our veterans' 
best interests.
    I am going to be speaking on behalf of traumatic brain 
injury (TBI), a bill which I introduced last year and passed by 
unanimous consent.
    More than 1.6 million troops have served in Iraq and 
Afghanistan and about half of those brave men and women are now 
veterans. Traumatic brain injury or TBI has become the 
signature wound of the wars in Iraq and Afghanistan.
    A RAND Corporation study estimates that up to 320,000 
troops who served in these conflicts suffer from brain trauma. 
Milder forms of TBI can result, this is milder forms, can 
result in cognitive problems such as headaches, difficulty in 
thinking, memory problems, abnormal speech or language, and 
limited functioning of arms and legs.
    TBI's effects on veterans and their families can be 
devastating.
    I have met personally with several veterans in my district 
who suffer from severe brain injury in Iraq. One is doing well 
in my hometown with a 4-year scholarship from the Sentinels of 
Freedom. I just had lunch with him a couple of weeks ago and I 
am very pleased to see how well he has adjusted.
    Unfortunately, many wounded veterans face an even more 
arduous path to recovery.
    The brain is probably the most adaptable organ of the body, 
but any time there is a traumatic injury or section of the 
brain that is damaged, it takes time to adjust and compensate.
    When a soldier is wounded, he or she is first transported 
to a trauma center to treat brain swelling. Brain swelling is 
the biggest and most immediate risk from a brain injury.
    After being stabilized, soldiers may face invasive surgical 
procedures and painful cooling treatments to combat 
inflammation, followed by extensive physical and psychological 
therapy.
    I have seen firsthand how difficult this treatment is and 
we owe our veterans the very best.
    Blasts from improvised explosive devices have become one of 
the most common causes of injury for troops currently serving 
in combat zones. And recent studies show that 59 percent of 
blast exposed patients at Walter Reed have been found to have 
some form of TBI.
    In April of 2007, the Veterans Administration began 
screening veterans who served in Iraq and Afghanistan since the 
beginning of October 2001 for symptoms that may be associated 
with TBI. Of the 61,285 veterans that the VA screened for TBI, 
11,804 or 19 percent of those veterans screened positive for 
TBI symptoms.
    U.S. Department of Defense (DoD) and Veterans 
Administration experts note that TBI can occur even if a victim 
does not suffer from an obvious physical injury which sometimes 
takes place when a person is within the vicinity of powerful 
detonation.
    In these instances, signs and symptoms of TBI, such as the 
ones I mentioned earlier, are not often readily recognized.
    According to the Department of Defense and the Veterans 
Administration mental health experts, mild TBI can also produce 
behavioral symptoms similar to post-traumatic stress disorder 
or other mental health conditions. And TBI almost always causes 
post-traumatic stress.
    The relationship between TBI and post-traumatic stress can 
further complicate diagnosis and treatment. As a result, 
further research must be conducted to examine the long-term 
effects of these injuries, which are not yet fully understood, 
and the best treatment models to address TBI and improve 
coordination of care for injured veterans.
    Traumatic brain injuries have often affected a large number 
of female servicemembers. And as the number of women enlisted 
in the Armed Forces continues to grow, we must ensure that our 
focus on health care continues to encompass all veterans.
    I hope we can continue to collect data to ensure that the 
women veterans receive the same quality of care as their male 
counterparts, and I am committed to working on this Committee 
to assist in that endeavor.
    When a soldier is transitioning to civilian life, it is 
imperative that we have a system in place that is able to 
properly evaluate and assess the risks and challenges, if any, 
these veterans and their families might face.
    Given that evidence suggests that combat-related TBI is an 
increasingly frequent occurrence and that the effects of TBI 
are still poorly understood, prioritizing research and 
oversight will help plan for addressing treatment and long-term 
care.
    Research into TBI is also particularly important for 
understanding post-traumatic stress because the amnesia that 
often occurs as a result of TBI increases the challenges of 
post-traumatic stress treatment.
    Studies have shown that in the absence of factual recall, 
individuals may have delusional or reconstruct memories of 
trauma. These individuals may retain false memories rather than 
factual results.
    Closely related to cognitive impairment are mental health 
issues such as depression and anxiety disorders. These 
psychological issues often interact with physical injury to 
decrease patients' overall health status and adherence to 
medical regimes.
    Those who experience TBI may behave impulsively because of 
damage that removes many of the brain checks on the regulation 
of behavior. Without the limits provided by these higher brain 
functions, these individuals may overreact to seemingly 
innocent or neutral stimuli.
    For these reasons, I was compelled to introduce legislation 
to address these critical issues. H.R. 1546, the ``Caring for 
Veterans with Traumatic Brain Injury Act,'' directs the 
Secretary of Veterans Affairs to establish within the Veterans 
Health Administration a Committee on Care of Veterans with 
Traumatic Brain Injury to continually assess the Veterans 
Health Administration's capability to meet the treatment and 
rehabilitation needs of veterans suffering with TBI.
    In addition, this legislation will help TBI specific 
education and training programs for VA health professionals in 
order to better serve our Nation's veterans.
    Though money has been allocated by Congress to help study 
and combat the effects of TBI, there is still room for 
improvement, something I hope H.R. 1546 will be able to help 
address.
    The bipartisan ``Caring for Veterans with Traumatic Brain 
Injury Act'' passed the House unanimously in the 110th Congress 
as a part of Chairman Michaud's H.R. 2199, the ``Traumatic 
Brain Injury Health Enhancement and Long-Term Support Act of 
2007.''
    TBI has become one of the signature injuries of the wars in 
Afghanistan and Iraq. As the Department of Veterans Affairs 
transitions to a 21st century institution that better meets its 
mission of serving veterans, it is imperative that it addresses 
the 21st century injuries such as TBI.
    I appreciate the testimony and comments expressed by all 
groups on the panel today and I am grateful for their service 
to this great country.
    I thank you for the opportunity to testify here today.
    Mrs. Halvorson. Mr. Teague?

                 STATEMENT OF HON. HARRY TEAGUE

    Mr. Teague. Yes. Madam Chairwoman Halvorson, thank you.
    Ranking Member and fellow Subcommittee Members, thank you 
all for allowing me the opportunity to speak on behalf of H.R. 
2738.
    It was my honor and pleasure to introduce this bill and I 
believe that this legislation will provide some needed relief 
for the families who care for our Nation's veterans.
    H.R. 2738 would allow family caregivers to get some of 
their travel expenses paid for when they are accompanying 
veterans to medical treatment facilities.
    This bill would provide lodging payments, a common cost 
that a veteran's family incurs when they are trying to ensure 
that their loved ones are receiving the care that they need.
    The bill also provides for some flexibility on the 
definition of caregivers, realizing that in this day and age, a 
veteran may not have immediate family members caring for them.
    This bill also recognizes not only the immediate family 
caregivers that reside with the veteran but also extended 
family members and stepchildren that may not reside with the 
veteran.
    Ms. Chairwoman, I do not need to tell anyone in this room 
or in this Congress that access to health care is not as easy 
as it should be or in my district and in many other districts 
that are rural, it is even harder.
    While my district is roughly the same geographic size as 
the State of Pennsylvania, there is no VA hospital located 
within its boundaries.
    Veterans who live in Silver City, New Mexico, are often 
forced to meet at the local VA clinic's parking lot at 1 
o'clock in the morning so that a DAV van can take them to the 
State's only VA hospital in Albuquerque.
    While this legislation does not create new hospitals, it 
helps to make travel easier for all of our veterans living in 
rural areas. They can make a trip to the VA facility and have 
their family assist them with that journey and not have the 
added worry of wondering how they will pay for such a trip 
during these difficult financial times.
    If an examination at the hospital takes a bit longer than 
usual, they do not have to rush back home late at night. We can 
now give them some peace of mind with this bill.
    Madam Chairwoman, I believe that this measure is the least 
we can do for our Nation's veterans after they have given so 
much in defense of our country.
    I do not think that forcing a veteran to take money out of 
his pocket or her pocket while they are accessing benefits that 
they have earned makes sense. And I do not think it is the 
right thing to do. We should not make it more difficult for our 
veterans to get to VA facilities. We should take steps to make 
it easier on them.
    I think that all of my colleagues would agree with me on 
that statement and I hope that I can have their support on this 
bill.
    Madam Chairwoman and Ranking Member, I thank you for the 
time that you have given me to speak on behalf of this bill 
today.
    I would also like to thank the staff of the Health 
Subcommittee for their assistance, expertise, and insight on 
this matter.
    This concludes my testimony and I am ready to answer any 
questions you may have regarding H.R. 2738. Thank you.
    [The prepared statement of Congressman Teague appears on 
p. 15.]
    Mrs. Halvorson. Thank you, Mr. Teague.
    Last on panel two are my two bills. But before I do that, 
we have some testimony on H.R. 1302 from Congressman Jerry 
Moran. I would like unanimous consent to include that in the 
record.
    [The prepared statement of Congressman Moran appears on 
p. 37.]

             STATEMENT OF HON. DEBORAH L. HALVORSON

    Mrs. Halvorson. My first bill is H.R. 1335, which would 
prohibit the collection of co-payments and other fees from 
catastrophically disabled veterans who receive medical or 
nursing home care from the Department of Veterans Affairs.
    Right now some catastrophically disabled veterans are 
thrown into financial hardship because of the health care co-
payment that they must pay to the VA.
    Catastrophically disabled veterans have severely disabling 
conditions that compromise their ability to carry out 
activities of daily living, including such basics as self-care 
tasks, such as eating, bathing, and dressing.
    Disabled veterans in situations like this have enough 
challenges to face on a daily basis and scraping together 
enough money to make their co-payment should not be another 
challenge that they have to deal with.
    I will allow the rest of my testimony to be included in the 
record.
    The other bill is H.R. 2898, which authorizes the VA to 
make available supportive services to family caregivers who 
provide critical health care services to our wounded warriors.
    My bill would provide counseling, better training, and 
respite care for family caregivers and it would make sure that 
the VA conducts community outreach through PSAs, brochures and 
information pamphlets.
    Finally, it would assist caregivers with locating support 
services from the public, private, and nonprofit agencies.
    Last year, my stepson was severely injured while serving in 
Afghanistan. At first, we were just relieved that he was simply 
alive. That, of course, was our number one priority. After 
that, it was clear that he would make it through all of his 
surgeries at Walter Reed. Our immediate concern then became how 
are we going to take care of him.
    He was not in a good state and needed constant care. We 
were blessed to have the resources and the time available to 
drive him to his rehabilitation every day and take care of him 
at home as he recuperated.
    Thankfully, after time and rehabilitation, he is back on 
his feet and going to be fine. But it was that experience, 
however, that has given me the insight to understand the 
sacrifice that family caregivers, and gladly so, give and make 
for our America's wounded warriors 24 hours a day and 7 days a 
week.
    H.R. 2898 is a strong step in the right direction. And I am 
so pleased that this was a bill that we were able to bring 
forward.
    So at this time, if anybody has questions for any of the 
bills that are before us.
    [No response.]
    If not, we will bring up panel three, Fred Cowell, Senior 
Health Policy Analyst, Paralyzed Veterans of America (PVA); Joy 
Ilem, Deputy National Legislative Director of the Disabled 
American Veterans; Mr. Joseph Wilson, Deputy Director of 
Veterans Affairs and Rehabilitation Commission of the American 
Legion; Mr. Christopher Needham, Senior Legislative Associate, 
National Legislative Service, Veterans of Foreign Wars; and 
Bernard Edelman, Deputy Director for Policy and Government 
Affairs, Vietnam Veterans of America.
    We will start with Mr. Cowell. I apologize if they start 
votes. What we will have you do is then submit all of your 
testimony for the record.
    So, please, Mr. Cowell, you will be recognized for 5 
minutes.

    STATEMENT OF FRED COWELL, SENIOR HEALTH POLICY ANALYST, 
                 PARALYZED VETERANS OF AMERICA

    Mr. Cowell. Thank you, Madam Chairperson, Ranking Member, 
Members of the Subcommittee.
    Paralyzed Veterans of America would like to thank you for 
the opportunity to provide testimony today on legislation 
pending before the Subcommittee and other draft legislation 
concerning the needs of caregivers who assist veterans on a 
daily basis.
    H.R. 1335, PVA would like to thank Member Halvorson for 
introducing this important bill. As you know, PVA members are 
some of the most frequent users of VA health care. In fact, PVA 
members receive 85 to 90 percent of their medical care through 
the VA health care system.
    With this in mind, PVA supports H.R. 1335 to prohibit the 
Secretary of VA from collecting co-payments from 
catastrophically disabled, Priority Group 4 veterans. However, 
we would like to recommend that the Subcommittee make a change 
to the legislative language prior to the markup of this bill.
    In examining this bill, we realized that the current 
language that refers to hospital and nursing home care does not 
meet the intent of the legislation. This language is very 
narrow in scope and would seemingly only benefit veterans in 
inpatient settings.
    However, the intent has always been to relieve these 
severely disabled veterans of all burdensome co-payments. To 
that end, we have recommended that Subcommittee staff change 
the language to hospital and medical care services so as to 
properly meet Congressional intent.
    This change would ensure that catastrophically disabled 
veterans who often require extensive VA outpatient 
rehabilitative care, VA inpatient and outpatient preventive 
services, and who often experience prolonged inpatient hospital 
stays will be protected.
    Catastrophically disabled veterans were pleased when the 
House Committee on Veterans' Affairs approved, and the House of 
Representatives passed H.R. 6445 during the 110th Congress to 
eliminate VA co-pays for catastrophically disabled veterans.
    In fact, the House bill received unanimous support from 
both sides of the aisle. Unfortunately, the Senate never took 
action on the measure.
    This year, however, the Senate Committee on Veterans' 
Affairs has approved S. 801, which includes the elimination of 
co-pays for Priority Group 4 veterans. The Senate version also 
includes the recommended language change.
    Together with H.R. 1335, PVA members and other 
catastrophically disabled veterans now have real hope that 
financial relief will soon be forthcoming.
    H.R. 1293, the HISA grant increase. First, Mr. Chairman, 
PVA would like to thank Congressman Buyer for introducing this 
important piece of legislation. PVA strongly supports H.R. 
1293, the ``Disabled Veterans Home Improvement and Structural 
Alteration Grant of 2009.''
    These increases will help defray the constantly rising cost 
for accessibility modifications to veterans' homes. This VA 
benefit enables veterans to maximize their functional abilities 
and return to a home following medical treatment that meets 
their needs.
    PVA certainly hopes that Congress will give this 
legislation favorable consideration as it will benefit 
America's most severely disabled veterans.
    PVA applauds the draft legislation to expand caregiver 
assistance opportunities. PVA actually believes that each of 
the four draft bills that take into consideration the needs of 
family caregivers should be combined into a single 
comprehensive bill as we believe that each of these bills has 
important aspects to assist veterans and their caregivers.
    Particularly we believe training assistance is a critical 
aspect in supporting caregivers who care for veterans.
    A particular focus on respite care mentioned in one of the 
draft bills is also an important part of any comprehensive 
caregiver assistance legislation.
    Respite care allows time for caregivers to ease their 
emotional and physical burdens for a period of time and it 
helps ensure that the caregiver will maintain their commitment 
to the disabled veteran and his or her needs.
    Additionally, PVA has no objection to the legislation that 
would provide health care services to caregivers through 
opening of CHAMPVA. In some cases, caregivers do not have other 
care options available to meet their own needs, particularly if 
the provision of caregiver services is essentially their job. 
This draft legislation will remedy this significant concern 
that many caregivers have.
    Regarding travel expenses for family caregivers 
accompanying veterans to medical treatment facilities, PVA 
strongly supports this draft legislation.
    As the Committee knows, many of our veterans returning from 
Operation Enduring Freedom and Operation Iraqi Freedom have 
significant disabling injuries, including TBI. Many of these 
individuals require constant care.
    PVA appreciates the efforts of the Committee to ensure that 
travel expenses for these needed assistants are provided.
    One disappointment that PVA would like to point out is the 
exclusion of any type of caregiver allowance from the draft 
bills being considered. Providing a financial benefit has been 
one of the important issues that we have advocated for in 
addressing caregiver issues.
    We hope that the Subcommittee will examine ways to 
incorporate this important idea into final legislation.
    And, finally, Mr. Chairman, PVA supports H.R. 2770's 
language to make improvements that will streamline the 
operations, increase the effectiveness, and maintain 
accountability of nonprofit research and education 
corporations.
    These entities provide extremely valuable services to VA, 
to VA researchers, and ultimately to the veterans who benefit 
from research breakthroughs.
    Madam Chairman and Members of the Subcommittee, PVA would 
like once again to thank you for the opportunity to provide our 
views on this important legislation. We look forward to working 
with you to continue to improve the health care services 
available to veterans.
    I will be happy to answer any questions that you might 
have.
    [The prepared statement of Mr. Cowell appears on p. 16.]
    Mrs. Halvorson. And before we go on to Mr. Edelman, Mr. 
Perriello would like to make a statement. He has a bill. He was 
somewhere else. He just made it. Before we head out.

 STATEMENT OF HON. TOM PERRIELLO, A REPRESENTATIVE IN CONGRESS 
                   FROM THE STATE OF VIRGINIA

    Mr. Perriello. Thank you very much, Chairlady.
    Good morning, everyone. Let me begin by thanking Chairman 
Michaud and Ranking Member Brown for holding this hearing on 
bills aimed at addressing some of the health care concerns 
faced by veterans and those who care for them.
    I appreciate the opportunity to offer testimony in support 
of 
H.R. 2734, the ``Health Care for Family Caregivers Act of 
2009.''
    In the words of former First Lady Rosalyn Carter, quote, 
``There are only four kinds of people in the world, those who 
have been caregivers, those who are currently caregivers, those 
who will be caregivers, and those who will need caregivers.''
    Mrs. Carter's observations are particularly telling when 
considering our brave men and women in uniform.
    Today more than ever revolutionary advances in military 
medicine have significantly increased a servicemember's chances 
of surviving a catastrophic injury sustained in combat. But in 
many cases, surviving such injuries is only half the battle.
    Recovering requires a long-term commitment not only from 
the veteran but also from those who love and care for the 
veteran.
    Simply stated, taking care of our veterans means taking 
care of those who care for them when they are unable to care 
for themselves.
    Once an injured veteran returns home from treatment at a 
DoD or VA hospital, it is often a spouse, mother, father, or 
other loving family member who steps up to the challenge of 
providing ongoing care. And while this care is provided out of 
a sense of love, compassion, and duty, it oftentimes shifts 
into a full-time commitment requiring the caregiver to make 
significant personal decisions regarding professional goals, 
commitments, and obligations.
    H.R. 2734, the ``Health Care for Family Caregivers Act,'' 
would help provide some relief to those family caregivers faced 
with the difficult decisions related to caring for a veteran 
confronting a catastrophic injury.
    The bill would extend CHAMPVA benefits to eligible family 
caregivers of a select group of veterans defined as those who 
receive special monthly compensation for aid and attendant care 
and homebound care under Title 38. The expanded CHAMPVA benefit 
is limited to the primary family caregiver who lacks health 
care coverage.
    Family members are defined to include nuclear and extended 
family members as well as step family members. And there is no 
residency requirement whereby the family member must live with 
the veteran.
    Because many family caregivers leave their positions of 
employment to undertake the full-time task of caring for the 
veteran, the bill also exempts eligible family caregivers from 
deductibles and co-payments required of other CHAMPVA 
beneficiaries.
    As a Nation, we have an obligation to care for those who 
have stood in the defense of freedom. H.R. 2734 is a 
commonsense bill which continues our commitment to American 
veterans.
    I would like to thank all of the veterans services 
organizations for their continued support. I would also like to 
thank the Department of Veterans Affairs for their testimony 
and willingness to work cooperatively to advance responsible 
legislation which effectively addresses the needs of veterans 
and those who care for them.
    I look forward to meeting with leaders and subject matter 
experts from the Veterans Health Administration this month to 
discuss this important matter in a comprehensive manner.
    I thank the Subcommittee for holding this hearing and look 
forward to answering any questions you may have. Many thanks.
    Mrs. Halvorson. At this time, I would like to acknowledge 
Mr. Boozman for comments.

             OPENING STATEMENT OF HON. JOHN BOOZMAN

    Mr. Boozman. Thank you.
    We appreciate you all being here, and I apologize that we 
have to interrupt. Yet, we do not want to have you have to wait 
around forever.
    The only thing that we have to do here, there are lots of 
things that we can get out of, but we do have to go vote when 
we are supposed to.
    I do want to congratulate you, Ms. Ilem, on your promotion 
to Deputy National Legislative Director. We all appreciate your 
hard work for the DAV. I know that you have been invaluable in 
many cases in providing some very, very good information. So we 
do want to congratulate you on behalf of, I think, all of us 
very much so, and especially our staffs. We appreciate your 
help and appreciate your hard work on behalf of veterans.
    I yield back.
    Mrs. Halvorson. Thank you, Mr. Boozman.
    Since there are 7 minutes left for us to vote, instead of 
making panels 3 and 4 wait until we are done with our 27 votes 
or somewhere around there, we are going to have you all submit 
your testimony for the record.
    And anybody who has questions, we will submit them and we 
will make sure everybody has a record of that.
    With that, I would like to adjourn the Subcommittee.
    [Whereupon, at 10:43 a.m., the Subcommittee was adjourned.]

                            A P P E N D I X

                              ----------                              

             Prepared Statement of Hon. Michael H. Michaud,
                    Chairman, Subcommittee on Health
    I would like to thank everyone for coming today.
    Today's legislative hearing is an opportunity for Members of 
Congress, veterans, the VA and other interested parties to provide 
their views on and discuss recently introduced legislation within the 
Subcommittee's jurisdiction in a clear and orderly process.
    I do not necessarily agree or disagree with the bills before us 
today, but I believe that this is an important part of the legislative 
process that will encourage frank discussions and new ideas.
    We have 11 bills before us today. Each of the bills address 
important issues affecting our veterans and their families. These bills 
address a wide range of issues including help for family caregivers of 
wounded veterans; improving the nonprofit research and education 
corporations; establishing a position of Director of Physician 
Assistant; and creating a Committee on Care of Veterans with Traumatic 
Brain Injury. We will also consider important bills to enhance health 
care and other benefits to veterans. This includes updating the benefit 
amount for the Home Improvement and Structural Alteration grant; 
eliminating the co-payments from veterans who are catastrophically 
disabled; extending health care benefits to Vietnam era herbicide 
exposed veterans and Gulf-War era veterans; and assigning Medal of 
Honor recipients to the Priority Group 3 category.
    I look forward to hearing the views of our witnesses on these bills 
before us.

                                 
                Prepared Statement of Hon. Harry Teague,
       a Representative in Congress From the State of New Mexico
    Mr. Chairman and Ranking Member Brown and fellow Subcommittee 
Members, thank you for allowing me the opportunity to speak on behalf 
of H.R. 2738. It was my honor and pleasure to introduce this bill, and 
I believe that this legislation will provide some much needed relief 
for the families who care for our Nation's veterans.
    H.R. 2738 would allow family caregivers to have some of their 
travel expenses paid for when they are accompanying veteran to medical 
treatment facilities. This bill would provide lodging payments, a 
common cost that a veteran's family incurs when they are trying to 
ensure that their loved ones are receiving the care that they need. The 
bill also provides for some flexibility on the definition of 
``caregivers,'' realizing that in this day and age, a veteran may not 
have immediate family members caring for them. This bill also 
recognizes not only the immediate family caregivers that reside with 
the veteran, but also extended family members and step-children that 
may not reside with the veteran.
    Mr. Chairman, I don't need to tell anyone in this room or in this 
Congress that access to health care is not as easy as it should be. In 
my district, and in many other districts that are rural, it's even 
harder. While my district is roughly the same geographic size as the 
State of Pennsylvania, there is no VA hospital located within its 
boundaries. Veterans who live in Silver City, New Mexico are often 
forced to meet in the local VA clinic's parking lot at one in the 
morning so that a DAV van can take them to the State's only VA hospital 
in Albuquerque.
    While this legislation does not create new hospitals, it helps to 
make travel easier for all of our veterans living in rural areas. They 
can make a trip to the VA facility and have their family assist them 
with that journey, and not have the added worry of wondering how they 
will pay for such a trip during these difficult financial times. If an 
examination at the hospital takes a bit longer than usual, they don't 
have to rush back home late at night. We can now give them some peace 
of mind with this bill.
    Mr. Chairman, I believe that this measure is the least we can do 
for our Nation's veterans, after they have given so much in defense of 
our country. I don't think that forcing a veteran to take money out of 
his or her pocket while they are accessing benefits that they've earned 
makes sense, and I don't think it's the right thing to do.
    We shouldn't make it more difficult for veterans to get to VA 
facilities. We should take steps to make it easier on them.
    I think that all of my colleagues would agree with me on that 
statement, and I hope that I could have their support on this bill.
    Mr. Chairman and Ranking Member Brown, I thank you for the time 
that you've given me to speak on behalf of this bill today. I would 
also like to thank the staff of the Health Subcommittee for their 
assistance, expertise and insight on this matter.
    This concludes my testimony and I am ready to answer any questions 
you may have regarding H.R. 2738.

                                 
                   Prepared Statement of Fred Cowell,
      Senior Health Policy Analyst, Paralyzed Veterans of America
    Chairman Michaud, Ranking Member Brown, and Members of the 
Subcommittee, Paralyzed Veterans of America (PVA) would like to thank 
you for the opportunity to provide testimony today on legislation 
pending before the Subcommittee and other draft legislation concerning 
veterans health care needs. We hope that the Subcommittee will take our 
concerns under consideration as it moves its legislation forward in the 
111th Congress. Mr. Chairman, we appreciate the legislative successes 
that veterans have realized under your leadership and we look forward 
to continued success in the future. PVA is particularly pleased with 
the emphasis on meeting the needs of veterans' caregivers.
 H.R. 1335, Co-Payments for Catastrophically Disabled Priority Group 4 
                                Veterans
    As you know, PVA members are some of the highest users of VA health 
care. In fact, catastrophically disabled veterans, like PVA members, 
receive 85 to 90 percent of their care from the VA.
    With this is mind, PVA supports H.R. 1335, to prohibit the 
Secretary of VA from collecting co-payments from catastrophically 
disabled Priority Group 4 veterans. However, we would like to recommend 
that the Subcommittee make a change to the legislative language prior 
to the markup for this bill. In examining this bill, we realized that 
the current language that refers to ``Hospital and Nursing Home Care'' 
does not really meet the intent of the legislation. This language is 
very narrow in scope and would seemingly only benefit veterans in 
inpatient settings. However, the intent has always been to relieve this 
important segment of the veteran population of all burdensome co-
payments. To that end, we have recommended that the Subcommittee staff 
change the language to ``Hospital and Medical Care Services'' so as to 
properly meet congressional intent. This would ensure that 
catastrophically disabled veterans who often take advantage of 
outpatient rehabilitative, preventive, and other health services will 
be protected.
    In 1985, Congress approved legislation which opened the VA health 
system to all veterans. In 1996, Congress again revised that 
legislation with a system of rankings establishing priority ratings for 
enrollment. Within that context, PVA worked hard to ensure that those 
veterans with catastrophic disabilities would be placed in a higher 
enrollment category. To protect their enrollment status, veterans with 
catastrophic disabilities were allowed to enroll in Priority Group 4 
even though their disabilities were nonservice-connected and regardless 
of their incomes. However, unlike other Priority Group 4 veterans, if 
they would otherwise have been in Priority Group 7 or 8, due to their 
incomes, they would still be required to pay all fees and co-payments, 
just as others in those categories do now for every service they 
receive from VA.
    PVA believes this is unjust. VA recognizes these veterans' unique 
specialized status on the one hand by providing specialized service for 
them in accordance with its mission to provide for special needs. The 
system then makes them pay for those services. Unfortunately, these 
veterans are not casual users of VA health care services. Because of 
the nature of their disabilities they require a lot of care and a 
lifetime of services. In most instances, VA is the only and the best 
resource for a veteran with a spinal cord injury, and yet, these 
veterans, supposedly placed in a higher priority enrollment category, 
have to pay fees and co-payments for every service they receive as 
though they had no priority at all.
    We were pleased when the House Committee on Veterans' Affairs 
approved and the House of Representatives eventually passed 
legislation--H.R. 6445--during the 110th Congress to eliminate this 
financial burden placed on catastrophically disabled veterans. In fact, 
the House bill received unanimous support from Republicans and 
Democrats as well as the VA. Unfortunately, the Senate never took 
action on the measure and the legislation was never enacted. This year, 
the Senate Committee on Veterans' Affairs has approved S. 801 which 
includes the elimination of co-payments for Priority Group 4 veterans. 
The Senate version also includes the recommended language change. 
Together with H.R. 1335, PVA members have real hope that we will 
finally be able to resolve this issue during the 111th Congress.
  H.R. 1293, the ``Disabled Veterans Home Improvement and Structural 
                Alteration Grant Increase Act of 2009''
    PVA strongly supports H.R. 1293, the ``Disabled Veterans Home 
Improvement and Structural Alteration Grant Increase Act of 2009.'' The 
costs for improvements and modifications for homes have continued to go 
up dramatically, in spite of the recent downturn in housing 
construction. There have been anecdotes of great deals now available 
for home improvements. But it can be expected that as we come out of 
the current recession, home improvement costs will continue to go up.
    The Home Improvement and Structural Alterations (HISA) grant is 
provided through local VA medical facilities and is often critical to 
allowing an injured veteran to leave the hospital setting and return 
home. The HISA grant allows these veterans to make basic modifications 
without having to tap into the benefit available through the Specially 
Adapted Housing grant. We certainly hope that Congress will give this 
quick and favorable consideration as it will particularly benefit the 
most severely disabled veterans.
H.R. 1546, the ``Caring for Veterans With Traumatic Brain Injury Act of 
                                 2009''
    PVA fully supports the provisions of H.R. 1546, the ``Caring for 
Veterans With Traumatic Brain Injury Act of 2009.''
    The RAND Corporation Center for Military Health Policy Research 
recently completed a comprehensive study titled Invisible Wounds of 
War: Psychological and Cognitive Injuries, Their Consequences, and 
Services To Assist Recovery. RAND found that the effects of TBI are 
still poorly understood, leaving a gap in knowledge related to how 
extensive the problem is or how to handle it. The study evaluated the 
prevalence of mental health and cognitive problems of Operation 
Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) servicemembers; 
the existing programs and services available to meet the health care 
needs of this population; the gaps that exist in these programs and 
what steps need to be taken to improve these services; and the costs of 
treating or not treating these conditions.
    According to RAND, 57 percent of those reporting a probable TBI had 
not been evaluated by a physician for brain injury. Military service 
personnel who sustain catastrophic physical injuries and suffer severe 
TBI are easily recognized, and the treatment regimen is well 
established. However, DoD and VA experts note that TBI can also be 
caused without any apparent physical injuries if a person is in the 
vicinity of powerful detonations and that signs and symptoms are often 
not readily recognized but can include chronic headache, irritability, 
behavioral disinhibition, sleep disorders, confusion, memory problems, 
and depression.
    Emerging literature (including the RAND study) strongly suggests 
that even mildly injured TBI patients may have long-term mental and 
physical health consequences. According to DoD and VA mental health 
experts, mild TBI can also produce behavioral manifestations that mimic 
PTSD or other mental health conditions. Additionally, TBI and PTSD can 
be coexisting conditions in one individual. Much is still unknown about 
the long-term impact of these injuries and the best treatment models to 
address mild-to-moderate TBI.
    On July 12, 2006, the VA Office of the Inspector General (OIG) 
issued Health Status of and Services for Operation Enduring Freedom/
Operation Iraqi Freedom Veterans after Traumatic Brain Injury 
Rehabilitation. The report found that better coordination of care 
between DoD and VA health care services was needed to enable veterans 
to make a smooth transition. The OIG Office of Health Care Inspections 
conducted follow on interviews to determine changes since the initial 
interviews were conducted in 2006. The OIG concluded that 3 years after 
completion of initial inpatient rehabilitation, many veterans with TBI 
continue to have significant disabilities and, although case management 
has improved, it is not uniformly provided to these patients.
    The creation of a Committee on Care of Veterans with Traumatic 
Brain Injury may help to improve this coordination and identify best 
practices for care for these injured warriors. However, Congress must 
be aggressive with its oversight to ensure that the Committee does not 
simply identify the issues, but works to implement them throughout the 
VA system.
          H.R. 1302, Director of Physician Assistant Services
    PVA supports H.R. 1302, a bill that would establish a position of 
Director of Physician Assistant Services. This legislation is 
consistent with a recommendation included in the FY 2010 edition of The 
Independent Budget.
    The Department of Veterans Affairs is the largest single Federal 
employer of physician assistants (PA), with approximately 1,800 full-
time PA positions, and has utilized PAs since 1969 when the profession 
started. However, once Congress enacted P.L. 106-419, the ``Veterans 
Benefits and Health Care Improvement Act of 2000,'' which directed that 
the Under Secretary for Health appoint a PA Advisor, the Veterans 
Health Administration (VHA) only assigned the PA position as a part-
time, field-based employee. Finally, in April 2008, VHA made the 
position a full-time employee, but the position is still field-based 
and often does not receive travel funding until late in the second 
quarter each year, resulting in missed opportunities to attend VHA 
meetings. It is time to establish a real, permanent staff PA at the VA 
to oversee these critical care providers.
    H.R. 1197, the ``Medal of Honor Health Care Equity Act of 2009''
    PVA strongly supports the provisions of H.R. 1197, the ``Medal of 
Honor Health Care Equity Act of 2009.'' It is clear that veterans who 
have been awarded our Nation's highest military award for valor should 
be afforded any and all benefits possible in recognition of their 
service.
H.R. 2722, the ``Veterans Nonprofit Research and Education Corporations 
                       Enhancement Act of 2009''
    PVA strongly supports the provisions of draft legislation regarding 
Nonprofit Research and Education Corporations. This bill should allow 
these corporations (also known as NPCs) to fulfill their full potential 
in supporting VA research and education, which ultimately results in 
improved treatments and high quality care for veterans, while ensuring 
VA and congressional confidence in NPC management.
    Since passage of P.L. 100-322 in 1988 (codified at 38 U.S.C. 
Sec. 7361-7368), the NPCs have served as an effective ``flexible 
funding mechanism for the conduct of approved research and education'' 
performed at VA medical centers across the nation. NPCs provide VA 
medical centers with the advantages of on-site administration of 
research by nonprofit organizations entirely dedicated to serving VA 
researchers and educators, but with the reassurance of VA oversight and 
regulation. During 2007, 85 NPCs received nearly $230 million and 
expended funds on behalf of approximately 5,000 research and education 
programs, all of which are subject to VA approval and are conducted in 
accordance with VA requirements.
    NPCs provide a full range of on-site research support services to 
VA investigators, including assistance preparing and submitting their 
research proposals; hiring lab technicians and study coordinators to 
work on projects; procuring supplies and equipment; monitoring the VA 
approvals; and a host of other services so the principal investigators 
can focus on their research and their veteran patients.
    Beyond administering research projects and education activities, 
when funds permit, these nonprofits also support a variety of VA 
research infrastructure expenses. For example, NPCs have renovated 
labs, purchased major pieces of equipment, staffed animal care 
facilities, funded recruitment of clinician-researchers, provided seed 
and bridge funding for investigators, and paid for training for 
compliance personnel.
    Although the authors of the original statute were remarkably 
successful in crafting a unique authority for VA medical centers, 
differing interpretations of the wording and the intent of Congress, 
gaps in NPC authorities that curtail their ability to fully support VA 
research and education, and evolution of VA health care delivery 
systems have made revision of the statute increasingly necessary in 
recent years. This draft legislation should allow the NPCs to better 
serve VA research and education programs while maintaining the high 
degree of oversight applied to these nonprofits.
    This legislation reinforces the idea of ``multi-medical center 
research corporations'' which provides for voluntary sharing of one NPC 
among two or more VA medical centers, while still preserving their 
fundamental nature as medical center-based organizations. Moreover, 
accountability will be ensured by requiring that at a minimum, the 
medical center director from each facility must serve on the NPC board. 
This authority will allow smaller NPCs to pool their administrative 
resources and to improve their ability to achieve the level of internal 
controls now required of nonprofit organizations.
    The legislation also clarifies the legal status of the NPCs as 
private sector, tax exempt organizations, subject to VA oversight and 
regulation. It also modernizes NPC funds acceptance and retention 
authorities as well as the ethics requirements applicable to officers, 
directors and employees and the qualifications for board membership. 
Moreover, it clarifies and broadens the VA's authority to guide 
expenditures.
    PVA has been a strong supporter of the NPCs since their inception, 
recognizing that they benefit veterans by increasing the resources 
available to support the VA research program and to educate VA health 
care professionals.
   Draft Legislation to Direct the Secretary of Veterans Affairs to 
     Provide Care for Certain Vietnam-era and Persian Gulf Veterans
    PVA fully supports the draft legislation that would require the VA 
to provide hospital care, medical services, and nursing home care for 
certain Vietnam-era veterans exposed to herbicide and veterans of the 
Persian Gulf War without expiration. These veterans have certainly 
earned this benefit through their dedicated service to this nation and 
due to the nature of the injuries and illness which they suffer.
      Draft Legislation to Address the Needs of Family Caregivers
               (H.R 2734, H.R. 2738, and Proposed Bills)
    PVA applauds the draft legislation to expand caregiver assistance 
opportunities. PVA actually believes that each of the four draft bills 
that take into consideration the needs of family caregivers should be 
combined into a single comprehensive bill as we believe that each of 
these bills have important aspects to address this issue. Particularly, 
we believe training and assistance is a critical aspect of supporting 
caregivers who care for veterans. We also applaud the fact that the 
legislation requires the Secretary to provide training through the use 
of the word ``shall'' instead of ``may.'' While seemingly a trivial 
concern, such language will ensure that the Secretary does not have the 
option of reducing these services if VA is faced with the budget 
challenges that inevitably will occur.
    As the veteran community is aware, family caregivers also provide 
mental health support for veterans dealing with the emotional, 
psychological, and physical effects of combat. Many PVA members with 
spinal cord injury also have a range of co-morbid mental illnesses; 
therefore, we know that family counseling and condition specific 
education is fundamental to the successful reintegration of the veteran 
into society. Providing education and training to family caregivers 
will pay dividends in care well beyond any costs associated with the 
program.
    The aspects of personal independence and quality care are of 
particular importance to veterans with spinal cord injury/dysfunction. 
Paralyzed Veterans has over 60 years of experience understanding the 
complex needs of spouses, family members, friends, and personal care 
attendants that love and care for veterans with lifelong medical 
conditions. These veterans need the health care expertise and care from 
a health team comprised of medical professionals, mental health 
professionals, and caregivers. As a part of the health care team, 
caregivers must receive ongoing support to provide quality care to the 
veteran. Legislation to provide these services is critically needed. 
But while the current draft text emphasizes ``interactive training 
session'' and ``Internet-based'' services, we want to ensure that this 
does not preclude VA from providing more effective ``in person 
training'' for those who may need it to provide the quality of care 
needed by veterans. The VA must also work to enforce and maintain an 
efficient case management system that assists veterans and family 
caregivers with medical benefits and family support services.
    A particular focus on respite care, mentioned in one of the draft 
bills, is also an important part of any comprehensive caregiver 
assistance legislation. Providing for the needs of catastrophically 
disabled veterans in particular can exact a heavy toll on the 
caregiver. Respite care allows that caregiver to ease the emotional, 
psychological, and physical burden for a period of time, and it ensures 
that the caregiver will maintain a real commitment to the disabled 
veteran and his or her needs.
    PVA has no objection to the legislation that would provide health 
care services to caregivers through the opening of CHAMPVA. In some 
cases, caregivers do not have other health care options available to 
meet their own needs, particularly if the provision of caregiver 
services is essentially their job. The draft legislation will remedy 
this significant concern that many caregivers have.
    There are approximately 44 million individuals across the United 
States that serve as caregivers on a daily basis. The contributions of 
caregivers in today's society are invaluable economically as they 
obviate the rising costs of traditional institutional care. The 
services rendered by caregivers are also priceless socially and 
emotionally, as they allow ailing and disabled veterans to live more 
independently and often in the comfort of their own homes with their 
friends and family. Unfortunately, VA can only estimate how many of 
these caregivers serve veterans. By conducting a survey of these 
valuable caregivers and the services they provide, VA can better 
estimate their impact and any associated costs to increase support to 
these individuals. Without this information, it will be difficult for 
VA to honestly provide recommendations on funding caregiver programs to 
the White House and Congress.
    Regarding travel expenses for family caregivers accompanying 
veterans to medical treatment facilities, PVA supports the draft 
legislation. As the Committee knows, many of our veterans returning 
from Operation Enduring Freedom and Operation Iraqi Freedom have 
significant disabling injuries including TBI. Many of these individuals 
require constant care. PVA appreciates the efforts of the Committee to 
ensure the travel expenses for these needed assistants are provided. We 
also understand and accept the VA's need to limit the number of 
attendants and use certain travel services, but we ask the Committee to 
use its oversight to ensure that regulations prescribed by VA are not 
so restrictive as to preclude family support activities.
    Our experience has shown that when the veteran's family unit is 
left out of the treatment plan, the veteran suffers with long 
reoccurring medical and social problems. However, when family is 
included in the health plan through services such as VA counseling and 
education services, veterans are more apt to become healthy, 
independent, and productive members of society.
    One disappointment that PVA would like to point out is the 
exclusion of any type of caregiver allowance from the draft bills being 
considered. Providing a financial benefit has been one of the important 
issues that we have advocated for in addressing caregiver issues. We 
hope that the Subcommittee will examine ways to incorporate this 
important idea in final legislation.
    Mr. Chairman and Members of the Subcommittee, PVA would once again 
like to thank you for the opportunity to provide our views on this 
important legislation. We look forward to working with you to continue 
to improve the health care services available to veterans. I would be 
happy to answer any questions that you might have.

                                 
             Prepared Statement of Robert A. Petzel, M.D.,
          Acting Principal Deputy Under Secretary for Health,
  Veterans Health Administration, U.S. Department of Veterans Affairs
    Good morning, Mr. Chairman and Members of the Subcommittee:
    Thank you for inviting me here today to present the 
Administration's views on 11 bills and drafts that would affect 
Department of Veterans Affairs (VA) programs that provide veterans 
benefits and services. With me today is Walter A. Hall, Assistant 
General Counsel. We appreciate the opportunity to discuss the bills on 
today's agenda, and are also pleased to support most of the proposed 
legislation. We believe that we could carry out the new authorities we 
are supporting within the funding levels proposed in the 2010 and 2011 
budget requests.
H.R. 1197--``Medal of Honor Health Care Equity Act of 2009''
    Mr. Chairman, the first bill on the agenda is H.R. 1197. This bill 
would amend 38 U.S.C. 1705 to give Medal of Honor recipients 
eligibility to receive VA medical care at the Priority 3 level. VA 
supports H.R. 1197. We estimate the increased cost to be insignificant 
and can be funded within existing funding levels.
H.R. 1293--``Disabled Veterans Home Improvement and Structural 
        Alteration Grant Increase Act of 2009''
    VA also supports H.R. 1293 which would increase the amount 
available to disabled veterans for home improvements and structural 
alterations (HISA) furnished as part of home health services. This bill 
represents the first increase in the HISA grant rate in 17 years. VA 
also recommends to the Chairman that the Subcommittee increase the rate 
periodically so that the grant amount keeps pace with the rate of 
inflation and the rising cost of materials and installation. We 
estimate the cost for H.R. 1293 to be $5.8 million in FY 2010, $5.9 
million in FY 2011, $29.8 million over 5 years, and $61.4 million over 
10 years. VA will provide a cost estimate to the Subcommittee for the 
record that assumes the additional cost of increasing the payments with 
inflation.
    The Veterans Benefits Administration offers the Specially Adapted 
Housing (SAH) and Special Housing Adaptations (SHA) grants, which are 
distinct from HISA grants administered through the Veterans Health 
Administration. With a cap of $60,000, the SAH grant is the largest and 
is for the most severely, service-connected, disabled veterans and 
servicemembers entitled to compensation for permanent and total 
disability due to:

      The loss or loss of use of both lower extremities, such 
as to preclude locomotion without the aid of braces, crutches, canes, 
or a wheelchair;
      Blindness in both eyes, having only light perception, 
plus loss or loss of use of one lower extremity;
      The loss or loss of use of one lower extremity together 
with (1) residuals of organic disease or injury, or (2) the loss or 
loss of use of one upper extremity, which so affect the functions of 
balance or propulsion as to preclude locomotion without the aid of 
braces, crutches, canes, or a wheelchair;
      The loss or loss of use of both upper extremities such as 
to preclude use of the arms at or above the elbows; or
      A severe burn injury.

    SHA grant is the next largest at $12,000 and is for veterans and 
servicemembers who are entitled to disability compensation for 
permanent and total service-connected disability that:

      Includes loss or loss of use of both hands;
      Is due to Blindness in both eyes with 5/200 visual acuity 
or less; or
      Is due to a severe burn injury.

    HISA grants are the only grants available for nonservice-connected 
veterans and conditions (currently limited to $1,200). An increased 
amount is available for service-connected veterans (currently $4,100). 
Although not required, the HISA grant can be used in conjunction with 
the SAH or SHA grant to help cover some of the additional costs a 
veteran may be facing when building or adapting a home to meet his/her 
unique needs. The HISA grant may be a stand alone project for veterans 
who are also receiving the SAH/SHA grant, or in most cases, used by 
veterans who are not eligible for the SAH or SHA grants.
    In October, the SAH and SHA grant amounts will be linked to a new 
cost-of-construction index that will adjust annually for inflation. 
Conversely, the HISA amounts have not been increased in several years 
and have not kept up with inflation. The proposed legislation serves to 
increase the amount available to veterans who are not covered by the 
SAH and SHA grants to make some modifications to their homes to 
accommodate their various disabilities. Those who are eligible for the 
SAH and SHA grant are our most severely injured, service-connected 
veterans, and these additional funds supporting modification or 
construction of their home is justified.
H.R. 1302--``To Establish a Director of Physician Assistant Services''
    H.R. 1302 would eliminate the Physician Assistant (PA) Advisor 
position established by Public Law 106-419, the Veterans Benefits and 
Health Care Improvement Act of 2000, and establish a Director of 
Physician Assistant (PA) Services within the Office of the Under 
Secretary for Health. VA does not support this bill.
    The functions of the proposed Director of PA Services are already 
being performed by the PA Advisor. Moreover, the PA Advisor position 
was converted to full-time on April 14, 2008, and it will be based in 
VA Central Office at the expiration of the current incumbent's term in 
April 2010.
    In addition, VA does not support the proposed organizational 
realignment of the Director of PA Services to the Office of the Under 
Secretary for Health. The position's current alignment within the 
Office of Patient Care Services is consistent with all other clinical 
program leadership positions and provides the PA Advisor access to the 
Under Secretary for Health for any issues that cannot be resolved 
within the current structure. Moreover, such a realignment would create 
a disparity and an artificial distinction between physician assistants 
and nurse practitioners. This situation could result in unnecessary 
friction or tension between these two categories of employees. The cost 
of implementing this bill is insignificant.
H.R. 1335--``Prohibition on Collection of Certain Co-payments''
    H.R. 1335 would amend 38 U.S.C. 1710 to prohibit a veteran who is 
catastrophically disabled from making any payment for the receipt of 
hospital care or nursing home care provided pursuant to that section.
    VA supports this proposal; however, we note it is unclear if this 
proposal is intended to eliminate nursing home care co-payments since 
the legislation refers only to section 1710 of title 38 and authority 
for nursing home care falls under 38 U.S.C. 1710A. We believe any co-
payment requirements under this section would remain in place. We 
further note that the bill does not address pharmacy co-payments. The 
projected cost would be about $2.6 million for FY 2010 and 2011, $13.3 
million over 5 years, and $28 million over 10 years. VA will provide a 
cost estimate to the Subcommittee for the record that assumes the 
legislation eliminates all co-payments for this population.
H.R. 1546--``Caring for Veterans with Traumatic Brain Injury''
    VA also supports H.R. 1546, which would establish a committee on 
the Care of Veterans with Traumatic Brain Injury to evaluate the care 
provided to veterans, identify problems in caring for such veterans, 
identify successful models of treatment, and advise the Secretary 
accordingly. The committee would be comprised of VA employees. The cost 
of this bill would be insignificant and can be absorbed within existing 
funding levels.
H.R. 2722--``Veterans Nonprofit Research and Education Corporation 
        Enhancement Act of 2009''
    H.R. 2722 would update the law applicable to VA's nonprofit 
research and education corporations (corporations). VA-affiliated 
nonprofit research corporations are critical to VA's overall research 
program because they provide flexible funding mechanisms for the 
administration of non-VA funds for the conduct of VA-approved research.
    A key provision of this bill would authorize a single corporation 
to facilitate the conduct of research and education at more than one VA 
medical center. H.R. 2722 would also make it clear that corporations 
may reimburse a VA laboratory for the preliminary costs it incurs 
before a research project has been officially approved by the 
Secretary. VA would also be authorized to reimburse corporations for 
costs incurred for the assignment of corporation employees to VA under 
the Intergovernmental Personnel Act of 1970 (IPA). This would ensure 
that, in this respect, corporations are treated like any other 
qualified nonprofit corporations under the IPA.
    Additionally, this bill would clarify that corporations may set 
fees for certain education and training programs they administer and 
retain those funds to offset program expenses. The legal prohibition on 
a corporation accepting fees derived from VA appropriations would 
remain.
    VA fully supports H.R. 2722. The authority to establish multi-
medical center research corporations would significantly advance VA 
research activities. Currently a corporation is established in only one 
medical center and can provide support as a flexible-funding mechanism 
for that facility. Small VA research programs that are currently unable 
to support the existence of a corporation at their facility would be 
able to obtain needed support from a multi-medical center research 
corporation. While providing the authority for this expanded utility of 
the nonprofit corporations, the bill would, nonetheless, ensure that 
all medical centers involved in a multi-medical center arrangement 
maintain a voice on the board of directors of the research corporation.
    The utility of the corporations to VA would also be increased by 
permitting them to reimburse the Department for research planning costs 
that are necessarily incurred prior to approval of a research project 
by VA. Currently corporations are prohibited from funding research 
projects that are not officially approved by VA. As a result, VA 
laboratories are responsible for the preliminary costs of any research 
project before it is officially approved, and they bear those costs 
entirely for projects that are ultimately disapproved. This paradigm 
creates a financial disincentive for VA laboratories to initiate 
research and a chilling effect on the conduct of innovative VA 
research. The bill would appropriately solve this problem.
    VA does have one technical concern with H.R. 2722. Section 7 of the 
bill attempts to rectify an impracticable extension of the criminal 
conflicts of interest laws to non-Government employees working for a 
non-Government employer. The proposed revisions to 38 U.S.C. 7366 
remove the words ``laws and,'' effectively subjecting covered persons 
to only the Federal ethics regulations. However, the Federal ethics 
regulations are also unenforceable in the NPC context. VA recommends 
replacing the current language in section 7366 with a new provision 
requiring all NPCs to adopt an enforceable code of conduct, reviewable 
by the VA, which prohibits conflicts of interest.
    There would be no costs associated with enactment of the H.R. 2722.
H.R. 2734--``Health Care for Family Caregivers Act of 2009''
    H.R. 2734 would amend 38 U.S.C. 1781 to medical care under Civilian 
Health and Medical Program of the Department of Veterans Affairs 
(CHAMPVA) to family caregivers who serve as the ``primary family 
caregiver'' for veterans receiving compensation under 38 U.S.C. 1114(r) 
or (s) and who have no entitlement to care or services under certain 
health-plan contracts. In addition, these family caregivers would not 
be subject to deductibles, premiums, co-payments, cost-sharing, or 
other fees for medical care. The bill would also amend 38 U.S.C. 1701 
to define the term caregiver services and the term family caregiver. 
The term family caregiver is defined as members of the disabled 
veteran's family (including parents, spouses, children, siblings, step-
family members, and extended family members) who provide caregiver 
services to the veteran for their disability.
    VA would like to address the Subcommittee's specific questions 
regarding CHAMPVA. Currently, VA has the authority to provide medical 
care for the survivors and dependents of certain veterans through 
CHAMPVA. In Fiscal Year (FY) 2008, approximately 317,000 beneficiaries 
were enrolled in CHAMPVA, and VA projects this number will increase to 
329,000 in FY 2009. Approximately 17 percent of CHAMPVA beneficiaries 
are under 23 years of age (approximately 54,000 children) and 83 
percent are over 23 years of age (approximately 263,000 spouses or 
surviving spouses). In FY 2009, these numbers are expected to increase 
to 56,000 children and 273,000 spouses or surviving spouses. In FY 
2008, just over 219,000 enrollees used CHAMPVA. Approximately 63,000 of 
these users were survivors of veterans, and about 156,000 receive 
benefits with a living veteran. In FY 2009, VA anticipates 230,000 
total users, 68,500 of whom will be survivors of a veteran and 161,500 
who will receive benefits with a living veteran.
    VA shares the Committee's desire to enhance the level of VA support 
provided to caregivers. To that end, the Department is currently 
undertaking a comprehensive review of existing benefits to determine 
potential gaps. We would like to ask that the Committee defer action on 
this bill until our work is complete. In addition, we would like to 
note a few immediate concerns with this bill. First, the legislation 
would authorize the primary family caregivers to receive care as 
CHAMPVA beneficiaries. CHAMPVA is a cost-sharing program. VA is 
concerned the bill specifies family caregivers would not be subject to 
the same deductibles, premiums, co-payments, cost-sharing, or other 
fees for medical care that are applicable to the existing population. 
Second, there is no scope or limitation to this benefit. If a veteran 
died or no longer needed caregiver services, the legislation as written 
would allow this individual to continue receiving benefits for the 
course of his or her lifetime. Third, the legislation provides 
eligibility to those veterans who receive special monthly compensation 
(SMC) under subsection (r) or (s) of section 1114 of title 38, some of 
who may not need caregiver support. The legislation as written would 
extend benefits to some veterans without clinical need. We anticipate 
the costs of this provision would be $261 million in FY 2010, $1.59 
billion over 5 years and a 10 year total of $3.8 billion.
H.R. 2738--``Travel Expenses for Family Caregivers Accompanying 
        Veterans to Medical Treatment Facilities''
    H.R. 2738 would amend 38 U.S.C. 111, which authorizes payments for 
certain beneficiaries' travel, to clarify that an attendant includes a 
family caregiver. Furthermore, it would make clear that the expenses of 
attendant travel include lodging and subsistence for the period of time 
a qualified person is traveling to and from a treatment facility as 
well as during the treatment episode for such person. In addition, the 
bill would amend 38 U.S.C. 1701 to define the term caregiver services 
and the term family caregiver. The term family caregiver in this draft 
is limited to members of the disabled veteran's family (including 
parents, spouses, children, siblings, step-family members, and extended 
family members) who provide caregiver services to the veteran for their 
disability. However, VA notes only those attendants who would otherwise 
be eligible under VA's beneficiary travel authority would qualify. If a 
veteran is not eligible for attendant benefits under VA's existing 
authority, his or her caregiver would not be eligible to receive the 
benefits available under this legislation.
    VA shares the Committee's desire to enhance the level of VA support 
provided to caregivers. As stated above, the Department is currently 
undertaking a comprehensive review of existing benefits to determine 
potential gaps. We would like to ask that the Committee defer action on 
this bill until our work is complete. The projected cost of this 
provision would be $314 million in FY 2010, $1.8 billion over 5 years, 
and $4.3 billion over 10 years.
Discussion Draft 1: Provision of Care and Services for Certain Veterans 
        Exposed to Herbicide and Veterans of the Persian Gulf War
    VA supports the draft bill to provide, without expiration, hospital 
care, medical services, and nursing home care for certain Vietnam-era 
veterans exposed to herbicide and for veterans of the Persian Gulf War, 
notwithstanding that there is insufficient medical evidence to conclude 
their disability is associated with their service. This legislation 
would restore statutory eligibility for care that existed from 1981 to 
2002. Since VA has continued to provide care under this authority, 
there are no additional costs associated with this bill.
    The Department cannot comment on the remaining discussion draft 
bills at this time. We will submit our views and cost estimates at a 
later date.
    Mr. Chairman, this concludes my prepared statement. I would be 
pleased to answer any questions you or any of the Members of the 
Subcommittee may have.

                                 
     Prepared Statement of American Academy of Physician Assistants
    On behalf of the more than 75,000 clinically practicing physician 
assistants (PAs) in the United States, the American Academy of 
Physician Assistants (AAPA) is pleased to submit comments in support of 
H.R. 1302, a bill to amend title 38, United States Code, to establish 
the position of Director of Physician Assistant Services within the 
office of the Under Secretary of Veterans Affairs for Health. The AAPA 
is very appreciative of Representatives Phil Hare and Jerry Moran for 
their leadership in introducing this important legislation. The Academy 
also wishes to thank Chairman Michaud, Chairman Filner, Ranking Member 
Buyer, and other Members of the Subcommittee and Committee for co-
sponsoring H.R. 1302.
    AAPA believes that enactment of H.R. 1302 is essential to improving 
patient care for our Nation's veterans, ensuring that the more than 
1,800 PAs employed by the VA are fully utilized and removing 
unnecessary restrictions on the ability of PAs to provide medical care 
in VA facilities. Additionally, the Academy believes that enactment of 
H.R. 1302 is necessary to advance recruitment and retention of PAs 
within the Department of Veterans Affairs.
    Physician assistants are licensed health professionals, or in the 
case of those employed by the Federal Government, credentialed health 
professionals, who----

      practice medicine as a team with their supervising 
physicians
      exercise autonomy in medical decisionmaking
      provide a comprehensive range of diagnostic and 
therapeutic services, including performing physical exams, taking 
patient histories, ordering and interpreting laboratory tests, 
diagnosing and treating illnesses, suturing lacerations, assisting in 
surgery, writing prescriptions, and providing patient education and 
counseling
      may also work in educational, research, and 
administrative settings.

    Physician assistants' educational preparation is based on the 
medical model. PAs practice medicine as delegated by and with the 
supervision of a physician. Physicians may delegate to PAs those 
medical duties that are within the physician's scope of practice and 
the PA's training and experience, and are allowed by law. A physician 
assistant provides health care services that were traditionally only 
performed by a physician. All States, the District of Columbia, and 
Guam authorize physicians to delegate prescriptive privileges to the 
PAs they supervise. AAPA estimates that in 2008, over 257 million 
patient visits were made to PAs and approximately 332 million 
medications were prescribed or recommended by PAs.
    The PA profession has a unique relationship with veterans. The 
first physician assistants to graduate from PA educational programs 
were veterans, former medical corpsmen who had served in Vietnam and 
wanted to use their medical knowledge and experience in civilian life. 
Dr. Eugene Stead of the Duke University Medical Center in North 
Carolina put together the first class of PAs in 1965, selecting Navy 
corpsmen who had considerable medical training during their military 
experience as his students. Dr. Stead based the curriculum of the PA 
program in part on his knowledge of the fast-track training of doctors 
during World War II. Today, there are 142 accredited PA educational 
programs across the United States. More than 1,800 PAs are employed by 
the Department of Veterans Affairs, making the VA the largest single 
employer of physician assistants. These PAs work in a wide variety of 
medical centers and outpatient clinics, providing medical care to 
thousands of veterans each year. Many are veterans themselves.
    Physician assistants (PAs) are fully integrated into the health 
care systems of the Armed Services and virtually all other public and 
private health care systems. PAs are on the front line in Iraq and 
Afghanistan, providing immediate medical care for wounded men and women 
of the Armed Forces. PAs are covered providers in TRICARE. In the 
civilian world, PAs work in virtually every area of medicine and 
surgery and are covered providers within the overwhelming majority of 
public and private health insurance plans. PAs play a key role in 
providing medical care in medically underserved communities. In some 
rural communities, a PA is the only health care professional available.
    Why are PAs so fully integrated into most public and private health 
care systems? We believe it's because they foster the use and inclusion 
of their PA workforce. Each branch of the Armed Services designates a 
PA Consultant to the Surgeon General. And, many major medical 
institutions credit their integration of PAs in the workforce to a 
Director of PA Services. To name just a few, the Cleveland Clinic, the 
Mayo Clinic, the University of Texas MD Anderson Cancer Center, and New 
Orleans' Ochsner Clinic Foundation all have Directors of PA Services. 
We believe that what works for the Armed Services and the private 
sector will also work for the VA.
    How does the lack of a Director of PA Services at the VA relate to 
recruitment and retention of the VA workforce? As far as the AAPA can 
tell, there are no recruitment and retention efforts aimed toward 
employment of physician assistants in the VA. The VA designates 
physicians and nurses as critical occupations, and so priority in 
scholarships and loan repayment programs goes to nurses, nurse 
practitioners, physicians, and other professions designated as critical 
occupations. The PA profession has not been determined to be a critical 
occupation at the VA, so moneys are not targeted for their recruitment 
and retention. PAs are not included in any of the VA special locality 
pay bands, so PA salaries are not regularly tracked and reported by the 
VA. We've been told that this has resulted in lower pay for PAs 
employed by the VA than for health care professionals who perform 
similar medical care. Why are PAs not considered a critical occupation 
at the VA? Is it possible they were overlooked, because there was no 
one to raise the issue?
    The outlook for PA employment at the VA does not differ from that 
for nurse practitioners and physicians. Approximately 40 percent of PAs 
currently employed by the VA are eligible for retirement in the next 5 
years, and the VA is simply not competitive with the private sector for 
new PA graduates. The U.S. Bureau of Labor Statistics, U.S. News and 
World Report, and Money magazine all speak to the growth, demand, and 
value of the PA profession. The challenge for the VA is that the growth 
and demand for PAs is in the private sector, not the VA.
    According to the AAPA's 2008 Census Report, PA employment in the 
Federal Government, including the VA, continues to decline. AAPA's 
Annual Census Reports of the PA Profession from 1991 to 2008 document 
an overall decline in the number of PAs who report Federal Government 
employment. In 1991, nearly 22 percent of the total profession was 
employed by the Federal Government. This percentage dropped to 
approximately 9 percent in 2008. New graduate census respondents were 
even less likely to be employed by the government (17 percent in 1991 
down to 5 percent in 2008).
    Unless some attention is directed toward recruitment and retention 
for PAs, the AAPA believes that the VA is in danger of losing its PA 
workforce. This is particularly critical because it is happening at a 
time when the U.S. and the VA are facing a primary care workforce 
shortage. The elevation of the PA Advisor to a full-time Director of PA 
Services in the VA Central Office is the first step in focusing the 
VA's efforts on recruitment and retention of PAs.
    The current position of Physician Assistant (PA) Advisor to the 
Under Secretary for Health was authorized through section 206 of P.L. 
106-419 and has been filled as a part-time, field position. Prior to 
that time, the VA had never had a representative within the Veterans 
Health Administration with sufficient knowledge of the PA profession to 
advise the Administration on the optimal utilization of PAs. This lack 
of knowledge resulted in an inconsistent approach toward PA practice, 
unnecessary restrictions on the ability of VA physicians to effectively 
utilize PAs, and an underutilization of PA skills and abilities. The PA 
profession's scope of practice was not uniformly understood in all VA 
medical facilities and clinics, and unnecessary confusion existed 
regarding such issues as privileging, supervision, and physician 
countersignature.
    Although the PAs who have served as the VA's part-time, field-based 
PA Advisor have made progress on the utilization of PAs within the 
agency, there continues to be inconsistency in the way that local 
medical facilities use PAs. In one case, a local facility decided that 
a PA could not write outpatient prescriptions, despite licensure in the 
State allowing prescriptive authority. In other facilities, PAs are 
told that the VA facility can not use PAs and will not hire PAs. These 
restrictions hinder PA employment within the VA, as well as deprive 
veterans of the skills and medical care PAs have to offer.
    The Academy also believes that the elevation of the PA Advisor to a 
full-time Director of Physician Assistant Services, located in the VA 
central office, is necessary to increase veterans' access to quality 
medical care by ensuring efficient utilization of the VA's PA workforce 
in the Veterans Health Administration's patient care programs and 
initiatives. PAs are key members of the Armed Services' medical teams 
but are an underutilized resource in the transition from active duty to 
veterans' health care. As health care professionals with a longstanding 
history of providing care in medically underserved communities, PAs may 
also provide an invaluable link in enabling veterans who live in 
underserved communities to receive timely access to quality medical 
care.
    Thank you for the opportunity to submit a statement for the hearing 
record in support of H.R. 1302. AAPA is eager to work with the House 
Committee on Veterans Affairs Subcommittee on Health to improve the 
availability and quality of medical care to our Nation's veteran 
population.

                                 
        Prepared Statement of Joseph L. Wilson, Deputy Director,
    Veterans Affairs and Rehabilitation Commission, American Legion
    Mr. Chairman and Members of the Subcommittee:
    Thank you for this opportunity to submit The American Legion's 
views on these various pieces of legislation: H.R. 2722; H.R. 1197; 
H.R. 1293; H.R. 1302; H.R. 1335; H.R. 1546; H.R. 2734; H.R. 2738; and 
Draft Discussions on Extending Health Care to Vietnam-era Veterans 
Exposed to Herbicides and Gulf War Era Veterans; Providing Supportive 
Services for Family Caregivers Accompanying the Veteran on Visits to 
VA; and Requiring the Department of Veterans Affairs (VA) to Collect 
Survey Data on Family Caregivers.
H.R. 2722
    This bill seeks to amend title 38, United States Code (U.S.C.), to 
modify and update provisions of law relating to nonprofit research and 
education corporations, and for other purposes.
    The American Legion has no official position on this piece of 
legislation.
H.R. 1197
    This bill seeks to assign priority status for hospital care and 
medical services provided through the Department of Veterans Affairs 
(VA) to certain veterans who are recipients of the Medal of Honor.
    The Medal of Honor is the highest military decoration awarded to a 
member of the United States Armed Forces. The recipients have earned 
this award by displaying heroism and bravery while risking their lives 
during service to this great Nation.
    In addition to supporting H.R. 1197, The American Legion would 
support legislation to place Medal of Honor recipients in Priority 
Group 1 for VA health care.
H.R. 1293
    This bill seeks to amend title 38, U.S.C., to improve the quality 
of care provided to veterans in VA medical facilities, to encourage 
highly qualified doctors to serve in hard-to-fill positions in such 
medical facilities, and for other purposes.
    The American Legion supports legislation that seeks to improve the 
quality of care for veterans, to include medical and structural 
accommodations that also improve quality of life. The American Legion 
feels section 2c of H.R. 1293 is unclear and thereby requests 
clarification.
H.R. 1302
    This bill seeks to amend title 38, U.S.C., to establish the 
position of Director of Physician Assistant Services within the office 
of the Under Secretary of Veterans Affairs for Health.
    The American Legion supports legislation to establish Director of 
Physician Assistant (PA) services in the Department of Veterans Affairs 
(VA). It is The American Legion's contention that the elevation of the 
current position of PA Advisor to Director is a necessity to increase 
veterans' access to quality medical care by ensuring efficient 
utilization of the programs and initiatives.
    The American Legion urges Congress to act on the matter immediately 
to ensure the approximately 2,000 PAs within VA have sufficient and 
full-time representation at the policy level.
H.R. 1335
    This bill seeks to amend title 38, U.S.C., to prohibit the 
Secretary of Veterans Affairs from collecting certain co-payments from 
veterans who are catastrophically disabled.
    The American Legion supports this piece of legislation.
H.R. 1546
    This bill seeks to amend title 38, U.S.C., to direct the Secretary 
of Veterans Affairs to establish the Committee on Care of Veterans with 
Traumatic Brain Injury (TBI).
    It is The American Legion's position that TBI is usually 
accompanied by various injuries to include Post Traumatic Stress 
Disorder (PTSD). We also contend that policies supporting care for this 
``Signature Wound'' must be implemented and communicated from the 
policy level to the field. The American Legion supports this piece of 
legislation.
H.R. 2734
    This bill seeks to amend section 1781 of title 38, U.S.C., to 
provide medical care to family members of disabled veterans who serve 
as caregivers to such veterans.
    The American Legion supports any legislation that accommodates 
those who care for this Nation's veterans.
H.R. 2738
    This bill seeks to amend title 38, U.S.C., to provide travel 
expenses for family caregivers accompanying veterans to medical 
treatment facilities.
    The American Legion supports any legislation that accommodates 
those who care for this Nation's veterans. Veterans who injure 
themselves while serving this great Nation are entitled to all that 
places them in the best of care. We also contend that expenses and 
support should be provided by VA to all who participate in care for the 
veteran.
Draft Discussion on Extending Health Care to Vietnam Era Herbicide 
        Exposed Veterans and Gulf-War Era Veterans
    The American Legion believes adequate and quality care should be 
provided for those who sustained illnesses and injuries while serving 
honorably. We also believe such discussion should be implemented 
expeditiously as there is no pause button for this Nation's veterans. 
As time progresses, so does the extent of pain of our Nation's 
veterans.
    The American Legion reaffirms its support for Vietnam veterans with 
Agent Orange exposure in VA Priority Group 6 for VA health care. The 
American Legion also supports legislation to give VA the authority to 
include ill Gulf War veterans in Priority Group 6 for VA health care.
    The American Legion supports the measures outlined in this bill 
which would provide health care, medical services and nursing home care 
for certain Vietnam era veterans exposed to herbicide and veterans of 
the Persian Gulf War.
Draft Discussion on Providing Supportive Services for Family Caregivers
    The American Legion supports legislation that adequately provides 
for those who are unselfishly caring for our Nation's veterans and 
believes such legislation should be implemented immediately.
Draft Discussion on Requiring VA to Collect Data on Family Caregivers 
        of Veterans Through Surveys
    It is The American Legion's position that the Department of 
Veterans Affairs maintains a database of those who are caring for this 
Nation's veterans. Collecting such data is only part of the 
accountability process. It's also imperative that VA, upon collecting 
this data, accurately assess services rendered and compensate 
caregivers adequately.
Conclusion
    Mr. Chairman and Members of the Subcommittee, The American Legion 
sincerely appreciates the opportunity to submit testimony on the above 
mentioned pieces of legislation and looks forward to working with you 
and your colleagues on these very important issues. Thank you.

                                 
                Prepared Statement of Hon. Steve Buyer,
       Ranking Republican Member, Committee on Veterans' Affairs,
       and a Representative in Congress from the State of Indiana
    On March 4, 2009, I introduced H.R. 1293, the Disabled Veterans 
Home Improvement and Structural Alteration Grant Increase Act of 2009. 
This bill would provide an increase in the amount payable to veterans 
under the Department of Veterans Affairs (VA) Home Improvement and 
Structural Alteration Program.
    Known as the HISA program, this important VA benefit provides 
grants to veterans who require home adaptations to provide access to 
in-home medical care.
    Typically, HISA grants are used for such things as widening doors; 
putting in handrails or special lighting; making kitchens, bathrooms, 
windows, or electrical outlets and switches more accessible; building 
ramps or improving entrance paths and driveways.
    The benefit is paid from the medical care appropriation and is 
available to both veterans with service-connected and non-service 
connected disabilities. A service-connected veteran can receive a HISA 
grant in addition to other home adaptations grants available through 
the Veterans Benefits Administration.
    Congress first authorized VA to establish the HISA program as part 
of outpatient care for home health services in 1973. We have been 
engaged in the Global War on Terror for nearly 8 years and are seeing 
an increasing number of servicemembers returning from Iraq and 
Afghanistan utilizing VA health care. It is especially important that 
this program remains relevant and can meet the needs of our newest 
generation of veterans.
    The current maximum amount of a HISA grant is $4,100 for service-
connected veterans and $1,200 for non-service connected veterans. This 
amount was established by Congress in 1992 and has not been raised in 
17 years.
    My bill would increase the maximum amount of a grant to $6,800 for 
service-connected veterans and $2,000 for non-service connected 
veterans. This is a 66 percent increase. It would reflect a 3 percent 
increase for each year since 1992 to account for inflation and the 
increased cost of home modifications.
    This increase is long overdue, and I urge my colleagues to support 
this legislation. It would have a direct and immediate impact on 
improving health care and the quality of life for our disabled 
veterans.

                                 
                   Prepared Statement of Joy J. Ilem
    Deputy National Legislative Director, Disabled American Veterans
    Mr. Chairman and other Members of the Subcommittee:
    Thank you for inviting the Disabled American Veterans (DAV) to 
testify at this legislative hearing of the Subcommittee on Health. We 
appreciate the Subcommittee's leadership in enhancing Department of 
Veterans Affairs (VA) health care programs on which many service-
connected disabled veterans must rely, and we also appreciate the 
opportunity to offer our views on the eight bills and three draft 
measures under consideration by the Subcommittee today.
        H.R. 1197--Medal of Honor Health Care Equity Act of 2009
    This bill would assign a higher priority status to Medal of Honor 
recipients for VA medical services and hospital care, by virtue of 
their extraordinary service to our country.
    Mr. Chairman, our Nation owes a tremendous debt to the individuals 
awarded the Medal of Honor. As of June 2009, only 96 recipients of this 
medal are still living. The Medal of Honor is the highest military 
award for valor in action against an enemy of the United States. This 
bill would uphold our Nation's commitment to these select few by 
conveying to them a higher enrollment priority status for access to VA 
hospital care and medical services. While the DAV has no national 
resolution from our membership that endorses this particular 
legislation, we would offer no objection to its enactment and we 
appreciate the effort being made on behalf of these extraordinary 
heroes.
H.R. 1293--Disabled Veterans Home Improvement and Structural Alteration 
                       Grant Increase Act of 2009
    This bill is intended to increase VA payments for improvements and 
structural alterations furnished as part of home health services to 
severely disabled veterans enrolled in VA health care. This bill would 
increase the amount payable to service-connected veterans from $4,100 
to $6,800, and for nonservice-connected veterans from $1,200 to $2,000.
    Structural alterations to homes enable the chronically sick and 
disabled to remain in their homes rather than be institutionalized at 
much higher overall cost to the government. The existing payment 
limitations have not been increased for many years, and unless the 
amounts of these grants are periodically adjusted, inflation erodes 
these benefits. The Independent Budget (IB) for fiscal year (FY) 2010 
recommends doubling the existing grant rate of payment in the case of 
service-connected veterans residing temporarily in homes owned by 
others and this similar proposed rate increase is fully consistent with 
our concerns as expressed therein. This measure would be beneficial to 
severely disabled veterans; therefore, we support the purposes of this 
bill and urge its enactment. Additionally, given that the rate has 
remained stagnant for so many years, we also ask the Subcommittee to 
consider amending the bill to include a periodic index to enable this 
rate to be adjusted from time to by the administration to reflect 
inflation in construction costs.
H.R. 1302--To establish the position of Director of Physician Assistant 
 Services Within the Office of the Under Secretary of Veterans Affairs 
                               for Health
    This measure would amend title 38, United States Code, section 
7306(a) to require the current position of Director of Physician 
Assistant Services within the office of the Under Secretary of Veterans 
Affairs for Health to serve in a full-time capacity at the Central 
Office of the Department. The bill would require the individual who 
serves in this position to encumber the full-time position in VA 
Central Office not later than 120 days after the date of enactment.
    The VA is the largest Federal employer of physician assistants 
(PAs), with approximately 1,800 full-time PA positions. In the VA 
health care system, PAs are essential primary care providers literally 
in millions of outpatient and inpatient encounters working in 
ambulatory care clinics, emergency medicine and 22 other VA medical and 
surgical subspecialties.
    When the position of PA Advisor was created in 2000, as authorized 
by the Veterans Benefits and Health Care Improvement Act of 2000, the 
position consisted of collateral administrative duties added to a 
field-based PA Advisor's direct patient care responsibilities. In April 
2008, the PA Advisor function was finally converted to a full-time 
position, but the incumbent continues to be field-based at a VA health 
care facility, rather than located at the VA Central Office.
    DAV and the other veteran service organizations that produce the IB 
have urged that this position be made full-time within Veterans Health 
Administration (VHA) headquarters. This would allow for:

      an increase in scope of PA-specific clinical and human 
resources policy issues;
      the opportunity to participate in major health care VA 
strategic planning Committees and functions; and
      inclusion in aspects of planning on seamless transition, 
polytrauma centers, traumatic brain injury staffing and the work of the 
newly established Office of Rural Health Care.

    Additionally, PAs could assist in emergency disaster planning since 
34 percent of all VA-employed PAs are veterans or currently serve in 
the military reserves.
    In addition to supporting this bill, we urge that this occupation 
be included in any recruitment and retention legislation the 
Subcommittee reports because, by 2012, it is projected that 28 percent 
of the VA PA workforce will be eligible for retirement. In our opinion, 
passage of this bill to require the PA Advisor to be located in VA 
Central Office on a full-time basis, would be a good start in 
addressing some of these challenges. Although we do not have a specific 
resolution in support of this measure, the bill is consistent with 
recommendations outlined in the FY 2010 IB and would help to ensure 
access to high quality health care services for veterans using the VA 
health care system. Therefore, DAV supports this bill and urges its 
enactment.
     H.R. 1335--To Prohibit the Secretary of Veterans Affairs From 
 Collecting Certain Co-payments From Veterans Who Are Catastrophically 
                                Disabled
    This bill would prohibit the Secretary of Veterans Affairs from 
collecting co-payments from catastrophically disabled veterans in 
receipt of VA hospital or nursing home care.
    Mr. Chairman, thousands of veterans survive catastrophic traumas in 
civilian life. Some of them have been able to overcome the tremendous 
challenges imposed on them by accidents or disease and have been able 
to rejoin the workforce and be productive, taxpaying citizens. We 
believe that catastrophically injured veterans should not face the 
double jeopardy of disability and an additional financial penalty of 
paying VA co-payments in order to access VA health care and services 
for which they are fully eligible. These veterans, many wheelchair-
bound and spinal-cord injured, already spend thousands of dollars 
annually on health-related supports and services (such as personal 
attendants, adapted housing and automobiles, special equipment, etc.) 
that able-bodied veterans do not need to bear, or even consider. If a 
catastrophically ill or spinal-cord injured veteran succeeds in the 
daunting personal quest to remain in, or re-join, the labor force, we 
believe where possible the government should provide that veteran 
proper incentives to remain employed. Setting aside co-payments would 
be one such appropriate incentive.
    In reviewing H.R. 1335, we note the language in the bill 
specifically refers to hospital and nursing home care. However, we 
would hope the bill is intended to exempt these designated veterans 
from co-payments for hospital care and medical services under title 38, 
United States Code, Sec. 1710. We are concerned that if left as 
currently crafted, the intent of the bill would be construed to include 
an exemption only from co-payments for inpatient services, forcing 
these targeted beneficiaries to continue paying co-payments for 
outpatient care and prescription medications. We recommend 
clarification in the bill to reflect Congressional intent.
    In conjunction with DAV's national resolution from our membership, 
resolution number 172, calling for legislation to repeal all co-
payments for military retirees and veterans' medical services and 
prescriptions, and as a partner organization constituting the FY 2010 
IB, the DAV fully supports this provision. This bill also corresponds 
to the IB's recommendation that veterans designated by VA as being 
catastrophically disabled for the purpose of enrollment in health care 
eligibility Priority Group 4 should be made exempt from health care co-
payments and other fees.
 H.R. 1546--Caring for Veterans with Traumatic Brain Injury Act of 2009
    This measure would direct the Secretary of Veterans Affairs to 
establish the Committee on Care of Veterans with Traumatic Brain Injury 
(TBI) in the VHA. The bill would require the Under Secretary for Health 
to appoint to the Committee employees of the Department with expertise 
in the care of veterans with TBI.
    The bill would task the Committee with initially and continually 
assessing the capability of the VA to treat and rehabilitate veterans 
with TBI by evaluating the care provided and identifying systemwide 
problems and specific VA facilities where program enrichment would be 
needed to improve TBI treatment and rehabilitation. The bill would 
require the Committee to identify successful model programs in the 
treatment and rehabilitation of veterans with TBI that should be 
implemented more widely in or through VA facilities.
    The Committee would be required to advise the Under Secretary for 
Health regarding the development of policies for TBI care and 
rehabilitation, make recommendations for improving programs of care at 
specific facilities throughout the VA, and for establishing special 
programs of education and training for VHA employees relevant to caring 
for veterans with TBI. The Committee would also concern itself with the 
research needs and priorities related to caring for veterans with TBI 
as well as the appropriate allocation of resources to underwrite such 
activities.
    Beginning June 1, 2010 and for each subsequent year thereafter, the 
bill would require the Secretary to submit a report on the activities 
of the TBI committee to the Committees on Veterans' Affairs of the 
Senate and House of Representatives. Under the bill, the Secretary's 
report would be required to include a list of the members of the 
committee; the assessment of the Under Secretary for Health after 
reviewing the initial findings of the committee regarding the 
capability of the VA to effectively meet the treatment and 
rehabilitation needs of veterans with TBI on a systemwide and facility 
by facility basis; the plans of the Committee for further assessments, 
the findings and recommendations made by the Committee to the Under 
Secretary and the view of the Under Secretary on such findings and 
recommendations; a description of the steps taken, plans made including 
a timetable for the execution of such plans; and resources to be 
applied toward improving the capability of the VA to effectively meet 
the treatment and rehabilitation needs of veterans with TBI.
    Mr. Chairman, DAV has no resolution that specifically identifies 
the need for this committee, but we do have a resolution, number 164, 
which calls for the VA and the Department of Defense (DoD) to 
coordinate efforts to address mild and moderate TBI and concussive 
injuries and establish a comprehensive rehabilitation program and 
standardized protocol utilizing appropriately formed clinical 
assessment techniques to recognize and treat neurological and 
behavioral consequences of all levels of TBI. It also calls for any TBI 
studies or research undertaken by VA and DoD to include older veterans 
of past military conflicts who may have suffered similar injuries that 
went undetected, undiagnosed, and untreated. We believe the intent to 
effectively care for and treat those with TBI is commendable, and that 
an advisory committee with this charter would be consistent with that 
important and timely goal. Therefore, DAV offers no objection to the 
purposes of this bill and we look forward to its enactment.
   H.R. 2722--Veterans Nonprofit Research and Education Corporations 
                        Enhancement Act of 2009
    This bill would modernize and enhance oversight and reporting 
requirements of nonprofit research and education corporations that 
support VA biomedical research by managing extramural grant funds made 
available to VA principal investigators. It would also provide new 
guidance and policy requirements for the operation of these 
corporations within the VA research program, and would be responsive to 
recent recommendations made by the VA Inspector General for improved 
accountability within some of these corporations.
    The basic statutory authority for these corporations was enacted in 
1988, so this bill would be the first significant amendment to that 
statute. If enacted, this bill would authorize the corporations to 
fulfill their full potential in supporting VA biomedical research and 
education, the results of which would improve treatments and promote 
high quality care for veterans, while underwriting VA and Congressional 
confidence in these corporations' management of public and private 
funds.
    Mr. Chairman, VA's research and education corporations, operating 
in almost 90 VA locations, provide an important element in VA's overall 
Medical and Prosthetic Research programs, and provide major support for 
its myriad health professions educational programs. Absent these 
corporations, VA principal investigators, the majority of whom are 
clinicians, would not be able to accept or use grant funds from 
numerous Federal granting agencies (e.g., National Institutes of 
Health, National Science Foundation, etc.) and VA would not be able to 
participate in numerous clinical trials, education and specialized 
clinical training programs sponsored by the pharmaceutical industry, 
medical equipment manufacturers, and other sponsors. Funded research 
from outside VA's annual discretionary appropriation makes up almost 
one-third of VA's global research budget. This legislation is endorsed 
by Friends of VA Medical Care and Health Research (FOVA), as well as 
the National Association of VA Research and Education Foundations 
(NAVREF).
    While DAV has no adopted resolution on this particular matter, DAV 
is a strong supporter of a robust VA biomedical research and 
development program, and we believe enactment of this bill would be in 
that program's best interest. Therefore, DAV would have no objection to 
enactment of this bill.
  Draft Bill--To Direct the Secretary of Veterans Affairs to Provide, 
 Without Expiration, Hospital Care, Medical Services, and Nursing Home 
Care for Certain Vietnam-era Veterans Exposed to Herbicide and Veterans 
                        of the Persian Gulf War
    This bill would permanently authorize hospital care, medical 
services and nursing home care to Vietnam veterans exposed to 
herbicides while deployed, and for all veterans of the Persian Gulf 
War. Title 38, United States Code, Sec. 1710(e)(3)(A) and (B) provided 
VA the authority to enroll in VA health care Vietnam War veterans who 
may have been exposed to herbicides while serving in Vietnam and for 
Persian Gulf War veterans who served in the Southwest Asia theater of 
operations. Both authorities expired on December 31, 2002.
    Mr. Chairman, Congress saw fit to provide ``special treatment 
authority'' in 1981 (P.L. 97-72) to provide care to Vietnam veterans 
who may have been exposed to herbicides, notwithstanding that there was 
insufficient medical evidence to conclude that their disabilities were 
associated with exposure to herbicides while serving in Vietnam. 
Congress repeatedly extended the authority through 1996 (P.L. 104-262) 
with certain limitations.
    Similarly, veterans who served in the Persian Gulf War in the 
Southwest Asia theater of operations were provided special treatment 
authority in 1993 \1\ to provide care to Persian Gulf veterans exposed 
to toxic substances or environmental hazards. In 1997, P.L. 105-114 
removed the requirement that the veteran had been exposed to toxic 
substances or environmental hazards, only requiring service in the 
Southwest Asia theatre of operations during the Persian Gulf War. In 
1998,\2\ Congress extended the authority through 2001, and subsequently 
through 2002.\3\
---------------------------------------------------------------------------
    \1\ Pub. L. 103-210 (1993).
    \2\ Pub. L. 105-368 (1998).
    \3\ Pub. L. 107-135 (2002).
---------------------------------------------------------------------------
    The DAV applauds VA for continuing to enroll veterans in these 
circumstances. Based on wartime service and the often unknown hazards 
of military duty, these veterans deserve access to VA health care, a 
system dedicated to the unique needs of veterans. The DAV believes this 
is an important bill and looks forward to the Subcommittee's approval 
and its eventual passage into law.
                   FAMILY CAREGIVER SUPPORT SERVICES
    Mr. Chairman, we note in the remaining four bills on which we offer 
testimony, that each legislative measure directed at family caregivers 
of disabled veterans would propose a standard definition for ``family 
caregiver.'' While we recognize the importance of defining a program's 
target population, we ask the Subcommittee to consider VA's position, 
with which the DAV agrees, that ``[f]amily structures are changing in 
all facets of society, and VA is sensitive to the fact that a specific 
list or a strict definition of family members may not be appropriate 
for many veterans. Discretion is needed to ensure that veterans retain 
autonomy in designating caregivers who are competent and in whom they 
are confident. . . . We believe the definition of caregiver should be 
broadly defined to encompass a variety of potential caregivers, thus 
eliminating the need for a discrete list that may inadvertently exclude 
a candidate (such as a friend, neighbor, or significant other) that 
meets the veteran's needs and preferences. Leaving discretion to the 
Secretary to approve any potential caregiver would ensure this 
adaptability.'' \4\
---------------------------------------------------------------------------
    \4\ Madhulika Agarwal (Chief Officer, Patient Care Services, 
Veterans Health Admin., U.S. Dept of Veterans Affairs). Testimony on 
Meeting the Needs of Family Caregivers before the House Veterans 
Affairs Committee, Subcommittee on Health. (June 4, 2009). http://
veterans.house.gov/hearings/hearing.aspx?NewsID=412.
---------------------------------------------------------------------------
    Family caregiving is a complex role that bridges both quality of 
care and quality of life of disabled veterans. Caregivers play a 
critical role in facilitating recovery and maintaining the veteran's 
independence and quality of life while residing in their community, and 
are an important component in the delivery of health care by the VA. 
Research has found that all too often the role of informal caregiver 
exacts a tremendous toll on that caregiver's health and well-being. 
Family caregiving has been associated with increased levels of 
isolation, depression and anxiety, higher use of prescription 
medications, compromised immune function, poorer self-reported physical 
health, and increased mortality. Research also suggests that caregiver 
support services can help to reduce adverse health outcomes arising 
from caregiving responsibilities, can improve overall health status of 
the caregiver and care recipient, and delay placement into a more 
costly nursing home care setting.\5\
---------------------------------------------------------------------------
    \5\ Mittelman, M.S., et al. A Family Intervention to Deplay Nursing 
Home Placement of Patients with Alzheimers Disease--A Randomized 
Controlled Trial. JAMA 276(21), 1725-1731. (April 2, 1997).
---------------------------------------------------------------------------
    The DAV believes caregivers of severely disabled veterans should be 
seen as a resource and supported in their role. Accordingly, the 
delegates to our most recent National Convention, held in Las Vegas, 
Nevada, August 9-12, 2008, approved resolution number 165, calling for 
legislation that would provide comprehensive supportive services, 
including but not limited to financial support, health and homemaker 
services, respite, education and training and other necessary relief, 
to family caregivers of veterans severely injured, wounded or ill from 
military service.
 Draft Bill--To Amend Title 38, United States Code, To Provide Support 
  Services for Family Caregivers of Disabled Veterans, and for Other 
                                Purposes
    This bill would establish a new section 1786 of title 38, United 
States Code, to authorize a series of new and enhanced benefits for 
caregivers of disabled veterans, and would establish a broadened 
definition of the term ``family caregiver'' to include persons such as 
parents who would become eligible under its terms. The new section 
would require the Secretary to make interactive training sessions 
available on an Internet Web site for family caregivers of disabled 
veterans. Under the bill, the training would teach family caregivers 
techniques, strategies, and skills for recording details regarding the 
health of a veteran and in general for caring for a disabled veteran, 
to include those with post-traumatic stress disorder (PTSD) or TBI, 
including those who have returned from deployments in Operations 
Enduring or Iraqi Freedom (OEF/OIF).
    The bill would also require the Secretary to provide family 
caregivers with information regarding public, private and nonprofit 
agencies that might offer support, and to work with the Assistant 
Secretary for Aging in the Department of Health and Human Services 
(HHS) to provide family caregivers of disabled veterans with access to 
the HHS Aging and Disability Resource Centers. Also the bill would 
require the establishment of an Internet-based service to include a 
directory of available services, an electronic message board, other 
tools for family caregivers to interact with each other to create areas 
of peer support, and comprehensive health-related information on issues 
relevant to the needs of disabled veterans and their family caregivers.
    The bill would require outreach to inform disabled veterans and 
their families of the services that would be provided under this bill, 
to include public service announcements, brochures, pamphlets, 
participation in social networking sites; methods for reaching rural 
families; and a dedicated Web page on VA's existing Web site that 
focuses on caregiver support. The bill would require VA's Web site to 
launch new interactive elements for caregivers, including furnishing 
information based on the location of the person using the Web site.
    This measure also would make technical and conforming changes to 
section 1782 of title 38, United States Code, pertaining to counseling 
and mental health services for family caregivers, by authorizing these 
services for family caregivers as defined in the new section 1786 
otherwise crafted in this bill. Also, this expanded definition of 
family caregiver would be technically extended by the bill to section 
1720B of title 38, United States Code, in order that respite care could 
be available for newly defined family caregivers. The final provision 
of the bill would require the Secretary to ensure that the needs of the 
veterans receiving family caregiver services are being met, and that 
respite facilities providing such care are appropriate, including age-
appropriate, for the veterans concerned.
    We believe the intent of this bill is laudable and as this 
Subcommittee is aware, VA has eight caregiver support pilot programs 
that the DAV believes should be evaluated for effectiveness and 
feasibility and if implemented, would be affected by this measure. For 
example, the pilot program being conducted in Long Beach, CA, works 
with a community coalition to provide interventions that support 
caregivers for veterans with TBI, PTSD and dementia across the State of 
California using telehealth, Web, telephone and video tele-
conferencing. Interventions are provided by the VA Cares Caregiver 
Center; California Caregiver Resource Centers; the ``Powerful Tools'' 
Caregiver Training program; and Stanford University's Internet-based 
Caregiver Self Management Program. The program will assess the 
effectiveness of a 6-week-long online workshop, called ``Building 
Better Caregivers,'' that provides training to at-home caregivers of 
veterans who suffer from TBI, PTSD, Alzheimer's disease or other forms 
of dementia. The interactive online workshop will also provide a forum 
in which small groups of caregivers can share personal experiences and 
insights on solving problems, handling difficult emotions and 
celebrating milestones. Each week, participants will be asked to log on 
at least three times and spend 2 hours on lessons and homework.
    We are pleased the bill mandates VA to provide training; and, while 
we believe training is a critical aspect of supporting family 
caregivers of disabled veterans, we ask the Subcommittee to ensure that 
online training will not be the only venue offered by VA.
    VA respite care is one of the few services available with a primary 
focus on supporting family caregivers to provide them temporary relief 
from their care responsibilities. Caregiver burden is common and 
frequently limits the ability of family and friends to provide that 
assistance. In fact, respite care is considered the dominant service 
strategy to support and strengthen family caregivers under the HHS 
Aged/Disabled Medicaid Home and Community-Based (HCBS) waiver program. 
A survey conducted on these programs where respondents were asked to 
choose from a list of 20 items which services their program provides 
specifically to family caregivers, respite care received a 92 percent 
response.\6\
---------------------------------------------------------------------------
    \6\ Feinberg, L and Newman, S. Medicaid and Family Caregiving: 
Services, Supports and Strategies Among Aged/Disabled HCBS Waiver 
Programs in the U.S. Rutgers Center for State Health Policy. (May 1, 
2005).
---------------------------------------------------------------------------
    While the VA policy allows respite care services to be provided in 
excess of 30 days, it requires unforeseen difficulties. Additionally, 
local facilities treat 30 days as a ceiling by requiring the approval 
of the medical center Director rather than the treating physician or 
treatment team. Moreover, for veterans who are required to make co-
payments, long-term care co-payments apply to respite care regardless 
of the setting. The DAV believes VA should improve its national respite 
care program to make it age appropriate, more flexible, and more 
readily available to all severely injured veterans and their 
caregivers. We believe VA should enhance this service to reduce the 
variability across a veteran's continuum of care by, at a minimum, 
allowing a veteran's primary treating physician to approve respite care 
in excess of 30 days; making more flexible the number of hours/days 
available for use; providing overnight and weekend respite care to 
veterans for relief of their caregivers; and eliminating applicable 
long-term-care co-payments. Three of the eight VA caregiver pilot 
programs previously noted use respite care as their primary focus. The 
DAV appreciates the bill's requirement, rather than a discretionary 
authority, to ensure the respite care needs of family caregivers of 
young and old severely injured veterans will be met.
    In addition, HHS announced in September 2008 it would provide VA 
with over $19 million to provide consumer-directed home and community-
based services to veterans regardless of age (designed to reach people 
who are not eligible for Medicaid). Under this arrangement, VA is 
already working with local, State, and Federal agencies including the 
Aging and Disability Resource Center (ADRC) unlike this proposed bill, 
which requires VA to only collaborate with HHS for access to ADRC, 
which has its own limitations for including in their network nonprofit 
and other community agencies.
    As noted above, this bill requires the VA to contract with a 
private entity to provide family caregivers with an Internet-based 
service to provide a directory of caregiver support services at the 
county level; online tools to allow family caregivers to interact with 
their peers and create support networks; and provide comprehensive 
information to meet the needs of disabled veterans and family 
caregivers. As part of the IB, the DAV believes caregiver support 
services should include family counseling and family peer groups so 
they can share solutions to common problems. One recommendation in the 
IB \7\ calls for VA to develop support materials for family caregivers, 
including a social support and advocacy support for the family 
caregivers of severely injured veterans. Such support should include: 
peer support groups, facilitated and assisted by committed VA staff 
members; appointment of caregivers to local and VA network patient 
councils and other advisory bodies within the VHA and Veterans Benefits 
Administration (VBA); and a monitored chat room, interactive discussion 
groups, or other online tools for the family caregivers of severely 
disabled OEF/OIF veterans, through My HealtheVet or other appropriate 
Web-based platform.
---------------------------------------------------------------------------
    \7\ The Independent Budget for the Department of Veterans Affairs 
Fiscal Year 2010, Medical Care Section, Family and Caregiver Support 
Issues Affecting Severely Injured Veterans Subsection, pp 157-162. 
(2009). http://www.independentbudget.org/pdf/IB_10medcare.pdf.
---------------------------------------------------------------------------
    Mr. Chairman, as noted above, DAV resolution number 165 calls for 
legislation that would provide comprehensive supportive services, 
including but not limited to financial support, health and homemaker 
services, respite, education and training and other necessary relief, 
to family caregivers of veterans severely injured, wounded or ill from 
military service. Also, the IB for FY 2010 recommends a series of 
supportive services and benefits for family caregivers of disabled 
veterans. Therefore, DAV strongly supports this bill and urges its 
enactment as soon as possible. On a final note, in light of the current 
VA caregiver pilot initiatives, we ask the Subcommittee to ensure the 
provisions outlined in the bill would not restrict or otherwise limit 
ongoing efforts by VA.
      H.R. 2734--The Health Care for Family Caregivers Act of 2009
    This bill would amend section 1781, title 38, United States Code, 
to extend eligibility for benefits under the Civilian Health and 
Medical Program of Veterans Affairs (CHAMPVA), to certain family 
caregivers of the most severely disabled veterans, as determined under 
subsections (r) or (s) of section 1114, title 38, United States Code, 
who are not currently eligible dependents of those veterans for that 
CHAMPVA benefit. The bill would exempt these family caregivers from the 
payment of deductibles, co-payments, cost sharing or other fees 
associated with their care under CHAMPVA.
    Eligibility for CHAMPVA services would be limited to those 
caregivers without other entitlements to care under a health-plan 
contract as defined under section 1725(f)(2), title 38, United States 
Code. Further, ``caregiver services'' and ``family caregiver'' would be 
defined similar to the manner they would be defined in other bills 
before the Subcommittee today, specifically including parents, spouses, 
children, siblings, step-family members and extended family members.
    The DAV applauds this worthwhile bill since family caregivers who 
provide 36 or more hours of care per week are more likely than non-
caregivers to experience mental health issues, including symptoms of 
depression or anxiety--for spouses the symptom rate is six times as 
high.\8\ Studies also demonstrate that family caregivers report having 
a chronic health condition at more than twice the rate of non-
caregivers.\9\ In addition, studies indicate that when family 
caregivers experience extreme stress, they age prematurely and this 
level of stress can take as much as 10 years off a family caregiver's 
life.\10\
---------------------------------------------------------------------------
    \8\ C.C. Cannuscio, C. Jones, et al., Reverberation of Family 
Illness: A Longitudinal Assessment of Informal Caregiver and Mental 
Health Status in the Nurses' Health Study, Am Jrnl of Pub. Health 92: 
305-11. (2002).
    \9\ Dept of Health and Human Services (DHHS), Informal Caregiving: 
Compassion in Action, Washington, D.C. (1998). http://aspe.hhs.gov/
daltcp/Reports/carebro2.pdf.
    \10\ Peter S. Arno, Economic Value of Informal Caregiving, 
presented at the VA Care Coordination and Caregiving Forum, Bethesda, 
MD (January 25-27, 2006).
---------------------------------------------------------------------------
    Family caregivers of severely disabled veterans with long-term care 
needs are able to divert those at risk from nursing home placement and 
in the absence of family caregivers, an even greater burden of direct 
care would fall to VA at significantly higher cost to the government 
and reduced quality of life for these veterans who have sacrificed so 
much. This bill is fully consistent with DAV resolution number 165 
supporting the needs of family caregivers of disabled veterans. 
Therefore, DAV fully supports its intent and urges this bill to be 
enacted.
    However, we believe under this proposal that only a minority of 
severely disabled veterans who require a high level of care from their 
family caregiver would meet the special monthly disability compensation 
rates (r) or (s), potentially leaving a majority of family caregivers 
in need of medical care without access to such care. We ask the 
Subcommittee to give due consideration to this high threshold for 
eligibility, which also lacks the appropriate clinical determination 
based on need for medical care due to a family member's role as 
caregiver of a severely disabled veteran. We recommend the Subcommittee 
consider lowering the threshold by adopting the eligibility standard 
that currently exists in section 1781(a)(1) of title 38, United States 
Code, for a veteran who has a total disability permanent and total in 
nature resulting from a service-connected disability.
  H.R. 2738--To Amend Title 38, United States Code, To Provide Travel 
    Expenses for Family Caregivers Accompanying Veterans to Medical 
                          Treatment Facilities
    This bill would amend section 111(e), title 38, United States Code, 
to authorize family caregivers of certain sick and disabled veterans to 
receive beneficiary travel reimbursement, including lodging and 
subsistence, during the periods these caregivers accompany such 
veterans to and from VA health care facilities, and during the duration 
of treatment episodes, with certain limitations.
    The bill would also amend section 1701, title 38, United States 
Code, to define ``caregiver services'' as one form of non-institutional 
care including homemaker and home health aide services, and it would 
define ``family caregiver'' as a member of a disabled veteran's family 
including parents, spouses, children, siblings, step-family members and 
extended family members of a disabled veteran, who provide caregiver 
services to a veteran.
    Mr. Chairman, VA currently provides beneficiary travel payments to 
a member of a veteran's immediate family, legal guardian, or person in 
whose household the veteran certifies an intention to live if such 
person is traveling for consultation, professional counseling, 
training, or mental health services concerning a veteran who is 
receiving care for a service-connected disability or is traveling for 
bereavement counseling.
    The DAV appreciates the intent of this bill since the availability 
of transportation is a key concern and barrier for many family 
caregivers of disabled veterans to access VA medical care. In order for 
veterans and their family caregivers to receive beneficiary travel 
payment, the veteran must meet certain eligibility criteria for VA's 
travel beneficiary program.\11\ This measure would define the term 
``family caregiver'' and include them in being able to receive mileage 
reimbursement, lodging, and subsistence under this program.
---------------------------------------------------------------------------
    \11\ 38 CFR Sec. 70.10(7) and (8). See also: Beneficiary Travel 
Handbook 1601B.05 (July 29, 2008).
---------------------------------------------------------------------------
    DAV resolution number 165, as discussed above, calls for 
legislation that would provide comprehensive support services to family 
caregivers of severely disabled veterans. Therefore, DAV endorses this 
legislation and urges its enactment.
  Draft Bill--To Direct the Secretary of Veterans Affairs to Annually 
  Conduct a Survey of Family Caregivers of Disabled Veterans, and for 
                             Other Purposes
    This bill would require the VA Secretary to annually conduct a 
survey of family caregivers, to determine the number of family 
caregivers in the United States; the range of caregiver services 
provided by family caregivers, including the average schedule of such 
services and the average amount of time a caregiver has spent providing 
such services; the support services needed by family caregivers; and 
other information the Secretary considers appropriate. The bill would 
also require the Secretary to consider the findings of the survey when 
carrying out programs regarding family caregivers, and provide these 
reports to the House and Senate Committees on Veterans' Affairs. The 
bill would also define ``caregiver services'' and ``family caregiver'' 
in ways similar to the provisions of the other draft bills before the 
Subcommittee today.
    Mr. Chairman, we agree with your opening statement for this 
Subcommittee's June 4, 2009, hearing on meeting the needs of family 
caregivers of disabled veterans, specifically that the VA does not 
collect data on this population and therefore, the number of family 
members who provide care for veterans is unknown. Moreover, in our 
testimony for that hearing we indicated a need for VA to conduct a 
longitudinal survey to obtain information and develop a nationally 
representative profile on the health and functional status of people 
who take care of severely disabled veterans.
    At that hearing, we cited in our testimony the National Long Term 
Care Survey (NLTCS) and Informal Caregiver Survey (ICS) that can be 
used to examine such things as how many hours of help caregivers 
provide with activities of daily living (ADLs) and instrumental 
activities of daily living (IADLs) for chronically disabled elders, and 
what number and percentage of those hours are provided by informal 
caregivers. It can also be further broken down by primary and secondary 
caregivers and by relationship, (e.g., spouse, son, daughter, friend, 
etc.) as compared to paid workers. This enables policy researchers to 
measure the time burden on caregivers of providing informal care 
(especially primary caregivers) in relation to the severity of 
disability and other care recipient characteristics. The relationship 
between weekly time burden of informal care and self-reported 
indicators of caregiver stress can then be analyzed. Further analyses 
could be carried out with respect to relationships among time burden of 
informal care, self-reported caregiver stress, use/non-use of formal 
services, and funding sources for formal services (public/private). 
Finally, the NLTCS/ICS contains numerous questions regarding the 
primary informal caregiver's perception of the need or lack of formal 
services and the reason why these services are not being used if they 
are perceived as needed (e.g., lack of affordability, lack of local 
availability, etc.). This enables policymakers to estimate (using 
various criteria) the potential size and characteristics of the target 
population for public policy interventions to assist caregivers.
    As part of the IB, the DAV recommends VA should conduct a baseline 
national survey of caregivers of veterans to address the needs of 
informal caregivers as a public health concern by looking at 
population-based public health outcomes of caregivers. Because health 
outcomes and quality of life of family caregivers affect the lives of 
disabled veterans, data on family caregivers is needed to capture the 
influence of their roles and responsibilities as caregivers on their 
lives, including influence on work, social, psychological, and physical 
burden. Considering the demographics of the enrolled and user 
population of the VA health care system, attention to caregivers has 
with reason been drawn to the needs of the aging veteran, but that 
group represents only one segment--although a large one--of those who 
receive and provide care; however, the survey should include a special 
emphasis on caregivers of OEF/OIF veterans. In addition, since 
caregiving is a lifespan experience, this survey should be conducted at 
regular intervals.
    In concert with a longitudinal survey, the DAV believes that 
caregiver assessments are equally important. In programs where 
caregivers are assessed, they can be acknowledged and valued by 
practitioners as part of the health care team. While requiring VA to 
perform caregiver assessments is not considered in this draft proposal, 
we urge VA to ensure this type of health care tool is utilized 
throughout the VA health care system. The DAV believes that unlike a 
longitudinal population survey, caregiver assessments can identify 
those family members most at risk for health and mental health effects 
and determine if they are eligible for additional support.
    This bill is fully consistent with DAV resolution number 165 and 
the IB recommendation that VA conduct annual surveys of family 
caregivers as well as periodic assessments to determine their unmet 
needs. Therefore, DAV fully endorses this bill and urges its enactment.
    Mr. Chairman, again, DAV appreciates the Subcommittee's interest in 
these issues, and we appreciate the opportunity to share our views on 
these important bills. I would be pleased to respond to questions from 
you or other Members of the Subcommittee on these matters.

                                 
                Prepared Statement of Hon. Jerry Moran,
         a Representative in Congress From the State of Kansas
    I want to thank Congressman Hare for his leadership on 
reintroducing this bill. I join Congressman Hare as an original co-
sponsor of H.R. 1302. This bill creates a full time Director of PA 
Services within the Department of Veterans Affairs. This legislation is 
beneficial in improving patient care for our Nation's veterans, 
ensuring that the more than 1,800 PAs employed by the VA are fully 
utilized to provide veterans medical care.
    As a Member of Congress who represents one of the most rural 
districts in the country, I know that physician assistants are a key to 
providing medical care in underserved areas. Often, they are the only 
health care professional available. PAs help ensure those who live in 
our communities receive timely access to quality health care.
    I want to be certain that PAs are appropriately utilized by the VA 
to serve our veterans. Like our armed forces that have full-time 
directors of PA services, this legislation will establish a dedicated 
expert in the VA Central Office. This PA Director will work to fully 
integrate the profession into VA health care, ensuring PAs have a 
stronger voice in the VA so they can better serve our veterans and 
their patients.
    In May of last year, the House approved this bill. I am hopeful 
this Committee will continue its support and this year we can enact 
H.R. 1302 into law.

                                 
 Prepared Statement of National Association of Veterans' Research and 
                         Education Foundations
    The National Association of Veterans' Research and Education 
Foundations (NAVREF) thanks Veterans Affairs Committee Chairman Bob 
Filner for introducing H.R. 2770, the Veterans Research and Education 
Corporations Enhancement Act of 2009, on June 9. We also thank Ranking 
Member Steve Buyer for collaborating with Mr. Filner to finalize and 
co-sponsor this legislation. We are grateful to Chairman Mike Michaud, 
Ranking Member Henry Brown and the Members and staff of the Health 
Subcommittee for holding a hearing on this and other important health-
related legislation.
    Upon enactment, H.R. 2770 will update and clarify provisions of the 
law authorizing the VA-affiliated nonprofit research and education 
corporations. The Senate counterpart of H.R. 2770 is title VI of S. 252 
which was introduced by Chairman Daniel Akaka on January 15, 2009. 
Subsequently, it was the subject of a Senate Committee on Veterans' 
Affairs hearing on April 22 and was marked up by the Senate Committee 
on Veterans' Affairs on May 21. The substantive provisions of S. 252 
and H.R. 2770 are identical. The only differences between the two bills 
are in the clause numbering and in a few provisions, the lead-in 
phrasing.
    NAVREF is the membership organization of the 82 VA-affiliated 
nonprofit research and education corporations (NPCs) originally 
authorized by Congress under Public Law 100-322, and currently codified 
at sections 7361 through 7366 of the United States Code. NAVREF's 
mission is to promote high quality management of the NPCs and to pursue 
issues at the Federal level that are of interest to its members. NAVREF 
accomplishes this mission through educational activities for its 
members as well as interactions and advocacy with agency and 
congressional officials. Additional information about NAVREF is 
available on its Web site at www.navref.org.
Background About the NPCs
    In 1988, Congress allowed the Secretary of the Department of 
Veterans Affairs to authorize ``the establishment at any Department 
medical center of a nonprofit corporation to provide a flexible funding 
mechanism for the conduct of approved research and education at the 
medical center'' [38 U.S.C. Sec. 7361(a)]. Currently, 82 NPCs provide 
their affiliated VA health care systems and medical centers with a 
highly valued means of administering non-VA Federal research grants and 
private sector funds in support of VA research and education.
    The fundamental purpose of the nonprofits is to serve veterans by 
supporting VA research and medical education to improve the quality of 
care that veterans receive. For example, a seed grant provided by the 
Palo Alto Institute for Research and Education (PAIRE) to a 
gastroenterology clinician-investigator resulted in his finding that an 
easily overlooked type of abnormality in the colon is the most likely 
type to turn cancerous, and is more common in this country than 
previously thought. This finding, reported on the front page of the 
March 5, 2008, New York Times and in the Journal of the American 
Medical Association, is changing colonoscopy practices and may well 
lead to widespread earlier detection of a cancer that is preventable or 
curable through surgery. During 2008 PAIRE made nine similar awards to 
VA Palo Alto investigators in the hope of equally significant research 
success down the road. Similarly, a few years ago funds administered by 
the Seattle Institute for Biomedical and Clinical Research (SIBCR) 
allowed a psychiatry clinician-investigator to test use of Prazosin, an 
inexpensive, already approved drug, for treatment of veterans with 
debilitating post-traumatic stress-related nightmares. The SIBCR 
funding allowed the investigator to accumulate positive preliminary 
data that then led to DoD and NIH awards to further test this promising 
treatment.
    Last year, the NPCs collectively administered more than $250 
million with expenditures that supported approximately 4,000 VA-
approved research and education programs. These nonprofits are 
dedicated solely to supporting VA and veterans. This includes providing 
VA with the services of nearly 2,500 without compensation (WOC) 
research employees who work side-by-side with VA-salaried employees, 
all in conformance with the VA background, security and training 
requirements such appointments entail.
    Beyond administering VA-approved research projects and education 
activities, these nonprofits support a variety of VA research 
infrastructure and administrative expenses. As described above, they 
have provided seed and bridge funding for investigators; staffed animal 
care facilities; funded recruitment of clinician researchers; paid for 
research administrative and compliance personnel; supported staff and 
training for institutional review boards (IRBs); and much more.
Legislation Would Enhance and Clarify NPC Authorities
    The purpose of H.R. 2770 is to modernize and clarify the 1988 
statute after 20 years of experience under its current terms. The NPCs 
have already proven themselves to be valued and effective ``flexible 
funding mechanisms for the conduct of approved research'' [38 U.S.C. 
Sec. 7361(a)]. VA's most recent annual report to Congress regarding the 
NPCs stated, ``The VA-affiliated NPCs continue to make a substantial 
contribution to the VA research and education missions.'' This 
legislation will further enhance their value to VA.
    The objectives of this legislation are consistent with the findings 
in the May 2008 VA Office of Inspector General (OIG) review of five 
NPCs and VHA's oversight of them. VHA is working hard to address the 
shortcomings in oversight that the OIG identified. NAVREF and the NPCs 
are working equally hard to ensure that NPCs have appropriate controls 
over funds and equipment (including strengthening the documentation for 
all transactions), and that all NPC officers, directors and employees 
are certifying their awareness of the applicable Federal conflict of 
interest regulations. While NAVREF firmly believes that NPC boards and 
administrative employees strive to be conscientious stewards of NPC 
funds, NAVREF thanks the OIG for its thorough review of those five NPCs 
and for bringing to light these areas in need of improvement.
    It is noteworthy that the OIG report cited no misuse of funds or 
instances of conflicts of interest, no dual compensation of Federal 
employees and no fraud. However, we take very seriously the OIG finding 
that these NPCs nonetheless may not have had adequate controls over 
some of the funds they manage. Two major provisions in H.R. 2770 
directly address this finding:
    First, section 2(a) allows voluntary formation of ``multi-medical 
center research corporations.'' That is, two or more VA medical centers 
may share one NPC, subject to board and VA approval, while preserving 
their fundamental nature as medical center-based organizations. This 
provision--the centerpiece of the legislation--will allow interested VA 
facilities with small research programs to join voluntarily with larger 
ones. Or several smaller facilities may pool their resources to support 
management of one NPC with funds and staffing adequate to ensure an 
appropriate level of internal controls, including segregation of 
financial duties.
    Second, the last item in section 5(a)--``(f) Policies and 
Procedures''--addresses the OIG criticism by broadening VA's ability to 
guide NPC expenditures. The only constraint on VA is that such guidance 
must be consistent with other Federal and State requirements as 
specified in laws, regulations, Executive orders, circulars and 
directives--of which there are many--applicable to other 501(c)(3) 
organizations. The purpose of this limitation is to prevent the 
possibility of imposing on NPCs conflicting requirements and to ensure 
that they remain independent ``flexible funding mechanisms.''
    H.R. 2770 provides a number of other welcome enhancements to the 
NPC authorizing statute.

      Section 4(b) of the bill broadens the qualifications for 
the two mandatory non-VA board members beyond familiarity with medical 
research and education. This will allow NPCs to use these board 
positions to acquire the legal and financial expertise needed to ensure 
sound governance and financial management.
      Section 4(c) deletes the overly broad stipulation in the 
current statute that these non-VA board members may not have ``any 
financial relationship'' with any for-profit entity that is a source of 
funding for VA research or education. This absolute prohibition 
conflicts with regulations applicable to Federal employees with respect 
to conflicts of interest, which are invoked for all NPC directors and 
employees in section 7366(c)(1) of title 38, United States Code. Unlike 
the standard currently applied to NPC board members, Federal conflict 
of interest regulations provide means of recusal as well as de minimus 
exceptions. Additionally, the current prohibition may be applied to any 
individual who has accepted compensation or reimbursement from a for-
profit sponsor of VA research for purposes unrelated to VA research, 
thereby eliminating many otherwise desirable and qualified individuals 
from serving on NPC boards.
      Section 5(a) ``(b) ``(1) ``(C) increases the efficiency 
of NPC administration of funds generated by educational activities. 
This clause allows NPCs to charge registration fees for the education 
and training programs they administer, and to retain such funds to 
offset program expenses or for future educational purposes. However, it 
also explicitly sustains the existing prohibition against NPCs 
accepting fees derived from VA appropriations.
      Section 5(a) ``(b) ``(1) ``(D) provides NPCs with 
authority to reimburse the Office of General Counsel (OGC) for legal 
services related to review and approval of Cooperative Research and 
Development Agreements (CRADAs), the form of agreement used to 
establish terms and conditions for industry-funded studies performed at 
VA medical centers and administered by NPCs. Although OGC is already 
obligated to review these agreements without reimbursement, the funds 
generated under this provision would help OGC to staff Regional Counsel 
offices to accommodate the substantial workload these agreements entail 
and to provide training for VA attorneys in CRADA requirements and 
related VA policies. The NPCs support making these reimbursements.
      Section 5(a) ``(b) ``(2) of the legislation provides VA 
with authority to reimburse NPCs for the salary and benefits of NPC 
employees loaned to VA under Intergovernmental Personnel Act (IPA) 
assignments conducted in accordance with section 3371 of title 5, 
United States Code. This provision responds to recent OIG questions 
asking whether such reimbursements are allowable and permits VA to 
continue to benefit from this efficient and cost-effective mechanism to 
acquire the temporary services of skilled research personnel.
      Section 5(a) ``(c) ``(3) establishes explicit authority 
for VAMCs to accept funds provided by NPCs that may fall outside of 
VA's gift acceptance authority. It also allows VAMCs to retain such 
funds locally and to deposit them in the appropriate VA account without 
having to route them through the Treasury, necessitating cumbersome 
steps to get the funds to the right VA account. Finally, this provision 
makes these reimbursements ``no year'' money to give VAMCs needed 
flexibility in timing for use of the funds.

         Although VA has broad authority to accept gifts (38 U.S.C. 
        Sec. 8301), many NPC payments to VAMCs are more accurately 
        described as reimbursements to the VAMC or payments for 
        services and may not be consistent with VA's gift acceptance 
        authority. For example, NPCs typically reimburse VAMCs for the 
        cost of clinical services provided exclusively for research 
        purposes; VA employees' time spent on NPC-administered 
        programs; and animal per diems. This clause also will allow VA 
        to resolve longstanding VAMC uncertainty about how to treat 
        such reimbursements and will let the VAMC that incurred the 
        cost retain the amounts reimbursed. Currently, VAMCs must send 
        such reimbursements to the Treasury and then the Fiscal Office 
        must use a cumbersome process to bring the funds back to the 
        VAMC.
    H.R. 2770 also contains a number of useful clarifications of NPC 
status and purposes.

      Sections 2(b), (c) and (d) codify--without changing--the 
legal status of the NPCs as State-chartered, independent organizations 
exempt from taxation under section 501(c)(3) of the Internal Revenue 
Service (IRS) code and subject to VA oversight and regulation. Clause 
(c) of this section codifies the congressional intent, previously 
expressed in the House report that accompanied the original NPC 
authorizing statute (H. Rept. 100-373), that nonprofits established 
under this authority would not be corporations controlled or owned by 
the government. As a result, this legislation resolves longstanding 
differences of opinion among stakeholders, overseers and funding 
sources about the legal status of NPCs.
      Section 3(a)(1) of the legislation establishes that in 
addition to administering research projects and education activities, 
NPCs may support ``functions related to the conduct of research and 
education.'' This resolves differences of opinion about the 
appropriateness of NPC expenditures that support VA research and 
education generally, such as purchase of core research equipment used 
by many researchers for multiple projects, and enhances the value of 
NPCs to VA facilities.
      Section 5(a) ``(d) ascertains that all NPC-administered 
research projects must undergo ``scientific'' rather than ``peer'' 
review. This change recognizes that peer review is not necessary or 
appropriate for all research projects administered by NPCs. However, 
the legislation leaves in place the overarching requirement for VA 
approval and the medical center's Research and Development Committee 
remains in a position to determine on a case-by-case basis whether a 
project also requires peer review as a condition of VA approval.

    In addition to these enhancements and clarifications, H.R. 2770 
reorganizes the NPC authorizing statute to put all provisions regarding 
their establishment and status in one section; describes their purposes 
in another; and gathers in one section the clauses enumerating their 
powers. Other revisions are largely technical and conforming 
amendments.
Proposed Legislation Preserves Measures Providing Oversight of NPCs
    H.R. 2770 makes no changes in VA's power to regulate and oversee 
the NPCs. Further, NPC records remain fully available to the Secretary 
and his designees; to the Inspector General; and to the Government 
Accountability Office (GAO). Likewise, NPCs are still required to 
undergo an annual audit by an independent auditor in accordance with 
the sources--Federal or private--and the amount of their prior year 
revenues, and they must submit to VA an annual report that includes the 
resulting audit report along with detailed financial information and 
descriptions of accomplishments.
    In the wake of the Sarbanes-Oxley Act and changing Federal 
Accounting Standards Board (FASB) auditing standards, even the most 
basic form of nonprofit audit has become an effective means for 
assessing an organization's financial controls. Additionally, the 
percentage of NPC funds subject to audits conducted in accordance with 
OMB Circular A-133, the most rigorous level of applicable auditing 
standards, will continue to increase as more NPCs assume responsibility 
for non-VA Federal grants. According to reports submitted to VA in June 
2008, nearly 80 percent of prior year NPC expenditures were subject to 
an A-133 audit and overall, 99.7 percent of NPC expenditures were 
subject to an audit of one type or another. These audits are 
comprehensive and provide a sound framework for examining an 
organization's controls over funds as well as compliance with program 
requirements.
Conclusion
    In conclusion, NAVREF urges the Congress to pass H.R. 2770 at the 
earliest possible opportunity. The NPCs are already a highly efficient 
means to maximize the benefits to VA of externally funded research 
conducted in VA facilities, ably serving to facilitate research and 
education that benefit veterans. Additionally, they foster vibrant 
research environments at VA medical centers, enhancing VA's ability to 
recruit and retain clinician-investigators and other talented staff who 
in turn apply their knowledge to state-of-the-art care for veterans.
    Twenty years after the VA-NPC public-private partnership was first 
authorized by Congress, this is a timely opportunity to update and 
clarify the NPCs' enabling legislation. This legislation will 
accomplish those objectives. Experience working within the current 
statute has brought to light its many strengths, but also areas that 
will benefit from modification, enhancement and updating, particularly 
in light of the increasing complexity of both research and nonprofit 
compliance. We believe enactment of H.R. 2770 will allow NPCs to better 
achieve their potential to support VA research and education while 
ensuring VA and congressional confidence in their management.
    NAVREF thanks the Health Subcommittee of the House Committee on 
Veterans Affairs and its staff members, as well as the Full Committee 
staff, for their work on H.R. 2770. We look forward to working with the 
Members of the Committee toward enactment of this bill. Please direct 
any questions you may have to NAVREF Executive Director Barbara West at 
301-656-5005 or [email protected].

                                 
                 Prepared Statement of Barbara Cohoon,
    Government Relations Deputy Director, National Military Family 
                              Association
    The National Military Family Association is the leading nonprofit 
organization committed to improving the lives of military families. Our 
40 years of accomplishments have made us a trusted resource for 
families and the Nation's leaders. We have been at the vanguard of 
promoting an appropriate quality of life for active duty, National 
Guard, Reserve members, retired servicemembers, their families, and 
survivors from the seven uniformed services: Army, Navy, Air Force, 
Marine Corps, Coast Guard, Public Health Service, and the National 
Oceanic and Atmospheric Administration.
    Association Representatives in military communities worldwide 
provide a direct link between military families and the Association 
staff in the Nation's capital. These volunteer Representatives are our 
``eyes and ears,'' bringing shared local concerns to national 
attention.
    The Association does not have or receive Federal grants or 
contracts.
    Our Web site is: www.MilitaryFamily.org.

                               __________
    Chairman Michaud and Distinguished Members of the Subcommittee on 
Health of the U.S. House of Representatives Committee on Veterans' 
Affairs, the National Military Family Association would like to thank 
you for the opportunity to submit for the record for your legislative 
hearing. The National Military Family Association will take the 
opportunity to discuss our views on pending legislation to this 
Subcommittee.
    Wounded servicemembers and veterans have wounded families. The 
system should provide coordination of care; VA and DoD need to work 
together to create a seamless transition. Our Association recommends 
there be a comprehensive approach to caregiver support services to 
ensure everything is covered and there are no gaps in the support 
system. We need one overall approach rather than having DoD, VA, and 
Members of Congress making ad hoc fixes as they arise. We cannot 
continue to approach the problem in a vacuum. We ask this Subcommittee 
to assist in meeting that responsibility.
`Veterans Nonprofit Research and Education Corporations Enhancement Act 
                                of 2009'
    The National Military Family Association supports this proposed 
legislation that will modify and update provisions of the law that 
relate to nonprofit research and education corporations. We appreciate 
the amended section that will now include ``education and training for 
patients and families.'' The provision allowing the established 
corporation to accept, administer, retain, and spend funds derived from 
gifts, contributions, grants, fees, reimbursements, and bequests from 
individuals and public and private entities would create an environment 
of flexibility allowing the corporation to receive and spend funds in 
the most efficient and beneficial manner.
    Our Association would like to see a provision added creating an 
overview by the Under Secretary for Health to ensure there is a 
coordination of research projects done across the multi-medical center 
research corporations. This provision would prevent the potential for 
the duplication of research projects and allow for the opportunity for 
projects to be expansions of existing research projects.
  `Disabled Veterans Home Improvement and Structural Alteration Grant 
                         Increase Act of 2009'
    The National Military Family Association supports this proposed 
legislation increasing the funds available to disabled veterans for 
improvements and structural alterations as part of home health 
services. We appreciate the monetary increase; however, our Association 
recommends the amount in this provision not be tied to a flat fee. The 
amount should be flexible and allow for regional differences in costs 
across the United States for improvements and alterations. There are 
variations on how much $6,800 can provide in services depending on 
where the veteran lives. We believe this benefit should be equal in 
purchase power regardless of where the veteran resides.
            `Medal of Honor Health Care Equity Act of 2009'
    The National Military Family Association supports this proposed 
legislation assigning a higher priority status for hospital care and 
medical services provided through the Department of Veterans Affairs 
(VA) for veteran recipients of the Medal of Honor. This provision 
recognizes the distinguished service these veterans provided for our 
Nation.
  Establishes the Position of Director of Physician Assistant Services
    The National Military Family Association has no position on this 
proposed legislation.
 Prohibits the Collection of Certain Co-payments from Catastrophically 
                           Disabled Veterans
    The National Military Family Association supports this proposed 
legislation to prevent the VA from collecting certain co-payments from 
catastrophically disabled veterans. This provision recognizes the 
severity of injury and its potential financial impact on these veterans 
when receiving hospital or nursing home care. However, this provision 
prevents the collection for only in-patient care. Our Association would 
like to see this provision expanded to include out-patient services for 
catastrophically disabled veterans.
     `Caring for Veterans with Traumatic Brain Injury Act of 2009'
    The National Military Family Association supports the intent of 
this proposed legislation directing the Secretary of Veterans Affairs 
to establish the Committee on Care of Veterans with Traumatic Brain 
Injury (TBI). Traumatic Brain Injury has been referred to as the 
signature wound of this current conflict. Many of our servicemembers 
and now veterans have sustained this type of wound. However, we have 
some concerns. Currently, there exists a joint Center to address TBI in 
both active duty servicemembers and veterans. This Center is called the 
Defense Center of Excellence (DCoE). There is also a state-of-art 
health care facility being built in the National Capitol Region called 
the National Intrepid Center of Excellence (NICoE) that will provide 
evidence-based health care for servicemembers and veterans with TBI and 
post-traumatic stress disorder (PTSD). We are wondering how this newly 
established committee will interface with these two already established 
entities.
    Another concern is that many of our wounded are affected by more 
than one injury. Who will ensure there is a system or committee in 
place to oversee continuity of care for those veterans with polytrauma? 
Seamless care will be difficult to obtain if we continue to create one-
injury focused committees. We must be cognizant of our resources and 
acknowledge our injured veterans begin as active duty servicemembers. 
Members of Congress and the VA must work closely with the Department of 
Defense (DoD) to ensure there is coordination of services and that we 
are not creating duplicate services. We recommend these concerns be 
considered as Congress and the VA move forward in the creation of 
additional committees to address injuries affecting our veterans.
            `Health Care for Family Caregivers Act of 2009'
    The National Military Family Association supports the intent of 
this proposed legislation to provide medical care to family members of 
disabled veterans who serve in the role as caregiver. Our Association 
recommends caregivers of our veterans be recognized for the important 
role they play in maintaining the wellbeing of the disabled veteran, 
often resulting in personal financial sacrifices. Providing access to 
medical care for caregivers would go a long way in recognizing their 
important contribution. However, the bill's language needs further 
clarification.
    We appreciate the inclusion of ``family members'' in the definition 
of caregiver. Most individuals and government agencies recognize and 
understand the blood and marriage connection. However, the definition 
of caregiver needs to be expanded to include those who are normally not 
considered a ``member of the family,'' such as a girlfriend, fiancee or 
fiance, and significant other. We frequently hear they are part of the 
caregiver structure. The difference between DoD and VA in regards to a 
caregiver definition and eligibility is important because the choice or 
self selection of the caregiver begins while the wounded, ill, and 
injured servicemember is still on active duty. According to the VA, `` 
`informal' caregivers are people such as a spouse or significant other 
or partner, family member, neighbor or friend who generously gives 
their time and energy to provide whatever assistance is needed to the 
veteran.'' We would like to make sure DoD and VA have the same 
definition of caregiver and the eligibility is broad enough to capture 
additional individuals.
    We believe we also need to know what constitutes a ``caregiver.'' 
We need to have a better understanding of their roles and the scope of 
responsibilities that would allow them to be considered a caregiver? 
This proposal as written would allow for a wide range of caregivers to 
qualify for this benefit and receive medical care.
    Another area of concern involves the provision for the family 
caregiver to not be subject to ``deductibles, premiums, co-payments, 
cost sharing, or other fees for medical care.'' Given the broad 
definition of caregiver, this provision could be very costly for the 
VA. Is the VA adequately funded to provide these services for free? We 
recognize the potential financial strain the caregiver may be under; 
however, we ask about the widow whose husband made the ultimate 
sacrifice. They too have experienced tremendous financial impact 
following the loss of their loved one, but are subject to these fees. 
According to this proposal's language, they would not be eligible for 
this generous benefit.
    Our Association feels we need further clarification on what is 
currently being offered as a medical care benefit for caregivers. For 
example, the National Defense Authorization Act for Fiscal Year 2008 
(NDAA FY08) section 1672 provides for medical care at DoD Military 
Treatment Facilities (MTFs) or VA facilities on a space-available basis 
authorized for certain family members, not otherwise eligible for 
medical care, caring for a recovering servicemember. According to a 
briefing by General Elder Granger, Deputy Director and Program 
Executive Officer for TRICARE Management Activity, on April 13, 2009, 
DoD has implemented this section of the NDAA FY08. This law allows for 
non-emergent care. How has the VA complied with this provision in 
allowing access to care for caregivers? We need to have a better 
understanding of the eligibility and availability of medical care for 
our caregivers before we can identify areas of quality care and where 
gaps still exist.
Provides Travel Expenses for Family Caregivers Accompanying Veterans to 
                                  MTFs
    The National Military Family Association supports this proposed 
legislation to provide travel expenses for family caregivers 
accompanying veterans to MTFs. This proposed legislation recognizes the 
important services the caregiver provides in assisting our 
servicemembers and veterans by acknowledging the fact that the 
caregiver often accompanies the wounded, ill, or injured servicemember 
and veteran to their medical appointments at the various MTFs. Often 
caregivers find themselves having to pay out of their own pockets for 
lodging and other unintended expenses, such as for meals. There are 
many benefits being created by DoD, VA, and Members of Congress to help 
address many of the issues arising from care of our wounded, ill, and 
injured servicemembers and veterans. Our Association appreciates 
everyone's commitment to do the right thing; however, we must be aware 
that these solutions need to be seamless when addressing these 
problems. For example, a benefit created by the DoD to address travel 
expenses should be equal to the one offered by the VA. Our military and 
veteran families do not understand that there are two different 
agencies caring for them. The families, along with the servicemember 
and veterans, should only feel as though there is one system of care. 
On June 17th the House Armed Service Committee approved the NDAA FY10. 
This legislation would provide for travel and transportation assistance 
for three designated persons, including non-family members and enable 
seriously injured servicemembers to use a non-medical attendant for 
help with travel for medical treatment. Our Association recommends 
there be coordination of caregiver travel benefits, making it work 
seamlessly for our wounded, ill, and injured servicemembers, veterans, 
their families, and caregivers.
    Provides Continued Health Care for Certain Vietnam-era Veterans
    The National Military Family Association supports this proposed 
legislation to direct the Secretary of Veterans Affairs to provide, 
without expiration, hospital care, medical services, and nursing home 
care for certain Vietnam-era veterans exposed to herbicide and veterans 
of the Persian Gulf War. This provision recognizes the need for 
uninterrupted medical care for veterans who were exposed to herbicides. 
This legislation also acknowledges the important service these veterans 
provided for our Nation at a time of war.
  Provides Support Services for Family Caregivers of Disabled Veterans
    The National Military Family Association supports the intent of 
this proposed legislation to provide support services for family 
caregivers of disabled veterans. However, our Association would like to 
make a few comments. First of all, we should not be duplicating 
services. Currently, the National Resource Directory established by DoD 
and the Department of Labor provides a Web-based service for obtaining, 
tracking, and maintaining important support services for the caregiver 
and the wounded, ill, and injured servicemember and veteran. This 
service is already being provided and this proposal will be a 
duplication of service.
    We understand the intent to limit the availability for training to 
the current wounded, ill, and injured population. However, we would 
recommend this program be expanded to capture all caregivers of 
veterans regardless of where or when the wound, injury, or illness took 
effect.
    A caregiver curriculum is currently being developed for family 
caregivers of servicemembers and veterans with TBI. This curriculum is 
being created by a panel of experts, per guidance in the NDAA FY07 
section 744. Our Association recommends this caregiver curriculum be 
expanded to cover all types of wounds, illness, and injuries of 
servicemembers and veterans.
                 Conduct a Survey of Family Caregivers
    The National Military Family Association supports this proposed 
legislation to annually conduct a survey of family caregivers of 
disabled veterans. Our Association believes this survey will help the 
VA gain a better understanding of this population. This information can 
then be used to develop and implement better benefits to assist the 
caregivers in performing their duties. However, we recommend the survey 
should capture a wider range of information than what is currently 
included in this proposal. We suggest the survey start with caregiver 
demographics, and include additional items, such as the financial 
impact, identify gaps and successes in the support system, and the 
disruption to the family unit, especially children. Also, the survey 
should capture data on caregivers' experiences with both the VA and DoD 
support programs and benefits. We would also encourage the 
establishment of a panel of experts to help with the survey's design 
and implementation. This panel would consist of, but not be limited to, 
members representing: Veteran Service Organizations; Military Service 
Organizations; caregivers of our wounded, ill, and injured 
servicemembers and veterans; staff from the VA and DoD who work on 
caregiver issues; and members from each of the Services' wounded 
warrior programs.
    The National Military Family Association would like to thank you 
again for the opportunity to provide testimony on proposed legislation. 
We look forward to working with you to improve the quality of life for 
veterans, their families, and caregivers.

                                 
               Prepared Statement of Christopher Needham,
      Senior Legislative Associate, National Legislative Service,
             Veterans of Foreign Wars of the United States
    MR. CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE:
    On behalf of the 2.2 million men and women of the Veterans of 
Foreign Wars of the U.S. and our Auxiliaries, I would like to thank you 
for the opportunity to testify at today's legislative hearing. Before 
us is a wide range of health care related bills, all of which would 
make improvements to the system that benefits America's veterans.
H.R. 1197
    This legislation would change the VA health care enrollment status 
of veterans who were awarded the Medal of Honor. It would put them in 
Category 3, putting them on par with veterans who are former POWs and 
those who were awarded the Purple Heart.
    There is no doubt about the sacrifice and bravery of the recipients 
of the Medal of Honor. They clearly have given everything they could 
for this country and for their fellow service men and women. Changing 
their enrollment status--which would also exempt them from having to 
pay hospital care co-payments--is an acknowledgement of the deep debt 
we as a Nation owe them, and it is a small price to pay for these true 
heroes.
H.R. 1293
    The Disabled Veterans Home Improvement and Structural Alteration 
Grant Increase Act would increase the amounts payable under VA's Home 
Improvement and Structural Alteration (HISA) program. The VFW strongly 
supports this legislation.
    HISA was created to provide funding for home adaptations to allow 
veterans to receive care at home. These grants help make houses more 
accessible through small, but necessary improvements. With the number 
of severely disabled servicemembers returning from Iraq and 
Afghanistan, it is a program that will continue to grow in importance 
and relevance.
    Despite this, Congress has not raised the amount of the grants--
$4,100 for service-connected veterans and $1,200 for those without 
service connections--since 1992. It is time to change that. The 
increases in this bill--to $6,800 and $2,000--reflect an annual 3-
percent increase since the last adjustment and are a step in the right 
direction for what we need to do for these severely injured men and 
women. This small improvement would make a meaningful impact in the 
lives of hundreds of veterans.
H.R. 1302
    This legislation would create a full-time Director of Physician 
Assistant Services to report to the Under Secretary of Health with 
respect to the training, role of, and optimal participation of 
Physician Assistants (PA). We are pleased to support it.
    Congress created a PA Advisor role when it passed the Veterans 
Benefits and Health Care Improvement Act of 2000 (P.L. 106-419). The 
law required the appointment of a PA Advisor to work with and advise 
the Under Secretary of Health ``on all matters relating to the 
utilization and employment of physician assistants in the 
Administration.'' Since that time, however, the Veterans Health 
Administration (VHA) has not appointed a full-time advisor, instead 
appointing a part-time advisor who serves in the role in addition to 
his or her regularly scheduled duties while working in the field, far 
from where VA makes its decisions.
    The current PA Advisor role is likely not what Congress envisioned 
when it created the role, and the PA Advisor has had little voice in 
the VA planning process; VA has not appointed the PA Advisor to any of 
the major health care strategic planning committees.
    With the role that PAs play in the VA health care process, it only 
makes sense to invite their participation and perspective. VA is the 
largest employer of PAs in the country, with approximately 1,600. They 
provide health care to around a quarter of all primary care patients, 
treating a wide variety of illnesses and disabilities under the 
supervision of a VA physician. Since they play such a critical role in 
the effective delivery of health care to this Nation's veterans, they 
should have a voice in the larger process. We urge passage of this 
legislation and the creation of a full-time PA Director position within 
the VA Central Office.
H.R. 1335
    The VFW strongly supports this legislation, which would exempt 
catastrophically disabled veterans from paying certain co-payments. The 
VFW has had a longstanding resolution in support of this concept.
    Veterans who are deemed catastrophically disabled--typically those 
with severe spinal cord injuries--are placed in VA enrollment Category 
4. Despite this enhanced enrollment status, they still must pay a co-
payment for hospital and nursing home care. These men and women require 
complex, specialized health care. The nature of their injuries requires 
frequent, intensive uses of VA services throughout their lifetime as VA 
is typically better positioned to provide care to them than other 
health care facilities and insurance programs.
    Enacting this legislation would reduce the heavy financial burden 
these men and women face. Since we already acknowledge their special 
circumstances by providing them an enhanced health care enrollment 
status, we should exempt them from hospital and nursing home co-
payments as well.
H.R. 1546
    The VFW supports this bill, which would create a Committee on Care 
of Veterans with Traumatic Brain Injury within VA. This committee would 
be a part of the Veterans Health Administration and would be comprised 
of VA employees with expertise in TBI. It would evaluate the care, 
services, gaps in care, and treatment options for veterans suffering 
from TBI, making recommendations to VHA leadership.
    With TBI being described as the signature wound of the war, this is 
the right thing to do. Emphasizing the treatment and study of TBI--
especially in its milder forms--should be a high priority, especially 
because there is much we still do not know about its effects, and these 
men and women are likely to be in the VA system for many years. Getting 
on top of the problem will better allow VA to manage their care and 
improve outcomes.
H.R. 2734
    This legislation would provide medical care to family members who 
serve as caregivers to disabled veterans. The VFW supports this 
measure.
    This bill would give the same level of access to care to these 
family caregivers as is provided to surviving spouses and children of 
disabled servicemembers who die from service-connected conditions. It 
would apply only to those who lack private health insurance. Since most 
private health insurance is provided through a person's employer, and 
being a family caregiver is the family member's full-time job, it 
ensures that they have access to the basic care and services they need 
to lead healthy lives.
    Numerous studies of other caregiver programs have shown that 
caregivers often have more severe health problems than others in their 
peer group. Providing this level of care is a stressful experience that 
affects their mental and physical health, as documented by the 1996 
National Caregiver Survey.
    Giving them access to care and services helps them deal with these 
difficulties, which, in turn, improves the level of care they are 
providing to the disabled veteran.
H.R. 2738
    The VFW is pleased to support this bill, which would provide a 
lodging and subsistence allowance to family caregivers who accompany 
disabled veterans to medical facilities.
    The disabled veterans eligible for the family caregiver program are 
likely to require lifelong care, and many trips to VA. They are 
unlikely to be able to travel alone, and will need their caregiver to 
accompany them. This is a compassionate change in policy that 
recognizes the unique circumstances faced by these veterans and their 
caregivers, and we urge its passage.
H.R. 2770
    The VFW endorses the Veterans Nonprofit Research and Education 
Corporations Enhancement Act. This legislation would make several 
changes, which would strengthen and improve the nonprofit research 
corporations affiliated with VA. These NPCs help VA to conduct research 
and education and assist in the raising of funds for VA's essential 
projects from sources VA otherwise might not have access to, including 
private and public funding sources.
    Included in the legislation is a section that would reaffirm that 
these NPCs are 501(c)(3) organizations that are not owned or controlled 
by the Federal Government. This is important to ensure that they are 
able to receive funding from all intended sources and to clarify their 
purpose in accordance with various State laws or private foundation 
regulations.
    It would also allow for the creation of multi-medical center NPCs 
to streamline and make the administration of these important 
organizations more efficient. Ultimately, this should make more funds 
available for critical research purposes. Additionally, it would 
improve the accountability and oversight of these corporations, 
requiring more information in their annual reports and periodic audits 
of their activities. As these corporations continue to expand, we urge 
continued oversight of their actions to ensure that they continue to 
serve the best interest of America's veterans.
    The legislation would address some of the concerns laid out in the 
recent VAOIG report, ``Audit of Veterans Health Administration's 
Oversight Nonprofit Research and Education Corporations.''
Draft Bill, Family Caregivers Support
    The VFW is pleased to support the draft bill on family caregivers.
    Section 1 of the bill would expand support services for family 
caregivers by providing Internet-based training on caregiver 
techniques, strategies and skills. It would also require the Secretary 
to give access to information from public, private and nonprofit 
agencies that offer support for caregivers, as well as requiring VA to 
perform more outreach so that families are aware of the range of 
services available to them.
    These resources would be of great use to the loved ones of disabled 
servicemembers, and they would provide them with information, 
resources, and personal connections with others dealing with the 
challenges of being a caregivers.
    Section 2 would expand the counseling and mental health services VA 
already provides to immediate family members to any family member who 
provides caregiver services, to include step- and extended-family 
members. This is clearly the right thing to do.
    Section 3 would require VA to provide respite care to assist family 
caregivers. This would help to alleviate the burden on family 
caregivers, giving them a much-deserved break when they need it. It 
also would serve as another incentive for a loved one to provide these 
necessary services to their disabled veteran family member, since they 
know they could receive the occasional break.
Draft Bill, Family Caregivers Survey
    VFW supports the draft bill that would require the VA Secretary to 
conduct an annual survey of family caregivers. The information from the 
survey could be useful to help shape the critical program, allowing VA 
and Congress to make adjustments to better meet the demands of 
critically wounded servicemembers and their families.
Draft Bill, Health Care for Gulf War and Herbicide Exposures
    The VFW supports the draft bill that would indefinitely offer 
hospital care, medical services and nursing home care to certain 
Vietnam-era veterans exposed to herbicides and veterans of the Persian 
Gulf War.
    Both groups have unique health needs that often manifest over a 
lifetime. And there is still much we do not know about the condition of 
these men and women. By eliminating the sunset dates for their 
eligibility for care, we can ensure that these former servicemembers 
will continue to have access to the health care and services they need 
because of the exposures and illnesses they may have encountered during 
their service to this country.
    Mr. Chairman, this concludes my testimony. I would be happy to 
answer any questions that you or the Members of this Subcommittee may 
have.

                                 
                 Prepared Statement of Bernard Edelman,
           Deputy Director for Policy and Government Affairs,
                      Vietnam Veterans of America
    Good morning, Chairman Michaud, Ranking Member Miller, and other 
Members of this distinguished Subcommittee. We appreciate your giving 
Vietnam Veterans of America (VVA) the opportunity to testify today on 
legislation that relates to improving the health care of veterans and 
issues involving their caregivers. And on behalf of the members and 
families of VVA, we thank you for the stellar work this Subcommittee 
has been doing.
    We would like first to comment on H.R. 1197, the ``Medal of Honor 
Health Care Equity Act of 2009.'' VVA supports enactment of this bill 
unequivocally. We would like to offer a bit of commentary as to why.
    Americans are hungry for heroes. We confer this status on people 
who lead their sports teams to championships to the adoration of their 
fans: guys who can throw for 50 touchdowns or run for 2,000 yards in a 
season; guys who can rocket baseballs into the stands 50 times a 
season; guys who score 30 points a game; guys who drive race cars 
really fast. We tend, too, to overuse this term when we honor men and 
women in uniform.
    In reality, all who serve are not heroes. Yes, they don the uniform 
and, during times of war or conflict, put themselves in harm's way. 
Some are killed. Others are wounded, some grievously. Mostly, though, 
they are men and women doing the jobs for which they've been trained 
(and oftentimes doing jobs for which they haven't been trained).
    While this gesture--dubbing them heroes--may be understandable, and 
even commendable, it in some ways diminishes what a hero really is: one 
who puts his (and as more women serve in the military, her) life in 
danger, and sometimes loses it, attempting to protect or save the lives 
of his comrades.
    We have heroes--true heroes--who have met this standard. Their 
heroism, their selfless acts of valor and bravery in the chaos of 
combat, has been acknowledged with the awarding of the Medal of Honor. 
Others who have committed heroic acts have been honored with the Silver 
Star, the Navy Cross, the Distinguished Service Cross.
    These heroes are deserving of our enduring appreciation and honor. 
This is what, in one small way, H.R. 1197 seeks to do. To accord all of 
these men, and women, who obtain their health care from VA facilities 
higher priority status is warranted. We are willing to bet, however, 
that most will not take advantage of this. Humble as most tend to be, 
they will not flaunt a medal to ``get to the head of the line.'' They 
will stand in line, with the rest of their comrades, awaiting their 
turn.
    H.R. 2770, the ``Veterans Nonprofit Research and Education 
Corporations Enhancement Act of 2009.'' This bill, introduced by 
Chairman Filner and Ranking Member Buyer in what we wish was a 
permanent display of bipartisanship, seeks to modify and update 
provisions of law relating to nonprofit research and education 
corporations by facilitating the conduct of research, education or both 
at more than one VA medical center. If enacted, this bill should help 
facilitate research projects, the fruits of which can help not only 
veterans and their families but so many others as well.
    VVA supports passage of H.R. 2770.
    H.R. 1293, introduced by Mr. Buyer and designated the ``Disabled 
Veterans Home Improvement and Structural Alteration Grant Increase Act 
of 2009,'' in effect acknowledges the realities of inflation by 
increasing the amount available to disabled veterans for improvements 
and structural alterations furnished as part of home health services.
    VVA supports the enactment of H.R. 1293.
    As physician assistants have come to play increasingly important 
roles in the Veterans Health Administration, it seems to us a logical 
if somewhat belated effort with H.R. 1302 to establish the position of 
Director of Physician Assistant Services under the Under Secretary of 
Veterans Affairs for Health. As stipulated in this bill, the Director, 
who would be a qualified physician assistant, ``shall be responsible to 
and report directly to the Under Secretary for Health on all matters 
relating to the education and training, employment, appropriate 
utilization, and optimal participation of physician assistants within 
the programs and initiatives of the Administration.'' The last three 
persons to occupy the position of Under Secretary of Health have 
refused to accord Physician Assistants, most of whom are veterans, 
equal prestige and respect with Nurse Practitioners (most of whom are 
not veterans). The reasons are puzzling, and to say the aforementioned 
individuals and their functionaries have been less than honest in 
discussing this issue with Congress, veterans' service organizations, 
and organized labor would be an understatement.
    Whomever President Obama ultimately selects as the next Under 
Secretary of Health must be an individual who will be open, 
transparent, respectful of the clear will of the Congress (as in the 
case of the status of Physician Assistants within the Veterans Health 
Administration), and above all truthful and honest. It is frankly 
shameful that this bill needs to be enacted to get the VHA to act 
decently, honestly, and as common sense would dictate, but this is the 
case.
    VVA applauds Congressman Hare for having introduced this 
legislation, thanks him for his leadership on this and so many other 
issues, and supports its enactment without reservation.
    It is a stark reality that as the military is able to save more and 
more troops who have received catastrophic wounds or injuries on the 
battlefield, more and more veterans will survive who are 
catastrophically disabled. H.R. 1335, introduced by Mrs. Halvorson, 
would prohibit the Secretary of Veterans Affairs from collecting 
certain co-payments and other fees for hospital or nursing home care 
from these veterans.
    This bill is right-minded and forward-thinking. As such, VVA 
endorses for enactment H.R. 1335.
    While we are not thrilled about creating yet another committee to 
focus on yet another facet of combat injury, H.R. 1546, the ``Caring 
for Veterans with Traumatic Brain Injury Act of 2009,'' would meet a 
growing and highly visible need if enacted. As TBI has become the 
``signature wound'' of the fighting in Iraq and increasingly in 
Afghanistan, it has garnered a great deal of attention in the media as 
well as in the medical and veterans' communities. Millions of dollars 
have been appropriated to learn more about it. Is this money being 
spent wisely and well? Which treatment modalities are working? Which 
aren't? What ought to be the role of community-based organizations in 
caring for veterans with such wounds?
    Establishment of a Committee on Care of Veterans with TBI does make 
sense and we commend Congressmen McNerney and Boozman for introducing 
it. However, such a committee should be comprised not only of VA 
employees ``with expertise in the care of veterans with'' TBI. It 
should integrate outside experts with perhaps differing expertise who 
might offer other and perhaps better ideas, along with representatives 
of veteran consumers and their families, who should be appointed by the 
Secretary of Veterans Affairs. Further, VVA recommends that we ensure 
that the operations of this committee are transparent, and that all 
deliberations and notes of this committee be open for public scrutiny.
    As a general comment, the secrecy of the last 8 years, and the 
unwarranted arrogance that has taken hold in the culture of the VA, 
particularly within the VHA, needs to be reversed and transparency, 
full public disclosure, consultation with veterans and veterans' 
advocacy groups, and meaningful measures of accountability must be 
written into all areas. Frankly, it will take the Congress working 
closely in a bi-partisan manner with the new leadership team to undo 
the considerable damage that has been done, and to begin to resurrect 
significant gains and progress that could have been achieved in so many 
areas.
    With these caveats, VVA endorses H.R. 1546.
    H.R. 2734, the ``Health Care for Family Caregivers Act of 2009,'' 
would provide medical care to family members of disabled veterans who 
serve as caregivers to such veterans. As noted above, more and more 
troops who survive catastrophic wounds face life with extraordinary 
needs for medical services and home care. Home care is provided by a 
parent, or a spouse, in some cases a child, in others some other family 
relation, significant other, or other companion. To make life easier 
for these individuals, Mr. Perriello's bill would inure such caregivers 
from ``deductibles, premiums, co-payments, cost sharing, or other fees 
for medical care provided to such caregiver.''
    Even though a family member will take on the burden of caring for 
these veterans out of love and familial obligation, H.R. 2734 would 
provide a small measure of assistance to them. As such, VVA endorses 
this bill.
    H.R. 2738, introduced by Congressman Teague, would also assist 
family caregivers accompanying veterans to medical treatment 
facilities, in this case by paying for ``lodging and subsistence'' as 
well as ``expenses of travel'' to and from such facilities.
    As this seems eminently fair, VVA supports enactment of this bill.
    Two of the three Draft Bills relate to family caregivers. The bill 
that would direct the Secretary of Veterans Affairs to conduct annual 
surveys of such caregivers makes eminently good sense. If properly 
conducted with well-thought-out questionnaires, it can help provide the 
VA with information that will better help caregivers assist the 
veterans for whom they are caring.
    The bill that would ``provide support services for family 
caregivers'' contains some important and viable clauses. One 
potentially valuable clause is (b)(2), which would provide caregivers 
with an Internet-based service containing ``a directory of services 
available at the county level; message boards and other tools that 
provide family caregivers with the ability to interact with each other 
and disabled veterans for the purpose of fostering peer support and 
creating support networks; and comprehensive information explaining 
health-related topics and issues relevant to the needs of disabled 
veterans and family caregivers.''
    We do not, however, agree that to accomplish this, the VA must 
``contract with a private entity.'' This ought to be done in-house, by 
folks with the necessary expertise and technical savvy. To do so will 
eliminate an unnecessary layer of bureaucracy, and a potentially costly 
one at that.
    Similarly, in the ``Information and Outreach'' clause, which would 
direct the Secretary to mount what is in effect a multi-faceted media 
campaign, ought to be done in-house. However, we would advocate that 
such a campaign be coordinated with other VA health care outreach 
efforts. In this realm, we have advocated a major effort by the VA to 
use various media and methods to communicate with veterans and their 
families about health conditions that may have derived from their 
service while in the military and the care and other benefits to which 
veterans are entitled to by virtue of their service. In the past, the 
VA's attempts at outreach have been, to be generous, an embarrassment. 
The VA needs budget lines for its outreach activities, which must go a 
lot further than booklets and brochures in kiosks in VA health care 
facilities, and in-house media productions that are rarely, if ever, 
actually viewed by patients at these facilities.
    We also would encourage this Subcommittee to meld the bills 
relating to family caregivers into a single ``Disabled Veterans Family 
Caregivers Support Act of 2009.''
    It is our understanding that the Draft Bill that would direct the 
VA Secretary ``to provide, without expiration, hospital care, medical 
services, and nursing home care for certain Vietnam-era veterans 
exposed to herbicide and veterans of the Persian Gulf War'' would 
codify in statute what the VA already is doing. The bill would 
basically grant permanent authorization for the VA to provide this care 
for herbicide-exposed Vietnam-era veterans and Gulf War-era veterans 
who have insufficient medical evidence to establish a service-connected 
disability by placing them in Priority Group 6.
    VVA will support this legislation.
    Mr. Chairman, we again thank you for the opportunity to present our 
thoughts before this Subcommittee, and we welcome the opportunity to 
respond to any questions you might have.

                                 
             Prepared Statement of Wounded Warrior Project
    Chairman Michaud, Ranking Member Brown and Members of the 
Subcommittee:
    Thank you for inviting the Wounded Warrior Project (WWP) to provide 
views regarding proposals before the Subcommittee today, and for 
including measures of concern to family caregivers, WWP's highest 
legislative priority. In candor, we are disappointed that H.R. 2342, 
the Wounded Warrior Project Family Caregiver Act, is not among the 
measures under consideration today, as it provides comprehensively for 
the needs of family caregivers. In our view, the Subcommittee's hearing 
of June 4th underscored the importance of family caregiving to the 
well-being and rehabilitation of wounded warriors, and the compelling 
need for comprehensive caregiver assistance, as provided for in H.R. 
2342.
    The Department of Veterans Affairs' Veterans Health Administration 
can have no higher obligation than providing for the treatment, 
rehabilitation, and long-term care needs of veterans who have been 
severely injured in war, including providing these warriors' the 
fullest opportunity for meaningful, productive lives in the community. 
The experience of this war, however, has been unique in exposing gaps 
in the services VA provides. Among the most profound of those gaps is 
the absence of a comprehensive VA program to ensure that family members 
who have given up jobs, lost health insurance, and otherwise sacrificed 
to care for wounded warriors at home have the supports needed to 
sustain that lonely vigil.
             Needs of Family Caregivers of Wounded Warriors
    Each warrior's situation and each family's experience is unique. 
But all face the very real danger that without solid supports 
caregiving will become unsustainable--whether due to utter exhaustion, 
severe interpersonal strain, incapacitating illness, personal 
bankruptcy, or nervous breakdown. And when family caregiving cannot be 
sustained, there may be no other alternative for the veteran than 
institutional care. Such an outcome would not only be tragic for 
wounded warriors and their families, but could become enormously costly 
to the VA health care system which will likely be called upon to care 
for them.
          More Comprehensive Support through Medicaid than VA
    Congress provides for generous programs of support for low-income 
caregivers through Medicaid, notably through what is generally known as 
its Cash and Counseling program. (See Public Law 109-171, section 
6087.) Surely the Department of Veterans Affairs should provide no less 
for family caregivers of severely wounded warriors. These families need 
comprehensive supports, and should not have to impoverish themselves to 
become eligible for a caregiver program.
    We did note VA's June 4th testimony before this Subcommittee that 
it has begun to purchase home care services for family caregivers 
through a partnership with the Administration on Aging (AoA). While a 
positive step in that this may be a helpful option for some families, 
the initiative is being mounted in only a limited number of States. 
Moreover, it offers no assurance that those in greatest need would even 
be accepted into the ``program,'' given that the VA/AoA program 
standards explicitly state that ``Aging Network Agencies can refuse to 
accept veteran participants and their family caregivers when it is 
anticipated that the services required would exceed the scope of the 
Agency's ability to meet the veteran's needs.'' In short, despite this 
initiative, VA has no comprehensive solution to offer wounded warriors' 
family caregivers.
    That program gap is critical given that certain fundamental needs 
must be met to sustain family caregiving. These include basic support 
services:

      an ongoing source of assistance to meet routine, 
specialized, and emergency needs;
      access to needed mental health services;
      provision for age- and medically-appropriate respite 
care;
      provision of needed medical care; and
      some modest level of economic support.

    WWP strongly supports H.R. 2342, the Wounded Warrior Project Family 
Caregiver Act, because it would meet those needs.
                          Proposed Legislation
    We appreciate that several of the proposals under consideration 
today address aspects of caregiving. However, none of those measures, 
individually or collectively, provide the level of support required to 
sustain caregiving for veterans with the kinds of needs identified in 
H.R. 2342.
    Family caregivers from around the country, taking a few precious 
days away from their caregiving roles, will share their experiences 
with legislators next month as they come to the Nation's Capital to 
attend a WWP-sponsored caregiver summit. Most have been caring for 
wounded warriors for years, and would not need the training and 
informational services provided for in the discussion draft bill before 
the Subcommittee. Caregivers already have access to informational 
services addressed in the draft bill, but what they need are 
comprehensive support services that are rarely available in the 
community, and not provided for through VA. Most caregivers would get 
little benefit from other provisions of the draft bill, which (in 
amending relatively limited provisions of law) fall short of providing 
the extent of respite or mental-health support many families need. 
Moreover, the measure would not provide the comprehensive supports so 
critical to sustaining caregiving. In short, while we appreciate the 
effort to help family caregivers, this well-intentioned proposal is not 
a solution.
    VA is certainly remiss in not having systematically compiled 
information on the needs of veterans' caregivers and on the services 
they provide. But while we see no objection to the draft bill that 
proposes an annual survey on family caregiving, we believe enough is 
known about the burdens wounded warriors' caregivers are shouldering--
often full time and with only the most limited respite--that Congress 
can and must move beyond piecemeal measures immediately.
    To illustrate, we appreciate the recognition in H.R. 2734 that 
family caregivers are at increased health risk, and that health 
coverage under the CHAMPVA program is an important, needed support. But 
health coverage, important as it is, is but one of the core needs 
experienced by caregivers of severely wounded veterans. Moreover, the 
bill does not fully answer that need as it would limit this benefit to 
family caregivers of veterans who receive compensation under 
subsections (r) or (s) of section 1114 of title 38, U.S. Code. Yet many 
OIF/OEF veterans with profound service-incurred wounds who require 
full-time personal care receive, or would be entitled to, special 
monthly compensation, but not under those particular provisions of 
section 1114.
    There can be no question that severely wounded veterans continue to 
depend on loved ones for round-the-clock care. While the numbers of 
those veterans is not large, their needs are great--as is the debt we 
owe them. That debt is not discharged simply because the veteran has 
left a hospital and returned to the community and home. We must support 
their rehabilitation and long-term care needs. Surely we best serve 
those veterans--and honor their service--by enabling their families to 
care for them at home.
    We call on the Committee to fill this critical gap by taking up and 
moving H.R. 2342 at the earliest possible date.
    Finally, we welcome the opportunity to supplement this statement in 
the days ahead with additional views on other measures under 
consideration today.

                 POST-HEARING QUESTIONS FOR THE RECORD
                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                      June 22, 2009

Honorable Eric K. Shinseki
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, D.C. 20420

Dear Secretary Shinseki:

    Thank you for the testimony prepared by Dr. Robert A. Petzel, 
Acting Principal Deputy Under Secretary for Health, at the U.S. House 
of Representatives Committee on Veterans' Affairs Subcommittee on 
Health Legislative Hearing that took place on June 18, 2009.
    Please provide answers to the following questions by August 3, 
2009, to Jeff Burdette, Legislative Assistant to the Subcommittee on 
Health.

    1.  Dr. Petzel's testimony noted that the cost of H.R. 1197 is 
insignificant. Does this mean that the cost is estimated to be below 
$500,000? How many living Medal of Honor recipients are there?

    2.  H.R. 1302 would establish a full-time Director of Physician 
Assistant Services, who reports directly to the Under Secretary for 
Health. Which positions currently report directly to the Under 
Secretary for Health? In other words, is there a comparable, full-time 
Central Office position for other health professions? Please provide 
the Committee with a visual organizational chart outlining the 
positions that report directly to the Under Secretary for Health.

    3.  What efforts are being made to recruit and retain physician 
assistants, presently and in the foreseeable future?

    4.  If H.R. 1335 eliminated all co-payments for nursing home care, 
pharmacy, and outpatient care, would VA continue to support this 
proposal?

    5.  How many veterans were enrolled in Priority Group 4 in 2008? Of 
this total, how many were veterans who are catastrophically disabled 
from nonservice-connected causes and have income levels that would have 
placed them in Priority Group 7 or Priority Group 8?

    6.  I have several questions on VA's position on H.R. 2734.
      a.  You note that defining this group as veterans who receive 
special monthly compensation for aid and attendance or homebound care 
may include veterans who do not need caregiver support. Please explain. 
Doesn't aid attendant and homebound care only include veterans who are 
the most severely disabled and cannot function on their own?
      b.  Is there a way of targeting the intended beneficiaries of 
this bill by linking it to the existing disability evaluation system in 
VBA so that VHA does not have to set up a new system for evaluating the 
eligibility criteria for this benefit?
      c.  How many individuals would newly qualify under the provisions 
in H.R. 2734?
      d.  What is your response to VSO recommendations that the 
eligible veteran be redefined to capture more individuals?

    7.  H.R. 2738 authorizes lodging and subsistence payments to family 
caregivers of veterans. Under current law, what services are available 
under the VA's beneficiary travel authority? Who is eligible for these 
services under current law?

    8.  VA has conducted several demonstration projects to provide 
supportive services to family caregivers. Please provide the Committee 
with a brief summary and copies of the detailed reports on what VA 
found from these projects.

    9.  Providing some type of relief and services to the caregiver is 
an issue that every organization on the VSO panel supports. However, 
how to provide this relief and what the benefits should look like has 
been an ongoing discussion for years. Congressional hearings have been 
held on this issue. Despite this intense focus, VA did not provide 
views on two pieces of caregiver legislation, with the stated rationale 
that VA is currently undertaking a comprehensive review of existing 
benefits to determine potential gaps.
      a.  Besides the demonstration projects underway, what else is VA 
doing?
      b.  How is the comprehensive review structured and who is 
responsible for the final recommendations of this review? When will the 
review be completed?
      c.  For the two pieces of caregiver legislation that VA did not 
comment on, why was VA unable to submit views? The Subcommittee would 
like VA's views and cost estimates on these two pieces of legislation.

    10.  VA established the Caregiver Advisory Board in June 2008 to 
develop caregiver assistance programs that address issues facing 
caregivers of veterans. Please provide an update on the activities of 
the Advisory Board, including a summary of the caregiver needs the 
Board identified and any initial recommendations to expand support 
services for caregivers. In addition, please share all internal reports 
and memorandums authorized by this Advisory Board.

    Thank you again for taking the time to answer these questions. The 
Committee looks forward to receiving your answers by August 3, 2009.

            Sincerely,

                                                 MICHAEL H. MICHAUD
                                                           Chairman
                               __________
                        Questions for the Record
               The Honorable Michael H. Michaud, Chairman
      Subcommittee on Health, House Committee on Veterans' Affairs
                             June 18, 2009
                          Legislative Hearing
    Question 1: Dr. Petzel's testimony noted that the cost of H.R. 1197 
is insignificant. Does this mean that the cost is estimated to be below 
$500,000? How many living Medal of Honor recipients are there?

    Response: The Department of Veterans Affairs (VA) estimates that 
the fiscal 2010 cost to provide care to the 17 living Medal of Honor 
recipients currently not already enrolled in or eligible for enrollment 
in a higher VA health care priority group would be $216,520 if all were 
placed in Priority Group 1. According to the official Congressional 
Medal of Honor Society Web site (www.cmohs.org), there were 96 living 
Medal of Honor recipients as of July 2, 2009.

    Question 2: H.R. 1302 would establish a full-time Director of 
Physician Assistant Services, who reports directly to the Under 
Secretary for Health. Which positions currently report directly to the 
Under Secretary for Health? In other words, is there a comparable, 
full-time Central Office position for other health professions? Please 
provide the Committee with a visual organizational chart outlining the 
positions that report directly to the Under Secretary for Health.

    Response: Currently, the Associate Deputy Under Secretary for 
Health for Quality and Safety, the Chief of Staff, the Principal Deputy 
Under Secretary for Health, the Medical Inspector, and the Chief 
Officer for Research Oversight report directly to the Under Secretary 
for Health. The most comparable position to that proposed is the Chief 
Nursing Officer. Section 7306, of title 38, provides that the Director 
of Nursing Service shall report directly to the Under Secretary for 
Health. The Veterans Health Administration's (VHA) Chief Nursing 
Officer reports to the Under Secretary through the Principal Deputy 
Under Secretary for Health. Other clinical care providers, such as 
optometry and podiatry, report to the Chief Officer for Patient Care 
Services, who reports to the Principal Deputy Under Secretary for 
Health. VHA has attached an organizational chart of chief officers, 
current as of June 25, 2009.
    VA would like to note an error in the Department's June 18, 2009, 
testimony on H.R. 1302. The testimony indicated that all clinical 
leadership positions are aligned within the Office of Patient Care 
Services. As illustrated by the attached VHA organizational chart, the 
Chief Nursing Officer reports to the Principal Deputy Under Secretary 
for Health, not Patient Care Services. However, VA remains opposed to 
the proposed realignment of the Director of Physician Assistant 
Services as the position's current placement within Patient Care 
Services provides the necessary access to the Under Secretary for 
Health.

    Question 3: What efforts are being made to recruit and retain 
physician assistants presently and in the foreseeable future?

    Response: VA continues significant efforts to recruit and retain 
physician assistants to meet patient care workload demands. Physician 
assistant recruitment efforts are coordinated by the VA Health Care 
Recruitment and Retention Office. VA recruitment exhibits at major, 
national physician assistant events have proved to be a very effective 
recruitment tool. The Education Debt Reduction Program which assists VA 
employees in repayment of student loans and the Employee Incentive 
Scholarship Program, providing tuition assistance to VA employees who 
wish to obtain advanced degrees are available to physician assistants 
in difficult to recruit areas. VA facilities also have the option of 
requesting special pay rates for physician assistants to offset any 
labor market salary discrepancies. VA continues to explore other 
recruitment and retention initiatives to ensure sufficient numbers of 
physician assistants are available to meet VHA's patient care needs.

    Question 4: If H.R. 1335 eliminated all co-payments for nursing 
home care, pharmacy, and outpatient care, would VA continue to support 
this proposal?

    Response: VA has no objection to eliminating all co-payments for 
those veterans determined to be catastrophically disabled. VA estimates 
that it would incur lost collections amounting to $7.8 million in 
fiscal year (FY) 2010, $7.9 million in FY 2011, $40.5 million over 5 
years, and $85.2 million over 10 years.

    Question 5: How many veterans were enrolled in Priority Group 4 in 
2008? Of this total, how many were veterans who are catastrophically 
disabled from nonservice-connected causes and have income levels that 
would have placed them in Priority Group 7 or Priority Group 8?

    Response: In FY 2008, 237,208 veterans were enrolled in Priority 
Group 4. The number of veterans placed in Priority Group 4 based on a 
catastrophic determination that would have otherwise been placed in a 
Priority Group 7 or 8 based on income is 7,978.

    Question 6(a): I have several questions on VA's position on H.R. 
2734. You note that defining this group of veterans who receive special 
monthly compensation for aid and attendance or homebound care may 
include veterans who do not need caregiver support. Please explain. 
Doesn't aid and attendance and homebound care only include veterans who 
are the most severely disabled and cannot function on their own?

    Response: The statutes regulating entitlement to additional 
compensation based on the need for aid and attendance or housebound 
care are found in subsections (r) and (s) of section 1114 of title 38, 
United States Code. While it is true that subsections (r) and (s) apply 
to veterans with severe injuries or illnesses, VA believes that the 
population of veterans who qualifies for one or both of these benefits 
is not synonymous with the population of veterans that is the focus of 
H.R. 2734 and other pending caregiver legislation.
    The language in subsection (r) concerning aid and attendance 
benefits supports this view. Clause (r)(1) states that veterans 
eligible for regular aid and attendance shall be paid a monthly aid and 
attendance allowance. Clause (r)(2) goes farther and asserts that ``if 
the veteran, in addition to such need for regular aid and attendance, 
is in need of a higher level of care, such veteran shall be paid 
monthly aid and attendance [at a much higher rate].'' Subsection (r) 
then states that ``for the purposes of clause (2) of this subsection, 
need for a higher level of care shall be considered to be need for 
personal health care services provided on a daily basis in the 
veteran's home. . . .'' Therefore, it is VA's position that a veteran 
who qualifies for benefits under clause (1) would not be eligible for 
caregiver benefits, whereas a veteran who qualifies for the higher 
level benefits under clause (2) most likely would be eligible for 
caregiver benefits.
    Subsection (s) relates to eligibility for additional compensation 
based on a veteran's status as housebound. For the purposes of this 
subsection, the requirement of ``permanently housebound'' is considered 
to have been met when the veteran is substantially confined to such 
veteran's house . . . due to a service-connected disability or 
disabilities which it is reasonably certain will remain throughout such 
veteran's lifetime.'' It is VA's view that many veterans who would 
qualify for caregiver benefits would not qualify for housebound 
benefits: for example, veterans who have severe mental disabilities 
resulting from post-traumatic stress disorder (PTSD) or Traumatic Brain 
Injury (TBI). Indeed, in many cases, the need for a caregiver might be 
justified precisely because such caregiver would allow the veteran a 
level of support that would prevent the veteran from having to be 
housebound.
    These examples demonstrate that H.R. 2734 and other caregiver 
legislation should not define an eligible veteran as being one who 
would qualify for either aid and attendance benefits or housebound 
benefits. In the case of subsection (r), eligibility would include 
veterans who should not qualify for a caregiver while restriction to 
subsection (s) qualifications would exclude many veterans who should be 
entitled to a caregiver.

    Question 6(b): Is there a way of targeting the intended 
beneficiaries of this bill by linking it to the existing disability 
evaluation system in VBA so that VHA does not have to set up a new 
system for evaluating the eligibility criteria for this benefit?

    Response: VA believes eligibility criteria for the special monthly 
compensation administered by the Veterans Benefits Administration (VBA) 
are appropriate for financial support decisions but are inappropriate 
for clinical decisionmaking. VA would not need to develop new 
eligibility criteria if factors such as activities of daily living or 
instrumental activities of daily living were used to determine 
caregiver benefits. VA already uses these clinical factors to determine 
eligibility for home maker and home health aide services and other 
benefits through the Geriatrics and Extended Care program, and 
consequently would not need to set up a new system for evaluation. 
Moreover, VA could define severely injured veterans as those in need of 
a higher level of care, due to injury or illness suffered in the line 
of duty, and in the absence of such care, would require 
hospitalization, nursing home level care, or other residential, 
institutional care. This population would include fewer than 2,500 
veterans of all combat eras. The definition suggested above is very 
similar to those receiving special monthly compensation at the R2 level 
under section 1114 of title 38, U.S.C.

    Question 6(c): How many individuals would newly qualify under the 
provisions in H.R. 2734?

    Response: VA estimates that if the legislation is passed as 
written, 47,049 additional beneficiaries would receive Civilian Health 
and Medical Program of VA (CHAMPVA) benefits in FY 2010, increasing to 
60,009 by FY 2019.

    Question 6(d): What is your response to VSO recommendations that 
the eligible veteran be redefined to capture more individuals?

    Response: VA is sensitive to the growing need of veterans for 
caregivers as the population of enrolled veterans continues to age. We 
also understand that, as the population of enrolled veterans increases, 
the costs of caregiver benefits will continue to grow. VA believes 
resources appropriated by Congress for the medical care of America's 
veterans must be used efficiently and effectively to care for those 
with the greatest need. Therefore, we believe that caregiver benefits 
should primarily be provided to caregivers of veterans with certain 
service-connected disabilities.

    Question 7: H.R. 2738 authorizes lodging and subsistence payments 
to family caregivers of veterans. Under current law, what services are 
available under VA's beneficiary travel authority? Who is eligible for 
these services under current law?

    Response: Current VA beneficiary travel regulations at 38 CFR Part 
70 authorize VA to pay for certain travel costs of an attendant when VA 
medically determined that an attendant is required to assist the 
veteran during travel. Benefits include the actual cost of travel 
(unless traveling with the veteran in a shared personal vehicle), and 
lodging and per diem at 50 percent of the area Federal employee rate 
during the actual period of travel. Should a veteran be admitted to a 
VA facility for care following travel and VA determines the veteran no 
longer needs a non-VA attendant, per diem and incidental costs have 
usually been at the caregiver's or attendant's expense.

    Question 8: VA has conducted several demonstration projects to 
provide supportive services to family caregivers. Please provide the 
Committee with a brief summary and copies of the detailed reports on 
what VA found from these projects.

    Response: Section 214 of Public Law 109-461 authorized VA to 
allocate $5,000,000 for FY 2007 and 2008 to carry out a pilot program 
on improvement of caregiver assistive services. VA conducted a robust 
review of 52 applications based on a request for proposals and selected 
8 caregiver assistance pilot programs. These pilots represented 
projects from across the country (including rural areas), different 
patient populations, different clinical needs and different approaches. 
VA designed these pilots to assess the feasibility and advisability of 
various mechanisms to expand and improve caregiver assistance services. 
The caregiver assistance pilot programs were launched in October 2007 
and will end in September 2009. A 1-year extension of the legislative 
authority was approved through Public Law 110-329 Appropriations Act of 
2009. VA will submit its final report to Congress in the first quarter 
of FY 2010 and may replicate or expand successful initiatives in other 
locations. A brief description of each program follows:

    1.  Resources for enhancing Alzheimer's caregiver health (REACH) 
VA. The coordinating site is Memphis, Tennessee.

       Eligibility for participation and description of services 
provided: Caregivers of veterans diagnosed with dementia enrolled in 
home-based primary care. REACH VA is currently piloted in 24 home-based 
primary care programs across the country in 15 States. This program 
provides an intervention translated from a similar, evidence-based 
National Institutes of Health initiative that provides education, 
support and skills building to help caregivers manage both patient 
behaviors and their own stress. In October 2008, REACH VA won the 
Rosalynn Carter Institute Leadership in Caregiving Award.

    2.  Transition assistance program. The coordinating site is 
Gainesville, Florida, while actual pilots are underway at the Stroke 
Centers of Excellence in Houston, Texas, and San Juan, Puerto Rico.

       Eligibility for participation and description of services 
provided: Caregivers of veterans with stroke-related disabilities. 
Caregivers are taking part in a transition assistance program, which 
provides skills training, education and supportive problem solving 
using videophone technology for new stroke patients or patients with 
stroke-related disabilities and their caregivers.

    3.  Use of caregiver advocates to develop, expand and coordinate 
services for veterans' caregivers. The pilots are underway in 
Cincinnati and Dayton, Ohio.

       Eligibility for participation and description of services 
provided: Caregivers of frail impaired veterans at highest risk for 
institutionalization, including veterans with multiple chronic 
conditions such as chronic obstructive pulmonary disease, congestive 
heart failure, hypertension, diabetes mellitus and dementias. Veterans 
Integrated Service Network (VISN) 10 has established a 24/7 hotline 
titled, Caregiver Advocates. Caregiver advocates assist caregivers in 
identifying, accessing and coordinating between VA and existing 
community providers in home-based primary care programs and augmented 
caregiver support services and providing therapeutic interventions to 
the caregiver. This pilot also provides additional hours for adult day 
health care, in-home respite and inpatient respite care.

    4.  VA California Office on Caregiving. VISNs 21 and 22.

       Eligibility for participation and description of services 
provided: Caregivers of veterans with Traumatic Brain Injury (TBI), 
post-traumatic stress disorder (PTSD), or dementia. VA is working with 
a community coalition to provide interventions that support caregivers 
for veterans with TBI, PTSD or dementia across the State of California 
using telehealth, Web, telephone and video tele-conferencing. 
Interventions are provided by VA and the State of California caregiver 
resource centers, the caregiver training program (Powerful Tools), and 
Stanford University's Internet-based caregiver self management program.

    5.  Communicating Effectively with Health Care Professionals. 
Albany, New York.

       Eligibility for participation and description of services 
provided: Caregivers of veterans having a chronic disease and who have 
received care in a VA facility within a period of 12 months prior to 
the start of the study. This pilot program converted a 3-hour workshop 
developed by the National Family Caregivers Association, Communicating 
Effectively with Health Care Professionals, into a DVD and manual. 
Face-to-face workshops have been implemented to offer an additional 
delivery method. If this program proves effective, VA may be able to 
add this content to the My HealtheVet Web site to promote further 
distribution.

    6.  Telehealth Technology to Support Family Caregivers. Atlanta, 
Georgia.

       Eligibility for participation and description of services 
provided: Caregivers to veterans 60 years old or older who have at 
least one chronic illness requiring daily activity of daily living or 
instrumental activity of daily living assistance. Caregivers must live 
with the veteran. This pilot uses a model telehealth program adapting 
Health Buddy devices, which are existing technologies used by VA, to 
provide help and emotional support for caregivers who live in remote 
areas or cannot leave the veteran by him or herself.

    7.  Joint program between the Tampa and Miami medical centers to 
provide support to caregivers of high-risk veterans.

       Eligibility for participation and description of services 
provided: Tampa's existing respite program is being expanded to provide 
24-hour in-home respite care for temporary relief to caregivers (up to 
14 days per calendar year) and emergency respite in local assisted 
living or medical foster care facilities. The Miami program provides 
and coordinates comprehensive community-based care services including 
respite, home companions, adult day care, and use of an emergency 
response system for high risk veterans.

    8.  Heroes of the heart. VA Pacific Islands Health Care System.

       Eligibility for participation and description of services 
provided: Caregivers of veterans who meet the criteria for respite and 
live on the more rural, less populated islands of Hawaii, Kauai and 
Maui in the State of Hawaii. The medical foster home concept is used to 
provide overnight respite for veterans in areas where no other 
inpatient respite options are available, particularly in remote and 
rural service areas. Currently, overnight respite care can only be 
provided at the VA Pacific Islands Health Care System Center for Aging 
in Honolulu or in contract nursing homes located on Oahu.

    Question 9(a): Providing some type of relief and services to the 
caregiver is an issue that every organization on the VSO panel 
supports. However, how to provide this relief and what the benefits 
should look like has been an ongoing discussion for years. 
Congressional hearings have been held on this issue. Despite this 
intense focus, VA did not provide views on two pieces of caregiver 
legislation, with the stated rationale that VA is currently undertaking 
a comprehensive review of existing benefits to determine potential 
gaps. Besides the demonstration projects underway, what else is VA 
doing?

    Response: VA is committed to providing clinically appropriate home 
health care services as an integral component of medical care services. 
VA provides in-home services to enhance or build a comprehensive array 
of resources necessary to address the short-term or long-term care 
needs of enrolled veterans. All enrolled veterans are eligible for a 
comprehensive array of medically necessary in-home services as 
identified in VA's medical benefits package (see title 38 CFR 
17.38(a)(1)(ix)). These in-home services support the caregiver in 
meeting the needs of the veteran whose desire is to remain in his or 
her own home setting. Below is a description of the Veterans Health 
Administration (VHA) and VBA programs that support caregivers.

----------------------------------------------------------------------------------------------------------------
                                      Eligibility for       Description of Services
         Name of Program               Participation               Provided              Provision of Services
----------------------------------------------------------------------------------------------------------------
Respite Care                          Enrolled    Of limited duration     Provided in CLCs
                                               veteran          Inpatient (CLC,and adult day health care
                                       Chronic   acute or community facility)         Contract:
                                             condition          Home respite        nursing homes, home
                                     Caregiver      Adult day health     health agencies, adult
                                     who needs respite                          care            day health care
----------------------------------------------------------------------------------------------------------------
Volunteer                             Enrolled     Volunteer program    Volunteer base,
                                               veteran                                                     with
 Home Res-                                                       providing full-time         training materials
 pite Care                                                       caregivers break to         provided by Senior
                                                             perform required duties      Companion Program and
                                                          outside home or for needed        American Red Cross.
                                                                               break   Program is operational in
                                                           Recently expanded      8 sites, with over 60
                                                            to include buddy program      service organizations
                                                            matching volunteers with   briefed on the program to
                                                             veterans. Provides sup-         generate potential
                                                             portsystemandadditional                 volunteers
                                                               services outside home
----------------------------------------------------------------------------------------------------------------
Home Based                            Enrolled         Education and    Provided by VHA
                                               veteran                   training on                      staff
 Primary                                                      care needs of veterans      at 131 facilities and
 Care                                                       Caregiver burden assess-       more than 90 CBOCs *
                                                           ment annually and
                                                         follow up with resources as
                                                                           indicated
----------------------------------------------------------------------------------------------------------------
Adult Day                             Enrolled    Alternative setting         Currently
                                               veteran                           for                provided on
 Health Care                          who would other-                  respite care       campus of 21 VAMCs *
 (ADHC)                               wiserequirenurs-     Caregiver support            VA also
                                         ing home care   and education (e.g., instruc- contracts with community
                                                              tion on managing chal-     providers in locations
                                                           lenging behaviors of vet-    where the VAMC does not
                                                             erans with Alzheimer's)         have onsite ADHC *
----------------------------------------------------------------------------------------------------------------
Veteran                               Enrolled    Budget provided by                   Local VAMC
                                               veteran                         local
 Directed                                                       area agency on aging       agreement with local
 Home and                                                        (AAA) to veteran to         AAA to arrange for
 Community                                                      purchase own support       home care of veteran
 Based Care                                                                 services
                                                           AAA provides case
                                                               management and fiscal
                                                         intermediary to assist with
                                                                purchase of services
----------------------------------------------------------------------------------------------------------------
Home-maker/                           Eligible     Provides personal    Contracted home
                                               veteran                          care
 Home                                who is in need of       and supportive services        health agency (HHA)
 Health                              nursing home care                                  Employee of HHA
                                                                                        can be family caregiver
----------------------------------------------------------------------------------------------------------------
Temporary                              Veteran               Persons    VHA with support
                                                  with                  accompanying
 Lodging                                appointment at         veterans receiving VA     from service and other
 and Fisher                                 VA medical           medical care or C&P         volunteer agencies
 Houses                                    facility to            exams are provided
                                               receive
                                        health care or         temporary lodging and
                                        compensation &   support. Provided in Fisher
                                   pension (C&P) exam &     Houses, non-used beds in
                                   family member of vet-        medical center or at
                                    eran or person ac-       community hotels/motels
                                   companying vet- eran
                                            to provide
                                         equivalent of
                                      familial support
----------------------------------------------------------------------------------------------------------------
Home Im-                              Enrolled     Amount $4,100 for        VHA benefit
                                              veterans                          most
 provement                                                         service-connected
 and Struc-                                                 veterans, $1,200 for all
 tural Alter-                                                other enrolled veterans
 ations
----------------------------------------------------------------------------------------------------------------
Beneficiary                           Eligible               Mileage         VHA travel
                                              veterans                 reimbursement                    related
 Travel                              & attendant under               Special              reimbursement
                                               certain   transportation reimbursement
                                         circumstances
----------------------------------------------------------------------------------------------------------------
Special                               Service-    Can be used 3 times       VBA benefit
                                             connected                         for a
 Adaptive                                 veterans who       lifetime max of $60,000
 Housing                                  meet special    Veteran must be on
                                              criteria             deed for the home
----------------------------------------------------------------------------------------------------------------
Special                               Service-      Provides $12,000        VBA benefit
                                             connected                           for
 Housing                              veterans meeting        temporary or permanent
 Adaptation                           special criteria                       housing
                                    Active Duty
----------------------------------------------------------------------------------------------------------------
Service-                            Active Duty    Payments of up to        VBA benefit
 members                              participating in       $100,000 according to a
 Group Life                             Servicemembers         schedule of traumatic
 Insurance                                      Group Life                  injuries
 Traumatic                                   Insurance
 Injury
 Protection
 (TSGLI)
----------------------------------------------------------------------------------------------------------------
Automobile                          Veteran and       1 time benefit        VBA benefit
                                                                          automobile
 Grant                                  servicemembers      grant up to $11,000 paid
                                          with certain                     to seller
                                          disabilities
----------------------------------------------------------------------------------------------------------------
* Acronyms: CLC, community living center; VAMC, VA medical center; CBOC, community-based outpatient clinic;
  ADHC, adult day health care

    Question 9(b): How is the comprehensive review structured and who 
is responsible for the final recommendations of this review? When will 
the review be completed?

    Response: A VA caregiver support task force has been chartered by 
the Office of Patient Care Services to develop a comprehensive model 
for caregiver support across VHA. VA has implemented multiple programs 
and services throughout the Department to address the needs of 
caregivers. VA recognizes there is a need to better orchestrate 
efforts, to establish a process to identify gaps, and to identify core 
characteristics of a comprehensive model for caregiver support. The 
caregiver support task force will develop an integrated approach to 
caregiver support that encompasses all practice areas. The caregiver 
support task force review and recommendations will be completed by 
October 2009 for submission to VA senior leadership. The taskforce, 
with support from other program offices in VA, has also developed 
proposals for expanding benefits to caregivers of veterans severely 
injured in the line of duty who would otherwise require institutional 
care. VA estimates this population would include fewer than 2,500 
veterans of all eras. These benefits would include travel and lodging 
benefits, support services, and a triennial survey of caregivers. In 
light of the current Federal efforts regarding comprehensive health 
care reform, VA believes any proposals in this area may duplicate 
coverage for individuals who may soon be granted such access without VA 
incurring responsibility for caregiver medical services.
    For the caregiver assistance pilot programs, a comprehensive review 
is structured through the Caregiver Advisory Board, which is chaired by 
the Caregiver Support Program Manager. Two subcommittees of the 
Caregiver Advisory Board have been developed to start preliminary 
comprehensive reviews of the caregiver assistance pilot programs to 
assess the feasibility and advisability for nationwide implementation 
and to review their final fiscal 2009 budgets. The Caregiver Support 
Program Manager is responsible for the final recommendations, which 
will be completed by November 30, 2009. A final report of the caregiver 
assistance pilot programs will be written at this time and sent to 
Congress by December 31, 2009.

    Question 9(c): For the two pieces of caregiver legislation that VA 
did not comment on, why was VA unable to submit views? The Subcommittee 
would like VA's views and cost estimates on these two pieces of 
legislation.

    Response: VA was unable to provide views on the two draft pieces of 
legislation because they were received later than the initial docket of 
bills included in the Subcommittee's invitation letter and the 
Administration was unable to fully analyze these issues in time. Below 
is VA views and cost estimates on the two caregiver bills.
Views on Two Caregiver Bills (H.R. 2898 Supportive Services and Annual 
                                Survey)
    H.R. 2898: Supportive Services for Family Caregivers. H.R. 2898 
would add a new section 1786 to title 38 to provide support services 
for family caregivers. The term ``family caregiver'' is defined as a 
member of the disabled veteran's family (including parents, spouses, 
children, siblings, step-family members, and extended family members) 
who provide caregiver services to the disabled veteran. Section 1 of 
the bill would require the Secretary to make interactive training 
sessions available for family caregivers and individuals who support 
such caregivers. Such training must be available both in person and via 
the Internet and should incorporate telehealth technologies to the 
extent practicable. The bill provides that it should also teach 
techniques, strategies and skills for caring for a disabled veteran 
including effective methods for caring for veterans with PTSD, TBI, or 
who deployed in support of Operation Enduring Freedom or Operation 
Iraqi Freedom.
    In addition, section 1 would require the Secretary to provide 
family caregivers with information concerning public, private, and 
nonprofit agencies that support caregivers. In providing this 
information, the Secretary would be required to collaborate with the 
Assistant Secretary for Aging for the Department of Health and Human 
Services and contract with a private entity to provide family 
caregivers an Internet-based directory of services at the county level, 
message boards and other tools to allow caregivers to interact with 
each other and disabled veterans, as well as comprehensive information 
explaining health-related topics and issues relevant to the caregivers' 
needs.
    Pursuant to the bill, the Secretary would also be required to 
conduct outreach to inform disabled veterans and their families about 
these caregiver support services. The outreach must include public 
service announcements, brochures, social networking sites, the VA Web 
site and methods which target rural families.
    Section 2 of the bill would also amend 38 U.S.C. 1782 to make 
family caregivers eligible for counseling and mental health services. 
Section 3 would amend 38 U.S.C. 1720B to allow the Secretary to provide 
respite care to veterans who receive care from a family caregiver.
    Before discussing our views on each of the sections, we must again 
note our concern with the narrow definition of ``family caregiver.'' 
This definition applies to all three sections of the bill.
    VA supports the concepts outlined in section 1 of the legislation 
but does not support this provision as written because it is too 
prescriptive. Section 1 requires VA to conduct outreach and information 
sharing in specific means and through defined media, while an alternate 
draft bill would require VA to conduct an annual survey of caregivers 
to determine their needs. The results of this survey may provide 
evidence that VA should adopt methods of outreach different than those 
identified in this legislation. We agree that VA must do more to use 
technologies and existing networks, but the agency should not become 
committed in law and restricted to only specific approaches. We believe 
an adaptive and responsive campaign will be the most effective way to 
reach the changing demographics and needs of veterans and their 
caregivers. We estimate the cost of section 1 to be $64.5 million in FY 
2010, $68.5 million in FY 2011, $364.9 million over 5 years and $854.7 
million over 10 years.
    VA supports the concept behind section 2. This section would extend 
counseling and mental health services to family caregivers. We 
recognize that last year Congress expanded VA's authority to provide 
mental health care as well as marriage and family counseling to the 
members of the immediate family, the legal guardian of a veteran, and 
the individual in whose household such veteran certifies an intention 
to live. Care may only be provided under this authority as necessary in 
connection with the treatment of the veteran. Section 2 would expand 
this principle to include family caregivers as potentially eligible 
participants. VA estimates that there would be no significant 
additional costs associated with section 2 or H.R. 2898. We note that 
H.R. 2734 would allow VA to satisfy both the mental and physical health 
care needs of primary family caregivers through CHAMPVA.
    VA supports section 3, which would extend eligibility for respite 
care to veterans receiving services from a family caregiver. VA 
believes this authority would largely duplicate existing authorities, 
as any veteran with another caregiver would already receive these 
services. As such, VA anticipates there would be no significant costs 
associated with this proposal.
    Discussion Draft: Annual Survey of Caregivers. This discussion 
draft would require the Secretary to conduct an annual survey of family 
caregivers to determine the number of family caregivers, the range of 
caregiver services provided by family members, the amount of time spent 
providing such services and the support services needed by family 
caregivers. The draft would also require the Secretary to report to 
Congress the findings of the survey as well as a summary of the 
services available to family caregivers, the number of family 
caregivers receiving such services, and the cost of each service. The 
term ``family caregiver'' in this draft is limited to members of the 
disabled veteran's family (including parents, spouses, children, 
siblings, step-family members, and extended family members) who provide 
caregiver services to the veteran for their disability.
    VA supports this bill in concept but recommends the survey be 
required less frequently. VA has previously testified that the exact 
number of caregivers is currently unknown, but that caregivers fill an 
important role. Receiving such feedback from family caregivers would 
provide important insights into their needs and help us better care for 
severely injured or ill veterans. This legislation would ensure VA 
monitors and identifies caregiver needs and would provide valuable data 
to help VA better develop, enhance, or implement programs benefiting 
caregivers and veterans. However, we would like to note that the 
definition of ``family caregiver'' is quite narrow and will exclude 
veterans who may not have family members available to serve as 
appropriate caregivers. VA would prefer a broader definition that would 
allow a veteran to select the appropriate caregiver of his or her 
choice, including non-family members. We estimate the cost of this 
provision to be $930,000 for FY 2010, $1.4 million for FY 2011, $9.8 
million over 5 years, and $21.56 million over 10 years.

    Question 10: VA established the Caregiver Advisory Board in June 
2008 to develop caregiver assistance programs that address issues 
facing caregivers of veterans. Please provide an update on the 
activities of the Advisory Board, including a summary of the caregiver 
needs the Board identified and any initial recommendations to expand 
support services for caregivers. In addition, please share all internal 
reports and memoranda authorized by this Advisory Board.

    Response: The Caregiver Advisory Board has been focusing much of 
its time on reviewing the caregiver assistance pilot programs, 
determining program needs including infrastructure, and building 
relationships with partners internal to VA with other Federal agencies 
and national caregiver advocacy and support organizations. Legislative 
proposals by Congress will also play a key role in how programs and 
support services for caregivers are shaped.

                                 

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                      June 24, 2009

Honorable Eric K. Shinseki
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

Dear Mr. Secretary:

    On Thursday, June 18, 2009, the Subcommittee on Health held a 
legislative hearing and received testimony from Dr. Robert Petzel, 
Acting Principal Deputy Under Secretary for Health. As a followup to 
the hearing, I request that you respond to the following questions in 
written form for the record:

    1.  Already in existence are the Defense Center of Excellence for 
Psychological Health and Traumatic Brain Injury (TBI) and the Defense 
and Veterans Brain Injury Center (DVBIC). DVBIC devotes significant 
resources to its mission of providing education on the prevention, 
treatment and rehabilitation of TBI. A DoD/VA workgroup recently 
released clinical practice guidelines for the management of concussive 
and mild TBI. Specifically, what advice and recommendations would a TBI 
Committee, as required in H.R. 1546, provide that is not currently 
being provided through existing resources?

    2.  One of the concerns with TBI is that it has co-morbidities, 
including post-traumatic stress disorder (PTSD) and visual impairments. 
Would the responsibilities of the committee that would be established 
in H.R. 1546 include assessing care for co-morbid conditions?

    3.  The Vietnam Veterans of America (VVA) testified that the 
organization is ``not thrilled about creating yet another committee to 
focus on yet another facet of combat injury.'' Please respond to this 
concern.

    4.  H.R. 2734 would establish a new health care benefit under the 
Civilian Health and Medical Program of the Department of Veterans 
Affairs (CHAMPVA) for ``primary'' family caregivers. Would it make 
sense to carry out a study to have a better understanding of the 
eligibility, availability, and health care service gaps of family 
caregivers before enacting this legislation?

    5.  The average length of time that an eligible veteran may need a 
primary caregiver can vary and a family caregiver could change 
throughout the course of a veteran's life. Would H.R. 2734 obligate VA 
to continue CHAMPVA coverage for a family caregiver that may no longer 
be the veteran's family caregiver?

    6.  H.R. 2734 would exempt family caregivers from co-payments and 
cost sharing as other CHAMPVA beneficiaries are required to pay, 
resulting in family care- givers having a greater benefit 
than the current CHAMPVA beneficiaries. What administrative, equity and 
other challenges would this create for CHAMPVA?

    7.  H.R. 2734 would allow a broad array of family caregivers to 
qualify for this benefit. Please describe in detail the obligations and 
implementation challenges this legislation would create for the 
Department.

    8.  Does H.R. 2734, in your view, provide an appropriate definition 
of ``primary family caregiver?'' If not, how would you recommend 
defining this term?

    9.  In your view, would it be prudent to require that a family 
caregiver also have a ``medical power of attorney'' to be eligible for 
benefits under H.R. 2734? If so, why? If not, why not?

    10.  H.R. 2734 limits eligibility to caregivers of veterans 
receiving aid and attendance (38 U.S.C. 1114 (r)), or entitled to the 
highest rate of Special Monthly Compensation (38 U.S.C. 1114 (s)), and 
have no other health care coverage. What is the purpose of providing 
aid and attendance and the special monthly compensation?

    11.  What challenges would VA face in implementing H.R. 2734?

    12.  Section 1672 of Public Law 110-181, provides for medical care 
for certain family members caring for a wounded warrior that are not 
otherwise eligible for medical care on a space-available basis in 
military treatment and VA facilities. What and how much care has VA 
provided in compliance with the law?

    13.  What are the current beneficiary travel benefits for a veteran 
traveling to a medical center for care and benefits for an attendant 
traveling with the veteran?

    14.  H.R. 2738 would allow VA to prescribe regulations to limit the 
number of attendants and require that certain travel services be used. 
However, it does not allow VA the authority to prescribe eligibility 
regulations based on the need for a caregiver to accompany a veteran. 
Would H.R. 2738 allow a veteran to travel to a VA medical center with 
both an attendant and a family caregiver? Should there be limits on the 
length of time a family caregiver could receive this benefit?

    15.  H.R. 2738 would require VA to provide ``lodging and 
subsistence'' to eligible family caregivers. How would VA implement the 
subsistence requirement--would VA pay a per diem similar to that which 
is provided to Federal employees on official travel?

    16.  In your view, would H.R. 2738 require VA to provide an 
eligible family caregiver lodging and subsistence if the veteran is 
receiving inpatient treatment?

    17.  Section 744 of Public Law 109-364 required VA and DoD to work 
together to develop a training curricula for family caregivers of 
veterans with TBI. What is the status of this curriculum? When should 
Congress expect to receive the report this law also requires? What 
challenges did you face in developing this training?

    18.  H.R. 2898 would require VA to provide family caregivers such 
consultation, professional counseling, marriage and family counseling, 
training and mental health services as are necessary in connection with 
that treatment. Please describe in detail the type and extent of 
services VA would be providing under this requirement.

    19.  The National Resource Directory was created in collaboration 
with DoD, VA, and the Department of Labor. The Directory is a Web-based 
center of resources for wounded warriors and veterans and includes 
maintaining important support and training services for family 
caregivers. Would certain requirements under section 1 of H.R. 2898 
duplicate the purpose of the National Resource Directory? Should 
certain requirements under section 1 of the bill be changed to enable 
servicemembers and veterans to have a centralized resource to further 
our goal of achieving a true seamless transition?

    20.  H.R. 2898 would require VA to make available interactive 
training sessions for family caregivers. Is it your view that the bill 
would allow VA to meet this requirement using an independent entity 
with expertise in training to meet this requirement?

    21.  A draft bill would require VA to conduct a survey of family 
caregivers. Would this proposal capture the information that you 
believe would be beneficial to developing better policies for family 
caregivers?

    22.  Regarding the draft bill to conduct a survey of family 
caregivers, please respond to the following recommendations included in 
the National Military Family Association Statement for the Record of 
June 18, 2009: ``However, we recommend the survey should capture a 
wider range of information than what is currently included in this 
proposal. We suggest the survey start with caregiver demographics, and 
include additional items, such as the financial impact, identify gaps 
and successes in the support system, and the disruption to the family 
unit, especially children. Also, the survey should capture data on 
caregivers' experiences with both the VA and DoD support programs and 
benefits. We would also encourage the establishment of a panel of 
experts to help with the survey's design and implementation. This panel 
would consist of, but not be limited to, members representing: Veteran 
Service Organizations; Military Service Organizations; caregivers of 
our wounded, ill, and injured servicemembers and veterans; staff from 
the VA and DoD who work on caregiver issues; and members from each of 
the Services' wounded warrior programs.''

    The attention to these questions is much appreciated, and I request 
that they be returned to the Subcommittee on Health no later than close 
of business, 5:00 p.m., Friday, July 3, 2009. If you or your staff have 
any questions, please contact Dolores Dunn, Republican Staff Director 
for the Subcommittee on Health, at 202-226-1293.

            Sincerely,

                                                        Henry Brown
                                          Ranking Republican Member
                               __________
                        Questions for the Record
               The Honorable Henry Brown, Ranking Member
      Subcommittee on Health, House Committee on Veterans' Affairs
                             June 18, 2009
                          Legislative Hearing
    Question 1: Already in existence are the Defense Center of 
Excellence for Psychological Health and Traumatic Brain Injury (TBI) 
and the Defense and Veterans Brain Injury Center (DVBIC). DVBIC devotes 
significant resources to its mission of providing education on the 
prevention, treatment and rehabilitation of TBI. A DoD/VA workgroup 
recently released clinical practice guidelines for the management of 
concussive and mild TBI. Specifically, what advice and recommendations 
would a TBI Committee, as required in H.R. 1546, provide that is not 
currently being provided through existing resources?

    Response: The Department of Veterans Affairs (VA) Committee on Care 
of Veterans with Traumatic Brain Injury (TBI) to be established by H.R. 
1546 would specifically advise the Secretary of up-to-date information 
on optimizing the quality of clinical care, maintaining superior 
training programs in TBI-specific specialties, providing contemporary 
education to the field in TBI rehabilitation advances, and recommending 
research priorities for the Department. The Committee would be 
comprised of VA employees from multiple specialty areas of care with 
expertise in TBI, including: physical medicine and rehabilitation, 
neurology, mental health, care management and social work, telehealth, 
readjustment counseling, public health, research and development, and 
academic affiliations. This interdisciplinary structure would 
facilitate support for veterans across the entire VA health care system 
and would serve as a consultative body with specific and direct 
knowledge of VA's benefits and services. Representatives from 
Department of Defense (DoD) and the civilian sector, who represent a 
broad national perspective on the care needs and are recognized as 
experts in TBI rehabilitation, could also be used to provide input to 
VA as requested.
    The Defense and Veterans Brain Injury Center and the Defense Center 
of Excellence for Psychological Health and TBI fulfill important but 
complementing roles. The DVBIC's mission is to serve active duty 
military, their dependents and veterans with TBI through state-of-the-
art medical care, innovative clinical research initiatives and 
educational programs. The Defense Center of Excellence for 
Psychological Health and TBI's mission is to assess, validate, oversee 
and facilitate prevention, resilience, identification, treatment, 
outreach, rehabilitation and reintegration for psychological health and 
TBI to ensure DoD meets the needs of the Nation's military communities, 
warriors and families.

    Question 2: One of the concerns with TBI is that it has co-
morbidities, including post-traumatic stress disorder (PTSD) and visual 
impairments. Would the responsibilities of the committee that would be 
established in H.R. 1546 include assessing the care for co-morbid 
conditions?

    Response: Yes. The VA TBI/polytrauma system of care (PSC) 
represents the largest system of treatment and management for TBI in 
the United States. VA is currently using the knowledge and experience 
of interdisciplinary TBI experts within this system of care to evaluate 
and stratify the assessment, treatment, and investigation of co-
occurring symptoms with TBI, such as post-traumatic stress disorder 
(PTSD), depression, chronic pain, and other symptoms. This committee 
can readily assume responsibility for overseeing this effort.

    Question 3: The Vietnam Veterans of America (VVA) testified that 
the organization is ``not thrilled about creating yet another committee 
to focus on yet another facet of combat injury.'' Please respond to 
this concern.

    Response: VA greatly values the opinion of Vietnam Veterans of 
America (VVA) and is pleased to respond to the concerns. TBI is a high 
priority program for VA, Congress, and the American public. TBI-related 
impairments and disability significantly impact a large number of 
veterans, and the previous Vietnam Head Injury Study represents one of 
the largest medical investigations conducted for that cohort of 
veterans. Improved trauma care and an aging population are resulting in 
increasing numbers of veterans who sustain TBI and have long-term 
survival. Other conditions and problems that frequently co-occur with 
TBI (such as PTSD and chronic pain) can readily lead to increased 
probability for secondary problems, such as depression, substance 
abuse, coping problems, and social integration problems. Also, the 
science of TBI management is a rapidly growing field that requires 
rigorous clinical, research and academic collaboration. As previously 
explained, the multi-disciplinary VA Committee on Care of Veterans with 
TBI not only would facilitate better understanding of the complexities 
and medical effects of TBI, but also focus efforts on addressing these 
secondary and co-occurring issues.

    Question 4: H.R. 2734 would establish a new health care benefit 
under the Civilian Health and Medical Program of the Department of 
Veterans Affairs (CHAMPVA) for ``primary'' family caregivers. Would it 
make sense to carry out a study to have a better understanding of the 
eligibility, availability, and health care service gaps of family 
caregivers before enacting this legislation?

    Response: VA acknowledges there are many issues related to family 
caregivers, including their access to available health care coverage, 
where more information is needed. VA agrees that a study to have a 
better understanding of the eligibility, availability, and health care 
service gaps of family caregivers before enacting this legislation 
would be helpful to determine the impact of increased access and scope 
of eligibility for family caregivers.

    Question 5: The average length of time that an eligible veteran may 
need a primary caregiver can vary and a family caregiver could change 
throughout the course of a veterans' life. Would H.R. 2734 obligate VA 
to continue CHAMPVA coverage for a family caregiver that may no longer 
be the veteran's family caregiver?

    Response: It is unclear to VA if the intent of H.R. 2734 would 
require VA to continue CHAMPVA coverage for a family caregiver that may 
no longer be the veteran's family caregiver, or how many family 
caregivers a severely injured veteran could elect at one time or over a 
period of time. It is similarly unclear if CHAMPVA benefits would 
continue if a veteran died or no longer needed caregiver services. VA 
believes these issues would require further study, and either need to 
be resolved through regulations or through amendment to the legislation 
to properly define and limit the scope of this benefit to those with 
genuine need.

    Question 6: H.R. 2734 would exempt family caregivers from co-
payments and cost sharing as other CHAMPVA beneficiaries are required 
to pay, resulting in family caregivers having a greater benefit than 
the current CHAMPVA beneficiaries. What administrative, equity and 
other challenges would this create for CHAMPVA?

    Response: VA is concerned that H.R. 2734 would result in equity and 
administrative challenges. CHAMPVA is a cost-sharing program. H.R. 2734 
specifies family caregivers would not be subject to the same 
deductibles, premiums, co-payments, cost-sharing and other fees for 
medical care that are available to the existing population. The 
language in the legislation provides the family caregiver a benefit 
that the dependent children, spouse, or surviving spouse of permanently 
and totally disabled veterans or those veterans who died as a result of 
their service-connected disability do not have. VA recommends there be 
parity of benefits for the family caregivers and the existing program 
beneficiaries, rather than preferential benefits for family caregivers.
    VA is also concerned about the lack of clarity concerning whether 
or not benefits expire if a veteran identifies a new caregiver or if a 
veteran no longer requires caregiver services. If only one family 
caregiver is eligible for benefits at a time, there would be some 
administrative burden to VA in designating a new beneficiary if the 
veteran switches caregivers. The legislation as written does not limit 
the veteran's ability to change caregivers. VA believes that for such a 
mechanism to work properly, veterans should be provided a periodic 
opportunity to identify a new caregiver, except for cases of patient 
safety or well-being, when a veteran should be allowed to immediately 
identify a different caregiver. Additionally, when a new caregiver is 
identified, CHAMPVA benefits should end for the previous caregiver and 
begin for the newly appointed caregiver. This approach would balance 
the interests of the veteran, the caregiver and VA.

    Question 7: H.R. 2734 would allow a broad array of family 
caregivers to qualify for this benefit. Please describe in detail the 
obligations and implementation challenges this legislation would create 
for the Department.

    Response: As noted above, VA is concerned with an open-ended 
commitment to an identified caregiver, even if the veteran later 
selects another person to perform as his or her caregiver. VA believes 
a system that allows veterans a periodic opportunity to select a new 
caregiver, much like an open season for selecting new health insurance 
benefits available to employers, would facilitate the administration of 
this program and allow veterans and caregivers sufficient flexibility. 
This would also not be as administratively burdensome as an at-will 
assignment of caregivers where a veteran could change caregivers 
whenever and as often as he or she pleased. VA believes that veterans 
who qualify should have equal latitude in determining their appropriate 
caregiver, be it a family member or non-family member. This latitude 
would not be unduly burdensome to VA.

    Question 8: Does H.R. 2734, in your view, provide an appropriate 
definition of ``primary family caregiver?'' If not, how would you 
recommend defining this term?

    Response: VA is concerned the definition of ``family caregiver'' 
included in H.R. 2734 is too narrow as it limits the scope of possible 
caregivers to a veteran's family. VA is concerned such a limitation 
would unfairly disadvantage veterans who do not have available or 
appropriate family members for their day-to-day care, but are in need 
of caregiver services, or veterans whose family members are unable or 
unwilling to participate as the veteran's primary caregiver. Caregiver 
services sometimes involve intimate care that a veteran may be 
unwilling to have a family member perform.
    VA recommends defining eligible caregivers as the spouse, dependent 
child of a veteran, parent, legal guardian, or other as determined by 
the veteran (including an individual in whose household a veteran 
certifies an intention to live).

    Question 9: In your view, would it be prudent to require that a 
family caregiver also have a ``medical power of attorney'' to be 
eligible for benefits under H.R. 2734? If so, why? If not, why not?

    Response: VA does not believe requiring a family caregiver to have 
medical power of attorney is appropriate. We understand the Committee 
is interested in ensuring caregivers are invested in the treatment and 
well-being of the veteran, but this recommendation is unnecessary for 
that purpose. A medical power of attorney is often given to a family 
member in a position to make the hard health care decisions required 
for health care providers to care for a family member. However, this 
family member is not always the individual taking care of the veteran 
on a daily basis. A veteran could prefer a situation where one family 
member provides caregiver services and another holds medical power of 
attorney. VA believes it is not prudent to require a family caregiver 
to also have a medical power of attorney to be eligible for benefits 
under H.R. 2734. To do so would place a veteran in the position of 
choosing a benefit for his family caregiver over another family member 
who, in the veteran's opinion, would best represent his or her medical 
interests.

    Question 10: H.R. 2734 limits eligibility to caregivers of veterans 
receiving aid and attendance (38 United States Code 1114(r)), or 
entitled to the highest rate of Special Monthly Compensation (38 U.S.C. 
1114(s)), and have no other health care coverage.
    What is the purpose of providing aid and attendance and the special 
monthly compensation?

    Response: Initially, we want to point out that the highest rate of 
special monthly compensation (SMC) is provided at 38 U.S.C. 1114(r)(2). 
Compensation under section 1114(s) is lower than under many of the 
other subsections in section 1114.
    Many of the current eligibility criteria for SMC date back to 1933, 
including compensation provided under subsection (l) based on need for 
aid and attendance. SMC differs from disability compensation in that 
the rates provided take into account other factors in addition to loss 
of earning capacity. For example, the lowest level of SMC, which 
provided under subsection (k), includes as eligibility criteria 
anatomical loss or loss of use of a creative organ and certain losses 
of breast tissue. These disabilities may not result in significant 
earnings loss. SMC based on need for aid and attendance is based on the 
veteran's need for the personal assistance of another individual in 
performing the basic activities of daily living, such as bathing, 
eating, attending to the needs of nature, and protecting him or herself 
from the hazards of daily living. Congress has recognized the 
additional expense of securing the personal care needed by veterans who 
require such assistance by authorizing increased compensation benefits.

    Question 11: What challenges would VA face in implementing H.R. 
2734?

    Response: H.R. 2734 does not define the scope or limitation of 
these benefits. As noted above, VA is concerned with an open-ended 
commitment to an identified caregiver, even if the veteran later 
selects another person to perform as his or her caregiver. VA believes 
a system that allows veterans a periodic opportunity to select a new 
caregiver, much like an open season for selecting new health insurance 
benefits available to employers, would facilitate the administration of 
this program and allow veterans and caregivers sufficient flexibility. 
This would also not be as administratively burdensome as an at-will 
assignment of caregivers where a veteran could change caregivers 
whenever and as often as he or she pleased. VA believes veterans should 
have equal latitude in identifying an appropriate caregiver, be it a 
family member or non-family member. This latitude would not be unduly 
burdensome to VA. These limits would need to be defined through 
regulation if the legislation as written became law. Additionally, the 
legislation needs to define whether family caregiver eligibility and 
benefits would extend to those severely injured veterans and their 
caregivers living abroad. VA is also concerned about the technology 
required to support this initiative across multiple agencies and 
business lines for real-time eligibility management. This level of 
technology may be difficult to achieve within the timeframe defined in 
the legislation for program implementation.

    Question 12: Section 1672 of Public Law 110-181 provides for 
medical care for certain family members caring for a wounded warrior 
that are not otherwise eligible for medical care on a space-available 
basis in military treatment and VA facilities. What and how much care 
has VA provided in compliance with the law?

    Response: This provision is currently in the regulatory process; 
however, VA already has authority to provide care on a humanitarian and 
emergency basis. At this point, VA does not track care provided to such 
specificity.

    Question 13: What are the current beneficiary travel benefits for a 
veteran traveling to a medical center for care and benefits for an 
attendant traveling with the veteran?

    Response: Current VA beneficiary travel regulations at 38 CFR Part 
70 authorize VA to pay for certain travel costs of an attendant when VA 
had medically determined that an attendant is required to assist the 
veteran during travel. Benefits include the actual cost of travel 
(unless traveling with the veteran in a shared personal vehicle), and 
lodging and per diem at 50 percent of the area Federal employee rate 
during the actual period of travel. Should a veteran be admitted to a 
VA facility for care following travel and VA determines the veteran no 
longer needs a non-VA attendant, per diem and incidental costs have 
usually been at the caregiver's or attendant's expense.

    Question 14: H.R. 2738 would allow VA to prescribe regulations to 
limit the number of attendants and require that certain travel services 
be used. However, it does not allow VA the authority to prescribe 
eligibility regulations based on the need for a caregiver to accompany 
a veteran. Would H.R. 2738 allow a veteran to travel to a VA medical 
center with both an attendant and a family caregiver? Should there be 
limits on the length of time a family caregiver could receive this 
benefit?

    Response: VA would not require new regulations to limit the scope 
of H.R. 2738 because the bill would modify VA's existing statutory 
authority to provide travel benefits to someone accompanying a veteran. 
Essentially, this legislation would only authorize benefits to 
caregivers comparable to what attendants who would otherwise be 
eligible under VA's beneficiary travel authority would receive. If a 
veteran is not eligible for attendant benefits under VA's existing 
beneficiary travel authority, his or her caregiver would not be 
eligible to receive benefits under this legislation.
    It is unlikely that a family caregiver would not also be the 
appropriate attendant during the majority of veteran travel where an 
attendant is medically required. In such situations where a more 
skilled attendant is required, it is likely that special mode transport 
(e.g., ambulance, wheelchair van, air medical evacuation, etc.) would 
be used, and in such cases, the scope of H.R. 2738 would provide for car
egiver travel.

    Question 15: H.R. 2738 would require VA to provide ``lodging and 
subsistence'' to eligible family caregivers. How would VA implement the 
subsistence requirement--would VA pay a per diem similar to that which 
is provided to Federal employees on official travel?

    Response: Current VA beneficiary travel regulations at 38 CFR Part 
70 authorizes VA to reimburse eligible attendants during a period of 
travel up to 50 percent of the area Federal employee lodging and 
subsistence rates. If H.R. 2738 became law, it would provide a per diem 
to caregivers accompanying a veteran for care. It is unclear whether a 
per diem rate similar to DoD per diem benefits for family members 
accompanying an injured servicemember on special travel orders, the 
same per diem benefit provided to Federal employees, or the current 
regulated 50 percent of Federal employee per diem rate would be 
appropriate. VA notes an exception that would waive any applicable 
monetary payments if available facilities such as a Fisher House or VA 
lodging are available.

    Question 16: In your view, would H.R. 2738 require VA to provide an 
eligible family caregiver lodging and subsistence if the veteran is 
receiving inpatient treatment?

    Response: VA believes H.R. 2738 would require VA to provide an 
eligible family caregiver lodging and subsistence benefits if the 
veteran is receiving inpatient treatment. VA notes that DoD's authority 
for providing benefits in these situations is capped to a specific 
number of days per year.

    Question 17: Section 744 of Public Law 109-364 required VA and DoD 
to work together to develop a training curricula for family caregivers 
of veterans with TBI. What is the status of this curricula? When should 
Congress expect to receive the report this law also requires? What 
challenges did you face in developing this training?

    Response: The DoD/VA TBI family caregiver project panel, with 
oversight by the Defense and Veterans Brain Injury Center (DVBIC), has 
developed a four-module written curriculum entitled, A Caregiver's 
Guide to Traumatic Brain Injury: Roadmap to Recovery. A Web version of 
the curriculum is also under development with the Center of Excellence 
for Medical Multimedia (CEMM). Focus groups to evaluate the curriculum 
are scheduled to be completed July 31, 2009, with a full report to the 
panel due August 31, 2009. Feedback from the focus groups must be 
evaluated and subsequent revisions completed before the vendor can 
format the curriculum into the various modalities for distribution. The 
complete curricula package is due to Congress with a full report by 
December 31, 2009. DVBIC has requested an extension to meet the 
standards recommended by the panel to effectively evaluate the 
curriculum. The panel faced challenges in determining the scope of the 
curriculum, identifying family preferences for the content, depth and 
modality of the curriculum, identifying qualified medical writers to 
assist in the editing and compilation of the curriculum, and in the 
development of a contract to conduct the focus groups.

    Question 18: H.R. 2898 would require VA to provide family 
caregivers such consultation, professional counseling, marriage and 
family counseling, training and mental health services as are necessary 
in connection with that treatment. Please describe in detail the type 
and extent of services VA would be providing under this requirement.

    Response: Public Law 110-387, the Veteran's Mental Health and Other 
Care Improvement Acts of 2008 (enacted October 10, 2008), added 
marriage and family counseling to the list of suggested services 
available for veterans. Such services include consultation, 
professional counseling, and other mental health services considered 
necessary in connection with treatment of the veteran. This law also 
removed the contingency that the non-service connected veteran needed 
to be hospitalized before their family members would be eligible for 
these services. Immediate family members, guardians, or individuals in 
whose home the veteran intends to reside are eligible for this benefit. 
Examples of these services include behavioral family therapy, multiple 
family group therapy, the support and family education program, the 
National Alliance on Mental Illness family-to-family education program 
and family consultation.
    In developing treatment plans and providing care, clinicians 
consider whether there are problems or conditions experienced by a 
member of the veteran's family that could result in health or mental 
health problems for the veteran. VA clinicians also consider whether 
relational problems for the veteran with a spouse or other family 
member could exist or manifest. For example, being a caregiver for a 
parent who has Alzheimer's disease could lead to high levels of stress 
and negative health and mental health problems. Alternatively, a 
veteran's spousal caregiver could experience stress that, in turn, 
could affect the veteran and the veteran's marital relationship. With 
the changes implemented by P.L. 110-387, VA clinicians can provide 
marital or family counseling services for the veteran's benefit.
    H.R. 2898 would not broadly extend services available for the 
family. The only impact of this legislation would be to make available 
these benefits to extended family members who do not provide housing to 
the veteran or to a designated family caregiver.
    Every veteran and their caregiver has access to a VA social worker 
who provides an assessment of individualized needs of the family 
caregiver with respect to the family caregiver's role, assistance with 
the development of a plan for long-term care of the veteran, and 
implementation of a treatment plan. Social workers also provide ongoing 
counseling and education to veterans and family caregivers.

    Question 19: The National Resource Directory was created in 
collaboration with DoD, VA, and the Department of Labor. The Directory 
is a Web-based center of resources for wounded warriors and veterans 
and includes maintaining important support and training services for 
family caregivers. Would certain requirements under section 1 of H.R. 
2898 duplicate the purpose of the National Resource Directory? Should 
certain requirements under section 1 of the bill be changed to enable 
service members and veterans to have a centralized resource to further 
our goal of achieving a true seamless transition?

    Response: DoD, VA, and Department of Labor developed and maintain 
the National Resource Directory (www.nationalresourcedirectory.org, 
NRD), an online portal that provides access to information from over 
11,000 services and resources from Federal, State, and local 
governmental agencies; veteran service and benefit organizations; non-
profit community-based and faith-based organizations; academic 
institutions, professional associations and philanthropic 
organizations. The mission of the NRD is to provide a one-stop online 
resource for up-to-date, easily accessible, information about services 
and resources for servicemembers, veterans, their families and all who 
support them. Available information is organized into six categories: 
benefits and compensation; education, training & employment; family and 
caregiver support; health, housing and transportation; services; and 
resources.
    The specific requirement of H.R. 2898 for the Secretary to contract 
with a private entity could be interpreted to require a new and 
separate effort apart from the current collaborative NRD structure. 
Many of the specific elements required by H.R. 2898 have been discussed 
by the NRD governance group and are in various stages of development as 
future requirements.
    The NRD is part of a larger effort to improve wounded warrior care 
coordination and access to information, and provides a foundation for 
the ongoing development of Web portals that will tailor resources upon 
login. Additional improvements to the NRD site are under development 
and include Web feeds, E-mail-A-Friend capability, and a Link to Us 
page. All resources added to the NRD are evaluated and edited using a 
25-point content management style guide, as well as guidance provided 
by the site's partner agencies. To ensure the quality and acceptability 
of posted content, as well as consistency and clarity of language, all 
links uploaded to the NRD undergo a series of reviews and cross-
reviews. NRD content has recently been leveraged in other Web portal 
development efforts including ebenefits.gov and the Wounded Warrior 
resource center Web site.

    Question 20: H.R. 2898 would require VA to make available 
interactive training sessions for family caregivers. Is it your view 
the bill would allow VA to meet this requirement using an independent 
entity with expertise in training to meet this requirement?

    Response: VA would likely need to contract with at least one 
independent entity to fulfill the requirements of H.R. 2898 section 1. 
Section 1 would require the Secretary to make interactive training 
sessions available for family caregivers and individuals who support 
such caregivers. Such training must be available both in person and via 
the Internet and should incorporate telehealth technologies to the 
extent practicable. VA provides training to family members or 
caregivers related to the clinical needs of the veteran prior to his or 
her discharge from a VA facility. However, VA would probably contract 
with an independent entity to provide interactive training sessions 
online.
    The bill also provides that VA should teach techniques, strategies 
and skills for caring for a disabled veteran including effective 
methods for caring for veterans with PTSD, TBI, or who deployed in 
support of Operation Enduring Freedom/Operation Iraqi Freedom. Again, 
VA social workers and clinicians regularly work with family members to 
identify concerns and treatment plans while the veteran is still 
receiving care in VA. Our staff remains available to veterans and their 
family members after their release to provide additional support as 
needed.
    In addition, section 1 would require the Secretary to provide 
family caregivers with information concerning public, private, and 
nonprofit agencies that support caregivers. In providing this 
information, the Secretary would be required to collaborate with the 
Assistant Secretary for Aging for the Department of Health and Human 
Services and contract with a private entity to provide family 
caregivers an Internet-based directory of services at the county level, 
message boards and other tools to allow caregivers to interact with 
each other and disabled veterans, as well as comprehensive information 
explaining health-related topics and issues relevant to the caregivers' 
needs. This requirement within the legislation specifically states VA 
would contract with an independent entity, and VA would do so in 
compliance with the law.
    Pursuant to H.R. 2898, the Secretary would also be required to 
conduct outreach to inform disabled veterans and their families about 
these caregiver support services. The outreach must include public 
service announcements, brochures, social networking sites, the VA Web 
site and methods which target rural families. VA may be required to 
contract for these services, specifically concerning public service 
announcements.
    VA recommends adopting less prescriptive language in section 1 to 
allow VA the flexibility to adapt new methods of outreach as they 
become available and as they are appropriate to different generations 
of veterans. Communication technology changes rapidly and VA would 
prefer to change outreach methods as necessary to best meet the varied 
demographics and needs of family caregivers.

    Question 21: A draft bill would require VA to conduct a survey of 
family caregivers. Would this proposal capture the information that you 
believe would be beneficial to developing better policies for family 
caregivers?

    Response: VA believes the survey required by the draft bill would 
provide needed information to develop and tailor programs to the 
specific needs of veterans and their caregivers. VA has previously 
testified that the exact number of caregivers is currently unknown, but 
that caregivers fill an important role. Receiving feedback from family 
caregivers would provide important insights into their needs and help 
us better care for severely injured or ill veterans. This legislation 
would ensure VA monitors and identifies caregiver needs and would 
provide valuable data to help VA better develop, enhance, or implement 
programs benefiting caregivers and veterans. VA anticipates it would 
conduct focus groups in the first year following enactment of this law 
to develop appropriate questions and to refine the survey to best 
gather the necessary data. This process would improve the quality of 
the survey instrument and the quality of VA benefits and services.

    Question 22: Regarding the draft bill to conduct a survey of family 
caregivers, please respond to the following recommendations included in 
the National Military Family Association's Statement for the Record of 
June 18, 2009: ``However, we recommend the survey should capture a 
wider range of information than what is currently included in this 
proposal. We suggest the survey start with caregiver demographics, and 
include additional items, such as the financial impact, identify gaps 
and successes in the support system, and the disruption to the family 
unit, especially children. Also, the survey should capture data on 
caregivers' experiences with both VA and DoD support programs and 
benefits. We would also encourage the establishment of a panel of 
experts to help with the survey's design and implementation. This panel 
would consist of, but not be limited to, members representing: Veterans 
Service Organizations; Military Service Organizations; caregivers of 
our wounded, ill and injured servicemembers and veterans; staff from VA 
and DoD who work on caregiver issues; and members from each of the 
Services' wounded warrior programs.''

    Response: VA anticipates it would conduct focus groups in the first 
year following enactment of this law to develop appropriate questions 
and to refine the survey to best gather the necessary data. VA agrees 
that the organizations identified by the National Military Family 
Association could provide important insight and it anticipates working 
with these groups and others to craft a survey that will be effective 
and provide meaningful data.
    VA would recommend modifying the legislation to specifically limit 
the scope of this survey to only family caregivers of enrolled 
veterans, rather than the entire population of family caregivers within 
the United States. VA also notes the legislation could benefit from 
providing flexibility to determine if annual surveys are necessary and 
to modify the survey as needed from year to year, since new issues, 
concerns or programs could warrant client feedback.

                                 

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                      June 22, 2009

Mr. Joseph L. Wilson
Deputy Director, Veterans Affairs and Rehabilitation Commission
The American Legion
1608 K Street, NW
Washington, D.C. 20006

Dear Mr. Wilson:

    Thank you for the testimony you prepared on behalf of The American 
Legion for the U.S. House of Representatives Committee on Veterans' 
Affairs Subcommittee on Health Legislative Hearing that took place on 
June 18, 2009.
    Please provide answers to the following questions by August 3, 
2009, to Jeff Burdette, Legislative Assistant to the Subcommittee on 
Health.

    1.  What other health care legislation does your organization 
recommend for this Subcommittee?

    2.  In a statement for the record, The Wounded Warrior Project 
notes that the caregiver legislation we are considering today are not 
as comprehensive as they should be. Additionally, they note that we 
already know enough about the burdens of caregivers and that an annual 
survey is not needed.
      a.  What are your thoughts on WWP's position? Do you believe that 
modifications to the caregiver legislation are necessary?
      b.  Is it my understanding that VA does not currently collect any 
data on family caregivers, such that we don't even know how many family 
caregivers there are or the types of services they are receiving. While 
I agree that we have many anecdotes to understand the burden of 
caregiving, more information is needed to better help this population. 
Do you believe that the annual survey and reporting requirements are 
not necessary?

    Thank you again for taking the time to answer these questions. The 
Committee looks forward to receiving your answers by August 3, 2009.

            Sincerely,

                                                 MICHAEL H. MICHAUD
                                                           Chairman
                               __________
                   Joseph L. Wilson, Deputy Director,
             Veterans Affairs and Rehabilitation Commission
                          The American Legion
                     Questions and Responses from:
              Health Legislative Hearing on June 18, 2009
    Question 1: What other health care legislation does your 
organization recommend for this Subcommittee?

    Response: The American Legion supports legislation to expand and 
improve VA health care services for the 1.8 million women who have 
served our country. We also ask that proper oversight be reimplemented 
and/or maintained on issues such as increasing access to veterans 
health care, especially in rural areas; to revisit efforts to address 
the issues of an aging veteran population as well as veterans suffering 
the effects of Gulf War illness, Traumatic Brain Injury, post-traumatic 
stress disorder and exposure to toxic substances such as Agent Orange. 
We must keep the woman veteran in mind when addressing the above-
mentioned pertinent issues and ensure all receive comprehensive care 
when visiting VA Medical Centers.

    Question 2: In a statement for the record, The Wounded Warrior 
Project notes that the caregiver legislation we are considering today 
are not as comprehensive as they should be. Additionally, they note 
that we already know enough about the burdens of caregivers and that an 
annual survey in not needed.

    Question 2(a): What are your thoughts on WWP's position? Do you 
believe that modifications to the caregiver legislation are necessary?

    Response: It is The American Legion's position that a stronger 
piece of legislation is required to ensure the Operation Enduring 
Freedom/Operation Iraqi Freedom (OEF/OIF) Veteran Caregiver Program 
includes but is not limited to, a comprehensive package, including, 
respite care, to minimize complacency while caring for severely wounded 
veterans, mental health counseling, health care coverage, and adequate 
financial support.

    Question 2(b): Is it my understanding that VA does not currently 
collect any data on family caregivers, such that we don't even know how 
many family caregivers there are or the types of services they are 
receiving. While I agree that we have many anecdotes to understand the 
burden of caregiving, more information is needed to better help this 
population. Do you believe that the annual survey and reporting 
requirements are not necessary?

    Response: The American Legion believes the absence of a 
recordkeeping system for those who care for this Nations' wounded 
veterans contributes to the lack of oversight required to ensure 
veterans are receiving adequate specialty and comprehensive care. 
Therefore, it is essential an accountability system be in place to 
ensure veterans' care remains adequate and seamless within their 
respective communities as well. Adequacy and seamless care can be 
maintained through the Department of Veterans Affairs continuous 
communication with and education of the caregiver on caring for the 
wounded veteran.
    Please feel free to contact me @ 202-861-2700 ext. 2998 or 
[email protected] if you have questions.

            Thank you,

                                                   Joseph L. Wilson

                                 

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                      June 22, 2009

Ms. Joy J. Ilem
Deputy National Legislative Director
Disabled American Veterans
807 Maine Avenue, SW
Washington, D.C. 20024

Dear Ms. Ilem:

    Thank you for the testimony you prepared on behalf of Disabled 
American Veterans for the U.S. House of Representatives Committee on 
Veterans' Affairs Subcommittee on Health Legislative Hearing that took 
place on June 18, 2009.
    Please provide answers to the following questions by August 3, 
2009, to Jeff Burdette, Legislative Assistant to the Subcommittee on 
Health.

    1.  What other health care legislation does your organization 
recommend for this Subcommittee?

    2.  In a statement for the record, The Wounded Warrior Project 
notes that the caregiver legislation we are considering today are not 
as comprehensive as they should be. Additionally, they note that we 
already know enough about the burdens of caregivers and that an annual 
survey is not needed.
      a.  What are your thoughts on WWP's position? Do you believe that 
modifications to the caregiver legislation are necessary?
      b.  Is it my understanding that VA does not currently collect any 
data on family caregivers, such that we don't even know how many family 
caregivers there are or the types of services they are receiving. While 
I agree that we have many anecdotes to understand the burden of 
caregiving, more information is needed to better help this population. 
Do you believe that the annual survey and reporting requirements are 
not necessary?

    Thank you again for taking the time to answer these questions. The 
Committee looks forward to receiving your answers by August 3, 2009.

            Sincerely,

                                                 MICHAEL H. MICHAUD
                                                           Chairman
                               __________
                Post-Hearing Questions for Joy J. Ilem,
 Deputy National Legislative Director of the Disabled American Veterans
                From the Subcommittee on Health Hearing
                     Committee on Veterans' Affairs
                 United States House of Representatives
                             June 18, 2009
    Question 1: What other health care legislation does your 
organization recommend for this Subcommittee?

    Answer: As a partner organization in producing the Independent 
Budget (IB) for fiscal year (FY) 2010, we have offered many new (and 
some recurring) health care legislative and policy ideas to Congress 
and the Administration. Some of them, such as improvements in caregiver 
support, mental health services, women veterans health care, Department 
of Veterans Affairs (VA) health care funding reform, Traumatic Brain 
Injury services and related research, VA capital infrastructure, 
medical and prosthetic research and its infrastructure, long term care 
for veterans in VA and State sponsored facilities, and other relevant 
topics, are being addressed in the regular order. We appreciate the 
Subcommittee's attention to these critical issues and its efforts in 
trying to address gaps in services for sick and disabled veterans and 
their families.
    We remain hopeful that Congress will enact, and that the President 
will approve, the majority of bills addressing these issues hopefully 
before Congress adjourns this year. With that prospect in mind, 
Disabled American Veterans (DAV) proposes no additional bills for the 
Subcommittee's consideration at this time however, we anticipate that 
the IB for FY 2011, and our DAV Legislative Program for 2010 emerging 
from DAV's upcoming National Convention, will include new ideas and 
proposed legislation. We look forward to continuing to work with you 
and your staff to enact these proposals to help sick and disabled 
veterans and their caregivers.

    Question 2: In a statement for the record, The Wounded Warrior 
Project (WWP) notes that the caregiver measures we are considering 
today are not as comprehensive as they should be. Additionally, they 
note that we already know enough about the burdens of caregivers and 
that an annual survey is not needed.
      a.  What are your thoughts on WWP's position? Do you believe that 
modifications to the caregiver legislation are necessary?
      b.  Is it my understanding that VA does not currently collect any 
data on family caregivers, such that we don't even know how many family 
caregivers there are or the types of services they are receiving. While 
I agree that we have many anecdotes to understand the burden of 
caregiving, more information is needed to better help this population. 
Do you believe that the annual survey and reporting requirements are 
not necessary?

    Answer: At the June 18th hearing, the Subcommittee considered four 
bills aimed at enhancing services for caregivers of disabled veterans. 
These measures included provisions to: provide Internet-based training 
for caregivers; travel expenses for family caregivers accompanying 
veterans to medical care appointments; expand outreach and ensure 
access to mental health and respite services; extend eligibility for 
CHAMPVA services; and to conduct an annual survey of family caregivers 
of disabled veterans.
    Collectively, if enacted, these measures would begin to form a 
package of services to support caregivers of disabled veterans. 
However, we concur with WWP and would have preferred that H.R. 2342, 
the Wounded Warrior Project Family Caregiver Act, be considered during 
the legislative hearing since this measure would provide a more 
comprehensive caregiver support program. In addition, we urge the 
Subcommittee to consider amending H.R. 2342 to expand the eligible 
population beyond those who were injured in Operations Enduring and 
Iraqi Freedom.
    A more comprehensive package would be in line with DAV's position 
that caregivers of severely disabled veterans should be seen as a 
resource and fully supported in their role. During our most recent 
National Convention, delegates approved resolution number 165, calling 
for legislation that would provide comprehensive supportive services, 
including but not limited to financial support, health and homemaker 
services, respite, education and training and other necessary relief, 
to family caregivers of veterans severely injured, wounded or ill from 
military service. Likewise, the IB includes similar recommendations.
    Additionally, Mr. Chairman, we believe the survey and reporting 
features included in the draft measure are critically important and 
should be included in the final caregiver legislation. The DAV believes 
that in crafting a new program for veterans' caregiver support 
services, it is important from a health policy standpoint, among other 
factors, to clearly define the population to be served, and properly 
assess that population. We believe it prudent to ensure that a new 
caregiver support program, one that DAV strongly advocates, should be 
evaluated to determine whether it is achieving its intended purposes of 
addressing the impact of the imposition into their lives and on their 
obligations and responsibilities as caregivers, including influences or 
barriers on their ability to work or pursue other activities, and to 
assess the social, psychological, physical and medical burdens that 
caregiving places upon them.
    Although the combined National Long-Term Care Survey (NLTCS) and 
Informal Caregiver Survey (ICS) are not the only tools used to assess 
caregivers, we included these surveys in our testimony as examples in 
which data are being gathered. Information from NLTCS and ICS has 
served the needs of the Department of Health and Human Services, 
Congress, policymakers and researchers, to help produce and improve 
successful programs and public policy interventions that have benefited 
informal caregivers and their care recipients in other publicly-funded 
programs.
    The lack of information on this caregiver population within the VA 
is a prime reason why the DAV recommends VA conduct a statistically 
significant longitudinal survey. Accordingly, we recommend the draft 
legislation be amended to require VA to conduct a longitudinal survey 
that would allow VA to obtain information and develop a nationally 
representative profile on the demographics, quality of life, available 
social support services, health status and outcomes of people who care 
for severely disabled veterans. With subsequent surveys, VA could look 
at population-based public health outcomes of caregivers as one way to 
ensure the support services it provides are effective. Also, with 
statistically valid survey data, VA would be in a position to compare 
and contrast its caregiver programs with those outside VA--something 
that today VA cannot do.

                                 

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                      June 22, 2009

Mr. Fred Cowell
Senior Health Policy Analyst
Paralyzed Veterans of America
801 18th St., N.W.
Washington, D.C. 20006

Dear Mr. Cowell:

    Thank you for the testimony you prepared on behalf of Paralyzed 
Veterans of America for the U.S. House of Representatives Committee on 
Veterans' Affairs Subcommittee on Health Legislative Hearing that took 
place on June 18, 2009.
    Please provide answers to the following questions by August 3, 
2009, to Jeff Burdette, Legislative Assistant to the Subcommittee on 
Health.

    1.  What other health care legislation does your organization 
recommend for this Subcommittee?

    2.  In a statement for the record, The Wounded Warrior Project 
notes that the caregiver legislation we are considering today are not 
as comprehensive as they should be. Additionally, they note that we 
already know enough about the burdens of caregivers and that an annual 
survey is not needed.
      a.  What are your thoughts on WWP's position? Do you believe that 
modifications to the caregiver legislation are necessary?
      b.  Is it my understanding that VA does not currently collect any 
data on family caregivers, such that we don't even know how many family 
caregivers there are or the types of services they are receiving. While 
I agree that we have many anecdotes to understand the burden of 
caregiving, more information is needed to better help this population. 
Do you believe that the annual survey and reporting requirements are 
not necessary?

    Thank you again for taking the time to answer these questions. The 
Committee looks forward to receiving your answers by August 3, 2009.

            Sincerely,

                                                 MICHAEL H. MICHAUD
                                                           Chairman
                               __________

                                      Paralyzed Veterans of America
                                                    Washington, DC.
                                                      July 28, 2009

Honorable Michael H. Michaud
Chairman, Subcommittee on Health
House Committee on Veterans' Affairs
Room 335 Cannon House Office Building
Washington, DC 20515

Dear Mr. Chairman:

    Thank you for the opportunity to respond to questions from 
Paralyzed Veterans of America's (PVA) June 18, 2009 testimony on 
pending legislation before the Committee.
    Regarding your questions:

    Question 1: What other health care legislation does your 
organization recommend for this Subcommittee?

    Response: PVA recommends several pieces of legislation for the 
Subcommittee to consider. The best source for this is The Independent 
Budget coauthored annually by AMVETS, Disabled American Veterans (DAV), 
PVA and the Veterans of Foreign Wars (VFW). This document provides a 
comprehensive overview of our concerns and recommendations for 
legislation and policy changes and is endorsed by many Veterans Service 
Organization supporters of the IB.

    Question 2: In a statement for the record, The Wounded Warrior 
Project notes that the caregiver legislation we are considering today 
are not as comprehensive as they should be. Additionally, they note 
that we already know enough about the burdens of caregivers and that an 
annual survey is not needed.

    Question 2(a): What are your thoughts on WWP's position? Do you 
believe that modifications to the caregiver legislation are necessary?

    Response: PVA agrees with the concerns of WWP that the legislation 
may need modifications to make it more comprehensive, points clearly 
identified in their statement for the record. PVA would also support 
the passage of H.R. 2342, the Wounded Warrior Project Family Caregiver 
Act. However, we see the legislation the Subcommittee is currently 
working on as an important first step. We agree that more can always be 
done and we encourage the Subcommittee to reach for a more 
comprehensive goal.
    Specifically, PVA agrees with WWP's position that the current VA 
program in partnership with the Administration on Aging (AoA) is of 
limited value by allowing the Aging Network Agencies to refuse to 
accept veteran participants. This program can not be expected to meet 
the needs of veterans if there is the option to exclude veterans.
    PVA wants to work with the Subcommittee and other Veterans Service 
Organizations to create the most comprehensive and complete legislation 
possible that provides for support to veteran caregivers.

    Question 2(b): Is it my understanding that VA does not currently 
collect any data on family caregivers, such that we don't even know how 
many family caregivers there are or the types of services they are 
receiving. While I agree that we have many anecdotes to understand the 
burden of caregiving, more information is needed to better help this 
population. Do you believe that the annual survey and reporting 
requirements are not necessary?

    Response: Unfortunately, the VA collection of data on caregivers is 
limited at best and as noted in our testimony, ``. . . VA can only 
estimate how many of these [44 million] caregivers serve veterans.''
    PVA supports the annual survey for two reasons. First, it is 
critical that VA develop detailed information on the situation of 
caregivers. Legislation can not be built on anecdotal background. As VA 
understands the scope of the problem and the benefits provided to 
veterans by family caregivers, it builds a stronger and more 
sustainable case for legislation. Second, if the population of 
caregivers is not surveyed, it is impossible to know if the programs 
are working and what programmatic changes may be needed and ``Without 
this information, it will be difficult for VA to honestly provide 
recommendations on funding caregiver programs to the White House and 
Congress.'' [PVA 18 June 09 testimony]

            Sincerely,

                                                        Fred Cowell
                                       Senior Health Policy Analyst

                                 

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                      June 22, 2009

Mr. Christopher Needham
Senior Legislative Associate, National Legislative Service
Veterans of Foreign Wars
200 Maryland Avenue, N.E.
Washington, D.C. 20002

Dear Mr. Needham:

    Thank you for the testimony you prepared on behalf of the Veterans 
of Foreign Wars for the U.S. House of Representatives Committee on 
Veterans' Affairs Subcommittee on Health Legislative Hearing that took 
place on June 18, 2009.
    Please provide answers to the following questions by August 3, 
2009, to Jeff Burdette, Legislative Assistant to the Subcommittee on 
Health.

    1.  What other health care legislation does your organization 
recommend for this Subcommittee?

    2.  In a statement for the record, The Wounded Warrior Project 
notes that the caregiver legislation we are considering today are not 
as comprehensive as they should be. Additionally, they note that we 
already know enough about the burdens of caregivers and that an annual 
survey is not needed.
      a.  What are your thoughts on WWP's position? Do you believe that 
modifications to the caregiver legislation are necessary?
      b.  Is it my understanding that VA does not currently collect any 
data on family caregivers, such that we don't even know how many family 
caregivers there are or the types of services they are receiving. While 
I agree that we have many anecdotes to understand the burden of 
caregiving, more information is needed to better help this population. 
Do you believe that the annual survey and reporting requirements are 
not necessary?

    Thank you again for taking the time to answer these questions. The 
Committee looks forward to receiving your answers by August 3, 2009.

            Sincerely,

                                                 MICHAEL H. MICHAUD
                                                           Chairman
                               __________
VFW Responses to Questions for the Record of the Subcommittee on Health
         With Respect to the June 18, 2009 Legislative Hearing
    Question 1: What other health care legislation does your 
organization recommend for this Subcommittee?

    Response: We thank the Subcommittee for their actions this year. 
The Subcommittee has taken action on a significant number of VFW 
priorities, such as the Women Veterans' Health Care Improvement Act and 
the exemption of catastrophically disabled veterans from having to pay 
medical care co-payments. The Subcommittee has had an aggressive 
agenda, which has addressed many of our highest priorities.
    One issue that we feel could improve the consistency of the 
delivery of health care is a consolidation of contracts within 
Community-Based Outpatient Clinics (CBOCs), as we outlined on pages 81-
82 of the FY 2010 Independent Budget.
    We are strongly supportive of CBOCs and their role in expanding the 
availability of care to veterans throughout the country, especially to 
those who are not located near a large VA Medical Center. CBOCs serve 
as extensions of each Medical Center, and each VAMC establishes its own 
requirements based upon local needs.
    As they have expanded, the growth in these clinics has involved 
multiple contracts with different entities to provide care. Along with 
this, each contract can have different measurements of quality care, 
pricing models and administration structure. Accordingly, there may not 
be consistency within a VAMC's area, nor on the VISN level. There is 
almost certainly no uniform standard throughout the health care system.
    Consolidating contracts could offer VA many administrative 
benefits, and it could improve the quality of care provided to 
veterans. Benefits include: greater continuity of care and uniformity 
of the benefits; simplified contract administration and oversight; 
efficiency within contracts; improvements to access; efficiencies of 
procurement; standardized reporting and assessments, etc.

    Question 2: In a statement for the record, The Wounded Warrior 
Project notes that the caregiver legislation we are considering today 
are not as comprehensive as they should be. Additionally, they note 
that we already know enough about the burdens of caregivers and that an 
annual survey is not needed.

    Question 2(a): What are your thoughts on WWP's position? Do you 
believe that modifications to the caregiver legislation are necessary?

    Response: We agree that veterans and their families need a more 
comprehensive program for caregiving. P.L. 109-461 created a pilot 
program for family caregivers, and we understand that VA has begun 
programs at eight locations throughout the country.
    We all understand the need for this type of program. With the 
number of severely wounded servicemembers returning from Iraq and 
Afghanistan continuing to grow, its importance will increase. As these 
veterans stabilize in VA's polytrauma centers, most of these veterans 
will be able to return home, at least on a part-time basis. Many others 
will find comfort in therapeutic residential care settings. In all 
these cases, family members of veterans often will be the key link to 
providing care, helping their loved one deal with the challenges their 
health care needs create.
    The VFW strongly believes that we should implement a systemwide 
program as soon as possible, implementing whatever lessons have been 
learned from those pilot programs, combined with information from 
caregiving programs run by other Federal and State agencies and lessons 
learned from private-sector implementation. We feel that we have enough 
information and data to implement a successful program, and that we 
must not let the search for a perfect program become the enemy of the 
good. We have laid out our vision of what a successful program looks 
like in the Independent Budget. I would refer you to pages 157-163 of 
the FY 2010 version for details.
    In short, a family caregiver program must have several key 
components, all of which stress quality of life issues for both the 
veteran and the caregiver.

    1.  VA must provide training for family members to serve as the 
caregiver, as well as certifying that they are able to provide care. VA 
should provide regular training and provide information and resources 
for caregivers so that they can understand the veterans' demands for 
care. The Department must also ensure that the family member is capable 
of meeting the intense demands for care. Caregiving has been shown to 
provide immense physical, emotional, and psychological challenges, and 
it is critical for these veterans that their caregivers are up to the 
challenge.
    2.  VA must provide compensation to these certified family 
caregivers. They often have to put their lives on hold to provide care. 
It is not enough, as VA has sometimes suggested, for these family 
members to work for providers who already contract care, especially 
with the limitations VA provides on the contract care it provides.
    3.  VA must provide respite care services. Caregivers need a break 
from time to time for their physical, emotional and psychological 
health. Respite services help to alleviate caregiver burden and are 
critical for the quality of care veterans receive.
    4.  VA must provide family caregivers access to mental health care 
services and help provide other medical care services. Studies have 
shown that caregivers experience increased likelihoods of stress, 
depression, and other physical problems when compared to their peer 
group who do not provide care. It is a difficult, stressful job. These 
family members are serving on behalf of disabled veterans, to provide 
services the veteran is entitled to through the VA system. Accordingly, 
their well-being should be taken care of by the Department, if only to 
ensure the quality of care for the veteran remains first rate.

    These are just some of the principles of a comprehensive national 
caregiver program that the VFW would like to see become law.
    The VFW believes that H.R. 3155, which recently passed, is a step 
in the right direction. Although we have concerns over who ultimately 
is covered by this legislation, the overall program it would create is 
in line with our recommendations.

    Question 2(b): It is my understanding that VA does not currently 
collect any data on family caregivers, such that we don't even know how 
many family caregivers there are or the types of services they are 
receiving. While I agree that we have many anecdotes to understand the 
burden of caregiving, more information is needed to better help this 
population. Do you believe that the annual survey and reporting 
requirements are not necessary?

    Response: We disagree with their position. We feel that collecting 
information and input from caregivers and their families is going to be 
critical to understanding and adapting the program in the future. It is 
certainly true that we know many of the burdens and problems with 
caregiving programs through numerous studies of other agencies and 
organizations with caregiving programs. But it is likely that any VA 
program will have unique challenges, and any information we can get to 
improve and tailor the program in the future is beneficial.
    What we do not want to see, however, is the demands for a study and 
the calls for more information and data about caregiving programs being 
used as a roadblock to implementing a program this session of Congress. 
This study should look to the future with whatever program is 
ultimately implemented for adaptation in the years to come. Congress 
must not use this study to prevent passage of these critical 
improvements.

                                 

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                      June 22, 2009

Mr. Bernard Edelman
Deputy Director for Policy and Government Affairs
Vietnam Veterans of America
8605 Cameron Street, Suite 400
Silver Spring, MD 20910

Dear Mr. Edelman:

    Thank you for the testimony you prepared on behalf of Vietnam 
Veterans of America for the U.S. House of Representatives Committee on 
Veterans' Affairs Subcommittee on Health Legislative Hearing that took 
place on June 18, 2009.
    Please provide answers to the following questions by August 3, 
2009, to Jeff Burdette, Legislative Assistant to the Subcommittee on 
Health.

    1.  What other health care legislation does your organization 
recommend for this Subcommittee?

    2.  In a statement for the record, The Wounded Warrior Project 
notes that the caregiver legislation we are considering today are not 
as comprehensive as they should be. Additionally, they note that we 
already know enough about the burdens of caregivers and that an annual 
survey is not needed.
      a.  What are your thoughts on WWP's position? Do you believe that 
modifications to the caregiver legislation are necessary?
      b.  Is it my understanding that VA does not currently collect any 
data on family caregivers, such that we don't even know how many family 
caregivers there are or the types of services they are receiving. While 
I agree that we have many anecdotes to understand the burden of 
caregiving, more information is needed to better help this population. 
Do you believe that the annual survey and reporting requirements are 
not necessary?

    3.  For H.R. 1546, the ``Caring for Veterans with Traumatic Brain 
Injury Act of 2009,'' you state that you are not ``thrilled'' about 
creating another committee to focus on another facet of combat injury. 
By this comment, do you mean that you believe that there are too many 
committees focusing on combat veterans' issues? If so, do you have an 
alternative recommendation regarding the care and treatment of veterans 
with TBI?

    4.  In your testimony on H.R. 1546, you recommend that we must 
ensure that the operations of the TBI Committee are transparent and 
that all deliberations and notes of the Committee be open to public 
scrutiny. Please elaborate and explain what you mean by this statement.

    Thank you again for taking the time to answer these questions. The 
Committee looks forward to receiving your answers by August 3, 2009.

            Sincerely,

                                                 MICHAEL H. MICHAUD
                                                           Chairman
                               __________

                                        Vietnam Veterans of America
                                                 Silver Spring, MD.
                                                      July 23, 2009

The Honorable Mike Michaud
Chairman
Subcommittee on Health
House Veterans' Affairs Committee
335 Cannon House Office Building
Washington, D.C. 20515

Dear Chairman Michaud:

    In reply to your June 22nd letter following up on our written 
testimony for the hearing on health care legislation conducted by your 
Subcommittee on June 18th, let me respectfully submit to you the 
following:

    Question 1: What other health care legislation does your 
organization recommend for this Subcommittee?

    Response: Concerning other health care legislation, VVA would 
suggest that the Subcommittee hold a hearing on the intergenerational, 
or multigenerational, effects of a veteran's exposure to Agent Orange/
dioxin while serving in Vietnam and the cancers, birth defects, and 
learning disabilities that have afflicted not only his/her children but 
their children as well. We hear far too many stories from the daughters 
(mostly) of veterans who wonder if the health conditions that they were 
born with, and that now their children have as well, could derive from 
their father's service in Vietnam. The results of such a hearing might, 
we would hope, suggest specific legislation concerning research into 
the association between exposures to dioxin and other toxic substances 
with reproduction.
    In this realm, your Subcommittee might also consider looking into 
the studies on groundwater contamination at Camp Lejeune, North 
Carolina, from which birth defects and childhood cancers may derive.
    We also would suggest your Subcommittee, perhaps in concert with 
Oversight and Investigations, look into Project HERO, a pilot program 
in four VISNs, that is supposed to get a handle on fee-basis health 
care expenditures. We have serious concerns about this program, 
particularly with regard to its ability to effectively enlist 
clinicians in rural/remote areas. (Currently, all of the health care 
contracts have been ``won'' by Humana, and the dental contracts by 
Delta Dental.) Is HERO part of the answer in getting a handle on the 1 
in 10 health care dollars expended by the VA out of the VA system?

    Question 2: In a statement for the record, the Wounded Warrior 
Project notes that the caregiver legislation we are considering today 
are not as comprehensive as they should be. Additionally, they note 
that we already know enough about the burdens of caregivers and that an 
annual survey is not needed.

    Question 2(a): What are your thoughts on WWP's position? Do you 
believe that modifications to the caregiver legislation are necessary?

    Response: Concerning caregiver legislation, certainly a 
comprehensive approach is needed, one that might incorporate the 
various initiatives of the draft legislation as well as H.R. 2378 and 
2734.

    Question 2(b): Is it my understanding that VA does not currently 
collect any data on family caregivers, such that we don't even know how 
many family caregivers there are or the types of services they are 
receiving. While I agree that we have many anecdotes to understand the 
burden of caregiving, more information is needed to better help this 
population. Do you believe that the annual survey and reporting 
requirements are not necessary?

    Response: Yes, we do believe that the annual survey and reporting 
requirements concerning caregivers are both warranted and potentially 
valuable. To argue that we know all we need to know because we know it, 
doesn't hold up. Anecdotal evidence is fine. Having a database of solid 
information can assist the VA in adapting to the needs of caregivers, 
and in tracing how dollars are expended in this admirable effort.

    Question 3: For H.R. 1546, the ``Caring for Veterans with Traumatic 
Brain Injury Act of 2009,'' you state that you are not ``thrilled'' 
about creating another committee to focus on another facet of combat 
injury. By this comment, do you mean that you believe that there are 
too many committees focusing on combat veterans' issues? If so, do you 
have an alternative recommendation regarding the care and treatment of 
veterans with TBI?

    Response: Perhaps my original testimony was a bit unclear as to 
what I attempted to say concerning the creation of a committee to focus 
on assisting troops who return home with Traumatic Brain Injury. Often, 
committees and commissions are created when legislators and Governors 
and Presidents don't want to make a hard decision on a particular 
issue. In this case, however, such a committee is needed, to help 
coordinate and get a handle on the multitude of efforts both public and 
private aimed at helping troops/veterans afflicted with TBI.
    As we wrote: ``Millions of dollars have been appropriated to learn 
more about [TBI]. Is this money being spent wisely and well? Which 
treatment modalities are working? Which aren't? What ought to be the 
role of community-based organizations in caring for veterans with such 
wounds?''

    Question 4: In your testimony on H.R. 1546, you recommend that we 
must ensure that the operations of the TBI Committee are transparent 
and that all deliberations and notes of the Committee be open to public 
scrutiny. Please elaborate and explain what you mean by this statement.

    Response: The discussions and deliberations during meetings should 
be open to the public, and to public scrutiny, just as hearings are for 
(most) Committees and Subcommittees in Congress. I think the ``and 
notes'' may be a bit misleading. We do not mean that all notes and e-
mails from one Committee Member to another should be laid out to be 
examined by anyone. Certainly, we recognize the necessity for private 
communications between Committee Members and staff if such a Committee 
is to function properly.
    We hope that these responses to your questions, Mr. Chairman, offer 
some illumination as to what we said in our written testimony. And we 
appreciate your efforts, and that of your colleagues and staff, in a 
most important undertaking.

            Sincerely,

                                                    Bernard Edelman
                  Deputy Director for Policy and Government Affairs

                                 
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