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[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]

 
                LEGISLATIVE HEARING ON H.R. 1460, H.R. 3016, 
                H.R. 3245, H.R. 3279, H.R. 3337, H.R. 3723, AND 
                H.R. 4079
=======================================================================

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS

                     U.S. HOUSE OF REPRESENTATIVES

                      ONE HUNDRED TWELFTH CONGRESS

                             SECOND SESSION

                               __________

                         MONDAY, APRIL 16, 2012

                               __________

                           Serial No. 112-56

                               __________

       Printed for the use of the Committee on Veterans' Affairs

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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

CLIFF STEARNS, Florida               BOB FILNER, California, Ranking
DOUG LAMBORN, Colorado               CORRINE BROWN, Florida
GUS M. BILIRAKIS, Florida            SILVESTRE REYES, Texas
DAVID P. ROE, Tennessee              MICHAEL H. MICHAUD, Maine
MARLIN A. STUTZMAN, Indiana          LINDA T. SANCHEZ, California
BILL FLORES, Texas                   BRUCE L. BRALEY, Iowa
BILL JOHNSON, Ohio                   JERRY McNERNEY, California
JEFF DENHAM, California              JOE DONNELLY, Indiana
JON RUNYAN, New Jersey               TIMOTHY J. WALZ, Minnesota
DAN BENISHEK, Michigan               JOHN BARROW, Georgia
ANN MARIE BUERKLE, New York          RUSS CARNAHAN, Missouri
TIM HUELSKAMP, Kansas
MARK E. AMODEI, Nevada
ROBERT L. TURNER, New York

            Helen W. Tolar, Staff Director and Chief Counsel

                                 ______

                         SUBCOMMITTEE ON HEALTH

                 ANN MARIE BUERKLE, New York, Chairman

CLIFF STEARNS, Florida               MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida            CORRINE BROWN, Florida
DAVID P. ROE, Tennessee              SILVESTRE REYES, Texas
DAN BENISHEK, Michigan               RUSS CARNAHAN, Missouri
JEFF DENHAM, California              JOE DONNELLY, Indiana
JON RUNYAN, New Jersey

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

                               __________

                             April 16, 2012

                                                                   Page

Legislative Hearing on H.R. 1460, H.R. 3016, H.R. 3245, H.R. 
  3279, H.R. 3337, H.R. 3723, and H.R. 4079......................     1

                           OPENING STATEMENTS

Chairwoman Ann Marie Buerkle.....................................     1
    Prepared Statement of Chairwoman Buerkle.....................    33
Hon. Michael H. Michaud, Ranking Democratic Member...............     2
    Prepared Statement of Hon. Michael M. Michaud................    33
Hon. Russ Carnahan, prepared statement only......................    34

                               WITNESSES

Hon. William Owens, U.S. House of Representatives, (NY-23).......     3
    Prepared Statement of Hon. Owens.............................    35
Hon. John Barrow, Member, Committee on Veterans' Affairs, U.S. 
  House of Representatives, (GA-12)..............................     4
    Prepared Statement of Hon. Barrow............................    35
Hon. Jeff Denham, U.S. House of Representatives, (CA-19).........     5
    Prepared Statement of Hon. Denham............................    36
Hon. Silvestre Reyes, Member, prepared statement only............    37
Hon. W. Todd Akin, U.S. House of Representatives, (MO-2).........     6
    Prepared Statement of Hon. Akin..............................    37
Hon. Robert T. Schilling, U.S. House of Representatives, (IL-17).     7
    Prepared Statement of Hon. Schilling.........................    38
Hon. David B. McKinley, U.S. House of Representatives, (WV-1)....     9
    Prepared Statement of Hon. McKinley..........................    39
Shane Barker, Senior Legislative Associate, Veterans of Foreign 
  Wars...........................................................    13
    Prepared Statement of Mr. Barker.............................    40
Adrian Atizado, Assistant National Legislative Director, Disabled 
  American Veterans..............................................    15
    Prepared Statement of Mr. Atizado............................    43
Rene A. Campos, Commander, U.S. Navy (Ret.), Deputy Director, 
  Government Relations, Military Officers Association of America.    16
    Prepared Statement of Mrs. Campos............................    48
Ramsey Sulayman, Legislative Associate, Iraq and Afghanistan 
  Veterans of America............................................    18
    Prepared Statement of Mr. Sulayman...........................    51
Ralph Ibson, National Policy Director, Wounded Warrior Project...    19
    Prepared Statement of Mr. Ibson..............................    53
Robert L. Jesse, M.D., Ph.D., Principal Deputy Under Secretary 
  for Health, Veterans Health Administration, U.S. Department of 
  Veterans Affairs...............................................    25
    Prepared Statement of Dr. Jesse..............................    57
    Accompanied by:

      Susan Blauert, Deputy Assistant General Counsel, Office of 
          General Counsel, U.S. Department of Veterans Affairs

                       STATEMENTS FOR THE RECORD

Institute of Medicine............................................    63
Burn Pits 360....................................................    64
Humana Government................................................    65
National Coalition of Homeless Veterans..........................    68
Paralyzed Veterans of America....................................    69

LEGISLATIVE HEARING ON H.R. 1460, H.R. 3016, H.R. 3245, H.R. 3279, H.R. 
                     3337, H.R. 3723, AND H.R. 4079

                              ----------                              

                         MONDAY, APRIL 16, 2012

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 4:00 p.m., in 
Room 334, Cannon House Office Building, Hon. Ann Marie Buerkle 
[Chairwoman of the Subcommittee] presiding.
    Present: Representatives Buerkle, Roe, Denham, Michaud, 
Reyes, and Barrow.

         OPENING STATEMENT OF HON. ANN MARIE BUERKLE, 
                           CHAIRWOMAN

    Ms. Buerkle. Good afternoon. This hearing will now come to 
order.
    Thank you all for being here today as we begin to discuss 
seven legislative proposals concerning the care and services 
provided to our Nation's veterans and their families through 
the Department of Veterans Affairs.
    The seven bills on our agenda this afternoon are: H.R. 
1460, to provide for the automatic enrollment of veterans 
returning from combat zones into the VA medical system; H.R. 
3016, to direct the Secretary of Defense and the Secretary of 
Veterans Affairs to jointly operate the Federal Recovery 
Coordination Program; H.R. 3245, the Efficient Services for 
Veterans Act; H.R. 3279, to clarify that caregivers for 
veterans with serious illnesses are eligible for assistance and 
support services provided by the VA; H.R. 3337, the Open Burn 
Pit Registry Act; H.R. 3723, the Enhanced Veteran Healthcare 
Experience Act of 2011; and H.R. 4079, the Safe Housing for 
Homeless Veterans Act.
    Together, these bills touch on a full range of issues 
affecting our veterans as well as their families.
    The proposals we will discuss include measures to address 
fire and building safety code enforcement for homeless veterans 
participating in VA grant and per diem programs; streamline the 
eligibility determination for veterans seeking readjustment 
counseling services at Vet Centers; establish a registry for 
OEF/OIF veterans who may have been exposed to toxic chemicals 
caused by open burn pits; and allow veterans greater access to 
the health care they earned and deserve by reforming the VA's 
fee-basis care program and by providing for the automatic 
enrollment of returning combat veterans into the VA health care 
system.
    Additionally, we will discuss two bills, H.R. 3016 and H.R. 
3279, that seek to improve programs that support some of our 
most seriously Wounded Warriors, the Federal Recovery 
Coordination Program and the Comprehensive Assistance for 
Family Caregivers Program, respectively. These programs in 
particular are very familiar to this Subcommittee, which has 
held a total of four oversight hearings last year to examine 
them in depth.
    Our discussion today will provide us with the opportunity 
to thoroughly examine each of these proposals with their 
sponsors and the Department, as well as our partners in the 
veteran service organizations to find out what works, what 
doesn't, and what needs to be improved.
    I thank my colleagues this afternoon for sponsoring the 
bills on our agenda and for their leadership in this very 
important endeavor. I also appreciate our witnesses from the 
veterans' service organizations as well as the VA for taking 
the time to join us today and for working so hard, day in and 
day out, in support of our Nation's heroes. I am very much 
looking forward to our discussion; and, at this time, I now 
yield to the Ranking Member, Mr. Michaud.

    [The prepared statement of Chairwoman Buerkle appears in 
the Appendix]

         OPENING STATEMENT OF HON. MICHAEL H. MICHAUD, 
                   RANKING DEMOCRATIC MEMBER

    Mr. Michaud. Thank you very much, Madam Chair.
    I, too, want to thank all three groups of panelists for 
coming before us today. I look forward to hearing your 
testimony.
    As you heard, the purpose of today's hearing will be to 
explore the policy implications of seven bills before us that 
cover a wide range of topics to help expand and enhance VA's 
health care programs and services.
    Madam Chair, to allow for the maximum amount of time for 
our three panelists, since we are in session this afternoon, I 
would ask unanimous consent that the rest of my opening remarks 
be submitted for the record.

    [The prepared statement of Hon. Michaud, appears in the 
Appendix]

    Ms. Buerkle. Without objection, thank you.
    We will now turn to our first panel where I am very proud 
and pleased to welcome such a distinguished group of my 
colleagues and friends.
    Joining us this afternoon to discuss the legislation they 
have introduced is: Air Force veteran and fellow New Yorker, 
Mr. Bill Owens; Georgian and fellow Committee Member, John 
Barrow.
    Californian and Subcommittee Member, Jeff Denham; (Jeff 
Denham isn't here yet but will be here.)
    Vietnam-era combat veteran, Subcommittee Member, and proud 
Texan, Silvestre Reyes; Show-Me State Representative Todd Akin; 
a small business owner all the way from the Land of Lincoln, 
Mr. Bobby Shilling; and David McKinley, a civil engineer from 
West Virginia.
    Gentlemen, thank you very much for being here with us this 
afternoon and for your advocacy on behalf of our Nation's 
veterans.
    Mr. Owens, we will start with you. Thank you.

              STATEMENT OF THE HON. WILLIAM OWENS

    Mr. Owens. Thank you very much, Madam Chair, Ranking Member 
Michaud, and Members of the Committee. I appreciate the 
opportunity to come before you today and testify on H.R. 1460, 
which is legislation I have introduced to provide for the 
automatic enrollment of military servicemembers in the VA 
health care system. As a veteran of the Air Force, I am honored 
to have the opportunity to help improve access to the benefits 
that men and women in uniform have earned in the service to 
their country.
    The soldiers, sailors, airmen, and marines of the Armed 
Forces have served with great honor and distinction over a 
decade at war in the Middle East. PCS orders, increased op-
tempo, repeat deployments, and shortened dwell times have only 
added to the pressures facing the military and their families 
to Operations Enduring Freedom, Iraqi Freedom, and New Dawn.
    There is no question that we as a country have made great 
strides over the past 10 years to strengthen systems of care 
for American veterans, but obstacles remain for the men and 
women transitioning from service to civilian life. 
Representatives from various veterans' service organizations 
have testified on their concerns for military families being 
overwhelmed by the bureaucracies of both the Veterans 
Administration and the Department of Defense, and it should 
come as no surprise that VA paperwork is only one in a number 
of challenges facing servicemembers in their transition to 
civilian life.
    Under my legislation, combat veterans discharging from 
service within 45 days must be provided enrollment in the VA, a 
veterans identification card demonstrating enrollment and 
allowing access to hospital and medical services at VA 
facilities, a list of VA facilities located within 100 miles of 
the vet's home, or the closest veterans home if there is none 
located near the veteran, a description of available Federal 
benefits, job training, placement programs, educational 
benefits, et cetera.
    Any veteran considered under this bill will be given an 
option to decline enrollment beforehand and proactively given 
an option to disenroll from the program no more than 6 months 
later. The bill goes into effect 90 days after enactment.
    To be clear, this legislation does not change the benefits 
for which a veteran is eligible or the care they are entitled 
to within the VA. The men and women enrolled under this 
legislation are already eligible for VA care. All we are doing 
is shifting the burden of enrollment away from those who have 
just returned from a theater of war to those who are deployed 
to serve American veterans.
    In addition to reducing the government paperwork required 
of them, we can help ensure that overburdened servicemembers do 
not slip through the cracks and miss an opportunity to enjoy 
the benefits they have earned.
    I remain particularly concerned for servicemembers 
afflicted with traumatic brain injury or post-traumatic stress 
disorder who face unique pressures in transitioning from 
service. This legislation will ensure that they have early 
access to screening for TBI and PTSD from experts at the VA who 
can improve the long-term prognosis for those affected and 
ensure proper treatment in the years ahead.
    I thank you again for the opportunity to speak to you on 
behalf of H.R. 1460 and respectfully request that you consider 
lending your support to the bill. I look forward to your 
questions.
    Thank you and I yield back.

    [The prepared statement of Hon. Owens appears in the 
Appendix]

    Ms. Buerkle. Thank you very much.
    Mr. Barrow.

               STATEMENT OF THE HON. JOHN BARROW

    Mr. Barrow. Thank you, Chairwoman Burke, Ranking Member 
Michaud, and Members of the Subcommittee. Thanks for giving me 
the opportunity to speak to you about H.R. 3016, my bill to 
improve the Federal Recovery Coordination Program.
    Today's returning armed servicemembers face a unique 
combination of challenges as they reintegrate into the 
community. One important means for helping these folks is the 
Federal Recovery Coordination Program, which was originally 
envisioned by the Dole-Shalala Commission to help Wounded 
Warriors navigate the bureaucracy of the VA and the DoD health 
systems.
    A Federal Recovery Coordinator is a nurse or a social 
worker with graduate-level training who helps guide Wounded 
Warriors to the proper treatment and benefits options. 
Unfortunately, administrative roadblocks have prevented the 
program from achieving its full potential. That is why I 
introduced H.R. 3016, which would correct the administrative 
problems that prevent the Federal Recovery Coordination Program 
from succeeding.
    H.R. 3016 establishes joint administration of this program 
by placing it under the supervision of both the Secretaries of 
Defense and Veterans Affairs. It ensures severely injured armed 
servicemembers and veterans receive a Federal Recovery 
Coordinator, and it gives coordinators the authority to act 
earlier in the recovery process, and it makes certain that each 
branch of DoD will refer Wounded Warriors to the program.
    Jim Lorraine, the Executive Director of the Augusta Wounded 
Warrior Project--an outstanding organization that builds 
collaborative relationships with local, State, and national 
organizations that support Wounded Warriors and their families 
in the Augusta area--explains how this legislation will benefit 
veterans:
    The Federal Recovery Coordinator Program is essential to 
helping our most severely wounded, ill, and injured who have 
given so much for our Nation, help them figure out how to 
navigate these complex bureaucracies and improve their access 
to existing services. This legislation not only formally 
establishes the program but directs its management from the 
highest levels of the Department of Defense and Veterans 
Affairs to ensure unimpeded access to care.
    I hope this Committee will join me in strengthening the 
Federal Recovery Coordination Program through this legislation. 
It is time we fulfilled the promises we made to our 
servicemembers by improving their care throughout the recovery 
process.
    Madam Chair, thank you again for the opportunity to speak 
to this Committee. I yield back the balance of my time.

    [The prepared statement of Hon. Barrow appears in the 
Appendix]

    Ms. Buerkle. Thank you very much.
    Mr. Denham, you may proceed.

               STATEMENT OF THE HON. JEFF DENHAM

    Mr. Denham. Thank you, Madam Chair, Ranking Member Michaud, 
and Members of the Subcommittee, for holding this legislation 
hearing today; and thank you to the Chairwoman for co-
sponsoring this legislation as well as Mr. Roe and Mr. Benishek 
for their support. Let me also thank Mr. McNerney, who joined 
me in a Subcommittee hearing last week on this very topic.
    Vet Centers offer a wide range of readjustment counseling 
services to eligible veterans and their families. At our field 
hearing, we were able to hear firsthand how effective these 
centers are at delivering the care our veterans need 
confidentially and without any delay. This bill would provide 
Vet Centers with one additional tool to serve our veterans: the 
ability to search in the electronic database base of DD-214 
records.
    A DD-214 is the swiftest way to determine eligibility for 
the services provided by Vet Centers. A DD-214 is the capstone 
military service document, as it represents the complete, 
verified record of a servicemember's time in the military, 
awards, medals, and other pertinent service information such as 
promotions, combat, or overseas service, military occupational 
specialty identifiers, and the record of training and schools 
completed.
    In the event that a veteran has lost his access to a DD-
214, it can take up to 6 weeks to receive a copy; and there is 
no single prevailing method used by Vet Centers to request a 
copy of the DD-214. While during the delay, a veteran will 
still have access to the facility, instant verification will 
allow the Vet Center to immediately provide veterans the 
highest possible level of service and eliminate the 
bureaucratic hurdle for the servicemember.
    There are two electronic records systems that allow users 
to view a DD-214 form. These systems are the Defense Personnel 
Records Image Retrieval System and the VA/DoD identity 
repository.
    The latter receives nightly and near realtime transmissions 
from the Defense Enrollment and Eligibility Reporting System/
Defense Manpower Data Center of military service information 
for servicemembers leaving the military.
    The former provides authorized U.S. Government agencies 
controlled access to military personnel record images that no 
other sources contain. This system was initially implemented in 
the late 1990s, so not all personnel records are available and 
implementation was staggered across all branches of service. 
DPRIS contains narrative information in the DD-214 that no 
other sources contain.
    The bill simply directs the Secretary of Veterans Affairs 
and the Secretary of Defense to jointly ensure that the Vet 
Centers of the Department of Veterans Affairs have access to a 
veteran's DD-214. As we speak, there are 7,500 current users of 
the system within the VBA alone and many others across the VA 
system. I strongly believe that the professional staff and 
counselors at Vet Centers should be given the same tools to 
serve our veterans and believe that it can be done in a way 
that preserves the integrity of the Vet Center system. I thank 
the American Legion and the VFW, Veterans of Foreign Wars, for 
their support of this legislation.
    As a veteran myself, I know the difficulties experienced by 
those transitioning to civilian life and how common it is for 
veterans to be missing records that are important to keep. I am 
sure you can all agree that whenever we have the opportunity to 
streamline service for our veterans we should seize that 
chance.
    Again, I thank the chairwoman, the Ranking Member, and 
Members of the Committee for allowing me to speak here today. I 
look forward to working with all of you to get this bill moving 
swiftly.

    [The prepared statement of Hon. Denham appears in the 
Appendix]

    Ms. Buerkle. Thank you very much.
    Mr. Akin.

                STATEMENT OF THE HON. TODD AKIN

    Mr. Akin. Thank you, Chairwoman Buerkle and also Ranking 
Member Michaud. Thank you for the opportunity to testify before 
you today regarding my bill, H.R. 3337, the Open Burn Pit 
Registry Act.
    And I am going to go on with the testimony in just a 
minute, but the short version is that people are exposed to the 
fumes that come off of burn pits, and it sometimes had delayed 
medical effects on people. And because it is not very easy to 
diagnose, it is hard for people to get connected.
    And the whole point of this thing, it is not giving any 
money away. It is just simply saying that we are going to 
create a registry so that people have a chance to coordinate 
together, get the medical information and the symptoms and put 
that together. I think it is a $2 million bill total over, I 
don't know how many years. So that is the quick version.
    It has over 50 bipartisan co-sponsors, has been endorsed by 
a wide range of veterans' organizations.
    The issue of burn pit exposure first came to my attention 
through veterans in my district who served honorably in Iraq 
and Afghanistan and are now suffering serious health effects 
apparently linked to exposure to burn pits. I will share one 
short story.
    Tim Wymore is a Missouri Guardsman suffering from the 
effects of working around burn pits while deployed to Iraq in 
2004 and 2005. His wife, Shanna--if his wife Shanna were here 
today she would tell you of the dramatic impact burn pits have 
had on the life of her husband and hundreds of others she has 
gotten to know as a result of fighting for Tim's treatment.
    For nearly a year before contacting my office, as Tim's 
health continued to deteriorate, Shanna Wymore fought an often 
indifferent and sometimes hostile VA medical system trying to 
get care of her husband's unexplained illnesses. Tim, once a 
strong, athletic machinist, was suffering debilitating bouts of 
abdominal pain, weight loss, and fatigue. Despite the 
adversity, Shanna persisted in her fight to get the help her 
husband was both entitled to and deserved. Along the way, she 
became an expert on burn pits and the growing number of Iraq 
war veterans suffering the effects of their exposure.
    After more than 2 years of indecision and broken promises, 
with assistance from my district staff, the VA finally agreed 
to send Tim to the Mayo Clinic. The doctors there confirmed 
what the VA had long denied. Tim was suffering from the effects 
of what could only be attributed to the work he performed 
around the burn pits in Iraq.
    I have had at least one other constituent, Aubrey Tapley, 
who has suffered the burn pit exposure and who has strongly 
advocated for taking proactive steps to help others who may be 
suffering from burn pit exposure.
    Unfortunately, the health consequences of burn pit exposure 
are hard to understand and difficult to prove. Last fall, the 
Institute of Medicine released a report which concluded in part 
that there is insufficient data available to determine the 
long-term health effects of exposure to burn pits and that more 
study is warranted.
    The intent of my bill is to establish a registry at the 
Department of Veterans Affairs for those individuals who have 
been exposed to open burn pits during their military service. 
This would help the Department study the issue more effectively 
and enable them to communicate to interested veterans as 
medical research on this issue develops. This registry would 
not affect the benefits any veteran is already entitled to 
receive but would help the Department take better care of our 
veterans.
    The experience I have had with veterans in my district is 
enough to convince me that we need to be proactive about 
studying and analyzing the potential health effects of open 
burn pits. We have sent our best and brightest young men and 
women into harm's way, and it is our responsibility as a Nation 
to take care of them when they return. And although there is a 
small cost for this bill, I think it is an affordable and 
reasonable approach to dealing with the issue of open burn pits 
and ask your Subcommittee to support this bill and consider 
moving it forward.
    Again, thank you for the opportunity to testify today. I 
look forward to answering any questions you may have. Thank 
you.

    [The prepared statement of Hon. Akin appears in the 
Appendix]

    Ms. Buerkle. Thank you very much.
    Mr. Schilling, you may proceed.

           STATEMENT OF THE HON. ROBERT T. SCHILLING

    Mr. Schilling. Chairwoman Buerkle, Ranking Member Michaud, 
and my colleagues, thank you for this opportunity to come 
before the House Veterans Affairs Subcommittee on Health to 
speak about my bill, H.R. 3723, the Enhanced Veteran Healthcare 
Experience Act of 2011. I truly believe that you can tell a lot 
about the country by the way they treat their veterans.
    I am pursuing this legislation in part because of the many 
constituents who constantly share their stories of having to 
drive long distances while experiencing substantial wait times 
in an effort to make sure they get the health care they need. 
But I also have a personal experience from my father who passed 
away in 2005. He served in Korea. And as we were driving many 
hours to and from the veteran hospital, you know, one day I 
thought to myself, why is it that the veteran has to travel so 
far to get the care that is needed and deserved? And, hence, 
the reason why I came up with this bill.
    We also must keep in mind the fact that we will have a new 
group of veterans entering into the VA system with needs that 
are different from the past veterans group--groups, actually. 
There have been many instances where the current VA fee-based 
system has been unable to accurately pay private providers the 
correct amounts, which has resulted in multiple overpayments 
and costs to taxpayers and their hard-earned tax dollars.
    My legislation, the Enhanced Veteran Healthcare Experience 
Act, would merge the best parts of Project HERO with the best 
parts of Project ARCH and provide an alternative to the current 
VA-run fee-based program as the primary source of fee-based 
care for veterans. It would ensure that the VA contracts with 
qualified outside entities that meet key competency 
requirements such as network credentialed providers and 
accredited facilities, care coordination, patient advocacy, and 
electronic claims processing capabilities. The bill would 
standardize referral and authorization processes at all VA 
medical centers, require continuity of care for the veteran, 
and require key performance metrics and incentive payments.
    The bill would not force veterans to stop using VA care. 
Veterans who prefer their current VA provider would still be 
able to continuing receiving care from that provider. Veterans 
that do go outside of the system are also not prevented from 
returning to the VA for care in the future.
    With a proven system that can properly keep track of 
payouts in place, the VA could save money it may have otherwise 
misspent, and very little additional fund would therefore be 
required for this more efficient program. The Congressional 
Budget Office has not yet officially scored this bill, but an 
unofficial CBO staff estimate indicated that this bill would 
require $3 million total for fiscal years 2012 to 2016. 
However, studies and statements by the GAO, the OIG, and the 
VSO indicated that implementing the changes in this bill will 
promote savings for the VA and address medical care concerns 
that veterans have when working with the VA fee-based system.
    The congressional process is in place, but we can perfect 
legislation. That is why I am working to do that on this bill. 
Since H.R. 3723's inception and also from its introduction, I 
have continued to work with the Veterans Service Organization, 
the VSO, to address their concerns. I hope to continue to do so 
with the VSO and the Committee. To that end, I have a draft 
legislation on the Committee that you can use to improve H.R. 
3723.
    Again, I would like to thank you for the opportunity to 
speak about ways that we can remain fiscally responsible while 
ensuring we keep better our promises to our veterans.
    With that, I yield back.

    [The prepared statement of Hon. Schilling appears in the 
Appendix]

    Ms. Buerkle. Thank you very much.
    Mr. McKinley, you may proceed.

            STATEMENT OF THE HON. DAVID B. MCKINLEY

    Mr. McKinley. Thank you.
    Chairwoman Buerkle, Ranking Member Michaud, Members of the 
Subcommittee. Thank you for holding this legislative hearing 
today on these important issues that affect our Nation's 
veterans. I appreciate this opportunity to give remarks about 
H.R. 4079, the Safe Housing for Homeless Veterans Act.
    Currently, there are over 2,100 community-based homeless 
veteran service providers across the country and many other 
homeless assistance programs that have demonstrated success 
reaching homeless veterans. I visited some of these shelters in 
my home district in West Virginia but have been struck by how 
many are not in compliance with State, local, and fire safety 
and building codes.
    Consequently, we began to investigate whether this is 
something that is isolated or other instances are occurring. It 
was unsettling to learn in our research about shelter fires 
where lives were lost. For instance, in 2009, an East Texas 
homeless shelter fire where five occupants were killed was 
found not to have a required sprinkler system. And an instance 
in New York City just this past year where two dozen people 
were injured because a sprinkler system was not working 
properly and the exits were blocked.
    I would like to enter news articles about these fires and 
an additional three articles regarding other instances of code 
violations into the record.

    [The attachment appears in the Appendix]

    Mr. McKinley. Unfortunately, there is no law mandating VA 
homeless shelters meet code. There is only a policy in place. 
As a licensed professional engineer who practices both 
architecture and engineering, I found this to be an egregious 
omission in the law governing homeless program funds. H.R. 4079 
would require an organization that seeks funding from VA for 
services to homeless veterans to provide documentation that 
their building meets or exceeds all Life Safety Codes.
    This legislation also requires VA to give priority to 
shelters that need financial assistance from the VA for 
improvements to ensure that the facility is in compliance with 
all safety codes.
    I am disappointed that the VA did not initially embrace 
H.R. 4079 in their written testimony. However, I do appreciate 
their willingness to work with us on this legislation so that 
the goal of maintaining a safe environment for homeless 
veterans can be achieved.
    This bill simply codifies what they already have as a 
policy. This is common-sense legislation that would ensure the 
well-being of our veterans who have fallen on hard times and 
are in most need of assistance; and, in extension, these same 
veterans are turning to society to assure them of safe, 
reliable housing.
    As a Nation, it should be unacceptable for us to allow 
homeless veterans be housed in potentially unsafe conditions. 
In defense of our country, these men and women were put in 
harm's way. They should not be in doubt about their own safety 
now that they are home again. These homeless veterans are 
experiencing a difficult phase of their lives and should be 
able to trust that they will be safe each night as they 
continue their rehabilitation as members of society.
    I appreciate the testimony in support of H.R. 4079 from 
other witnesses testifying here today, and I thank you for your 
concern for the safety and living environment of our veterans.
    I yield back my time. Thank you.

    [The prepared statement of Hon. McKinley appears in the 
Appendix]

    Ms. Buerkle. Thank you very much, and thank all of you for 
your testimony.
    I am going to yield myself 5 minutes now for questions.
    Mr. Owens, with regards to H.R. 1460, it has been a 
priority of this Committee to ensure a seamless transition for 
our veterans coming home--and so I want to thank you for your 
efforts on this behalf and also thank you for your service to 
our country.
    Mr. Owens. Thank you.
    Ms. Buerkle. We heard from the Disabled American Veterans 
in written testimony, that one of their concerns is if we 
automatically enroll this large influx of young veterans, will 
it squeeze out some of the older veterans from previous wars 
and engagements? And if they are not in the system but then try 
to enter the system at a later date, is that a problem? Would 
you like the opportunity to address that issue?
    Mr. Owens. I would say that, from my perspective, if you 
think about the process that a veteran is going through when 
they are being--in the terms of my experience--mustered out--
maybe something of an ancient phrase now--they simply are 
making choices at that point in time. And you walk out of the 
CPBO with a pack of papers about this thick. And one of the top 
priorities for people who are eligible for VA benefits should 
be they are getting those. And so, even if it does create a 
little bit more of an initial influx, most of those people are 
going to come into the system down the line anyway; and I think 
it is most appropriate that they have the opportunity to go in 
immediately.
    Ms. Buerkle. One other concern that was raised by the 
Paralyzed Veterans of America, was the need to ensure that 
veterans who decide not to enroll in the VA through that 
automatic enrollment process, if at a later date they needed to 
or chose to reenter the system, is that a problem?
    Mr. Owens. They would not be precluded. The disenrollment 
provisions that are in the bill simply allow people to make 
that choice but do not prohibit, as long as they are 
statutorily eligible, to reenter the system down the road.
    Ms. Buerkle. Thank you very much.
    Mr. Barrow, if I could.
    Mr. Barrow. Yes, ma'am.
    Ms. Buerkle. With regards to H.R. 3016, this Subcommittee 
has had two hearings on the Federal Recovery Coordination 
Program. We have grave concerns, so I am absolutely delighted 
that you are bringing this up and we are addressing this issue. 
There seems to be such an overlap between what the VA is doing 
and what DoD is doing, and we are really concerned about making 
this happen for veterans and their families.
    Your testimony references administrative roadblocks that 
have prevented the Federal Recovery Coordination Program from 
achieving its full potential. Can you elaborate on that for the 
Committee?
    Mr. Barrow. Yes, ma'am.
    There is a need to get referrals from the DoD side of 
things, and the DoD is not as responsive in the chain of 
command. The recovery program has direct access to the 
Secretary of the VA but not the DoD, and we think it is 
important that that be remedied, that they have access to the 
highest levels of authority in both, the two main silos in 
which our concerns for Wounded Warriors originate, those where 
they began and those where they transition to.
    Also, I think it is important that they be codified and 
established in law so that we have an ongoing commitment to the 
program.
    Those are just a couple of ways in which I think we can 
overcome some of the obstacles that folks have encountered.
    Ms. Buerkle. Very good, thank you.
    Mr. McKinley, if you could just elaborate a little bit 
further on --
    Mr. McKinley. I am sorry. I can't hear.
    Ms. Buerkle. If you could just elaborate a little bit 
further on what were the conditions that you saw and, 
specifically, how your bill would address those conditions.
    Mr. McKinley. I still didn't hear.
    Mr. Akin. What were the conditions that you saw and how 
would your bill affect it?
    Ms. Buerkle. I can repeat it.
    Mr. McKinley. What we saw were lack of sprinkler systems, 
fire doors that were not rated fire doors. Wall assemblies that 
did not meet code. Fire exit ways that did not meet code. ADA 
requirements of accommodations on upper floors.
    These would not be acceptable in almost any other 
circumstance, and it is unfortunate. I think it has fallen 
through the cracks, that these could be addressed over a period 
of time and corrected, and our veterans would be housed in an 
equal, comparable to many other situations.
    Thank you.
    Ms. Buerkle. Thank you very much.
    I now yield to the Ranking Member for questions.
    Mr. Michaud. Thank you, Madam Chair.
    Once again, I would like to thank all of the panelists for 
coming here today and look forward to working with you as we 
move forward dealing with your individual pieces of 
legislation. So I have no questions for any of the panelists. I 
yield back.
    Ms. Buerkle. Thank you.
    I yield to the gentleman from Tennessee, Dr. Roe.
    Mr. Roe. First of all, I want to thank the panelists. Every 
one of you stayed within your 5 minutes. Thank you. That is 
amazing. I have never been to one where everybody did. So this 
is the first time since I have been here.
    Just a couple of quick questions, one to Congressman Akin.
    I want to strongly encourage us to support this piece of 
legislation, and I will tell you why. I served in Korea, 11 
miles south of the DMZ almost 40 years ago. And sometime before 
that, Agent Orange was used there but there is no record of 
that. And now it is just a disaster trying to figure out who 
was there, who was not there and can you get their benefits.
    You are right on by doing this. Let's just put a record 
down. You don't know 40 years from now what is going to come up 
and who is going to need that. So let's document who was there 
so that a congressman, much after we are all gone, can deal 
with this years later. I think it is a very good piece of 
legislation.
    And just for my clarification, from Congressman Owens, if 
you would tell me why was the date picked in 1998 for a soldier 
that would be signed up, as opposed to a troop before that that 
may have been in a combat zone?
    Mr. Owens. I think it was simply for administrative 
convenience. We needed to pick a date, and we picked that. It 
also coincides with Gulf War 1, and we thought that those folks 
would be most likely in the position, whereas people who served 
in Vietnam were most likely, if they were going to be in the 
system, already in the system.
    Mr. Roe. I just didn't know why that was picked. That is 
fine. So it is arbitrary.
    And the other question I guess I had to Congressman 
McKinley is that, being a former mayor before I got here, how 
can you get a facility permitted past the building codes folks 
and the local fire marshal? That wouldn't happen where I live.
    Mr. McKinley. Some things, Congressman, occur over time. We 
determined up in New York, where they actually blocked fire 
exit ways, they may have been approved at one time. But then 
the way it operated, they were closed, locked. Sprinkler 
systems were turned off because they were not being repaired 
properly. So they were dripping, leaking. Instead of fixing 
them, they just turned them off. So you have got it initially. 
But there has to be and should be a follow-up. For something as 
serious as this, there should be ongoing investigation to see 
that our men and women are safe.
    Mr. Roe. I guess I am more pointing at the local officials 
than I am the VA. Because that is a local issue at home. I 
don't think that could happen. They are here all the time.
    Mr. McKinley. I am not going to finger point as to whether 
it was the VA or the local fire marshal, but I think someone 
needs to be doing an ongoing operation. Once they get 
permission to do it, someone needs to follow up to make sure 
that both groups are complying with the requirements that were 
passed.
    Mr. Roe. Thank you. I yield back.
    Ms. Buerkle. Thank you very much.
    If there are no further questions from the Committee, I 
would just like to say thank you to all of you again. Thank you 
for your commitment to our veterans. As a Nation, we owe them a 
debt of gratitude, and I appreciate your efforts on their 
behalf. Thank you all very much.
    If our second panel would come to the table. Good 
afternoon, everyone.
    With us on our second panel are representatives from our 
veteran service organizations:
    We have Mr. Shane Barker, Senior Legislative Associate for 
the Veterans of Foreign Wars; Mr. Adrian Atizado, Assistant 
National Legislative Director for the Disabled American 
Veterans; Commander Rene Campos, the Deputy Director of 
Government Relations for the Military Officers Association of 
America; Ramsey Sulayman, Legislative Associate for the Iraq 
and Afghanistan Veterans of America; and Mr. Ralph Ibson, 
National Policy Director for the Wounded Warrior Project.
    Thank you all very much for joining us this afternoon, and 
our sincere thanks to all of you for the good work you do for 
and on behalf of our veterans and their families. Thank you.
    With that, Mr. Barker, if you would like to begin with your 
testimony.

   STATEMENTS OF SHANE BARKER, SENIOR LEGISLATIVE ASSOCIATE, 
 VETERANS OF FOREIGN WARS; ADRIAN ATIZADO, ASSISTANT NATIONAL 
   LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS; RENE A. 
     CAMPOS, COMMANDER, U.S. NAVY (RET.), DEPUTY DIRECTOR, 
GOVERNMENT RELATIONS, MILITARY OFFICERS ASSOCIATION OF AMERICA; 
 RAMSEY SULAYMAN, LEGISLATIVE ASSOCIATE, IRAQ AND AFGHANISTAN 
VETERANS OF AMERICA; AND RALPH IBSON, NATIONAL POLICY DIRECTOR, 
                    WOUNDED WARRIOR PROJECT

                   STATEMENT OF SHANE BARKER

    Mr. Barker. Thank you.
    Chairwoman Buerkle, Ranking Member Michaud, and Members of 
the Committee, on behalf of the 2 million members of the 
Veterans of Foreign Wars and our auxiliaries, it is my pleasure 
to be here today to share our views with you on these important 
pieces of legislation.
    In the interest of time, I will limit my remarks to a 
selection of bills before the Committee.
    VFW does support the intent of H.R. 1460, which would 
direct VA to automatically enroll servicemembers returning from 
Iraq and Afghanistan into the Veterans Health Administration. 
However, as written, we are concerned that this bill would not 
enroll military personnel who are medically retired as a result 
of a stateside injury or other extenuating circumstances.
    The VFW does hope that this Committee will consider 
amending this legislation to provide a similar service as what 
you are trying to provide to people returning from Iraq and 
Afghanistan to all separating servicemembers and would give the 
VA the resources that it needs to be successful in that 
mission.
    VFW also supports H.R. 3016, a bill that could ensure those 
responsible for administering the Federal Recovery Coordination 
Program are located in the offices of the Secretaries of DoD 
and VA and not down the chain somewhere that would make them 
less visible to the respective Secretaries.
    This program was created to ensure properly coordinated 
care for our Wounded Warriors without placing the 
administrative burden on the servicemember or their family. We 
have fallen short on this promise for many of our returning 
warriors, and we feel that we must do more to alleviate the 
burden caused by simply being in the program.
    This legislation contains other helpful provisions, but 
problems within the FRC program will not be solved without 
taking this obvious step, and so we fully support this bill.
    We also strongly support H.R. 3279, legislation that would 
clarify the veterans eligible for caregiver support under 
Public Law 111-163 as a result of serious illness are just as 
eligible as those veterans who qualify as a result of a combat 
injury. Congressional intent is clear that those who are 
catastrophically harmed through a debilitating disease should 
have equal access to the full range of benefits under the 
caregiver law. This is the case in the Department of Defense 
Caregiver Program, and we cannot accept a program that would 
curtail essential caregiver benefits when a military member 
exits DoD care and enters VA care. This is the right thing to 
do for our servicemembers and their families, and we offer our 
full support.
    VFW supports H.R. 3337, the Open Burn Pit Registry Act of 
2011, and thanks Congressman Akin for his introduction of this 
bill. It is a recognition that we have not yet reached the 
level of scientific knowledge to properly care for the men and 
women who had no choice but to inhale the toxic fumes of a burn 
pit in Iraq or Afghanistan.
    This bill is also a recognition that our Nation wants to 
provide enhanced care for those exposed as new treatment 
options are discovered. It is important to show that those who 
are suffering from the effects of toxic inhalations that we 
care for them and want to provide the best possible treatment.
    The VFW does not support H.R. 3723, the Enhanced Veteran 
Healthcare Experience Act of 2011. We believe this bill is well 
intentioned and that it seeks to address a clear and 
significant problem within VA. Those problems are inherent in 
the current fee-based system. They are manifest. As an example, 
while the VA paid out more than $4 billion in fee-basis health 
care claims in 2010 alone, they have few tools at their 
disposal to ensure they are getting the most for their money.
    Among the serious problems that currently exist, VA has no 
way to ensure proper credentialing of those who bill VA for 
services rendered; no way to ensure bill procedures actually 
occurred; and no way to integrate the documentation into a 
veteran's electronic health record.
    Nevertheless, the remedy this bill offers is, at the same 
time, broad in its implication and overly proscriptive in its 
mandates. Essentially, it would wipe away the current system of 
fee-basis care and would replace it with a network of providers 
to be administered by one or more private companies on behalf 
of VA.
    In order for such a network to be affordable, we believe VA 
would have to direct a consistent number of veterans into the 
network to keep doctors participating and to drive down unit 
cost. In our view, such a calculation could make the health 
care needs of veterans a second priority as VA seeks to manage 
their network.
    We believe this paradigm also presupposes a robust and 
successful implementation of the Patient Aligned Care Teams 
across VHA to coordinate with the network provider to eliminate 
duplicative services and promote overall cost containment. The 
PACT model of care is not yet fully implemented, and we 
approach the concept of a bidirectional care coordination 
across VA with the private sector with a healthy amount of 
skepticism.
    We are appreciative of the introduction of this bill, and 
we are pleased to be a part of this discussion. We would hope 
to work with the Committee in the future to continue refining 
this legislation.
    And with that, Madam Chairwoman, this concludes my 
statement. I am happy to take any questions that you or Members 
of the Committee may have.

    [The prepared statement of Shane Barker appears in the 
Appendix]

    Ms. Buerkle. Thank you very much.
    Mr. Atizado, you may proceed.

                  STATEMENT OF ADRIAN ATIZADO

    Mr. Atizado. Madam Chairman, Ranking Member Michaud, and 
Members of the Subcommittee, the Disabled Americans Veterans is 
honored to testify at this legislation hearing before the 
Subcommittee on Health.
    Our organization has 1.2 million members, and we devote our 
energies to rebuilding the lives of disabled veterans and their 
families. For the sake of brevity, I will only speak on those 
bills for which DAV supports favorable consideration by this 
Subcommittee.
    The intent of H.R. 3279 is to clarify Congress' intent in 
passing Public Law 111-163. That is to make family caregivers 
of certain veterans with serious illnesses eligible for VA's 
comprehensive caregiver assistance and support services. Under 
current law, only family caregivers of certain veterans with 
serious physical injuries are eligible; and we thank the 
sponsor for introducing this bill and strongly urge its 
favorable consideration.
    Our national resolution passed at our most recent national 
convention supporting this important legislation also calls on 
Congress to expand the eligibility for comprehensive caregivers 
support services to caregivers of veterans of all eras. Those 
caregivers have carried a long and heavy burden for their loved 
ones and deserve the level of attention and support now being 
provided generously by VA to caregivers of the newest 
generation of veterans.
    DAV also supports H.R. 3337, the Open Burn Pit Registry Act 
of 2011, because it partially fulfills propositions in our 
national resolution on military exposure to toxic and 
environmental hazards. If enacted, this bill would direct VA to 
establish an open burn pit registry, advise veterans in how to 
participate, and periodically notify registrants about 
significant developments in the study and treatment of 
conditions associated with exposure to open burn pits.
    Madam Chairwoman, we note that participation in the 
registry is voluntary. That is the nature of the beast. And 
because such participants are self-selected, they do not 
constitute a representative sample of all U.S. soldiers who are 
exposed to open burn pits.
    While the limitation of a registry precludes it from being 
used to determine whether a particular condition is caused by a 
particular exposure, it does provide useful information to 
describe the health status of participants. That is to say, the 
burn pit registry could be used to determine whether to pursue 
research on a possible link between condition and exposure. For 
this importance, we support that provision of this bill.
    Now, in October, 2011, the IOM, the Institute of Medicine, 
did issue its report on long-term consequences of burn pits in 
Iraq and Afghanistan. They found numerous data gaps and 
uncertainties in monitoring the airborne pollutants that point 
to the need for additional study and analysis. The IOM 
recommended conducting a longitudinal study to evaluate the 
health status of servicemembers from their time of deployment 
to determine their incidence of chronic disease, including 
cancers, some which may not appear until many months after.
    Madam Chairwoman, although VA is sponsoring large-scale 
scientific studies that cover a wide spectrum of health 
effects, these studies may not meet IOM's call for a well-
designed study for this particular environmental exposure. We 
urge your Subcommittee to considered adding to this bill a 
prospective research component with the identification of 
specified cohort groups. Cohort studies over an extended period 
of time have the potential to provide more meaningful insight 
into the long-term health consequences from combined exposures, 
including exposures to open burn pits.
    Madam Chairwoman, this completes my testimony. I would be 
happy to answer any questions you or the Members of the 
Subcommittee may have.

    [The prepared statement of Adrian Atizado appears in the 
Appendix]

    Ms. Buerkle. Thank you very much.
    Commander Campos.

                  STATEMENT OF RENE A. CAMPOS

    Commander Campos. Madam Chair Buerkle, Ranking Member 
Michaud, and distinguished Members of the Subcommittee, on 
behalf of the 375,000 members of the Military Officers 
Association of America, I am grateful for the opportunity to 
present MOAA's views on the legislative provisions before the 
Subcommittee. MOAA greatly appreciates the Subcommittee's 
leadership in addressing the very important business of taking 
care of our veterans by your diligent oversight of their 
medical care and benefits.
    We would also like to acknowledge and thank the VA for its 
hard work and persistence in transforming the agency's culture 
and systems of care.
    Today, I will focus my remarks on three specific bills.
    MOAA thanks Congressman Owens for his commitment to 
seamless transition of veterans from the military to the VA 
health care system with H.R. 1460. MOAA supports the concept of 
automatic enrollment in VA health care and recommends that H.R. 
1460 be amended to authorize all Iraq and Afghanistan veterans. 
We believe that there should be no distinction between veterans 
who have served in combat theater and those who have served in 
other types of assignments. Automatic enrollment of only combat 
theater veterans will likely be perceived negatively by non-
combat veterans, causing them to view it as a form of health 
care rationing that devalues their contributions of service to 
their country.
    Automatic enrollment is consistent with MOAA's long-
standing support for seamless transition into the VA and 
civilian medical systems. Ongoing work on the DoD and VA 
electronic medical record could be advanced by automatic VA 
health care enrollment, but the provision does not eliminate 
the requirement for the veteran to physically enroll in a VA 
medical center. Perhaps VA's outreach system could be 
strengthened by having advance information on separating 
servicemembers put into the VA's enrollment system.
    Secondly, MOAA supports the concept of H.R. 3016, 
Congressman Barrow's bill, to direct the VA and DoD Secretaries 
to operate the joint Federal Recovery Care Coordination 
Program. We support, again, in concept, but we would recommend 
that Congress continue to provide oversight by conducting 
hearings and requiring reports from senior VA and DoD officials 
in lieu of additional legislation in order to determine the 
efficacy of these programs and increase accountability of the 
systems. The two departments have stepped up their 
collaborative efforts in recent months, but MOAA believes that 
congressional and VA-DoD leadership oversight continues to be 
needed until care coordination programs, policies, and systems 
mature and are operating efficiently and effectively.
    Finally, our association supports Congressman Reyes' bill, 
H.R. 3279. MOAA and others here today have already recommended 
that there should be a change in--or have recommended in the 
past formal changes to the VA's interim final rules concerning 
the new caregiver benefits program.
    Currently, VA rules define serious injury as any injury, 
including psychological trauma or other mental disorder 
incurred or aggravated in the line of duty in the active 
military, naval, or air service on or after September 11, 2001, 
that renders the veteran or servicemember in need of personal 
care services.
    It is not clear from that definition how VA will address 
individuals whose serious illnesses incurred during service 
worsened or changed to the point of needing a caregiver once 
they are in a veteran status.
    MOAA would like to make sure that the definition is not 
open to interpretation. We believe the intent of Congress was 
to allow both active duty and veteran caregivers to qualify for 
the benefit for both serious illness and injury.
    MOAA thanks the Subcommittee for being champions of our 
veterans and their families. We look forward to working with 
the Subcommittee and VA on ways to improve health care so that 
we can further enhance the quality of lives of these 
individuals in our veterans' community.
    I look forward to answering your questions and thank you 
again.

    [The prepared statement of Rene A. Campus appears in the 
Appendix]

    Ms. Buerkle. Thank you very much, Commander.
    Mr. Sulayman.

                  STATEMENT OF RAMSEY SULAYMAN

    Mr. Sulayman. Madam Chairwoman, Ranking Member, 
distinguished Members of the Subcommittee, on behalf of more 
than 200,000 members and supporters of Iraq and Afghanistan 
Veterans of America I thank you for the opportunity to share 
the views of our members on these very important pieces of 
legislation.
    My name is Ramsey Sulayman, and I am a Legislative 
Associate with IAVA. I am a veteran of Iraq, where I was an 
infantry platoon commander and company executive officer. I 
have spent 14 years in the Marine Corps trying to execute the 
Marine Corps' two missions: winning battles and making Marines.
    As an IAVA staff member, I don't make soldiers, sailors, 
airmen, or Marines, but I do try to make their lives better. 
The views expressed here are not the viewpoints of the Marine 
Corps. They are solely mine and IAVA's analysis. Thank you for 
your attention to the pressing issues facing our Nation's 
veterans.
    IAVA strongly supports H.R. 1460, ensuring that veterans 
are automatically enrolled in the VA health care system and 
required to opt out if they do not wish to be enrolled. 
Actually getting veterans into the VA system is the most 
important part of a smooth and seamless transition from the 
Department of Defense health care system to the Veterans 
Administration health care system.
    Currently, only 54 percent of Iraq and Afghanistan veterans 
are enrolled in the VA health care system. The steep cost of 
quality health care to the private sector and a high rate of 
veteran unemployment, almost 17 percent among our membership, 
means many veterans do not have access to any other health care 
system, often for their service-related injuries. IAVA believes 
that H.R. 1460's solution of changing enrollment is easy and 
effective, both in terms of cost and efficacy. Combat veterans 
should not have to opt in to receive a benefit they have earned 
through their service.
    We also support H.R. 3337, the Open Burn Pit Registry Act 
of 2011. Burn pits have the potential to be the insidious and 
long-term health issue for our generation of veterans that 
Agent Orange has been for our Vietnam era veterans. H.R. 3337 
gets ahead of the curve in responding to potential future 
health concerns by establishing facts. Who is exposed, where 
were they exposed, and for how long? These small but crucial 
pieces of information will be helpful in the future in 
ascertaining the health impacts, facilitating subject 
identification for epidemiological studies, and adjudicating 
claims.
    Burn pits were ubiquitous in Iraq and still are in 
Afghanistan. They are located in the midst of large numbers of 
troops. The twin facts that burn pits are the way waste is 
disposed and must be co-located with troops for logistical 
purposes guarantees exposure for most veterans.
    While IAVA supports H.R. 3337, we do so with a caveat. 
Because of the ubiquity of burn pits in these conflicts, we 
believe that the definition of burn pit must extend beyond 
solely those authorized by the Secretary of Defense to include 
those that were established by small unit commanders to 
facilitate mission accomplishment. In other words, there is no 
garbage service for our troops to rely on in Iraq and 
Afghanistan; and, by necessity, we burn all of the waste that 
we have.
    This is a necessary addition to this important piece of 
legislation, and IAVA encourages inclusion of such language in 
the bill before passage.
    We also support the goals of H.R. 3723. We believe they are 
laudable, and we support many of them. However, we cannot 
support H.R. 3723, because we believe that this legislation 
makes several changes that are untested and do not necessarily 
provide hope of significantly improved patient outcomes or 
access to care.
    There are significant issues in the VA health care system, 
and my colleagues in the other VSOs have addressed them at 
length. I would just say that we reiterate most of those, and 
we think that there are many questions that need to be answered 
before such a drastic step is taken.
    We would also point out that there are many medical options 
that are not cost effective in the private sector, such as 
prosthetics, and real questions exist regarding the fiscal 
benefits and patient outcomes when outsourcing these types of 
care.
    The bill begs the question of whether another system that 
makes the VA a third-party payer, essentially replicating the 
scenario we have with fee-care, or should the VA system be 
strengthened, funded, and fixed if the use of third-party non-
VA providers is minimized and truly used out of necessity. IAVA 
prefers the latter option, and therefore we cannot endorse 
3723.
    In the interest of time, I have submitted all of my other 
comments for the record, and I look forward to answering any 
questions that the Committee has.
    Thank you very much.

    [The prepared statement of Ramsey Sulayman appears in the 
Appendix]

    Ms. Buerkle. Thank you very much.
    Mr. Ibson, you may proceed.

                    STATEMENT OF RALPH IBSON

    Mr. Ibson. Thank you, Madam Chair, Ranking Member Michaud, 
Members of the Subcommittee. Thank you for inviting Wounded 
Warrior Project to offer our views on the legislation pending 
before the Subcommittee.
    We are particularly pleased that you are considering two 
bills that would close gaps in programs of real importance to 
Wounded Warriors. Let me first highlight our strong support for 
those two measures.
    First, H.R. 3016 would remedy fundamental problems in the 
governance and operation of the Federal Recovery Coordination 
Program, problems that were ably documented in this Committee's 
hearings on the program. The bill would require the two 
departments both to develop a memo of understanding for joint 
program governance and a specific plan for program operations.
    Importantly, in our view, a key provision would require the 
service Secretaries to refer eligible servicemembers to the 
program at the earliest possible time to gain the benefit of 
having an FRC assist all aspects of the transition process. It 
is clear from the experiences of our warriors and their 
families that having the FRC early in the process can make all 
of the difference. But as your hearings have documented, the 
service departments too often elect not to refer severely 
injured servicemembers for an FRC until after that member has 
retired, often far too late in the process to be helpful.
    We applaud your patient efforts to resolve these issues 
through hearings and discussion, but, at this point, with the 
risk of Wounded Warriors falling through the cracks, we believe 
a legislative solution is needed and strongly support the 
approach set out in H.R. 3016.
    A second bill under review, H.R. 3279, would, as others 
have testified, clarify that a veteran who has a serious 
illness incurred in service after 9/11 can be helped through 
VA's Comprehensive Caregiver Assistance Program. Although VA's 
interim rule draws a hard line, the statute itself is not that 
clear. Yet there may be little distinction between the 
caregiving needs of a young warrior profoundly disabled by a 
service-connected illness and one who is injured. In each 
instance, a parent or spouse may have permanently left the 
workforce to care at home for that veteran's daily needs, 
leaving that veteran vulnerable to the risk of VA 
institutionalization if the stresses of caregiving overwhelm 
that family member. Surely, Congress sought to address through 
the caregiver law the impact of caregiving, not the underlying 
etiology of the veteran's condition. Clarifying the law as 
proposed would provide needed support. We strongly support 
that.
    Mr. Ibson. In contrast, H.R. 3723 would change the 
statutory underpinnings of the VA's fee-based authority in a 
very fundamental but potentially problematic way, as others 
have suggested. Current law simply authorizes VA to provide 
fee-based treatment to certain veterans when it can't provide 
timely, geographically accessible care in its facilities. But 
H.R. 3723 would require contracting for care under those 
circumstances and require it for all enrolled veterans.
    It is not clear what the impact that mandate would 
ultimately have. It is possible that facilities might simply be 
instructed to provide contract care in accordance with the law. 
But we question whether the change would assure the intended 
outcome. And by way of illustration, we note that VA policy 
currently says that mental health care, for example, must be 
made available to eligible veterans either in VA facilities or 
under contract arrangements. Notwithstanding that very clear 
policy, fee-based care is seldom an option for OEF/OIF veterans 
with service-connected mental health conditions, despite the 
fact that VA facilities frequently cannot provide that care in 
a timely way.
    It is possible that the mandate in that bill would not have 
great practical effect. And yet on the other hand if the 
provisions were implemented literally, it could have sweeping 
operational and fiscal implications. In either case, we cannot 
support the measure.
    H.R. 1640, as discussed, would require VA to enroll any 
veteran who served in the combat zone, subject to an option not 
to enroll. While the bill appears aimed at facilitating access 
to care, in our view enrollment itself has not been a barrier. 
The bigger problem that warriors have encountered, particularly 
with the prevalence of PTSD, is getting timely, effective 
mental health care. We see high percentages of OEF/OIF veterans 
enrolling and being ``seen for care,'' but surveys indicate 
that VA facilities are often not adequately staffed to provide 
the timely care or even the right kind of care that veterans 
need.
    So our concern is that VA has put much more emphasis on 
enrolling as many veterans as possible, and less emphasis on 
assuring that veterans are receiving the specialty care that 
they may need. In short, we have no objection to this bill, but 
we don't believe that it solves the underlying fundamental 
access to treatment problems that many are facing.
    Seeing that I am running out of time, Madam Chair, I will 
close and be available for any questions you might have.

    [The prepared statement of Ralph Ibson appears in the 
Appendix]

    Ms. Buerkle. Thank you very much, and I thank all of the 
panelists for your testimony this afternoon.
    I yield myself 5 minutes for questions.
    Mr. Barker, regarding H.R. 1460, your concern is that it 
may send a message to nondeployed veterans that they may not be 
eligible for VA care. Is there a way that you could address 
that?
    Mr. Barker. Let me give it a shot. As I understand the 
bill, it basically facilitates enrollment but it has no bearing 
on whether or not a person is eligible for services. When I 
crafted my testimony, I wanted to try to describe the 
importance of allowing all veterans to have access to whatever 
services and benefits that they have earned. That is the 
important piece, and I would agree with what Mr. Ibson said. We 
haven't heard anyone complain about the enrollment process, it 
is what happens after the enrollment process in terms of 
delays, et cetera.
    And so in crafting an alternative to this bill, I think it 
would be preferable to see something that applies to everyone 
who is separating equally, as opposed to someone who is 
deployed versus nondeployed. That is the basic message I think 
we are trying to achieve here.
    Ms. Buerkle. Thank you.
    Mr. Atizado, regarding H.R. 1460--and I asked this question 
of our first panel--your concern with regard to when you are 
enrolling and you have this influx of young enrollees that 
might squeeze out and preclude older veterans from enrolling. 
How would you address that concern?
    Mr. Atizado. Thank you for that question, Madam Chairwoman.
    The main principle behind our position is that the 
Secretary of Veterans Affairs' ability to manage patient 
enrollment is one of a very few number of tools he or she has 
to control the health care system.
    This authority was exercised back in 2003 when VA decided 
to stop enrollment for Priority Group 8 veterans, and that was 
at a time when resources were not keeping up with demand. So in 
this era, I should say in this--in the recent past, we were 
looking at a fiscal environment where VA will once again be 
subjected to fiscal constraints. So what will happen is if the 
VA is unable to manage its patient enrollment because they are 
automatically enrolling one specific category of veteran, it 
will undoubtedly push out others. VA, after all, it operates in 
a resource-constrained environment. So that is the main thrust 
of our position.
    I want to reiterate what my colleagues here have mentioned 
about enrolling. I understand, and it is in my testimony, that 
the services are looking at or have been mandating transition 
assistance for all veterans, not just those that are seriously 
injured, not just those who are moderately injured. Even those 
who are not injured. Even Guard and Reserves are now being 
mandated to go through TAP, and I think done so in a much more 
responsible manner. That is, they are given appropriate time to 
determine what it is that they need. Because if a 
servicemember, in transitioning out of service, doesn't know 
that they really should enroll in VA because it is such a good 
value, I think there is something wrong with that transition 
program if that is not properly conveyed.
    Ms. Buerkle. Thank you very much.
    I have a few seconds left, and so I will ask Commander 
Campos, in your testimony you mentioned that DoD and the VA 
have stepped up with regards to H.R. 3016. As I mentioned in my 
comments to Mr. Barrow, we have had a couple of hearings on 
this issue. We have been really concerned with the inability to 
coordinate and the overlap. They have had 4 years to implement 
this. Do you think VA and DoD have made significant progress? 
Can you shed a little bit of light from your perspective?
    Commander Campos. I appreciate the Subcommittee really 
keeping the eye on this issue because I think it is very 
critical to the long-term care of these wounded and disabled 
veterans.
    We have watched this very closely. There seems to be a 
great deal of indication, especially after attending in early 
March, maybe it was late February, the recovering warrior task 
force where both DoD and VA recovery care coordination and the 
FRCP folks briefed the Committee or task force. And so it is 
clear that they are working together. But in our view, adding 
more legislation to something that is already in our minds 
mandated by Congress doesn't seem to be the answer. I think the 
only way that VA and DoD are going to continue to work close 
together and make this really seamless is to continue the 
oversight by your Subcommittee and Congress as a whole, both on 
the Armed Services Committee as well as the Veterans' 
Committee.
    Ms. Buerkle. Thank you very much.
    I yield 5 minutes to the Ranking Member, Mr. Michaud.
    Mr. Michaud. Thank you, Madam Chair. This question is for 
each of the panelists, and I will start with Mr. Barker first.
    Mr. Barker, under H.R. 3279, the VA estimates that 870 
additional veterans and servicemembers would qualify for 
service and benefits, and that in fiscal year 2013 it would 
cost the VA $45 million, and $263.5 million over a 5-year 
period under the caregivers bill. Do you believe this number is 
accurate given that, to the best of my knowledge, the VA hasn't 
even defined under the legislation the term of serious illness?
    Mr. Barker. If I may, I would like to take that for the 
record to give you an accurate statement from our organization, 
although I would just observe there are often things that are 
supposed when making these estimates that we often find fault 
with, and I would like to engage more in that process of 
articulating our view. So that would be something I would like 
to take for the record, if I may.

    [The attachment appears in the Appendix]

    Mr. Atizado. Ranking Member Michaud, thank you for that 
question. I do not have inside knowledge on VA's estimates; but 
what I do know, there are a significant number of applicants, 
caregivers and veterans who have applied and been denied 
because of the lack of illness in the eligibility criteria. So 
I think VA knows at least those that have applied but were 
denied.
    What they don't know and what I think they are trying to 
get a handle on as best they can are those caregivers and 
veterans who may not have applied because they realize, from 
hearing from the Subcommittee awhile back, that illness isn't 
included. So they just don't apply altogether. So I think that 
is the squishy part of the details.
    Commander Campos. I believe--I couldn't comment, our 
Association couldn't comment on the specific numbers. But I 
know that our work with the caregiver program and the folks 
there have been very receptive to answering questions and 
responding to our questions and even engaging in individual 
cases. So I would have no reason to question that. However, as 
part of the interim rules for the caregiver, we did comment on 
our concerns about how those who were denied would be able to 
appeal as well as getting some information as to why their 
request was denied.
    Mr. Sulayman. Ranking Member Michaud, thank you for the 
question.
    I would concur with Mr. Barker, that I would like to see a 
little bit more analysis on what that number is. It seems a 
little bit high to me, especially given the rather small 
proportion, or the rather small population that they have cited 
would take advantage of it. And I would agree with both Ms. 
Campos and Mr. Atizado, that the real question is what other 
numbers are they looking at. Are they trying to access those 
who have been turned away in the past, or is there some other 
metric that they are using? That would be my sense of it.
    Like Ms. Campos, we have had good relationships with those 
who manage the caregivers assistance program, and they have 
always been forthcoming, so I wouldn't doubt their answer. I 
would just wonder what the figure encompasses.
    Mr. Ibson. At the risk of being the skeptic in the group, 
Mr. Michaud, I would only suggest that the history of 
attempting to estimate costs on legislation involving caregiver 
assistance has been very uneven, in my view, at the VA. And at 
least from the perspective of an organization working with a 
largely very young population, it strikes me as difficult to 
imagine figures that high in terms of illnesses that would 
require a need for caregiver assistance.
    So while I certainly would be open to looking at that data 
and appreciate how hard the VA has worked on implementing the 
program, I remain skeptical of those numbers.
    Mr. Michaud. Mr. Ibson, how would your organization define 
serious illness?
    Mr. Ibson. Well, I think it goes to a need for caregiving, 
ultimately. Just as the phrase ``serious injury'' in the 
Caregiver Law itself ultimately gains meaning from the 
circumstances that require a need for caregiving, which is 
either on the basis of a need for supervision and protection, 
or a need for assistance based on inability to perform one or 
more activities of daily living. Loss of function or activities 
of daily living.
    Mr. Michaud. Thank you.
    Ms. Buerkle. I yield to the gentleman from Tennessee, Dr. 
Roe.
    Mr. Roe. I am just an old public school guy. I didn't go to 
private schools. But when you do the math, it is $50 million a 
year and you have 800-something people; that is over $50,000 
apiece per person. I don't know how they came up with the 
number, but the math isn't very hard. I don't know whether that 
is accurate or inaccurate, but those are the numbers. It is not 
hard to do the math on that. I don't think anybody knows. And I 
agree with you, Mr. Ibson, they historically have been pretty 
inaccurate. That may have been how they came up with the 
number: How much are you spending on a caregiver today? It 
would be easy enough to find out. How many you have, that is 
not hard to find out. So we should be able to get that 
information pretty easily.
    Just a couple of comments very quickly because I have 
another meeting to go to.
    I think in H.R. 1460, and I share your concerns, being a 
Vietnam-era veteran. I served in Korea. I am a category 8 
veteran, and so I can't go to the VA because of my income. I 
have never had a problem with that because I felt like veterans 
who did not have the resources I had, they should be in the 
front of the line and I should be in the back of the line. I 
think a lot of veterans feel that way. I know if the resources 
are limited, as you all have pointed out, we need to get those 
resources to the most needy veterans. To me, those are the 
veterans who have served in a combat zone. That may be why this 
is the way it is. I don't know that for a fact, but I just 
share that as a veteran sitting here, having gone through when 
the resources for veterans were very limited after the end of 
the Vietnam War. So perhaps in a perfect world, I agree with 
you, everybody should be in there.
    The other thing I need a little clarification on, and help 
me with this because we need to make some decisions, is in H.R. 
3723. I treated patients. I am an OB-GYN doctor. They didn't 
have a gynecologist at the local VA, and so I would see a lot 
of them, our group would, because they didn't provide that 
service. As you pointed out, that is already in the law. How 
would that change?
    In the real world, how do you all see a change in that 
relationship the VA would have with me as a provider? And I 
agree, a veteran who has been there and has done that probably 
sees things a little differently than a physician who has been 
trained but has not been in the military. I am trying to figure 
out your concern because I want to make sure that I get the 
right vote on that proposal. Anybody who can help me.
    Mr. Ibson. As I understand the bill, it aims at fostering 
contractual relationships with large providers. I think it 
would likely close the door on the individual authorization to 
an individual practitioner, notwithstanding a finding in the 
bill that suggests the importance of giving veterans that kind 
of opportunity.
    Mr. Roe. I think I need to go back and really look at that 
to see if--because I didn't fully understand what your all's 
objection was.
    Lastly, I just want to thank you all for representing our 
veterans. Each and every one of you do a great job, and thank 
you for the job you do in representing the interests of 
veterans in this country.
    I yield back.
    Ms. Buerkle. We have just been joined by Mr. Reyes, and we 
would like to give you the opportunity to speak about your bill 
if you would like to.
    Mr. Reyes. Thank you, Madam Chair. I apologize for being 
late. It is not all my fault; American Airlines has a role in 
that.
    In the interest of time, I ask unanimous consent to include 
my statement for the record. I thank you and all who were here 
that supported my legislation, and I yield back.

    [The prepared statement of Mr. Reyes appears in the 
Appendix]

    Ms. Buerkle. Thank you, and without objection.
    Unless there are any other questions for this panel, again, 
let me express my gratitude to you. As was mentioned by all of 
the Members of the Subcommittee, thank you for what you do for 
our veterans and their families as well. Thanks for being here 
today and for your testimony. We appreciate it very much. You 
are excused.
    Ms. Buerkle. Representing the Department this afternoon is 
Dr. Robert Jesse, the Principal Deputy Under Secretary for 
Health. Dr. Jesse is accompanied by Ms. Susan Blauert, Deputy 
Assistant General Counsel for the U.S. Department of Veterans 
Affairs. Thank you both very much for being with us this 
afternoon.
    Dr. Jesse, you may proceed.

  STATEMENT OF ROBERT L. JESSE, M.D., PH.D., PRINCIPAL DEPUTY 
  UNDER SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, 
   U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY SUSAN 
 BLAUERT, DEPUTY ASSISTANT GENERAL COUNSEL, OFFICE OF GENERAL 
          COUNSEL, U.S. DEPARTMENT OF VETERANS AFFAIRS

    Dr. Jesse. Thank you. Good afternoon, Madam Chairwoman 
Buerkle and Ranking Member Michaud and Members of the 
Subcommittee. I would like to start off by thanking you for 
having us here to present the administration views on several 
of these bills and how they might affect VA programs.
    I would also like to extend my thanks to all of the 
veterans organizations who were here and speaking on behalf of 
their opinions. I think their input is very important as we 
make these decisions.
    Five of the bills that are under consideration address 
aspects of the transition process from servicemembers to 
veterans. First, H.R. 1460 would require VA, in cooperation 
with DoD, to automatically enroll combat theater veterans. An 
important part of VA's mission is outreach on multiple fronts 
to let returning veterans know about the services that they 
have earned. We are working together in a number of areas to 
support this transition with information technology, an 
integrated disability benefits evaluation system and better 
information-sharing with veterans and servicemembers.
    While this bill is offered in the spirit, the proposal 
could have complex and unintended consequences, as explained in 
my written statement. Thus, we have requested additional time 
to evaluate the proposal before submitting a position and a 
cost estimate for the record.
    Another bill is H.R. 3016 which would require VA and DoD to 
jointly operate the Federal recovery coordination program. We 
do not believe this is necessary because a program already has 
the active support and engagement of the Secretaries of 
Veterans Affairs and of Defense, and we believe that the bill 
would result in duplication between the programs.
    Third, H.R. 3245 would require that VA's vet centers have 
access to certain DoD information databases. We do not object 
to the bill, but vet centers are already able to verify 
eligibility through a number of systems. We emphasize that 
access granted by this bill must ensure confidentiality of 
veterans' records. Vet centers currently maintain a separate 
system of records that effectively walls off any client 
information which reassures veterans that their readjustment 
counseling remains confidential.
    Fourth, H.R. 3279 would amend the eligibility criteria for 
the family caregiver program to include veterans with a serious 
illness. We agree with the intent of the legislation which 
would make the program more equitable in its application. It is 
often difficult for clinicians to distinguish between needs 
based on an injury rather than an illness. However, the bill 
would create significant additional obligations, and we caution 
that without additional resources, veterans' access to medical 
services may be negatively impacted.
    Fifth, H.R. 3337 would require VA to establish and maintain 
a registry for veterans who may have been exposed to toxin 
chemicals and fumes produced by open burn bits. While we share 
the concerns raised by this bill and its advocates, we believe 
a health registry is not the appropriate tool to monitor 
potential adverse effects. In our written statement, we 
highlight the work we are doing now as well as other approaches 
that would yield more comprehensive and complete data. We 
strongly encourage any veteran who served in a combat theater 
to enroll with the VA to assess health care and services for 
conditions possibly related to their combat service for 5 years 
after their discharge.
    For the remaining bills, H.R. 3723, the Enhanced Veteran 
Health Care Experience Act of 2011, would significantly alter 
VA's existing authority to contract for certain types of health 
care. Requests for non-VA care are currently evaluated based on 
the capacity to deliver needed services and the clinical need. 
We read the new bill as allowing veterans to elect to receive 
care from another provider separate from these limits. We 
believe existing authority allows VA to contract for health-
care services; and under that authority, the VA continues to 
develop broad-based national and regional contracts. The VA has 
proposed legislation this year that would provide helpful 
clarification to VA's contracting authority.
    Finally, in our written testimony, we do not support H.R. 
4079, the Safe Housing for Homeless Veterans Act, which amends 
safety standards for housing for homeless veterans. We express 
concerns about a number of issues presented, including changes 
that could reduce the pool of capital grantees. However, we 
understand that some of these consequences may have been 
created simply by the way the bill was drafted, and we would be 
glad to meet with your staff to offer technical assistance that 
could address those issues.
    Thank you for the opportunity to testify before the 
Subcommittee. I would be pleased to respond to your questions.

    [The prepared statement of Dr. Jesse appears in the 
Appendix]

    Ms. Buerkle. Thank you very much. I yield myself 5 minutes 
for questions.
    I want to get right to the caregivers assistance program 
because that is something--as I mentioned earlier, this 
Committee has been very concerned about the very slow 
implementation of that plan. It has been 4 years now, and we 
still don't feel like we are where we are at. There is 
duplication and there are gaps. It is very frustrating.
    And in your comments just now, you mentioned that wouldn't 
be necessary because you are afraid of duplication of 
processes. Can you just tell us a little bit today what 
specific efforts are underway to address the concerns that we 
had in the last couple of meetings?
    Dr. Jesse. So the implementation of caregivers has been 
complex and has required capabilities that were not accessible 
out of things we had done. It is also relatively complex in the 
fact of training caregivers, ensuring capabilities of 
caregivers, and a lot of the other social service underpinnings 
that are required. It did take a long time to get it up and 
running. I am actually a little surprised at veterans' 
comments, because I think right now it is moving along at a 
pace that is reasonable. It probably could have been moving 
that way a little bit sooner. But again, it has been a 
complicated and new-to-us system.
    I don't think the issue on the table here for extending it 
to illness has to--it is not going to be compounded in the same 
way. What we have learned from doing this with the injured 
veterans is very informing. And, in fact, as I understand it, 
it has been the wisdom of Congress that we had a 2-year point 
where we would evaluate the program, and, from that 
understanding, would be able to then talk about extending it to 
injured, is the language in the bill, of other--of the pre-9/11 
veteran population. Extending it out to illness is a different 
issue, and it raises not a different set of processes, but I 
think a different set of definitions.
    Ms. Buerkle. Can you just, if you can, and if you can't we 
will ask you to submit it to the Committee, can you talk to us 
about substantive improvements and changes that have occurred 
since the October hearing that we had?
    Dr. Jesse. I think it is probably best if I bring that back 
for the record.
    Ms. Buerkle. Thank you. I would appreciate that.

    [The attachment appears in the Appendix]

    Ms. Buerkle. Dr. Roe, before he left, the question came 
up--I'm sure you were listening--what is the cost for a 
caregiver. Do you have any idea what the number is?
    Dr. Jesse. Our cost estimates are at this point based on a 
lot of suppositions. When we talk about illness, really the 
cost is going to be dependent on what are the brackets around 
the population that is included and the needs of those specific 
populations. So we are learning from the current injured 
veterans what those costs are. They will be informing as we 
begin to expand this out. We don't know the answer for certain, 
but our best guess is what we have presented.
    Ms. Buerkle. Thank you. I have a few seconds left.
    In our second panel, Mr. Atizado testified that late last 
year, both the VA and the DoD had been coordinating a decision 
memorandum regarding the future direction of the FRCP. Is that 
true; and if so, can you tell us about the memorandum and any 
decisions it contains?
    Dr. Jesse. There exists actually a memorandum that goes 
back to 2007 or 2008, back with the original legislation. What 
I think he is referring to is the secretaries themselves have 
taken a renewed interest in making this program work.
    For the past, close to a year, it started about a year ago 
in January, February, in the very strong effort to get the 
integrated electronic medical record program moving forward, 
the secretaries have been meeting on a relatively frequent 
basis every couple of months and dealing with these substantive 
issues, and that program is squarely in their sights.
    Ms. Buerkle. Thank you. If I can ask you to provide those 
decisions of memorandum for the Committee, however many there 
might be, with regards to this issue. Thank you very much.

    [The attachment appears in the Appendix]

    Ms. Buerkle. At this time I yield the Ranking Member 5 
minutes.
    Mr. Michaud. Thank you, Madam Chair. Thank you, Doctor, for 
coming today as well. My questions are also regarding the 
caregivers legislation.
    How did you come up with the number of 870 additional 
servicemembers when you also state that you haven't come up 
with a definition of serious illness? How did you come up with 
that number?
    Dr. Jesse. I will take that for the record to give you the 
precise answer because I don't want to misstate it at this 
time.

    [The attachment appears in the Appendix]

    Dr. Jesse. But I think what you said is exactly correct. We 
can't come up with an exact number until we define what serious 
illness is. That would require regulation and would have to go 
through a due process in order to do that. So we can only make 
best-guess estimates.
    Mr. Michaud. So do you have a definition in mind of serious 
illness?
    Dr. Jesse. Again, let me get back to you for the record.

    [The attachment appears in the Appendix]

    Mr. Michaud. You know, it is just amazing that you are 
saying it is going to cost X amount when you don't even know 
what the definition is going to be. But you said it is going to 
be 870 additional servicemembers. I look forward to seeing what 
you come up with because I think it is very important because 
it gets right back to some of the issues we have had in the 
past about the credibility of the VA system. If you can't come 
up with a cost estimate, you should say you can't come up with 
a cost estimate. But to say that it is going to be 870 
additional servicemembers and it is going to cost X amount when 
you don't even know what the definition is going to be, that 
leads the Committee, and I know myself, to question the 
credibility of the VA. So I will be looking forward to that 
answer.
    And for the future, I wish the VA, whoever is drafting your 
testimony, would be up front and honest about it versus trying 
to determine whether our legislation is going to pass or fail 
because of a cost estimate. So I look forward to that answer.
    Dr. Jesse. Yes, sir.
    Mr. Michaud. Getting back to the burn pit issue, how does 
the VA train its health-care providers to address unexplained 
illnesses and symptoms that may be linked to open burn pits? 
How do you train?
    Dr. Jesse. The burn pit issue is relatively new in the 
sense of other issues that we have dealt with in terms of 
servicemembers' exposures in the course of deployment or even 
in the course of their military careers.
    The problem with training on burn pits specifically is 
understanding what are exactly those exposures. And one of the 
concerns about burn pits in particular is that everyone is 
different. So we know that exposure to burning things creates 
particulate matter, and we probably have a relatively 
reasonable understanding about what that can mean from other 
areas. But what happens to--what are the effects of the toxic, 
other toxic chemicals in burn pits, we don't know. I think what 
we train our providers is to pay attention to patients' 
complaints and symptoms and to bring them to resolution as 
absolutely best we can.
    We have struggled with this in several other areas. The 
Gulf War illness. As you know, we have dedicated significant 
resources in an ongoing fashion to try and understand what are 
the symptoms, what are the causes and the treatment of 
symptoms, and in many cases unexplained symptoms, that veterans 
of that conflict are coming forward with. It is no simple 
matter.
    Mr. Michaud. Getting accurate, up-to-date information on 
pre-deployment and post-deployment health records, where 
servicemembers were located and other pertinent information 
from the Department of Defense, has in the past been 
characterized as very difficult. What makes you believe that 
the exchange of information between the VA and the DoD has 
improved with the current deployment of Afghan and Iraqi 
soldiers?
    Dr. Jesse. I am going to answer that cautiously because we 
don't know that it has improved. We are only working very 
diligently with them to try and improve that. We have some 
isolated instances, Karmanah Li, for instance, where we think 
that we have a very solid lockdown on who was exposed. And that 
is relatively straightforward. Burn pits become another--you 
know, it is a whole different challenge.
    The radiation exposures, potential radiation exposures from 
the tragedy in Japan after the tsunami, we have a very solid 
lockdown on who those folks were.
    In the end, the VLER, the Virtual Lifetime Electronic 
Record, which is intended to be a consolidation of one's 
military service and one's health care record really should 
feed forward into that. And that is the intent of beginning to 
build that kind of a program.
    But I think going back to Agent Orange was a great example 
of how we had very little insight into who was exposed. I know 
that Secretary Shinseki is passionate about trying to get a 
handle on this because we cannot afford to have another example 
like that.
    Ms. Buerkle. I now yield 5 minutes to the gentleman from 
Texas, Mr. Reyes.
    Mr. Reyes. Thank you, Madam Chair.
    Thank you for being here. I am a little bit puzzled because 
as I understand it, the only objection to H.R. 3279 is the 
cost. And yet I am not sure you are prepared to give us a 
formula on how you arrived at the cost; is that correct, 
Doctor?
    Dr. Jesse. I personally am not. I don't want to give you a 
wrong answer, which is why I best take it for the record.
    Mr. Reyes. But that is correct? The objection from the 
administration is the cost, because the cost is too high?
    Dr. Jesse. No, no, no. I don't think that is the case at 
all. In fact, it is not an objection as much as a concern that 
we don't understand the true cost, and our comment on the bill 
is tempered by that. But in fact--
    Mr. Reyes. So how much time will you need to get back to us 
with your analysis on the cost on who is affected, on the 
definition of a serious illness, and all of these things that 
we have been talking about? How much time will it take?
    Dr. Jesse. It should not take long because that should 
already be there. It should be done. I just don't know the 
precision. I don't know the answer with the level of precision 
that I am comfortable giving it to you today.
    How long should it take us to get an answer? The data 
exists. We will get it to you. A couple of weeks. Is that okay?
    Mr. Reyes. As soon as possible, I would think. I tell you, 
when we take these to the floor, Members need to know exactly 
what the concerns are.
    Dr. Jesse. I agree. We will get it to you absolutely as 
soon as possible.
    Mr. Reyes. Can you give me an example of someone who would 
be denied caregiver assistance for an injury but approved if 
illness were included? Is there a way to give me an example of 
that? Can you give me an example with the cost analysis?
    Dr. Jesse. Someone with a serious injury should be covered 
under the existing caregivers. So what this is opening up to is 
to people who have serious illnesses as well.
    Let's take an example, ALS. It is a serious illness that is 
service-connected, and while those people have access now to a 
number of services, including aide and attendants and the like, 
this would markedly expand what we can provide to them. And I 
don't know--I am not sure that I understand, somebody who has--
    Mr. Reyes. Can an individual, who was denied caregiver 
assistance as a result of an injury, be subsequently approved 
because an illness was included?
    Dr. Jesse. I am not sure I can answer.
    Mr. Reyes. Can you take that for the record and I will be 
happy to provide some clarification if you need it?

    [The attachment appears in the Appendix]

    Mr. Reyes. My last comment, I have had a number of 
opportunities to discuss the difficulty that exists between 
giving the benefits to veterans from our perspective as a 
Congress to the reality at the VA hospitals and clinics around 
the country. And I have shared with General Shinseki, who was 
in Vietnam about the same time I was, the issue of Agent 
Orange. I think it is one of the best examples because those of 
us that had that experience flew in because we had to provide 
cover for the C-123s that were spraying the Agent Orange 
largely around these high artillery bases in Vietnam. And so 
they sprayed around the mountain where these bases were in 
order to get rid of the foliage because the VC and the NVA at 
night would come up through there. As they were spraying, they 
would get fired upon, so it was our job in the helicopters to 
go in and provide the protection. As we were providing that 
protection, we were flying through the mist of the Agent 
Orange. And I can tell you, it didn't taste anything like 
oranges. Many asked the question rhetorically: Is this stuff 
safe? Is it okay?
    I grew up on a farm where we used pesticides and crop 
dusters and all of that, and we took great pains to not be in 
the way of the crop duster. But we were repeatedly reassured 
that the government wouldn't use that if it weren't safe. Well, 
now generations later, and today I am concerned about my oldest 
daughter because of recent research that has been done, that 
now apparently you can pass on the effects of Agent Orange 
genetically. That is what makes it so frustrating for those of 
us who have had those experiences, to try to get legislation 
through and not be taken seriously by the way definitions are 
made, by the way people implement the law.
    I will tell you, we funded the alternative budget, the 4 
years we were in charge of the House, for that reason. Let's 
look and see if fully funding the VA would make things get 
better. Well, it wasn't money. I don't know what we need to do. 
But something has to change to be able to get the message that 
these guys that are coming back from Iraq and Afghanistan and 
other places with TBI, PTSD and all of these other things are 
hurting, and we are obligated to take care of them. We do the 
things we do because of their willingness to be out there. And 
this is generation after generation.
    I just get so exasperated when you can't answer our 
questions. I mean, if I were in charge, I would say here is 
what they are going to talk about. This is likely what they are 
going to ask. Here is the answer. It doesn't seem to be a 
problem to come up here and say well, ``we think,'' ``we 
might.'' And ``we can get back.'' Madam Chair, I just get so 
frustrated. I know it is not--and I don't mean it at the 
messenger--it is just the whole damn system that frustrates me.
    Thank you.
    Ms. Buerkle. Thank you, Mr. Reyes.
    I guess I will just echo my colleague's sentiments.
    Dr. Jesse, with all due respect, as Mr. Reyes mentioned, 
you are the messenger, but when you tell me it is complex and 
it is complicated and it takes a long time to figure these 
things out, we send men and women overseas. They go over and 
serve our Nation. The very least we can do as a country is to 
make sure that they get what they need. That is all the 
Veterans' Affairs Committee wants, is to make sure that the men 
and women who serve this Nation get what they need and deserve.
    What we are asking for today, and just to repeat, the cost 
analysis, the decision memorandums that we talked about 
earlier, and the definition of serious illness so we can get 
some clarification on those topics. Time is of the essence, as 
just expressed by my colleague's frustration. This isn't 
something arbitrary. This is something on which we have the 
luxury of time. The men and women care. They need access to 
services. Again, that is a message that needs to go back to the 
Department of Veterans Affairs. Time is of the essence.
    I thank you both for being here today. With that, panel 3 
is dismissed. Thank you so much.
    If there are no further questions, I move that Members have 
5 legislative days to revise and extend their remarks and 
include extraneous material. Without objection, so ordered.

    [The attachment appears in the Appendix]

    Ms. Buerkle. Once again, I just want to extend my gratitude 
to all of the witnesses, the Subcommittee Members and the 
audience for your participation and attendance this afternoon. 
We are a grateful Nation, and we must together work to make 
sure that the veterans, the men and women who serve, who are 
serving, and who have served, get what they need and what they 
deserve.
    With that, the hearing is now adjourned. Thank you.

    [Whereupon, at 5:48 p.m., the Subcommittee was adjourned.]

                            A P P E N D I X

                              ----------                              

        Prepared Statement of Hon. Ann Marie Buerkle, Chairwoman
    Good afternoon. This hearing will come to order.
    Thank you all for being with us today as we meet to discuss seven 
legislative proposals concerning the care and services provided to our 
Nation's veterans and their families through the Department of Veterans 
Affairs (VA).
    The seven bills on our agenda this afternoon are: H.R. 1460, to 
provide for the automatic enrollment of veterans returning from combat 
zones into the VA medical system; H.R. 3016, to direct the Secretary of 
Defense and the Secretary of Veterans Affairs to jointly operate the 
Federal Recovery Coordination Program; H.R. 3245, the Efficient 
Services for Veterans Act; H.R. 3279, to clarify that caregivers for 
veterans with serious illnesses are eligible for assistance and support 
services provided by VA; H.R. 3337, the Open Burn Pit Registry Act; 
H.R. 3723, the Enhanced Veteran Healthcare Experience Act of 2011; and 
H.R. 4079, the Safe Housing for Homeless Veterans Act.
    Together, these bills touch on a full range of issues affecting our 
veterans and their families. The proposals we will discuss include 
measures to address fire and building safety code enforcement for 
homeless veterans participating in VA grant and per diem programs; 
streamline the eligibility determination for veterans seeking 
readjustment counseling services at Vet Centers; establish a registry 
for OEF/OIF veterans who may been exposed to toxic chemicals caused by 
open burn pits; and allow veterans greater access to the health care 
they earned and deserve by reforming VA's fee-basis care program and 
providing for the automatic enrollment of returning combat veterans 
into the VA health care system.
    Additionally, we will discuss two bills--H.R. 3016 and H.R. 3279--
that seek to improve programs that support to some of our most severely 
wounded warriors, the Federal Recovery Coordination Program and the 
Comprehensive Assistance for Family Caregivers Program respectively. 
These programs in particular are very familiar to this Subcommittee, 
which has held a total of four oversight hearings last year to examine 
them in depth.
    Our discussion today will provide us the opportunity to thoroughly 
examine each of these proposals with their sponsors, the Department, 
and our partners in the veteran service organizations to find out what 
works, what doesn't, and what needs to be improved.
    I thank my colleagues for sponsoring the bills on our agenda this 
morning and for their leadership. I also appreciate our witnesses from 
the veterans' service organizations and VA for taking the time to join 
us today and for working so hard day in and day out in support of our 
Nation's heroes. I am looking forward to a very frank and productive 
discussion.

                                 
            Prepared Statement of Hon. Michael H. Michaud, 
                       Ranking Democratic Member
    Thank you, Madam Chairwoman.
    The purpose of today's hearing will be to explore the policy 
implications of seven bills before us today which cover a wide range of 
topics that would expand and enhance VA's health care programs and 
services. To allow maximum time for discussion, I will limit my opening 
remarks primarily to H.R. 1460, H.R. 3016, and H.R. 3279.
    H.R. 1460, offered by Mr. Owens of New York, instructs the 
Department of Defense, in conjunction with the VA, to automatically 
enroll veterans returning from combat zones into the VA medical system, 
while providing a chance to opt-out of the system both at the time of 
separation from the Armed Services and 6 months following.
    In 2008, Public Law 110-181 was enacted, which extended the 
eligibility period for free VA medical care from 2 to 5 years for 
veterans who served in a combat theater of operations after November 
11, 1998. This applies to active duty, National Guard, and Reserve 
servicemembers returning from recent conflicts for conditions that may 
be related to their combat service. Following this initial 5-year 
period, these veterans may continue their enrollment in the VA health 
care system, but they may be subject to applicable copayments for 
nonservice-connected conditions.
    H.R. 1460 does not create new classes of veterans eligible for free 
VA health care, but simply changes the process by which these veterans 
would become part of the system upon separation from the DoD. This 
legislation would ensure that combat veterans are able to seamlessly 
receive VA health care services upon their separation from the 
military.
    Next, H.R. 3016, introduced by Mr. Barrow of Georgia, a Member of 
the Full Committee, would improve reintegration efforts and require 
that the Federal Recovery Coordination Program (FRCP) operate jointly 
under both DoD and VA. This legislation follows up on two Subcommittee 
hearings held on this issue last year, where we discussed the 
continuing problems between the VA and DoD in working collaboratively. 
I still do not feel confident that VA and DoD can overcome existing 
barriers and the tangle of bureaucracy that seems to surround the 
implementation of this program. H.R. 3016 is intended to ensure that 
the FRCP moves forward in a more efficient and effective manner.
    Finally, H.R. 3279, sponsored by Mr. Reyes of Texas, a Member of 
the Subcommittee, would clarify that caregivers for veterans with 
serious illnesses are eligible for assistance and support services 
provided by the VA. This legislation also follows up on two 
Subcommittee hearings held on this issue last year, where we examined 
the delays in the rollout of the implementation plan, next steps, and 
the narrowing of criteria for eligibility of these benefits.
    When Public Law 111-163, the Caregivers and Veterans Omnibus Health 
Services Act of 2010, was enacted on May 5, 2010, the legislation 
required the VA to evaluate the program at 2 years. With this benchmark 
quickly approaching, I am interested in hearing more about the 
potential to expand this program to caregivers for veterans with 
serious illnesses-- not just those who are seriously injured-- as 
certain mental health conditions do require the full supervision of a 
family caregiver. I believe this change will expand the criteria for 
eligibility of these benefits to be more in line with the original 
intent of Congress.
    I look forward to hearing the views of our witnesses on the bills 
before us today.
    Madam Chair, I yield back.

                                 
                Prepared Statement of Hon. Russ Carnahan
    I would like to thank the Chair and Ranking Member for holding this 
hearing. We must ensure that the sacrifices of our current troops, 
veterans, and their families do not go unnoticed and that they are 
given the support and resources they deserve. Our troops are committed 
to protecting our freedom, and our commitment to them does not end when 
they return home.
    As veterans try to reintegrate into civilian life, many of our 
heroes struggle with the physical and mental effects of conflict. PTSD 
rates have been steadily growing since the overseas conflicts in 
Afghanistan and Iraq began. Diagnoses for depression are up 
particularly among younger active duty veterans who usually have higher 
combat exposure. Employment, effective health facilities, and 
psychological services are crucial to ensuring our veterans and their 
families are properly supported. Particularly in these times of tight 
Federal budgets and deficit reduction efforts, we must remain steadfast 
in our support of our veterans.
    This Subcommittee has held two hearings on the Caregivers and 
Veterans Omnibus Health Services Act of 2010. The intent of this law is 
to provide comprehensive assistance and support services to family 
caregivers of veterans with a serious illness or injury. Unfortunately, 
the current interpretation of the law excludes the caregivers of 
seriously ill veterans. The sacrifices made by our military families 
begin before deployment and continue after their loved one returns 
home. H.R. 3279 will ensure that we fulfill our commitment to the 
families of seriously ill veterans, families who continue to serve our 
country by caring for our Nation's heroes when they are most in need of 
care.
    I look forward to hearing from our witnesses today on ways that we 
can work together to guarantee our service men and women have the 
support they need and deserve when they return home.

                                 
                Prepared Statement of Hon. William Owens
    Prepared Statement of Honorable William Owens
    Chairwoman Buerkle, Ranking Member Michaud and Members of the 
Committee, I appreciate the opportunity to come before you today and 
testify on H.R. 1460, legislation I have introduced to provide for the 
automatic enrollment of military servicemembers in the VA health care 
system. As a veteran of the Air Force, I am honored to have the 
opportunity to help improve access to the benefits that the men and 
women in uniform have earned in their service to the country.
    The soldiers, sailors, airmen and marines of the armed forces have 
served with great honor and distinction over a decade at war in the 
Middle East. PCS orders, increased op-tempo, repeat deployments, and 
shortened dwell times have only added to the pressures facing the 
military and their families through Operations Enduring Freedom, Iraqi 
Freedom, and New Dawn.
    There is no question that we as a country have made great strides 
over the past ten years to strengthen systems of care for America's 
veterans, but obstacles remain for the men and women transitioning from 
service to civilian life. Representatives from various Veterans Service 
Organizations have testified on their concerns for military families 
being overwhelmed by the bureaucracies of both the Veterans 
Administration and the Department of Defense, and it should come as no 
surprise that VA paperwork is only one a number of challenges facing 
servicemembers in their transition to civilian life.
    My legislation would automatically enroll veterans who are eligible 
for VA health care into the system, while also taking steps to better 
inform them of other benefits for which they are eligible. The bill 
also offers two proactive opportunities for veterans to opt-out of the 
system, both before they enter and six months after. This legislation 
has been endorsed by the American Legion, and I believe is a step in 
the right direction towards the ``seamless transition'' from service 
that has long been the goal of many in Congress and veterans advocates 
across the country.
    To be clear, this legislation does not change the benefits for 
which a veteran is eligible or the care they are entitled to within the 
VA. The men and women enrolled under this legislation are already 
eligible for VA care. All we are doing is shifting the burden of 
enrollment away from those who have just returned from a theater of war 
to those who are employed to serve America's veterans.
    In addition to reducing the government paperwork required of them, 
we can help ensure that overburdened servicemembers do no slip through 
the cracks and miss an opportunity to enjoy the benefits they have 
earned. I remain particularly concerned for servicemembers afflicted 
with Traumatic Brain Injury or Post-Traumatic Stress Disorder, who face 
unique pressures in transitioning from service. This legislation will 
help ensure they have early access to screening for TBI and PTSD from 
experts at the VA who can improve the long-term prognosis for those 
affected and ensure proper treatment in the years ahead.
    I thank you again for the opportunity to speak before you on H.R. 
1460, and respectfully ask that you consider lending your support to 
the bill. I look forward to your questions.

                                 
                 Prepared Statement of Hon. John Barrow
    Chairman Buerkle, Ranking Member Michaud, and Members of the Sub-
Committee:
    Thank you for the opportunity to speak with you about H.R. 3016, my 
bill to improve the Federal Recovery Coordination Program.
    Today's returning Armed Service Members face a unique combination 
of challenges as they reintegrate into the community. One important 
means for helping these folks is the Federal Recovery Coordination 
Program, which was originally envisioned by the Dole/Shalala Commission 
to help wounded warriors navigate the bureaucracy of the VA and DoD 
health systems. A Federal Recovery Coordinator is a nurse or a social 
worker with graduate level training, who helps guide wounded warriors 
to the proper treatment and benefits options.
    Unfortunately, administrative roadblocks have prevented the Program 
from achieving its full potential. That's why I introduced H.R. 3016, 
which would correct the administrative problems that prevent the 
Federal Recovery Coordination Program from succeeding.
    H.R. 3016 establishes joint administration of this program by 
placing it under the supervision of both the Secretaries of Defense and 
Veterans Affairs. It ensures that severely injured Armed Service 
members and veterans receive a Federal Recovery Coordinator. It gives 
Coordinators the authority to act earlier in the recovery process, and 
it makes certain that each branch of DoD will refer wounded warriors to 
the Program.
    Jim Lorraine, the Executive Director of the Augusta Warrior Project 
- a fantastic organization that builds collaborative relationships with 
local, state, and national organizations to support wounded warriors 
and their families in the Augusta area - explains how this legislation 
will benefit veterans:

       The Federal Recovery Coordinator Program is essential to helping 
our most severely wounded, ill, and injured, who have given so much for 
our Nation figure out how to navigate these complex bureaucracies and 
improve their access to existing services. This legislation not only 
formally establishes the program, but directs its management from the 
highest levels of the departments of defense and veterans affairs to 
ensure unimpeded access to care.

    I hope this Committee will join me in strengthening the Federal 
Recovery Coordination Program through this legislation. It's time we 
fulfill the promises we've made to our servicemembers by improving 
their care throughout the recovery process.
    Thank you for the opportunity to speak before this Subcommittee, 
and I yield the balance of my time.

                                 
                 Prepared Statement of Hon. Jeff Denham
    Chairwoman Buerkle, Ranking Member Michaud and Members of the 
Subcommittee, thank you for holding this legislative hearing today. 
Thank you to the Chairwoman for cosponsoring this legislation as well 
as Mr. Roe and Mr. Benishek for their support. Let me also thank Mr. 
McNerney, who joined me two weeks ago for an important field hearing of 
this Subcommittee examining the role of Vet Centers within the VA 
system. Vet Centers offer a wide range of readjustment counseling 
services to eligible Veterans and their families. At our field hearing 
we were able to hear firsthand how effective these centers are at 
delivering the care our veterans need confidentially and without any 
delay. This bill would provide Vet Centers with one additional tool to 
serve our veterans: the ability to search an electronic database of DD-
214 records.
    A veteran's DD-214 is the swiftest way to determine eligibility for 
the services provided by Vet Centers. A DD-214 is the capstone military 
service document, as it represents the complete, verified record of a 
servicemember's time in the military, awards, medals and other 
pertinent service information such as promotions, combat or overseas 
service, Military Occupational Specialty (MOS) identifiers and their 
record of training and schools completed. In the event that a veteran 
has lost his access to a DD-214 it can take up to six weeks to receive 
a copy and there is no single prevailing method used by Vet Centers to 
request a copy of a DD-214. While during the delay a veteran will still 
have access to the facility, instant verification will allow the Vet 
Center to immediately provide veterans the highest possible level of 
service and eliminate the bureaucratic hurdle for the servicemember.
    There are two electronic records systems that allow users to view a 
DD-214 form. These systems are the Defense Personnel Records Image 
Retrieval System and the VA/DoD Identity Repository (VADIR).
    The latter receives nightly and near realtime transmissions from 
the Defense Enrollment and Eligibility Reporting System/Defense 
Manpower Data Center (DEERS/DMDC) of military service information for 
servicemembers leaving the military.
    The former provides authorized U.S. government agencies controlled 
access to military personnel record images maintained by the Military 
Services for members of the U.S. Armed Forces. This system was 
initially implemented in the late 1990's, so not all personnel records 
are available and implementation was staggered across all branches of 
service. DPRIS contains narrative information in DD-214 that no other 
sources contain.
    The bill simply directs the Secretary of Veterans Affairs and the 
Secretary of Defense to jointly ensure that the Vet Centers of the 
Department of Veterans Affairs have access to a veteran's DD-214. As we 
speak there are 7500 current users of the DPRIS system within the VBA 
alone and many others across the VA system. I strongly believe that the 
professional staff and counselors at Vet Centers should be given the 
same tools to serve our veterans and believe that it can be done in a 
way that preserves the integrity of the Vet Center System. I thank the 
American Legion and Veterans of Foreign Wars for their support of this 
legislation.
    As a veteran myself I know the difficulties experienced by those 
transitioning to civilian life and how common it is for veterans to be 
missing records that are important to keep. I am sure you can all agree 
that whenever we have the opportunity to streamline service for our 
veterans we should seize that chance.
    Again I thank the Chairman, the Ranking Member and Members of this 
Committee for allowing me to speak here today. I look forward to 
working with you all on this bill as I look for its swift passage by 
the Committee and this house.

                                 
               Prepared Statement of Hon. Silvestre Reyes
    Chairwoman Buerkle, Ranking Member Michaud, and my fellow Members 
of the Health Subcommittee thank you for hosting this hearing. I 
appreciate having the opportunity to provide additional information on 
a subject that is very important for our Nation's veterans.
    As you know, this Committee worked to draft and pass legislation to 
provide needed support to caregivers for seriously injured Iraq and 
Afghanistan veterans. Under this initiative, the VA provides a monthly 
stipend, health insurance, and other support for family members who 
provide round the clock care for those who suffered major injuries in 
the line of duty.
    Last year, the VA expanded the program, which helped bring the 
initiative closer to the intent of Congress, and I have introduced 
legislation, HR 3279, which would make a further needed improvement to 
the program.
    The original caregiver legislation covered those servicemembers who 
incurred or aggravated a serious injury as a result of their service. 
The intent was a provide a much-needed benefit for those families who 
had suffered the most, but, by limiting the program to injuries, a 
category of veterans facing the same issues have been excluded by a 
technicality.
    My legislation would expand the caregiver program to include not 
just serious injuries, but would also cover those who incurred or 
aggravated serious illnesses as well. Not every condition which would 
require caregiver support is related to an injury, and making this 
change also aligns the caregiver program with other VA programs which 
do not distinguish between injuries and illnesses.
    I want to thank the VSO's both for expressing their support of my 
legislation and for their efforts on behalf of our Nation's veterans 
and their families. HR 3279 has garnered the endorsement of the 
National Military Family Association, the Retired Enlisted Association, 
the Association of the United States Navy, the Veterans of Foreign Wars 
(VFW), the Disabled American Veterans (DAV), the Military Officers 
Association of America (MOAA), the American Legion, the Iraq and 
Afghanistan Veterans Association, and the Wounded Warrior Project.
    The VA has also expressed support for the intent of this 
legislation which will help them provide the care and support our 
veterans require. Expanding coverage to those veterans suffering from 
serious illnesses related to their service will help additional 
families and ensure that veterans are treated fairly, but this 
expansion is not without cost. Working together as a Committee, I am 
sure that we can find a way ensure that the caregiver program meets 
both the intent of Congress and the needs of veterans and their 
families.
    The men and women who volunteer to serve our Nation put themselves 
at great risk, and we owe them a great debt of gratitude and honor. We 
also owe them and their families care and support as they deal with 
injuries and illnesses that resulted from their service. Making this 
needed change in the caregiver program is one way we to honor their 
sacrifice.

                                 
                Prepared Statement of Hon. W. Todd Akin
    Chairwoman Buerkle, Ranking Member Michaud, thank you for the 
opportunity to testify before you today regarding my bill, H.R. 3337, 
the Open Burn Pit Registry Act. As of today, this bill has over fifty 
bipartisan cosponsors and has been endorsed by a wide range of 
veterans' organizations.
    The issue of burn pit exposure first came to my attention through 
veterans in my district who served honorably in Iraq and Afghanistan 
and are now suffering serious health effects apparently linked to 
exposure to burn pits. Let me share one short story.
    Tim Wymore is a Missouri Guardsman suffering from the effects of 
working around burn pits while deployed to Iraq in 2004 and 2005. If 
his wife Shanna were here today, she would tell you of the dramatic 
impact burn pits have had on the life of her husband and hundreds of 
others she has gotten to know as a result of fighting for Tim's 
treatment.
    For nearly a year before contacting my office, as Tim's health 
continued to deteriorate, Shanna Wymore fought an often indifferent and 
sometimes hostile V.A. medical system trying to get care for her 
husband's unexplained illnesses. Tim, once a strong, athletic 
machinist, was suffering debilitating bouts of abdominal pain, weight 
loss and fatigue. Despite the adversity, Shanna persisted in her fight 
to get the help her husband was both entitled too and deserved. Along 
the way, she became an expert on burn pits and the growing number of 
Iraq war veterans suffering the effects of their exposure.
    After more than two years of indecision and broken promises, with 
assistance from my District staff, the VA finally agreed to send Tim to 
the Mayo Clinic. The doctors there confirmed, what the VA had long 
denied, Tim was suffering the effects of what could only be attributed 
to the work he performed around the burn pits in Iraq.
    I have had at least one other constituent, Aubrey Tapley, who has 
suffered the consequences of burn pit exposure and who has strongly 
advocated for taking proactive steps to help others who may be 
suffering from burn pit exposure.
    Unfortunately, the health consequences of burn pit exposure are 
hard to understand and difficult to prove. Last fall the Institute of 
Medicine released a report which concluded in part that there is 
insufficient data available to determine the long-term health effects 
of exposure to burn pits and that more study is warranted.
    The intent of my bill is to establish a registry at the Department 
of Veterans Affairs for those individuals who may have been exposed to 
open burn pits during their military service. This would help the 
Department study the issue more effectively and enable them to 
communicate to interested veterans as medical research on this issue 
develops. This registry would not affect the benefits any veteran is 
already entitled to receive, but would help the Department take better 
care of our veterans.
    The experience I have had with veterans in my district is enough to 
convince me that we need to be proactive about studying and analyzing 
the potential health effects of open burn pits. We have sent our best 
and brightest young men and women into harm's way, and it is our 
responsibility as a Nation to take care of them when they return. 
Although there is a small cost for this bill, I think it is an 
affordable and reasonable approach to dealing with the issue of open 
burn pits, and I ask your Subcommittee to support this bill and 
consider moving it forward.
    Again, thank you for the opportunity to testify today and I look 
forward to answering any questions you may have.

                                 
             Prepared Statement of Hon. Robert T. Schilling
    Chairwoman Buerkle, Ranking Member Michaud, and my colleagues, 
thank you for this opportunity to come before the House Veterans' 
Affairs Subcommittee on Health to speak about my bill, H.R. 3723, the 
Enhanced Veteran Healthcare Experience Act of 2011.
    I truly believe you can tell a lot about a country by the way it 
treats its veterans. I'm pursuing this legislation in large part 
because of the many constituents who constantly share their stories of 
having to drive long distances while experiencing substantial wait 
times in an effort to make sure they can get the health care they need. 
But I also experienced this in my own family when helping to take care 
of my father near the end of his life. We had to drive several hours to 
and from Iowa City for him to get the care he needed. While we 
appreciated the service and the care provided by the Department of 
Veterans Affairs (VA), I also believe that we must continue to make 
improvements for our veterans.
    Under the current veterans' health care system, our veterans are 
shuttled back and forth between the VA and their local doctors' 
offices, bound by the red tape that exists in the fee-based care system 
administered by the VA. This red tape only exacerbates working with 
their local doctors' offices to receive the health care they need.
    We also must keep in mind the fact that we will have a new group of 
veterans entering the VA system with needs that differ from past 
veteran groups. These include not only different injuries, but also 
women and the children of veterans. These groups of folks may require 
care that cannot always be addressed by the VA and allowing them a more 
convenient way to get their health care needs addressed is vital.
    On top of that, there have been instances where the current VA fee-
based system has been unable to accurately pay private providers the 
correct amounts, which, has resulted in multiple overpayments and has 
cost taxpayers their hard earned dollars \1\. It has been under close 
scrutiny by the Government Accountability Office and the Office of the 
Inspector General. \2\ Veterans Services Organizations have also raised 
concerns about ensuring equal or better quality care when veterans are 
referred outside of the VA \3\. This system has also been unable to aid 
veterans in making and keeping their appointments.
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    \1\ http://www.napawash.org/publications/veterans-health-
administration-fee-care-program/
    \2\ http://www.va.gov/oig/pubs/VAOIG-statement-20111115-finn.pdf
    \3\ www.independentbudget.org/2012/5--medical--care.pdf
---------------------------------------------------------------------------
    This is unacceptable. Therefore, I am proposing we look at current 
systems that do work and have received a very positive response from 
veterans. The VA has two pilot programs, Project HERO (Health Care 
Effectiveness through Resource Optimization) and Project ARCH (Access 
Received Closer to Home), which allow veterans to use fee-based care in 
their hometowns with their own doctors. In addition to helping veterans 
cut down on commute time, these programs provide timely care to all 
veterans who have been placed on a long wait list. Instituting their 
models would revamp the VA's current fee-based care program and provide 
a fiscally responsible solution that results in more efficient and 
higher quality care for veterans seeking services outside of the VA. 
While these programs have not been used on a Nation-wide scale, their 
utility cannot be ignored.
    My legislation, the Enhanced Veteran Healthcare Experience Act, 
would merge the best parts of Project HERO with the best parts of 
Project ARCH, and provide an alternative to the current VA-run fee-
based care program as the primary source of fee-based care for 
veterans. It would ensure that the VA contracts with qualified outside 
entities that meet key competency requirements such as network 
credentialed providers and accredited facilities; care coordination; 
patient advocacy; and electronic claims processing capabilities. The 
bill would standardize referral and authorization processes at all VA 
medical centers, require continuity of care for veterans, and require 
key performance metrics and incentive payments.
    The bill would not force veterans to stop using VA care; veterans 
who prefer their current VA provider would still be able to continue 
receiving care from that provider. Veterans who do go outside of the 
system are also not prevented from returning to the VA for care in the 
future.
    However, the bill would supplement the current VA fee-based program 
and utilize the funds saved within the VA's regular operating budget 
expenses. With a proven system in place that can properly keep track of 
payouts, the VA could save money it may have otherwise misspent, and 
very little additional funding would therefore be required for this 
more efficient program. The Congressional Budget Office (CBO) has not 
yet officially scored this bill, but because the regular VA fee-based 
care program is much more costly than Project HERO, the proposed 
blended program would likely cut overall VA costs and therefore create 
savings. An unofficial CBO staff estimate indicated that this bill 
would require $3 million total for fiscal years 2012-2016. However, 
studies and statements by the GAO, OIG, and VSO's suggest that 
implementing the changes in this bill will create savings for the VA 
and address medical care concerns that veterans have when working with 
the VA fee-based care system.
    This idea is near and dear to me, and has received a positive 
response from veterans I have spoken with in my district. The 
Congressional process is in place so that we can perfect legislation. 
That is what I am working to do on this bill. Since H.R. 3723's 
inception and also from its introduction, I have continued to work with 
Veteran Service Organizations (VSOs) to address their concerns. I hope 
to continue to do this with the VSOs and the Committee. To that end I 
have draft legislation that the Committee can use to improve H.R. 3723 
in accordance with further input from Members of this Committee, 
veterans, and the VSOs.
    Again, thank you for this opportunity to speak about ways that we 
can remain fiscally responsible, improve care, and keep our promises to 
our veterans.

                                 
              Prepared Statement of Hon. David B. McKinley
    Chairwoman Buerkle, Ranking Member Michaud and Members of the 
Subcommittee, thank you for holding this legislative hearing today on 
important issues that affect our nation's veterans. I appreciate the 
opportunity to give remarks on my bill, H.R. 4079, the Safe Housing for 
Homeless Veterans Act.
    Currently, there are over 2,100 community-based homeless veteran 
service providers across the country and many other homeless assistance 
programs that have demonstrated impressive success reaching homeless 
veterans. I have visited some of the shelters in my home district in 
West Virginia and was struck by how many seemed to not be in compliance 
with state, local or federal safety codes.
    After seeing these conditions with my own eyes, we began to 
investigate whether this is something that is isolated or more 
instances are occurring. It was unsettling to learn in our research 
about shelter fires where lives were lost. For instance, in 2009, an 
East Texas homeless shelter fire where five occupants were killed was 
found to not have a required sprinkler system and an instance in New 
York City just this past year where two dozen people were injured 
because the sprinkler system was not working properly and the exits 
were blocked. I would like to enter news articles about these fires and 
an additional three articles regarding other instances of code 
violations into the record.
    Unfortunately there is no law mandating VA homeless shelters meet 
code; there is only a policy in place. As a licensed professional 
engineer, I found this to be an egregious omission in the law governing 
VA homeless program funds. H.R. 4079 would require any organization 
that seeks funding from VA for services to homeless veterans to have 
documentation that their building meets or exceeds all Life Safety 
Codes. This legislation also requires VA to give priority to shelters 
that need financial assistance from VA for improvements to ensure that 
the facility is in compliance with all the safety codes.
    I am disappointed that VA has chosen to not support H.R. 4079, a 
bill that would codify what they already have as a policy. This is 
common sense legislation that would ensure the wellbeing of veterans 
who have fallen on hard times and are in the most need of assistance; 
and in extension these same veterans are turning to society to assure 
them of safe, reliable housing.
    As a nation, it should be unacceptable for us to allow homeless 
veterans be housed in potentially unsafe conditions. In defense of our 
country, these men and women were put in harm's; they should not be in 
doubt about their own safety now that they are home again. These 
homeless veterans are experiencing a difficult phase of their lives and 
should be able to trust that they will be safe each night as they 
continue their return to being productive members of society.
    I appreciate the testimony in support of H.R. 4079 from other 
witnesses testifying here today and I thank you for your concern for 
the safety and living environment of our veterans.

                                 
                   Prepared Statement of Shane Barker
    Madam Chairwoman and Members of this committee, on behalf of the 
more than 2 million members of the Veterans of Foreign Wars of the 
United States (VFW) and our Auxiliaries, the VFW would like to thank 
this committee for the opportunity to present its views on the 
following bills:
H.R. 1460, to provide for automatic enrollment of veterans returning 
        from combat zones into the VA medical system:
    The VFW supports the concept of H.R. 1460, legislation that would 
automatically enroll service members who have deployed to Iraq or 
Afghanistan for health services in the Department of Veterans Affairs 
(VA). For years now, our nation has provided 5 years of no-cost health 
care for separating service members through VA, but they must first go 
through the enrollment process. This generous provision has been 
critically important to many veterans, and the enrollment numbers are 
high. However, for a variety of reasons, many veterans have not 
enrolled for VA care. We believe that this automatic enrollment could 
positively affect those individuals, and tip the scale in favor of them 
receiving the VA health care they have earned.
    H.R. 1460 will take the assistance we provide one step further by 
having VA initiate enrollment into the system on behalf of the combat 
veterans of our current conflicts, and taking the cumbersome work of 
enrolling off their shoulders while preserving their choice through a 
process to opt-out. Returning warriors have serious and pressing 
concerns they must address without delay when they return from combat - 
employment endeavors, rekindling relationships with family and friends, 
and coping with the emotional burden of their war experiences. The 
least we can do is remove burdens to begin receiving care from the VA 
so they can more quickly begin to address those important needs.
    However, the VFW is concerned that it would create a paradigm in 
which the injuries and illnesses veterans who do not deploy incur are 
not given similar priority as those who deploy but do not experience 
any adverse health effects immediately attributable to their military 
service. While it does not incentivize current conflict veterans who 
have deployed to hostile regions to avail themselves to VA care, it 
could prove to be polarizing, and send the message to non-deployed 
veterans that they do not qualify for VA health care.
    The VFW would support this legislation if it were amended to 
include enrolling all separating service members into VHA. This would 
allow service members who were injured or became ill during service, 
but who did not deploy, the same accessibility as those who have 
deployed. Also, Congress would need to ensure VA has the resources to 
properly facilitate enrollment.
H.R. 3016, to direct the Secretary of Defense and the Secretary of 
        Veterans Affairs to jointly operate the Federal Recovery 
        Coordination Program:
    The VFW supports H.R. 3016. In our view, the most important aspect 
of this legislation is the length it goes to keep the Federal Recovery 
Coordination program (FRC) a top priority of the Secretaries of Defense 
and Veterans' Affairs. By mandating the administration of this program 
must stay in the respective offices of each secretary, we can have more 
peace of mind that the wounded, ill and injured warriors the program 
was created to serve will receive the high-level attention they 
deserve. Administration of the FRC program has been shuffled around 
more than once since it was created in 2007, and we believe this 
legislation will end that by mandating in law that it be housed where 
it belongs - at the very top. This committee must also conduct 
continued oversight over this program as practicable to ensure that the 
letter and spirit of this law - and the critical importance of the FRC 
program - are embraced within DOD and VA. The men and women who go to 
war and come back with life-threatening injuries deserve no less, and 
we give our full support to this legislation.
H.R. 3245, the Efficient Service for Veterans Act:
    The VFW supports H.R. 3245. This legislation requires collaboration 
between the DOD and VA to ensure that VA's Vet Centers have access to 
the two data repositories that house a service member's DD-214. 
Granting Vet Centers access to these databases means that they can 
independently verify a veteran's eligibility for services without the 
veteran needing to provide a paper copy of the DD-214. This instant 
access to service records will remove an unnecessary and often time-
consuming hurdle to care for veterans needing peer support or mental 
health counseling from other veterans. At a time when so many of our 
veterans are in need of these kinds of counseling options, we should 
make this change without delay and continue to look for ways we can 
expedite and streamline services.
H.R. 3279, to amend title 38, United States Code, to clarify that 
        caregivers for veterans with serious illnesses are eligible for 
        assistance and support services provided by the Secretary of 
        Veterans Affairs:
    The VFW strongly supports H.R. 3279. The Caregivers and Veterans 
Omnibus Health Services Act of 2010, commonly known as the Caregiver 
Bill or P.L. 111-163, provided long-overdue financial and medical 
support for family members or other designated individuals who are 
willing to be trained to provide high-quality in-home health care for 
severely injured veterans of the conflicts in Iraq and Afghanistan. The 
Department of Defense provides similar support to family members of 
members of the armed forces who are catastrophically disabled, and 
includes disability caused by illnesses in their eligibility 
requirements. Because the law does not currently provide VA caregiver 
support to those who are seriously disabled because of an illness, the 
potential exists for military members and their families to lose a 
critical benefit as they transition out of the military into VA care.
    The caregiver benefit must be seamless. It is simply too important 
for the physical health and general well-being of the men and women who 
are catastrophically disabled in service to preclude those who have 
suffered from a debilitating illness from receiving this benefit.
H.R. 3337, the Open Burn Pit Registry Act of 2011:
    The VFW supports H.R. 3337. Open-air burn pits were used 
extensively in Iraq and Afghanistan to incinerate everything from 
medical supplies to automobiles, with possible hidden and grave health 
reactions on the military personnel exposed to them. VA, DOD, and other 
partners in the civilian sector are working to give us the tools 
necessary to properly diagnose and treat the conditions associated with 
open-air burn pits and other environmental exposures. However, much 
work remains to be done, and any delay means less than optimal 
treatment options now.
    Both DOD and VA have areas where they could improve their support 
to those suffering from an environmental exposure. In addition to 
working to treat these conditions, the Veteran Benefits Administration 
must continue to improve their ability to account for their effects 
when evaluating claims, and DOD could make a greater effort. 
Unfortunately, their lack of responsiveness to repeated requests for 
information from Congressman Akin in relation to this bill has made it 
difficult to ascertain what, if any, measures they have taken. We 
lament DOD's unwillingness to provide the requested information, and 
hope they will soon respond to that request. We would also very much 
like to see DOD reach out to veterans and military service 
organizations to forge a more productive working relationship on this 
important issue.
    The VFW believes that this registry is essential to allow service 
members the peace of mind of going on record with VA at the earliest 
possible time to say they were exposed, and to assist VA in knowing how 
to best deploy advances in medicine and technology as they become 
available to treat the serious conditions associated with burn pit 
exposure. We know that the physical effects of environmental exposures 
can go unnoticed for decades, and it can be extraordinarily difficult 
to establish causation to military service that has long since passed. 
This legislation is a positive step forward, and we ask the committee 
to pass this measure without delay.
H.R. 3723, the Enhanced Veteran Healthcare Experience Act of 2011:
    The VFW does not support H.R. 3723. While we do not support the 
legislation, we understand the impetus for it and agree that 
improvements to the current Fee-Basis system of referring veterans to a 
private-sector provider are long overdue. The program has many areas 
where improvements would provide more return on investment for the 
government and would improve the quality of care for veterans. 
Currently, coordination of care between VA and the private provider is 
virtually non-existent. As a result of limited controls and processes, 
VA does not have the ability to evaluate the quality of care provided, 
or integrate the associated private-sector medical records into 
existing medical history records the VA maintains for that veteran. VA 
also has little reach into the offices of doctors caring for veterans 
through the Fee-Basis paradigm to ensure the services being billed were 
actually performed. VA has no ability to guarantee or measure distance 
or timeliness standards, and veterans get no assistance from VA in 
finding doctors or assistance making appointments once a doctor is 
found. Clearly, there is much to be desired, especially when taking 
into account that the VA paid out more than $4 billion in health care 
claims in FY 2010 alone.
    Nevertheless, the VFW cannot support this legislation at the 
present time. The bill would mandate the Secretary to enter into 
contracts with network providers in order to provide a nationwide 
network of service providers to improve the non-VA care, thereby 
addressing many of the issues identified above. However, the VFW is 
concerned that the legislation would result in VA moving veterans 
outside of the VA system precipitously. Instead of working to improve 
processes and make the VA system more efficient and increase 
throughput, VA would have the obligation to move veterans into the non-
VA care program when timeliness or distance standards are not met.
    Complicating matters is the reality that the only way to make such 
a program cost-effective is to actively manage the volume of referrals 
into the program. Network providers would find it necessary to give 
care providers reasonable expectations of patient access and volume to 
negotiate a favorable rate for services being contracted.
    The VFW would also call into question the ability for contracts 
entered into under this paradigm to be successful without first seeing 
how VA executes the implementation of the Patient Aligned Care Team 
(PACT) model of patient-centric care within the VA. The proponents of 
this legislation pre-suppose that the PACT care coordinator would act 
as a conduit to a care coordinator employed by the network provider. 
However, we see no evidence to suggest that the PACT model will 
routinely and successfully coordinate the care provided internally at 
VA without this layer of complexity added to the equation. The VFW 
believes that the PACT model must be a success. Therefore, we should 
ensure that it is refined to smooth out the rough edges before taking 
this step.
    At the same time, VA is moving forward, if slowly, with their own 
efforts to implement the Patient Centered Community Care (PCCC) program 
that would establish contracts to provide a limited portfolio of 
services that would be more fully coordinated with VA. Publicly 
available data suggests that this portfolio is limited to medical and 
surgical services, but excludes dialysis, mental health, and primary 
care. While it is certainly true that we believe any successful program 
to coordinate non-VA care would include these services, we firmly 
believe VA must get this right. It is imperative that these issues be 
resolved, and we believe that VA's initiative must be given a chance to 
be executed and evaluated before fundamental and controversial changes, 
such that this bill would precipitate, are allowed to move forward.
    Our veterans deserve access to timely and high quality health care 
that is fully integrated and responsive to their needs. To achieve 
this, we strongly encourage the committee to expeditiously conduct due 
diligence on the Fee-Basis program to have a better understanding of 
this and other potential options before initiating further legislative 
changes to this program.
H.R. 4079, the Safe Housing for Homeless Veterans Act:
    The VFW supports H.R. 4079. We believe this legislation will ensure 
that homeless veterans are living in housing that is deemed safe and in 
compliance with codes required by county and state laws. Currently, VA 
is required to check housing certificates before awarding grants for 
housing services provided to homeless veterans. However, a thorough 
check of fire and safety requirements, as well as structural conditions 
of the building, are often overlooked.
    H.R. 4079 would require certification that the building has met all 
necessary code specifications before a grant would be awarded. It also 
gives priority in awarding grants to those seeking assistance for any 
project that would make improvements to a building in cases where plans 
exist to provide housing and services for homeless veterans.
    The VFW believes that there is no greater need than providing a 
safe and secure environment for our homeless veterans and their 
families. This legislation will protect the most vulnerable by making 
certain that the housing provided fills that need until they can return 
to independent community living.
    Madam Chairwoman, this concludes my statement. I would be happy to 
answer any questions that you or the members of the Committee may have.

                                 
                  Prepared Statement of Adrian Atizado
    Madam Chairwoman, Ranking Member Michaud, and Members of the 
Subcommittee:
    Thank you for inviting me to testify on behalf of the Disabled 
American Veterans (DAV) at this legislative hearing of the Subcommittee 
on Health. DAV is an organization of 1.2 million service-disabled 
veterans. We devote our energies to rebuilding the lives of disabled 
veterans and their families.
    Madam Chairwoman, the DAV appreciates your leadership in enhancing 
Department of Veterans Affairs (VA) health care programs on which many 
service-connected disabled veterans must rely. At the Subcommittee's 
request, the DAV is pleased to present our views on seven bills before 
the Subcommittee today.
                               H.R. 1460
    This measure would require VA to automatically enroll in VA health 
care certain veterans who served on active duty in combat operations 
during a period of war after the Persian Gulf War, or veterans who 
served in combat against a hostile force during a period of hostilities 
after November 11, 1998. These veterans would also have the option to 
decline enrollment. If automatically enrolled, the right to be dis-
enrolled as currently provided to all enrolled veterans under title 38, 
Code of Federal Regulations Sec.  17.36(d)(5) would be unaffected.
    While well intended, the policy this measure proposes would be 
inconsistent with DAV's longstanding view that all veterans who need VA 
health care should have equal access to enroll, irrespective of age, 
geographic barriers or of the particular health needs concerned. In the 
event such automatic enrollment increases utilization of VA medical 
care, our concern then turns to impacts on VA's resources.
    A large-scale ``automatic'' enrollment of the youngest population 
cohort could serve to squeeze out older generations of veterans who 
have not yet enrolled but will inevitably need health care in the 
future. VA would not be an option for them. Moreover, once enrolled, 
these veterans would be subjected to existing delays in access to care 
that other veterans are experiencing now. While we are not aware of any 
service-disabled veteran experiencing difficulty enrolling (and in 
fact, most of them are not required to enroll to gain treatment of 
service-connected disabilities), we are keenly aware of delays in 
timely access once enrolled, generally because of insufficient VA 
resources, capacity, or geographic barriers.
    We believe outreach and education are far more likely to improve 
the use of VA benefits and services, including health care services, 
and we believe this Subcommittee is already well aware of VA's outreach 
efforts to the newest generation of veterans.
    The Transition Assistance Program (TAP) is one of the formal pre-
discharge outreach programs in which VA is an active participant. TAP 
is conducted under the auspices of a Memorandum of Understanding 
between the Departments of Labor, Defense, Homeland Security, and VA. 
TAP programs are conducted nationwide and in Europe at US military 
installations, to prepare separating or retiring military personnel for 
their return to civilian life. As a partner agency, VA provides VA 
benefits and services briefings. At these briefings, service members 
are informed of the array of VA benefits and services available and 
instructed in completing VA applications forms. Following the general 
instruction segments, TAP counselors provide personal interviews for 
service members who desire assistance in preparing and submitting 
applications for VA health care, disability compensation and/or 
vocational rehabilitation and employment benefits.
    DAV has previously testified in support of Section 202 of H.R. 
2433, the Veterans Opportunity to Work Act of 2011, which would make 
mandatory the participation in TAP by members of the armed forces. The 
intent of this section was incorporated into Public Law 112-56, Title 
II of which is entitled ``Vow to Hire Heroes.'' Also, we note the US 
Navy and Marine Corps TAP and Disabled Transition Assistance Program 
are already mandatory for all separating members. The US Army recently 
announced it is requiring transition processing to begin at least 12 
months before a soldier departs active duty. According to the Army's 
plan, TAP participation is mandatory for all soldiers discharging from 
active duty, including Guard members and Reservists demobilizing after 
six months or more on active duty. \1\
---------------------------------------------------------------------------
    \1\ Jim Tice, ``Transition services now mandatory for soldiers,'' 
Army Times (APR 3, 2012). Accessed April 04, 2012 10:52 PM
---------------------------------------------------------------------------
                               H.R. 3016
    This measure would codify the Federal Recovery Coordination Program 
(FRCP) and would direct DOD and VA to jointly operate it. The FRCP's 
mission is to assist members of the armed forces who exhibit severe or 
catastrophic injuries or illnesses and who are unlikely to return to 
active duty but will most likely be medically separated. FRCP would 
also aid service members and veterans whose individual circumstances 
related to illness, injury, mental health are likely to cause 
difficulties in their transitions to civilian life.
    This measure requires both agencies to develop a joint plan to 
carry out the FRCP and submit this completed plan to committees of 
jurisdiction, then submit a subsequent report describing and evaluating 
plan implementation.
    The 2011 DOD Recovering Warrior Task Force report highlights a 
number of issues and provides recommendations pertinent to this bill, 
such as standardizing and clearly defining the roles, responsibilities 
and criteria for assigning federal recovery coordinators (FRC), 
recovery care coordinators (RCC) and other case managers. \2\
---------------------------------------------------------------------------
    \2\ http://dtf.defense.gov/rwtf/finalreport2011.pdf
---------------------------------------------------------------------------
    The continuing challenges of the overall recovery coordination 
effort can be best portrayed by differences in the definition of the 
FRCP between VA and DOD despite the FRCP being a joint program. Another 
troubling characteristic is the conflicting policies governing the 
referral of injured service members to the FRCP. \3\ The impact of 
these differing policies was made painfully clear during this 
Subcommittee's hearing on the FRCP on October 6, 2011.
---------------------------------------------------------------------------
    \3\ VA Directive 0802; DOD Instruction 1300.24
---------------------------------------------------------------------------
    Partly as a consequence of strong Congressional oversight and by 
this Subcommittee, VA and DOD have formulated options \4\ for improving 
coordination between the two agencies for a relatively small population 
of catastrophically injured service members. By late 2011, DOD and VA 
had been coordinating a decision memorandum presumably based on an 
options matrix regarding future direction of the FRCP and RCP. The most 
recent information available to DAV is that the memorandum was to have 
been delivered to the joint Senior Oversight Committee (SOC) for 
consideration and a joint decision in December 2011.
---------------------------------------------------------------------------
    \4\ Beginning in December 2010, the Senior Oversight Committee 
directed its care management work group, which includes officials from 
the FRCP and DOD's Recovery Coordination Program (RCP) to conduct an 
inventory of DOD and VA case managers and perform a feasibility study 
of recommendations on the governance, roles, and mission of DOD and VA 
care coordination.
---------------------------------------------------------------------------
    Madame Chairwoman, the DAV is deeply frustrated with the slow 
progress for VA and DOD to implement a joint, seamless program for 
these severely disabled veterans - a commitment VA and DOD made over 
four years ago. Further, we appreciate the sponsor's desire to codify 
the FRCP through this bill; however, the bill would still require VA 
and DOD to collaborate and implement the provisions of this bill if 
passed into law.
    We believe the proposal before the SOC has the potential to address 
the DOD Recovering Warrior Task Force recommendations and other known 
challenges, and improve the recovery coordination effort across VA and 
DOD programs. Therefore, we ask that the Subcommittee hold this measure 
in abeyance until such time as the fate of the joint decision 
memorandum under consideration by the SOC can be ascertained and if 
issued, the contents carefully examined.
           H.R. 3245, the Efficient Service for Veterans Act
    This measure seeks to address any delay in determining eligibility 
of veterans to receive Vet Center services by providing a streamlined 
electronic process to access military service and eligibility 
information. Specifically, this bill would require DOD and VA to ensure 
VA's Vet Centers gain access to the extant Defense Personnel Record 
Image Retrieval System (DPRIS) and VA/DOD Information Repository 
(VADIR).
    The DPRIS is a secure electronic gateway that enables veterans to 
access to their Official Military Personnel File (OMPF) information. 
OMPF is primarily an administrative record, containing information 
about the subject's service history, such as date and type of 
enlistment/appointment; duty stations and assignments; decorations and 
awards; date and type of separation/discharge/retirement (including DD 
Form 214, Report of Separation, or equivalent); and, other personnel 
actions. The Personnel and Readiness Information Management (P&RIM) 
office, in the office of the Under Secretary of Defense (Personnel and 
Readiness) is the office of primary responsibility for DPRIS.
    VADIR is intended by VA as its ``golden source'' for military 
service information. It is a database populated daily and 
electronically with military service data provided from DOD's Defense 
Manpower Data Center (DMDC). DMDC receives information from Defense 
Enrollment Eligibility Reporting System (DEERS) and the military 
service branches. Once received, DMDC synchronizes its data with VADIR.
    Information from VADIR is disseminated in three ways: 1) approved 
VA systems electronically request and receive data from VADIR over the 
internal VA network, 2) data are provided over the dedicated circuit 
between VADIR and DMDC for reconciliation of records or to identify 
military retirees and dependents with entitlement to DOD benefits but 
who are not identified in DEERS, and 3) periodic electronic data 
extracts of subsets of information contained in VADIR are provided to 
approved VA offices over the internal VA network.
    Madam Chairwoman, DAV has a special connection to the VA Vet Center 
program and the counseling services it provides. In 1976, the DAV 
funded the groundbreaking Forgotten Warrior Project, which first 
defined the issue of post-traumatic stress disorder (PTSD) among 
Vietnam war veterans. Vietnam veterans were experiencing serious post-
war problems at that time, and DAV hoped our new study would make it 
impossible for Congress, the VA, and the American public to continue 
ignoring the lingering dilemma that prevented many of these veterans 
from returning to normal lives after serving in a very unpopular and 
difficult war.
    Congress and the VA failed to act on the findings from our project; 
therefore, DAV initiated our own Vietnam Veterans Outreach Program in 
1978. This DAV-sponsored study and the DAV's clinical outreach work 
spurred new, broad realization and additional research by others that 
forced the federal government to confront the psychological impact of 
war on veterans of Vietnam, and subsequently of all wars. When that 
movement finally occurred, the DAV Vietnam Veterans Outreach Program 
was already there to serve as an effective treatment model to be 
adopted by the VA's Vet Center program as we know it today.
    Since the Readjustment Counseling Service program was established 
by Congress in 1979, eligibility for Vet Center readjustment counseling 
services has expanded from Vietnam-era veterans to include all combat 
veterans, to veterans who experienced military sexual trauma, to 
certain family members, and to survivors of veterans who die in combat 
or on active duty. \5\ Vet Centers also offer a list of vital services, 
including counseling for post-traumatic stress disorder (PTSD) and 
other readjustment challenges; marriage and family counseling; and, 
bereavement counseling. One key policy of Vet Centers is to ensure 
veterans seeking help are not required to wait to receive it.
---------------------------------------------------------------------------
    \5\ P.L. 111-163, the Caregivers and Veterans Omnibus Health 
Services Act of 2010, and P.L. 110-387, the Veterans' Mental Health and 
Other Care Improvements Act of 2008.
---------------------------------------------------------------------------
    Vet Centers are known for minimal barriers and almost no 
bureaucracy. The Vet Center is a non-medical setting in a safe 
environment with high confidentially and a strong emphasis on informed 
consent. \6\
---------------------------------------------------------------------------
    \6\ http://www.nytimes.com/2007/04/01/nyregion/
01veterans.html?pagewanted=all. Accessed March 28, 2012.
---------------------------------------------------------------------------
    Although providing the 300-plus Vet Centers direct access to DPRIS 
may improve speed in eligibility determinations, it may also compromise 
the confidential nature of services Vet Centers provide. We contacted 
the DOD office with primary responsibility for DPRIS. This office 
indicated that identifying who accesses DPRIS information and what 
DPRIS information is being retrieved is easily accomplished and is 
reportable information. Further, any personnel in DOD and in each 
military service branch that has designated ``manager'' status for the 
system has the capability to discover who is using that system for data 
retrieval. We urge the Subcommittee to consider removing the provision 
allowing Vet Center access to DPRIS.
    In light of VA's recent proposed rule to implement an important 
provision in section 401 of Public Law 111-163, to expand eligibility 
for Vet Center services to current members of the armed forces, 
including members of the National Guard and Reserve who serve on active 
duty in Operations Enduring Freedom, Iraqi Freedom and New Dawn (OEF/
OIF/OND), \7\ DAV believes protecting Vet Center confidentiality is 
critical to its effectiveness, outreach and success. Therefore, DAV 
opposes this measure as currently written.
---------------------------------------------------------------------------
    \7\ 77 Fed. Reg. 14707-14712
---------------------------------------------------------------------------
                               H.R. 3279
    The intent of this bill is to make family caregivers of certain 
veterans with serious illnesses eligible for a VA program of 
comprehensive assistance and support services. Under current law, only 
family caregivers of certain veterans with serious physical injuries 
are eligible.
    DAV testified before this subcommittee on July 11, 2011, 
recommending VA's adding the term ``seriously ill'' as we believe was 
intended by Congress under title 38 United States Code, section 1720G 
(a)(2)(B), and accordingly that VA revise its proposed eligibility 
criteria. To date, the final rule implementing Title I of the 
Caregivers and Veterans Omnibus Health Services Act of 2010, Public Law 
111-163, has yet to be published.
    DAV supports this measure based on our national Resolution No. 195, 
to support legislation that would expand eligibility for comprehensive 
caregiver support services. We thank the sponsor for introducing this 
bill and strongly urge the subcommittee to give it favorable 
consideration.
    We also note the same resolution supporting this important 
legislation also calls on Congress to expand the eligibility for 
comprehensive caregiver support services to caregivers of veterans from 
all eras of military service. Those caregivers have carried a long and 
heavy burden for their loved ones, and deserve the level of attention 
and support services now being provided generously by VA to caregivers 
of wounded and ill OEF/OIF/OND veterans.
           H.R. 3337, the Open Burn Pit Registry Act of 2011
    If enacted, this bill would direct VA to establish an open burn pit 
registry and ensure military personnel deployed to Afghanistan or Iraq 
who are exposed to toxic chemicals and fumes from open burn pits are 
advised about the existence of the registry and how to participate. 
Under the bill, eligible individuals would be periodically notified 
about significant developments in the study and treatment of conditions 
associated with exposure to toxic chemicals.
    This legislation would direct VA to enter into an agreement with an 
independent scientific organization to develop a report that evaluates 
the effectiveness of the VA in collecting and maintaining such 
information on the health effects of exposure to toxic chemicals from 
open burn pits. In addition, the selected independent consultant would 
evaluate other published epidemiological studies, and recommendations 
regarding the most effective means of addressing medical needs of 
individuals that are likely to be occasioned by exposure to open burn 
pits.
    DAV supports this bill because it partially fulfills the premises 
of DAV National Resolution No. 183, by providing improved surveillance 
of environmental hazards from military toxic and environmental hazards 
exposure. Hundreds of current and former service members have reported 
to DAV that they were exposed to heavy fumes from numerous burn pits 
throughout Iraq and Afghanistan, often becoming ill during such 
exposures, and that their illnesses from such exposures have continued 
to worsen thereafter.
    The October 2011 Institute of Medicine (IOM) report, ``Long-Term 
Health Consequences of Exposure to Burn Pits in Iraq and Afghanistan,'' 
found numerous data gaps and uncertainties in the monitoring of 
airborne pollutants that point to the need for additional studies and 
analysis. The IOM recommended a longitudinal study be conducted that 
would evaluate the health status of service members from their time of 
deployment to Joint Base Balad, Iraq to determine their incidence of 
chronic diseases, including cancers, some of which may not manifest for 
decades following exposure.
    Although VA is sponsoring scientific studies that cover a wide 
spectrum of health effects, these studies may not meet the IOM's call 
for a well-designed epidemiologic study of this particular 
environmental exposure in Iraq and Afghanistan. We urge this 
Subcommittee to consider adding to this bill a research component with 
the identification of cohort groups, one of which was deployed to the 
countries in question and one that was not. This comparative data would 
provide VA the opportunity to contrast the two cohorts' health concerns 
over an extended period, with the potential to provide more meaningful 
insight into the long-term health consequences of toxic exposures.
   H.R. 3723, the Enhanced Veteran Healthcare Experience Act of 2011
    This bill would require VA to provide all enrolled veterans with 
health services to be provided by a contracted non-VA provider, if the 
Secretary determined that VA facilities were incapable of furnishing 
such services because of geographical inaccessibility or a lack of 
required personnel, resources, or ability at VA facilities.
    Under the bill, in entering such contracts with non-VA providers, 
VA may consider only those contractors that demonstrate the ability to 
meet certain quality and safety standards and business processes on par 
with VA's. The measure also sets forth requirements concerning VA's 
eligibility determinations, coordination with non-VA providers, health 
information exchanges, and performance metrics for the purpose of 
incentives or bonus payments to the contractor(s). VA would also be 
required to submit a report to Congress based on implementation of the 
new authority.
    DAV National Resolution 182 calls for a non-VA purchased care 
coordination program that complements the capabilities and capacities 
of each VA medical facility and includes care and case management, non-
VA quality of care and patient safety standards equal to or better than 
VA's, timely claims processing, adequate reimbursement rates, health 
records management and centralized appointment scheduling. We are 
therefore pleased with some provisions in this bill that promote the 
coordination of cost effective non-VA health care; however, DAV is 
unable to support this measure since it proposes to significantly 
change current law that would adversely affect veteran patients and the 
VA system quite dramatically.
    Title 38, United States Code, section 1703 authorizes VA to 
contract for inpatient care and limited outpatient care for specified 
categories of veterans, when VA facilities are unable to provide the 
care, or when these VA facilities are geographically inaccessible. This 
contracting authority is not limited to contracts which contain 
negotiated prices. Title 38, Code of Federal Regulations, section 
17.52, which implements the statutory authority granted by section 
1703, allows for individual authorizations when demand is only for 
infrequent use. This is the foundational authority for VA fee-basis 
care, where individual authorizations are essentially a price offer to 
the non-VA provider, who then accepts that offer by performing services 
for the authorized veteran patient.
    This measure proposes to change VA's authority under title 38, 
United States Code, section 1703 from discretionary to mandatory such 
that if a VA facility is not capable of furnishing care to an eligible 
veteran, the Department must purchase the care by contract. We are 
concerned the mandatory language operates without exception, including 
clinical determinations or when the care needed is not available under 
existing negotiated contracts. Further, since the bill is intended to 
replace VA fee-basis care up to and including its entirety, this 
mandatory requirement may serve to obstruct a VA facility or a VA 
provider from acquiring non-VA medical care for eligible veterans. We 
therefore urge the Subcommittee to consider substituting a 
discretionary authority for the mandatory form in the current proposal.
    This measure would also expand currently specified categories of 
eligible veterans to all enrolled veterans. We note under current law, 
VA already possesses three major approaches to provide non-VA care - 
through contracts to purchase care; fee-for-service arrangements; and 
via sharing agreements with DOD and academic affiliates. Under title 
38, United States Code, section 8153, the VA possesses discretionary 
authority to use contracts with non-VA providers as a vehicle to 
provide hospital care and medical services (as those terms are defined 
in title 38, United States Code, section 1701) to all enrolled 
veterans.
    This authority will be employed in the near future to create 
centrally supported health care contracts available throughout the VA 
health care system. This effort is a soft approach toward applying 
lessons learned from a demonstration project, \8\ now in its fifth and 
final year, toward a new contract care initiative called Patient 
Centered Community Care (PCCC). According to VA, the goal of PCCC is to 
provide eligible veterans coordinated, timely access to high quality 
care from a comprehensive network of VA and non-VA providers.
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    \8\ Project on Healthcare Effectiveness through Resource 
Optimization (See H. Rept. 109-305 for the Military Quality of Life and 
Veterans Affairs Appropriations Act of 2006 (P.L. 109-114).
---------------------------------------------------------------------------
    Unlike H.R. 3723, the stated purpose of VA's contracting authority 
under title 38, United States Code, section 8153 is, ``[t]o strengthen 
the medical programs at Department facilities and improve the quality 
of health care provided veterans under this title by authorizing the 
Secretary to enter into agreements with health-care providers in order 
to share health care resources with, and receive health-care resources 
from, such providers while ensuring no diminution of services to 
veterans.'' On the other hand, exercising Sec. Sec.  8151-8154 only 
partially meets DAV Resolution 182 lacking certain quality of care and 
care coordination provisions that are contained in H.R. 3723.
    Finally, DAV is unable at this time to delineate what impact the 
enactment of this bill would have on title 38, United States Code, 
sections 8151-8154 and on numerous VA health services that are 
dependent on non-VA purchased care. We believe a more detailed and 
comprehensive discussion is needed with VA on these matters.
    With all these thoughts in mind, DAV is unable to support H.R. 3723 
in its current form.
         H.R. 4079, the Safe Housing for Homeless Veterans Act
    This bill would require those organizations receiving VA grants 
that provide assistance to homeless veterans through the Homeless 
Providers Grant and Per Diem Program (GPD) to certify their facilities 
meet current Life Safety Codes as well as state and local housing 
codes, licensing and safety requirements. This legislation would also 
require VA to give priority to those organizations that include making 
improvements to their housing or service facilities to meet these 
requirements. Those providers that do not currently meet the 
certification requirements would have up to two years to bring their 
facilities into compliance.
    While DAV has not received a National Resolution from our 
membership on this particular matter, we would not be opposed to 
favorable consideration of this legislation.
    Madam Chairwoman, this completes my testimony. Thank you again for 
inviting Disabled American Veterans to present this testimony today. I 
would be pleased to address questions from you or other Members of the 
Subcommittee.

                                 
                  Prepared Statement of Rene A. Campos
    MADAM CHAIR BUERKLE, RANKING MEMBER MICHAUD AND DISTINGUISHED 
MEMBERS OF THE SUBCOMMITTEE, on behalf of the 375,000 members of the 
Military Officers Association of America (MOAA), I am grateful for the 
opportunity to present MOAA's views on several legislative provisions 
impacting veterans' health care.
    MOAA does not receive any grants or contracts from the federal 
government.
    MOAA greatly appreciates the Subcommittee's leadership in 
addressing the very important business of taking care of our veterans 
by your diligent oversight of their medical care and benefits which 
tangibly honors their service and sacrifice.
    Our Association wants to acknowledge and thank the Department of 
Veterans Affairs (VA) for its hard work and persistence in transforming 
the agency. Clearly, VA has made significant strides in changing the 
culture, policies and programs and is moving towards a more veteran-
centric organization.
    MOAA's perspectives on the seven bills being considered by the 
Subcommittee today are outlined below.

      H.R. 1460, Congressman William Owens (R-NY)--allows 
veterans returning from combats zones to automatically be enrolled in 
the VA medical system.
       MOAA thanks Representative Owens for his commitment to ensuring 
veterans seamlessly transfer from the Department of Defense (DoD) 
military health care system into VA's medical system.
       While MOAA agrees with the need for seamless transition from the 
military to VA medical and benefits systems, we believe there should be 
no distinction between veterans who have served in combat areas and 
those who have served in other types of assignments.
       Automatic enrollment of only combat theatre veterans will likely 
be perceived as a negative decision by non-combat veterans, causing 
them to view it as a form of health care rationing and the government's 
attempt to diminish their contributions of service to their country.
       The concept of automatic enrollment is consistent with MOAA's 
longstanding support for actions that lead to the `seamless transition' 
of service women and men into the VA system and civilian life. Ongoing 
work on the bi-directional DoD - VA medical record could be advanced by 
automatic VA health care enrollment. But, the provision does not 
eliminate the requirement for the veteran to physically enroll at a VA 
medical center. Perhaps VA's outreach system could be strengthened by 
having advance information on separating service members put into VA's 
enrollment system.
       An automatic process will, of course, simplify enrollment data 
tracking and would likely drive the demand and cost of VA care. For 
example, when Congress authorized open enrollment in the VA health 
system from 1999-2003 for all honorably discharged American veterans, 
enrollment climbed but not to unmanageable levels. With the enormous 
increases in health care costs since then, more separating service 
members might seek VA care if they were automatically enrolled and 
informed of the action.
       MOAA supports the concept of H.R. 1460, automatic enrollment in 
VA health care and recommends H.R. 1460 be amended to authorize 
enrollment of all OIF - OEF veterans to advance seamless transition 
outcomes from military service to the VA.
      H.R. 3016, Congressman John Barrow (D-GA)--directs the 
Secretaries of VA and Defense to jointly operate the Federal Recovery 
Coordination Program (FRCP).
       MOAA testified in September 2011 before this Subcommittee at a 
hearing on the FRCP, promoting a joint VA-DoD care coordination program 
oversight office and policy modeled after the FRCP.
       We again testified in early March 2012, during a hearing before 
the House and Senate Veterans' Committees on MOAA's legislative 
priorities for veterans health care and benefits, stating the need for 
a single, joint VA-DoD office that consolidates the two agency 
programs. We did not recommend the program be modeled after the FRCP 
program because of the agencies' emphasis and desire to work more 
closely together to improve seamless transition of this extremely 
vulnerable population.
       The two Departments have stepped up their collaborative efforts 
significantly since the DoD Recovering Warrior efforts Task Force 
published its 2010-2011 Annual Report last September. Both agencies 
acknowledge more work needs to be done in improving care coordination. 
We believe VA and DoD are doing their best to meet the intent of Sec. 
1611 of Public Law 110-181 in the coordination of care require in the 
law.
       MOAA does, however, believe that congressional and VA-DoD 
leadership oversight continues to be needed until care coordination 
programs, policies and systems mature and are operating efficiently and 
effectively. We look to Congress to determine if ``a single, joint VA-
DoD program and office for managing, coordinating, and assisting 
wounded, ill, and disabled members through recovery, rehabilitation, 
and retention,'' is still needed as required in the law.
       MOAA supports the provision in concept but recommends Congress 
continue to provide oversight by conducting hearings and reports from 
senior officials in the Departments in lieu of additional legislation 
in order to determine the efficacy of programs and increase 
accountability of the systems for care coordination.
      H.R. 3245, Congressman Jeff Denham (R-CA)--the 
``Efficient Service for Veterans Act,'' directs the Secretaries of the 
VA and Defense to jointly ensure that the Vet Centers of the VA have 
access to the Defense Personnel Record Image Retrieval system and the 
VA/DoD Defense Identity Repository system.
       MOAA does not have enough information on these issues to take a 
position on H.R. 3245.
      H.R. 3279, Congressman Silvestre Reyes (D-TX)--amends and 
clarifies title 38, United States Code so that caregivers of veterans 
with serious illnesses (in addition to injuries) would be eligible for 
assistance and support services provided by VA.
       On June 30, 2011, MOAA submitted to VA our response to the 
Caregiver Program's interim final regulations concerning the new 
benefits program directed in title 1 of the Caregivers and Veterans 
Omnibus Health Services Act of 2010 (P.L. 111-163), signed May 5 of 
that year.
       The letter highlighted our concerns about the ``Definition of 
Serious Injury'' in Section 71.15. In the letter we stated the VA: 
defines `serious injury' as ``any injury, including psychological 
trauma, or other mental disorder, incurred or aggravated in the line of 
duty in the active military, naval, or air service on or after 
September 11, 2001, that renders the veteran or servicemember in need 
of personal care services.''
       It was not clear from the statement as to how VA will address 
those individuals whose conditions incurred during service worsen or 
change to the point of needing caregiver assistance once they are in a 
veteran status. We believe the intent of Congress was to allow both 
active duty and veteran caregivers to qualify for the benefit. 
Additionally, VA's definition of serious injury does not specifically 
address illness, though it could allow for such conditions but is left 
open to interpretation.
       In March, MOAA checked with the VA Caregiver Support Office 
about the status of the regulations and response to public comments. VA 
was quick to respond to our request for information letting us know 
that they were still coordinating the rules. VA's Caregiver Support 
Office has also been active in its efforts to educate and inform 
stakeholders on the program as well as responding to wounded, injured, 
ill, and disabled members and families when issues surface.
       MOAA supports H.R. 3279.
      H.R. 3337, Congressman Todd Akin (R-MO)--``Open Burn Pit 
Registry Act of 2011,'' directs the Secretary of Veterans Affairs to 
establish an open-air burn pit registry to ensure that members of the 
Armed Forces who may have been exposed to toxic chemicals and fumes 
caused by open-air burn pits while deployed to Afghanistan or Iraq.
       MOAA appreciates Congressman Atkins' concern over the health and 
welfare of those men and women who have served and are currently 
serving in uniform near burn pit operations in Iraq and Afghanistan.
       For years, the Air Force provided warnings in their pre-
deployment briefings and fact sheets stating that use of open burn pits 
``can be harmful to human health and environment and should only be 
used until more suitable disposal capabilities are established.'' Yet 
open-air burn pits continued operations in Iraq and Afghanistan.
       Over the past decade, many servicemembers have complained of 
headaches, nausea, and irritation of the eyes after immediate exposure 
while several servicemembers and veterans have contracted various 
symptoms and life-threatening medical conditions after being exposed to 
burn pits used to dispose of waste in Iraq and Afghanistan.
       MOAA fully supports H.R. 3337. Establishing a registry of 
servicemembers and veterans exposed to burn pit operations will provide 
a potential long-term link between exposure to harmful open-air burn 
pits and significant, long-term health problems.
      H.R. 3723, Congressman Robert Schilling (R-IL)--
``Enhanced Veteran Healthcare Experience Act of 2011,'' amends title 
38, United States Code, requiring VA to enter into contracts with 
health care providers to improve access to health care for veterans who 
have difficulty receiving treatment at a health care facility of the 
VA.
       Our Association, like Congressman Schilling, is very much 
concerned about the access, adequacy, and the quality of health care 
for our veterans. VA acknowledges a number of challenges to the 
existing fee-based care program and has committed significant resources 
and funds to look at alternative ways to deliver care while maintaining 
the integrity and quality of the medical system. They are also taking 
lessons learned from the contract pilots that have been launch in 
recent years, continuing to look at better and more efficient ways to 
deliver care and services.
       MOAA agrees with the Veterans' Independent Budget (IB) 
conclusion that current purchased care initiatives need time to mature. 
Imposing a mandate on VA could be counter-productive, disruptive, 
costly, and ultimately limit progress on ongoing purchased care 
efforts.
       In addition, VA currently has no mechanism to ensure medical 
data from fee-based care providers are transmitted back to VA and 
integrated in veterans' electronic medical records. MOAA strongly 
agrees with our Veterans Service Organization partners that any non-VA 
care must be fully integrated into the VA health care systems to 
protect not only the system, but also the safety of veterans.
       MOAA does not support H.R. 3723 as written. Rather, we urge the 
Subcommittee to consider the recommendations in the FY2013 IB that 
address the issues in VA's purchased care system. Specifically, we 
strongly recommend that:

      VA should provide Congress and the veteran community a 
final analysis and evaluation of Project HERO.
      VA should develop an effective integrated care 
coordination model for all non-VA purchased care to ensure eligible 
veterans gain timely access to care, in a manner that is cost-effective 
to the VA, preserves agency interests, and most important, preserves 
the level of service veterans have come to rely on inside the VA.
      VA should develop identifiable measures to assess its 
integrated care coordination model for all non-VA purchased care. The 
evaluation should be shared with Congress and the veteran community.

      H.R. 4079, Congressman David McKinley (R-WV)--``Safe 
Housing for Homeless Veterans Act,'' requires homeless veteran 
recipients of housing grants and other assistance from the Secretary of 
VA to comply with codes relevant to operations and level of care 
provided.
       MOAA does not have sufficient information on the issues to take 
a position on H.R. 4079.
Conclusion
    MOAA thanks the Subcommittee for being champions of our veterans 
and their families. We appreciate the opportunity to share our views on 
these important provisions and we look forward to working with the 
Subcommittee on ways to improve VA health care so we can further 
enhance the quality of lives of those individuals in our veterans' 
community.

                                 
                 Prepared Statement of Ramsey Sulayman
    Madam Chairwoman, Ranking Member, distinguished members of the 
subcommittee, on behalf of more than 200,000 members and supporters of 
Iraq and Afghanistan Veterans of America (IAVA), I thank you for the 
opportunity to share the views of our members on these very important 
pieces of legislation.
    My name is Ramsey Sulayman and I am a Legislative Associate with 
IAVA. I am a veteran of Iraq where I was an infantry platoon commander 
and company executive officer. I have spent 14 years in the Marine 
Corps trying to execute the Marine Corps' two missions: winning battles 
and making Marines. As an IAVA staff member, I don't make soldiers, 
sailors, airmen or Marines but I do try to make their lives better. The 
views expressed in this testimony reflect the views and analysis of 
IAVA and not the United States Marine Corps. Thank you for your 
attention to the pressing issues facing our nation's veterans.
    H.R. 1460 - IAVA strongly supports H.R. 1460, ensuring that combat 
veterans smoothly and seamlessly transition their care from the 
Department of Defense (DoD) healthcare system to the Veterans 
Administration (VA) healthcare system by automatically enrolling 
service members in the VA healthcare system and requiring them to opt-
out if they do not wish to be enrolled. The creation of an integrated 
health record and the electronic transfer of medical records are steps 
in the right direction but the most important step is actually getting 
veterans into the system. Currently, veterans must independently seek 
out care in the VA system. That is why only 54 percent of Iraq and 
Afghanistan veterans are enrolled in the VA healthcare system. The 
steep cost of quality healthcare through the private sector and a high 
rate of veteran unemployment (almost 17% among our membership) means 
many veterans do not have access to any other healthcare system, in 
many cases for service-related injuries. IAVA believes that H.R. 1460's 
solution, changing enrollment for VA healthcare to an opt-out system, 
is easy and effective, both in terms of cost and efficacy. Combat 
veterans should not have to opt-in to receive a benefit they have 
earned through their service.
    H.R. 3016 - IAVA supports H.R. 3016 which addresses the slow 
implementation of the Federal Recovery Coordination Program (FRCP) by 
mandating cooperation, setting deadlines and requiring oversight 
through reports to Congress. H.R. 3016 gets to the heart of the 
criticisms of the FRCP leveled by the General Accounting Office (GAO), 
specifically the lack of coordination between the DoD and VA. The 
remarkable advances in medical technology and treatment of traumatic 
injuries we have witnessed over the past decade have resulted in an 
increased survival rate for service members with formerly unrecoverable 
injuries. While great strides have been made in the treatment of these 
injuries, the fragmentation of care across multiple systems has 
resulted in difficulty and frustration for many injured service members 
and their families. The FRCP was a common-sense response that placed an 
experienced health care professional at the center of the process to 
help guide service members and their families through the intricate, 
confusing and stressful process of navigating the healthcare system. 
IAVA believes that those who fought for their country and were injured 
deserve every possible bit of help to restore their lives to order.
    H.R. 3279 - IAVA endorses H.R. 3279 which seeks to rectify an 
oversight in eligibility for family members of service members to 
participate in the caregivers' assistance program. Currently, service 
members who suffer a serious, life-altering illness as a result of 
service to their country are not afforded the option to participate. 
Only service members with physical injuries, loss of limbs for example, 
are eligible to apply for caregivers' assistance. A service member who 
contracts a debilitating disease, for example malaria, is not eligible. 
Many programs are hailed as ``important'' or ``vital'' but fail to live 
up to their billing. The VA caregivers' assistance program is vital and 
important, both to injured service members and their families. By 
promising what amounts to a very minimal safety net, caregivers' 
assistance allows families to make huge sacrifices in their own lives 
to care for severely injured service members. Families are able to make 
the choice to care for their loved one at home, rather than in a 
medical facility. Families are given the choice to stay together. The 
process for receiving caregivers' assistance is already robust and 
oversight is stringent. A relatively small number of veterans and their 
families receive assistance and explicitly stating that serious illness 
is covered as well as injury will not add significantly to the cost or 
numbers of veterans using caregivers' assistance but will make a 
significant difference in their lives.
    H.R. 3337 - IAVA supports H.R. 3337, the Open Burn Pit Registry Act 
of 2011. Burn pits have the potential to be the insidious and long-
lasting health issue for our generation of veterans that Agent Orange 
has been for Vietnam-era veterans. H.R. 3337 seeks to be ahead of the 
curve in responding to potential future health concerns by establishing 
facts: who was exposed, where they were exposed, and for how long. 
These small but crucial pieces of information will be helpful in the 
future in ascertaining health impacts of burn pits, facilitating 
subject identification for epidemiological studies, and adjudicating 
claims. Burn pits were ubiquitous in Iraq and still are in Afghanistan. 
They are located in the midst of large numbers of troops. The twin 
facts that burn pits are the way waste is disposed and must be co-
located with troops for logistical reasons guarantees exposure for most 
service members. While IAVA supports H.R. 3337, we do so with a caveat. 
Because of the ubiquity of burn pits in these conflicts, we believe 
that the definition of burn pit must extend beyond solely those 
authorized by the Secretary of Defense. That proviso must be 
interpreted as broadly as possible and language should be inserted into 
H.R. 3337 that recognizes burn pits established by small-unit leaders 
to facilitate mission accomplishment. There is no garbage service for 
our troops to rely on in Iraq and Afghanistan and small units, by 
necessity, burn all the waste they have. This is a necessary addition 
to this important piece of legislation and IAVA urges inclusion of such 
language in the bill before passage.
    H.R. 3723 - The goals of H.R. 3723, the Enhanced Veteran Healthcare 
Experience Act of 2011, are laudable and IAVA supports many of them. 
However, IAVA cannot support H.R. 3723 because we believe that this 
legislation makes several changes that are untested and do not 
necessarily provide hope of significantly improved patient outcomes or 
access to care. Increased access to healthcare for rural and 
underserved veterans, comprehensive care coordination, and a focus on 
metrics of quality care and patient satisfaction are reforms which IAVA 
has supported and campaigned for in the past. In addition, there are 
significant issues present in the VA's fee-care program that need to be 
addressed for the sake of patient outcomes and providing the highest 
quality healthcare services possible.
    The VA system has the capability to provide non-VA care to veterans 
who are either geographically constrained or who cannot be treated in a 
timely manner through VA providers. By removing the discretion of the 
VA to offer such options and mandating that services be provided on a 
contract basis, H.R. 3723 would effectively cripple VA healthcare. 
Entering into a contract for each veteran who would have previously 
fallen under the fee-care system would be unwieldy and cumbersome: 
would VA have to solicit several bids and pick the lowest bidder? Would 
the patient have to wait for care while the contracting process was 
being executed? Or would VA simply pay the fee charged by the 
healthcare provider without negotiation or comparison, a scenario under 
which upwardly spiraling healthcare costs and diminished access to 
services is easily envisioned? In addition, many medical options are 
not cost-effective in the private sector (i.e. prosthetics) and real 
questions exist regarding fiscal benefits and patient outcomes when 
outsourcing those types of care.
    As mentioned previously, there are many issues with the current 
fee-care system that have been raised. The National Association of 
Public Administrators (NAPA) issued a report which recommended that the 
VA cease the fee-care program because VA lacks the infrastructure and 
expertise to implement fee-care in the best manner possible. This begs 
the question: should the fee-care system be replaced by another system 
that makes the VA a third-party payer (essentially replicating the 
scenario encountered with fee-care) or should the VA system be 
strengthened, funded and fixed so that the use of third-party non-VA 
providers is minimized and truly used out of necessity? IAVA prefers 
the latter option. Therefore, we do not endorse H.R. 3723.
    H.R. 4079 - IAVA supports H.R. 4079, the Safe Housing for Homeless 
Veterans Act. This bill makes explicit what we would already assume to 
be the case: recipients of VA funds to house homeless veterans must be 
in compliance with all relevant building and safety codes. This is not 
an onerous burden. Rather, H.R. 4079 requires meeting minimum standards 
of safety and construction before an entity is eligible to receive or 
continue to receive federal funds. ``Minimum standards'' are explicitly 
``the least we can do.'' Homeless veterans are those who have fallen on 
hard times after honorably serving their country. Their service and 
sacrifice for this country should at least earn them a safe place to 
get back on their feet and the Safe Housing for Homeless Veterans Act 
accomplishes this goal.

                                 
                   Prepared Statement of Ralph Ibson
    Chairman Buerkle, Ranking Member Michaud, and Members of the 
Subcommittee: Thank you for inviting Wounded Warrior Project (WWP) to 
offer our views on legislation pending before the Subcommittee.
    WWP works to honor and empower this generation of wounded warriors 
- physically, psychologically and economically. Our policy objectives 
are targeted to filling gaps in programs or policies--and eliminating 
barriers--that impede warriors from thriving. Importantly, two of the 
bills before you this morning, H.R. 3016 and H.R. 3279, would close 
critical gaps facing warriors and their families and we strongly 
support their enactment.
                               H.R. 3016
    Among the recommendations in WWP's policy agenda is that Congress 
review the operation and effectiveness of the many programs created to 
improve warriors' transition from military service to civilian status. 
The Federal Recovery Coordination Program (FRCP) may be among the most 
important of those initiatives to our warriors and their families, and 
we appreciate the inclusion of H.R. 3016 on your subcommittee's agenda. 
H.R. 3016 would require the Secretaries of Defense and Veterans Affairs 
to develop a memo of understanding setting out a plan for joint 
Department of Defense (DoD) and Department of Veterans Affairs (VA) 
operation of the FRCP in accordance with the bill. As discussed below, 
a key provision of the bill would require the service secretaries to 
refer eligible servicemembers to the program at the earliest possible 
time, but not later than six months before expected retirement or 
separation from service.
    By way of background, the FRCP has its roots in the President's 
Commission on the Care of America's Returning Wounded Warriors (the 
Dole-Shalala Commission), which found that the system of care, 
services, and benefits created to assist those who had been injured was 
too complex to navigate alone. The Commission recommended the creation 
of ``recovery coordinators'' or, in the words of the father of a 
severely wounded Marine, ``a case manager to manage the case 
managers.'' Ultimately, the National Defense Authorization Act of 2008 
(NDAA 2008) directed DoD and VA to develop and implement a 
comprehensive policy to improve care, management and transition of 
recovering servicemembers and their families, to include the 
development of comprehensive recovery plans, and the assignment of a 
recovery care coordinator for each recovering servicemember. \1\ Early 
on, DoD and VA entered into a memorandum of understanding establishing 
a joint VA-DoD Federal Recovery Coordination Program to assist those 
with category 3 injuries - individuals with a severe or catastrophic 
injury or illness who are highly unlikely to return to active duty and 
will most likely be medically separated. A separate DoD Recovery 
Coordinator Program was designed for those with category 2 injuries who 
might or might not return to duty.
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    \1\ Public Law 110-181, sec. 1611.
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    In WWP's view, the services provided warriors and their families 
through the FRCP represent a too-rare instance of a holistic, 
integrated effort to help injured veterans successfully transition and 
adjust to their new normal. Federal Recovery Coordinators (FRCs) make 
unique contributions - both medical and non-medical--in facilitating 
wounded warriors' care-coordination and reintegration. Their invaluable 
work underscores the importance of ensuring that this program reaches 
all who need that help, and that it operate as effectively as possible. 
But while FRCs provide extraordinary assistance to warriors and their 
families, overarching systemic problems must be addressed to ensure 
that the program fully meets its objectives. We believe H.R. 3016 
effectively addresses those systemic problems and we strongly support 
its enactment.
    VA and DoD each share an obligation to severely wounded warriors 
and their families, but the reality is that they do not now share full 
responsibility for the FRC program. As this Subcommittee's hearings 
have ably documented, the FRC program suffers from acknowledged 
interdepartmental gaps.
    As both your hearings and the General Accountability Office have 
documented, individual Service departments are not uniformly referring 
severely and catastrophically wounded warriors to the FRCP for 
assignment, or are doing so at much too late a point in the transition 
process. It is difficult to reconcile service-department practices that 
defer referral of a severely wounded warrior until that individual has 
retired with DoD policy or with the DoD-VA understanding under which 
the FRC program was established. The DoD policy makes it clear that 
``all category 3 service members shall be enrolled in the FRCP [Federal 
Recovery Coordination Program] and shall be assigned an FRC [Federal 
Recovery Coordinator] and an RT [recovery team].'' \2\ The policy 
instructs further that the FRC is to coordinate with the recovery care 
coordinator and recovery team to ensure the needs of the service member 
and his or her family are identified and addressed.
---------------------------------------------------------------------------
    \2\ Department of Defense Instruction (DODI) Number 1300.24, 
``Recovery Coordination Program (RCP),'' Enclosure 4, sec. 2.d. 
(December 1, 2009).
---------------------------------------------------------------------------
    But rather than advancing seamless transition, individual Service 
department practices that defer referral for a possible FRC assignment 
until a severely wounded warrior has retired tend to frustrate 
realization of the goals the program was developed to achieve. By way 
of illustration, many severely and catastrophically wounded warriors 
may be eligible for assistance not only from military treatment 
facilities and the TRICARE program, but from the Veterans Health 
Administration, the Veterans Benefits Administration, the Social 
Security Administration, and Medicare. (As GAO recognized, ``FRCs are 
intended to be care coordinators whose planning, coordination, 
monitoring and problem-resolution activities encompass both health 
services and benefits provided through DoD, VA, other federal agencies, 
states, and the private sector.'' \3\) It is critical that a Federal 
coordinator have the depth of experience, training, and authority to 
navigate these multiple care/benefits systems. In contrast to those 
demanding requirements for an FRC, neither warrior transition unit 
staff nor recovery care coordinators (RCCs) - who are to assist 
servicemembers whose injuries are not deemed likely to result in a need 
for medical separation \4\--have the training, let alone the authority, 
to help coordinate care and other needs outside the military system. 
Resolving this referral problem is vitally important-- failing to make 
a referral for an FRC until severely wounded servicemembers retire can 
mean delay in their recovery, rehabilitation and re-integration. These 
are the very kinds of problems that sparked the call for a seamless 
transition.
---------------------------------------------------------------------------
    \3\ General Accountability Office, ``DoD and VA Health Care: 
Federal Recovery Coordination Program Continues to Expand but Faces 
Significant Challenges,'' GAO-11-250, (Mar 23, 2011) 2. accessed at 
http://www.gao.gov/products/GAO-11-250
    \4\ DoDI 1300.24, Enclosure 4, sec. 2.a.
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    The referral issue seems a manifestation of the fact that instead 
of being operated as a joint, integrated VA-DoD effort, the FRC program 
tends to be seen--and marginalized--as a ``VA program.'' Given the 
program's importance to severely wounded warriors, it is critical that 
both departments fully support it. Experience under the program 
strongly suggests that that goal will remain elusive until there is 
truly shared responsibility for the program. In our view, enactment of 
H.R. 3016 would achieve that important objective by providing a sound 
framework for joint operation of the program under principles to ensure 
early referrals and efficient, effective recovery, transition and 
reintegration of severely wounded warriors. We strongly support 
enactment of this bill.
                               H.R. 3279
    WWP is also pleased to lend our strong support to H.R. 3279. This 
bill would clarify that a veteran who has a serious illness incurred or 
aggravated in service on or after 9/11, and who is deemed to need 
personal care services, is an ``eligible veteran'' for purposes of the 
comprehensive caregiver-assistance program established under Public Law 
111-163. The rationale for providing support services to caregivers of 
our wounded apply equally to family members caring for a young veteran 
suffering from a serious illness incurred in service. Current law 
governing caregiver-assistance certainly makes it clear that there is 
not a hard ``eligibility-line'' between a traumatic injury and other 
medical conditions. That is clear since the law states that the 
defining term, ``serious injury,'' includes a mental disorder. Yet 
while it would cover some veterans with mental health conditions, VA's 
interim final rule otherwise reads the statute as covering only 
``injury'' not illness. But there may be little distinction between the 
caregiving needs of a young warrior who is profoundly disabled as a 
result of serious illness in service and one who is injured. In each 
instance, a parent or spouse may have permanently left the workforce to 
care at home for the veteran's daily needs, leaving that veteran 
vulnerable to the risk of VA institutionalization if the stresses of 
caregiving overwhelm that family member. Surely the needs Congress 
sought to address through the caregiver-assistance law relate to the 
emotional, psychological, physical, and financial impact of caregiving, 
not to the underlying etiology of a veteran's condition. Clarifying the 
law, as proposed in H.R. 3279, would provide needed support for 
deserving caregivers while averting risks of unwanted 
institutionalization.
                               H.R. 3723
    H.R. 3723 would change current law - which authorizes VA to provide 
fee-basis treatment to certain veterans for whom it cannot provide 
timely, geographically-accessible care in its facilities - to require 
it to contract for care under those circumstances for all enrolled 
veterans pursuant to a specified framework. It is helpful to review 
this measure in light of section 1, namely its proposed findings that 
(1) VA's health care system fails to provide veterans easily accessible 
treatment; (2) veterans can be provided care more efficiently closer to 
where they live and with more flexibility in choosing their own 
doctors; and (3) replacing VA's fee-basis care system with the model 
proposed under the bill can yield better care at little to no increased 
cost.
    We concur that the VA health care system does not consistently 
provide veterans easily accessible treatment. Of course there are many 
factors associated with access to care, to include funding and 
staffing, as well as eligibility-limits on fee-basis care set in 
current law. Under section 1703 of title 38, U.S. Code, VA's authority 
to provide care or treatment under contract is limited to specified 
circumstances (such as to provide ongoing needed care in follow-up to 
an episode of hospitalization \5\) and to specified categories of 
veterans (such as veterans needing treatment for a service-connected 
condition or veterans with service-connected disabilities rated 50% or 
more \6\). In short, existing law generally limits VA's use of this 
tool to ensuring continuity of care and to accommodate veterans that 
Congress has identified as having high priority for access to care.
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    \5\ 38 U.S.C. sec. 1703(a)(2)(B)
    \6\ 38 U.S.C. secs. 1703(a)(1)(A); (2)(A)
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    In this connection, our most recent experience, particularly as it 
relates to mental health care, is that fee-basis care is seldom an 
option for warriors with service-incurred mental health conditions 
despite VA facilities' too-frequent inability to provide timely care or 
even the kind of care some need. This troubling situation exists 
despite very clear direction to VA facility directors regarding mental 
health services:

       ``[These services] must be made accessible when clinically 
needed to patients receiving health care from VHA. They may be provided 
by appropriate facility staff, by telemental health, by referral to 
other VA facilities, or by sharing agreements, contracts or non-VA fee-
basis care to the extent the veteran is eligible.'' \7\ (Emphasis 
added.)
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    \7\ Department of Veterans Affairs, VHA Handbook 1160.01 (September 
11, 2008), sec. 3.a.(1)

    At a time that VA facilities are ignoring or circumventing a 
directive that calls for utilizing fee-basis care under the limited 
circumstances authorized in law, it is difficult to embrace the notion 
implicit in H.R. 3723 that it would be timely to expand eligibility for 
fee-care to all enrolled veterans. But, in our view, there also is a 
real question as to how best to craft a legislative response to a 
situation where--VA's own directive that action ``must'' be taken--is 
construed by some as simply a guideline. Under these circumstances, one 
cannot necessarily assume that amending a statutory provision governing 
fee-basis care to read ``shall'' rather than ``may,'' as the bill 
proposes, would ensure the desired change. On the other hand, the 
establishment of such a broad mandate could certainly create serious 
fiscal-management challenges for VA with unintended results. We submit 
that these uncertainties alone raise real concerns, and suggest that 
the Subcommittee consider the unintended consequences of such a far-
reaching bill.
    Finally, we would acknowledge that H.R. 3723 raises a fair question 
as to whether VA's fee-basis model can be improved or even redesigned. 
In that regard, there is certainly merit to establishing requirements 
that any health care provider would have to meet in contracting with VA 
to treat veterans. But it is not clear that the requirements proposed 
in H.R. 3723 represent an optimal contracting framework. For example, 
the measure calls for a contractor to have ``care coordinators to help 
veterans make, confirm and keep medical appointments.'' But it does not 
specifically require the contractor to coordinate care with VA 
clinicians, and as such would not necessarily assure real care-
coordination or continuity of care for the veteran. In addition, the 
bill's requirement that a contractor have the ability to process claims 
from others in the provider's network suggests that such a contract 
would likely not, as a practical matter, be open to most individual 
providers or small group practices. As such, it is not clear that the 
bill would, in fact, ``allow veterans more flexibility in choosing 
their own doctors'', as section 1(b)(3) suggests. In sum, while H.R. 
3723 raises questions that merit discussion, we cannot support its 
enactment.
                               H.R. 1460
    H.R. 1460 would, in essence, direct VA to enroll any veteran who 
served in a combat zone in the VA health care system, subject to an 
option not to enroll. The bill appears aimed at facilitating a combat 
veteran's access to care. As discussed above, however, it has not been 
our experience that warriors have encountered difficulty in enrolling 
or are unaware of their eligibility for VA health care. Rather, we hear 
of warriors encountering problems after enrollment, particularly in 
getting timely, effective mental health care. VA has reported 
historically high percentages of OEF/OIF veterans' enrolling and being 
``seen'' at VA health care facilities. But surveys of both warriors and 
VA mental health staff strongly suggest that at least some of those 
facilities may not be adequately staffed to provide timely care or even 
the right kind of care, and that in meeting VA's goal of enrolling as 
many veterans as possible have been less successful in providing the 
timely, effective care they should expect. In short, while we have no 
objection to H.R. 1460, we do not see this bill as solving the more 
serious access-to-treatment problems some returning warriors are 
facing.
                               H.R. 3337
    H.R. 3337 would require VA to establish a registry for individuals 
who may have been exposed to toxic chemicals and fumes from ``open burn 
pits'' in Iraq or Afghanistan, and require an independent scientific 
organization to assess that effort, and make recommendations on (1) 
collection and maintenance of such information, and (2) on how best to 
meet the medical needs of those exposed with respect to the likely 
result of such exposure.
    WWP shares the concern underlying this bill regarding unexplained 
respiratory and other illnesses among OEF/OIF veterans, and the 
possible role of environmental exposures in Iraq and Afghanistan. H.R. 
3337 focuses specifically on the potential vulnerability of those who 
were based or stationed at a location where an open burn pit was used. 
We note, however, the recent Institute of Medicine suggestions that 
``service in Iraq or Afghanistan - that is, a broader consideration of 
air pollution than exposure only to burn pit emissions--might be 
associated with long-term health effects . . . .'' \8\ While we have no 
objection to this legislation, IOM's findings and recent research \9\ 
suggesting other environmental factors in southwest Asia may also be 
implicated in increased risk of illness raise a question whether the 
proposed registry would ultimately be a sufficiently helpful tracking 
mechanism.
---------------------------------------------------------------------------
    \8\ Long-Term Health Consequences of Exposure to Burn Pits in Iraq 
and Afghanistan, Institute of Medicine (Oct. 2011), 114. http://
www.iom.edu/Reports/2011/Long-Term-Health-Consequences-of-Exposure-to-
Burn-Pits-in-Iraq-and-Afghanistan.aspx
    \9\ See ``Harsh Environment in Southwest Asia, Not Just Burn Pits, 
Cause Health Problems in Troops,'' U.S. Medicine, vol. 48, no. 3 (March 
2012), 33.
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    Finally, WWP has no position on the two remaining bills under 
consideration, H.R. 4079 (addressing requirements for VA's grant 
program to assist homeless veterans) and H.R. 3245 (to direct VA and 
DoD to provide Vet Centers with access to DoD electronic records 
systems in order to obtain service-discharge records (DD-214 forms). We 
would note, however, that warriors with whom we work have not reported 
any problems obtaining DD-214s or establishing eligibility for Vet 
Center services.
    We would be pleased to answer any questions.

                                 
                 Prepared Statement of Robert L. Jesse
    Good afternoon, Madam Chairwoman and Members of the Subcommittee:
    Thank you for inviting me here today to present the 
Administration's views on several bills that would affect Department of 
Veterans Affairs (VA) benefits programs and services. Joining me today 
is Susan Blauert, Deputy Assistant General Counsel.
H.R. 1460: ``Automatic Enrollment of Veterans''
    H.R. 1460 would require the Secretary of VA, in cooperation with 
the Secretary of the Department of Defense (DoD), to automatically 
enroll combat-theater Veterans described in 38 U.S.C. Sec.  
1710(e)(1)(D) in VA's health care system not later than 45 days after 
their discharge or separation from active military, air, or naval 
service. The Secretary of VA would be required to provide these 
Veterans with a ``Veteran identification'' card that: 1) shows they are 
enrolled in VA's health care system, and 2) allows them access to VA 
health care facilities. The Secretary would also be required to furnish 
these Veterans with a list of VA medical facilities (including 
hospitals, outpatient centers, and mental health clinics) that are 
located within 100 miles of the Veterans' homes, or the closest VA 
facilities if none falls within that distance. It would also require 
that these Veterans receive at the same time a description of Federal 
benefits and programs, including educational benefits and job training 
and placement programs, for which they may be eligible.
    H.R. 1460 would also permit Veterans to opt out of automatic 
enrollment by requiring, as part of the enrollment process described 
above, that they also receive the option to decline enrollment. In 
cases where automatic enrollment is declined, the Secretary of VA would 
be prohibited from automatically enrolling those individuals. A Veteran 
automatically enrolled in VA's health care system would have up to 6 
months (from the date of enrollment) to disenroll by providing notice 
to the Secretary. The Secretary would be required under the bill to 
disenroll the Veteran within 60 days of receipt of the notice.
    Finally, the provisions of H.R. 1460 would become effective 90 days 
after the date of enactment.
    H.R. 1460 would dramatically change the process for transitioning 
Servicemembers, and VA is still evaluating the impact this change would 
have on its enrollment model, budget projections, utilization rates, 
and overall access to our health care system.
    VA is working on many fronts to reach out to all separating 
Servicemembers and to ensure they know about the benefits they have 
earned, while making it as easy as possible to avail themselves of 
these benefits. Encouraging enrollment is certainly one piece of that 
effort.
    VA and DoD are working in close partnership to ensure that every 
Servicemember's transition from DoD to VA is as smooth as possible. 
Together, the two Departments continue to progress in providing a 
comprehensive continuum of care to optimize the health and wellbeing of 
Servicemembers, Veterans, and their eligible beneficiaries. Our joint 
efforts to provide a ``single system'' experience of lifetime services 
encompass efficiencies in three common areas: operations; health care; 
and benefits. Joint planning and resource sharing have reduced 
duplication and increased cost savings for both Departments. Our health 
care goal is a patient-centered health care system that consistently 
delivers excellent quality, access, and value across the Departments. 
We also strive to anticipate and address Servicemember, Veteran, and 
family needs through an integrated approach to delivering comprehensive 
benefits and services.
    VA and DoD are cooperating to improve the transition and 
coordination of care and benefits for Servicemembers and Veterans in 
four specific areas. First, in information technology, DoD and VA share 
a significant amount of health and benefits information today, and the 
Departments continue to spearhead numerous interagency data sharing 
activities and are delivering information technology solutions that 
significantly improve the secure sharing of appropriate electronic 
health and benefits information for those who have served our country. 
Second, in benefits determinations, VA and DoD's joint efforts have 
created an integrated disability evaluation process for Servicemembers 
who are being medically retired or separated. This new, joint process 
was designed to eliminate the duplicative, time consuming, and often 
confusing elements of the separate disability processes within VA and 
DoD. Third, in informing Veterans and Servicemembers of the benefits 
they have earned, the National Resource Directory (NRD) is a 
comprehensive, Web-based portal that provides Servicemembers, Veterans, 
and their families with access to thousands of resources to support 
recovery, rehabilitation, and reintegration. NRD is a collaborative 
effort between DoD, Labor, and VA and has more than 13,000 Federal, 
state and local resources which are searchable by topic or location. 
Finally, in mental health, one of our cooperative efforts is the 
Integrated Mental Health Strategy (IMHS), which was developed to 
address the growing population of Servicemembers and Veterans with 
mental health needs. The IMHS centers on a coordinated public health 
model to improve the access, quality, effectiveness, and efficiency of 
mental health services. Recipients of these services include Active 
Duty Servicemembers, National Guard and Reserve Component members, 
Veterans, and their families.
    Because of the complex issues this legislation raises and its wide-
ranging impact on VA, we are still developing a position and a cost 
estimate for this bill. We will provide these in a letter after the 
hearing.
H.R. 3016 Joint Operation of Federal Recovery Coordination Program
    H.R. 3016 would direct the Secretary of DoD and the Secretary of VA 
to jointly operate the Federal Recovery Coordination Program (FRCP). It 
would require the Departments to ensure that the FRCP assists members 
of the Armed Forces with severe or catastrophic injuries or illnesses 
who are unlikely to return to active duty and will most likely be 
medically separated, as well as Servicemembers and Veterans whose 
individual circumstances are determined by the Secretary concerned to 
cause difficulties to the Servicemember or Veteran in transitioning to 
civilian life. It would require the military services and the VA to 
make referrals to the FRCP at the earliest time feasible, including no 
later than 180 days prior to the last day of the month in which the 
Servicemember is expected to be retired or separated.
    The bill would also require that the Secretaries of VA and DoD 
ensure that each Federal Government agency and department provides 
Federal Recovery Coordinators (FRC) with information, coordination, and 
cooperation necessary to allow FRCs to: (1) ensure the efficient 
recovery, transition and reintegration of eligible Servicemembers and 
Veterans; (2) act as liaisons between such Servicemembers and Veterans 
and the team of care providers and other personnel involved with a 
Servicemember or Veteran's recovery, transition and reintegration; and 
(3) work closely with case and care-management programs that assist 
such Servicemembers and Veterans. H.R. 3016 would require the 
Secretaries of VA and DoD, no later than 180 days after enactment, to 
develop a plan to carry out the requirements of the bill, enter into a 
Memorandum of Understanding (MOU) to jointly carry out the plan, and 
jointly submit both the plan and the MOU to designated congressional 
committees. No later than 180 days after the MOU becomes effective, the 
bill would require the Secretaries to jointly submit to designated 
congressional committees, a report describing and evaluating the 
implementation of the plan and MOU.
    While VA appreciates the efforts of Congress to recognize and 
improve FRCP operations and provide high quality care coordination to 
wounded, ill, and injured Servicemembers and Veterans, VA does not 
support H.R. 3016. The Secretaries of VA and DoD are actively engaged 
on this issue and have directed that the Departments resolve the issue 
of coordinating efforts between and recognizing the value of each case 
management and care coordination program within the Departments- to 
include, but not limited to, the VA-administered FRCP and the Service-
administered Recovery Coordination Programs (RCP). Much of H.R. 3016 
represents a duplication of existing requirements for VA and DoD for 
providing care coordination, and the requirements in the bill are 
already included in an existing VA-DoD MOU and in VA and DoD policy.
    Because of the nature of the bill's requirements, VA cannot provide 
a reliable cost estimate of H.R. 3016. To provide a reliable estimate 
VA would need to work with DoD to develop estimates of potential 
clients who would be referred to FRCP under the eligibility criteria in 
the bill, which are significantly broader than under current policy.
    We note that section 1(a)(5) of the bill would direct the 
Secretaries of VA and DoD to ensure that information, coordination, and 
cooperation are provided by each Federal Government agency and 
department. We believe this provision was designed, rather, to ensure 
that VA and DoD appropriately coordinate with other Federal agencies 
and departments in supporting the responsibilities of FRCs - as VA and 
DoD cannot direct the actions and responsibilities of other Federal 
agencies and departments.
H.R. 3245 Efficient Service for Veterans Act
    H.R. 3245 would require the Secretaries of VA and DoD to ensure 
that Vet Centers, established under 38 U.S.C. 1712A, have access to 
``the Defense Personnel Records Information Retrieval System'' and 
``the Veterans Affairs/Department of Defense Identity Repository 
system.''
    VA is authorized, under 38 U.S.C. 1712A, to establish Vet Centers 
that provide readjustment counseling to eligible Veterans and certain 
family members, upon their request. To be eligible for readjustment 
counseling, an individual must: have a Form DD-214 (Certificate of 
Release or Discharge from Active Duty); have received at least one 
qualifying medal; have received combat pay or combat tax exemption 
after November 11, 1998; or allow VA to independently verify his or her 
eligibility with DoD. See Vet Centers, 77 Fed. Reg. 14707-14712 (March 
13, 2012) (adding 38 C.F.R. Sec.  17.2000). H.R. 3245 would allow Vet 
Centers direct access to DoD's Defense Personnel Records Information 
Retrieval System and the VA/DoD Identity Repository system. While the 
bill does not discuss the rationale for providing Vet Centers with 
access to these databases, we believe that the bill is designed to 
allow Vet Centers to utilize the databases to verify eligibility for 
readjustment counseling services if a Veteran does not have his or her 
DD-214.
    VA has no objection to this bill, as it would enable Vet Centers to 
verify eligibility information in a timely fashion even if the Veteran 
or Servicemember does not have his or her DD-214. We would, however, 
recommend that the bill clarify the purpose for Vet Center access to 
the databases and the extent to which access is required. We also 
recommend that the bill list the information, within these databases, 
that should be disclosed to Vet Centers--for instance, ``information 
relevant to Vet Center eligibility determinations.'' Without these 
clarifications, the bill would simply ensure that Vet Centers have 
access to the databases, but would not specify what level of access 
would be granted, or the purpose for that access.
    VA prides itself on maintaining Veteran and Servicemember 
confidentiality. To that end, Vet Centers currently maintain a separate 
system of records within VA, which effectively ``walls off'' any 
client's personal identifying information from individuals who do not 
need access to that information. The only time that Vet Centers 
disclose a client's personal identifying information is when VA has the 
client's authorization or there is an immediate crisis that requires 
the disclosure. To protect the confidentiality of active duty 
Servicemembers and Veterans who request readjustment counseling, we 
recommend that this bill include a provision to restrict the monitoring 
or ``logging'' of Vet Center activity within the databases, other than 
for lawful purposes, such as law enforcement.
    We would be happy to work with the Subcommittee to ensure the bill 
achieves its goals. Because Vet Centers already have the required 
technology to access these databases, we estimate that the costs for 
implementing this bill would be minimal. We also recommend a technical 
amendment to the language in H.R. 3245 to reference the ``Defense 
Personnel Records Information Retrieval System'' instead of 
the''Defense Personnel Record Image Retrieval System''.
H.R. 3279 Amending the Eligibility Criteria Under 38 U.S.C. Sec.  
        1720G(a)(2)(B) to Include Eligible Veterans who have a Serious 
        ``Illness''
    H.R. 3279 would amend the eligibility criteria for VA's Program of 
Comprehensive Assistance for Family Caregivers under 38 U.S.C. Sec.  
1720G(a)(2)(B) to include Veterans or Servicemembers who have incurred 
or aggravated ``a serious illness in the line of duty in the active 
military, naval, or air service on or after September 11, 2001.'' Under 
current law, eligibility for VA's Program of Comprehensive Assistance 
for Family Caregivers is limited to Veterans or Servicemembers who have 
incurred or aggravated ``a serious injury (including traumatic brain 
injury, psychological trauma, or other mental disorder) . . . in the 
line of duty in the active military, naval, or air service on or after 
September 11, 2001.'' See 38 U.S.C. Sec.  1720G(a)(2)(B).
    VA supports the intent of this bill. Expanding eligibility for VA's 
Program of Comprehensive Assistance for Family Caregivers to include 
Veterans and Servicemembers with a serious illness would eliminate the 
need to distinguish illness from injury and establish a more equitable 
program. Distinguishing between a Veteran or Servicemember who incurred 
or aggravated a serious injury in the line of duty from one who 
incurred or aggravated a serious illness is often a complex process 
since either individual may require the assistance of a caregiver. The 
amendment proposed by this bill is supported by public comments 
received by VA in response to its interim final rule. See Caregivers 
Program, 76 Fed. Reg. 26148 (May 5, 2011) (adding 38 C.F.R. Part 71). 
These comments requested that VA consider ``illness'' as one of the 
eligibility factors for VA's Program of Comprehensive Assistance for 
Family Caregivers. VA's Office of General Counsel, however, concluded 
that the statutory language did not permit the addition of illness as 
criteria in regulations, and instead would require a statutory change.
    The amendment would also align VA and the DoD Special Compensation 
for Assistance with Activities of Daily Living (SCAADL) program, 
authorized by section 603 of Public Law 111-84 (Oct. 28, 2010). Both 
SCAADL and VA's Program of Comprehensive Assistance for Family 
Caregivers provide monetary benefits; SCAADL provides monetary 
compensation to eligible Servicemembers, whereas VA provides a stipend 
to primary Family Caregivers. SCAADL does not distinguish between 
illness and injury when determining eligibility compared to VA's 
Program of Comprehensive Assistance for Family Caregivers, which limits 
eligibility to Veterans and Servicemembers who incurred or aggravated a 
``serious injury.'' 38 U.S.C. Sec.  1720G(a)(2)(B). This amendment 
would help align the two programs' eligibility requirements, since they 
both aim to serve Veterans and Servicemembers who require ongoing 
assistance with activities of daily living or need supervision or 
protection.
    To implement this amendment, VA would need to define the term 
``serious illness'' and solicit public feedback on this definition. VA 
would also need to amend its interim final rule to include the new 
eligibility criteria. The amendment would expand the population 
eligible for benefits and services under VA's Program of Comprehensive 
Assistance for Family Caregivers. An increase in the eligible 
population and the services and benefits that are provided to them 
would result in increased costs. At present, VA has approximately 3,500 
Veterans and Servicemembers who have family caregivers enrolled in VA's 
Program of Comprehensive Assistance for Family Caregivers. Based on 
this amendment, VA estimates that 870 additional Veterans and 
Servicemembers would qualify for services and benefits. These benefits 
and services include: a stipend available to primary family caregivers; 
VA health insurance available to eligible primary family caregivers; 
and respite care, mental health services, educational services, and 
beneficiary travel benefits available to family caregivers.
    VA estimates the total cost for this bill would be $45 million 
during Fiscal Year (FY) 2013, $263.5 million over 5 years, and $649.5 
million over 10 years. VA does support the intent of this bill, because 
caregiver benefits indirectly support Veterans by providing assistance 
to their designated caregivers. However, because of the cost of the 
expansion proposed under this bill, there could be a negative impact on 
access to medical care services for Veterans unless additional funding 
is provided.
H.R. 3337: ``Open Burn Pit Registry Act of 2011''
    H.R. 3337 would require the Secretary of Veterans Affairs, not 
later than 180 days after enactment, to establish and maintain a 
registry for eligible individuals who may have been exposed to toxic 
chemicals and fumes caused by open burn pits. The bill would define an 
``open burn pit'' as an area of land located in Afghanistan or Iraq 
that the Secretary of Defense designates for use for the disposal of 
solid waste by means of burning in the outdoor air without the use of a 
commercially manufactured incinerator or other equipment specially 
designed and manufactured for the burning of solid waste. It would 
define ``eligible individual'' as anyone who, on or after September 11, 
2001, was deployed in support of a contingency operation while serving 
in the Armed Forces and who during such deployment was based or 
stationed at a location where an open burn pit was used.
    H.R. 3337 would also require the Secretary of VA to include in the 
registry any information that the Secretary deems necessary to 
ascertain and monitor the health effects of such exposure. It also 
would require the Secretary to develop a public information campaign to 
inform eligible individuals about the registry and to periodically 
notify them of significant developments in the study and treatment of 
conditions associated with exposure to toxic chemicals and fumes from 
open burn pits. Additionally, the Secretary would have to enter into an 
agreement with an independent scientific organization to report on the 
effectiveness of the Department's actions to collect and maintain 
information on the health effects associated with this particular type 
of environmental exposure. Specifically, the organization would be 
required to make recommendations on how the Department may improve its 
efforts (in collecting and maintaining registry information) and on the 
most effective and prudent means of addressing the medical needs of 
this cohort for conditions likely to result from their exposure to 
toxic chemicals and fumes from open burn pits.
    Finally, H.R. 3337 would require the Secretary of VA to submit the 
scientific organization's report to Congress not later than 18 months 
after establishment of the registry.
    VA does not support H.R. 3337. Special authority for such a 
registry is not required. In carrying out the Department's medical and 
research missions, the Secretary may already establish under existing 
authority any needed health registry. Pursuant to section 703(b)(2) of 
Public Law 102-585 (1992), the Secretary may also provide, upon 
request, an examination, consultation, and counseling to any Veteran 
who is eligible for inclusion in any Department health registry. H.R. 
3337, therefore, duplicates existing authorities.
    We do not believe that a health registry is the appropriate 
epidemiological tool to use in identifying possible adverse health 
effects associated with certain environmental exposures. Health 
registries by their nature can only produce very limited and possibly 
skewed results. The major purpose of a registry is to enable medical 
follow-up and outreach efforts of those potentially exposed to an 
environmental hazard. Studies of self-selected individuals, such as 
those in a registry, are not representative of an entire population of 
potentially exposed individuals; they may therefore lead to false 
associations as to cause of perceived or actual illnesses. Indeed, for 
years, VA has maintained an Agent Orange health registry and a Gulf War 
health registry. While useful for outreach purposes, neither of these 
registries has been useful in terms of researching the types of health 
concerns raised by these Veterans. In addition to the issue of self-
selection, there are other reasons why studies of registry populations 
are not useful, including exposure misclassification (self-reported but 
with no availability of data to support amount and time of exposure) 
and an inability to link to medical records to substantiate concerns 
about illnesses (not all registrants receive care from VA). We also 
note the particular timeframes under the bill are far too short to 
produce scientifically valid evidence.
    Instead, it would be more appropriate to conduct a comprehensive 
prospective study of the long-term adverse health effects associated 
with specified environmental exposures, including exposure to toxic 
chemicals and fumes from open burn pits that were experienced by the 
OEF/OIF/OND cohort. Such a study would produce the most complete and 
representative information on possible adverse health effects 
associated with specified exposures. We are currently developing cost 
estimates and data requirements for a large-scale study and defining 
the outcomes it would provide. More importantly, VA and DoD are already 
engaged in several focused studies on health effects related to this 
cohort, including DoD's Millennium Cohort Study and VA's New Generation 
Study. Both Departments are also working on establishing clinical 
protocols for evaluating Veterans with respiratory complaints after 
deployment.
    Finally, we note that combat-theater Veterans are eligible to 
enroll in VA health care up to 5 years after discharge or separation 
from service and receive free hospital care and medical services for 
conditions possibly related to their combat service. Eligible Veterans 
may take advantage of their VA health care benefits to obtain any 
desired medical advice on this topic as well as any needed medical 
services.
    VA estimates the total cost for H.R. 3337 would be $2.3 million 
during FY 2013, $6.2 million over 5 years, and $11.5 million over 10 
years.
H.R. 3723 Enhanced Veteran Health Care Experience Act of 2011
    H.R. 3723 would make various revisions to 38 U.S.C. 1703, which 
currently provides authority for VA to contract for certain types of 
health care for select Veterans when Department facilities are not 
capable of furnishing economical hospital care or medical services 
because of geographic inaccessibility or are not capable of furnishing 
the care or services required. Specifically, this bill would require 
the Secretary to provide health care through contract providers if the 
Secretary determines that Department facilities are not capable of 
economically furnishing covered health services to a Veteran because of 
geographic inaccessibility or because such facilities lack the required 
personnel, resources, or ability. This contract care would be available 
to all enrolled Veterans who elect to receive care under this 
authority.
    With respect to standard acquisition practices, VA's existing 
authority, 38 U.S.C. 8153, to contract for health care resources from 
any health care provider or other entity or individual is sufficient. 
In fact, VA has an acquisition initiative under way to develop broad-
based nationwide and regional contracts with health care providers to 
enhance and expand VA's ability to refer Veterans to qualified health 
care providers when VA is unable to furnish the required health care 
while helping to contain overall costs. With regard to subsection 
(a)(2) of section 2 of the bill, addressing qualified providers and 
quality of care, VA currently includes these requirements in health 
care contracts.
    For the reasons described above, VA does not support this 
legislation. In addition, VA does not support H.R. 3723 because it 
would allow Veterans to elect to receive non-VA care under section 1703 
as amended. As outlined above, section 1703 currently allows VA to 
purchase non-VA health care for certain eligible Veterans when 
facilities are not capable of furnishing economical health care 
services because of geographical inaccessibility or such services are 
reasonably unavailable within VA. Requests for non-VA care from a VA 
provider must document that the local VA does not provide the requested 
service and that the services requested are medically necessary within 
generally accepted standards of medical practice. When such referral 
for non-VA services is received, local fee basis offices are required 
to verify geographic inaccessibility, availability of VA services (to 
include those of other VA medical centers), and eligibility for fee 
basis care. VA is concerned that H.R. 3723 as written would eliminate 
this step and marginalize the definition of what is considered 
geographically inaccessible as a result of the Veterans ability to 
elect to receive care. VA is still preparing cost estimates on this 
bill as written. We will provide it as soon as it is available.
    VA regulations implementing the current authority in section 1703 
have long provided that ``individual authorizations'' may be used as a 
method of making infrequent purchases of necessary non-VA health care 
for eligible Veterans. Individual authorizations provide the 
flexibility to purchase services necessary to a full continuum of care 
based on the patient's condition, frequency of need, and quality of 
care issues which would otherwise be unavailable from VA without 
negotiating the purchase under formal contracting provisions. VA, in 
its budget transmittal, summarized a proposal that will soon be 
transmitted to Congress to amend section 1703 to clarify that VA is not 
limited to formal contracting when purchasing health care services 
under this authority. We note that price reasonableness would be 
ensured by continuing to utilize Medicare payment rates as the payment 
methodology for these purchases.
    VA would welcome the opportunity to work with the Subcommittee to 
enhance 38 U.S.C. 1703 and thereby improve VA's ability to deliver high 
quality health care and provide Veterans with a full continuum of 
health care, where standard acquisition practices are inadequate.
H.R. 4079 Safe Housing for Homeless Veterans Act
    H.R.4079 would modify the Secretary's current requirements for 
entities seeking grants or other assistance to provide housing or 
services to homeless Veterans using the Life Safety Code of the 
National Fire Protection Agency, applicable state and local housing 
codes, licensing requirements, fire and safety requirements, and any 
other jurisdictional requirements.
    The proposed amendment requires that entities providing housing or 
services for homeless Veterans certify compliance with ``the most 
current Life Safety Code and all applicable State and local housing 
codes, licensing requirements [and], fire and safety requirements'' for 
the buildings where services or housing is being provided. The proposed 
law would require that community partners are fire and safety code 
compliant before they are otherwise eligible to receive a grant, as 
well as require compliance with standards that may be above and beyond 
what is required by local law. This new requirement could dramatically 
reduce the pool of eligible capital grantees and could even preclude 
entities seeking capital grants intended to fix fire and safety issues. 
This would effectively mean severely limiting eligibility to existing 
providers with existing approved structures and could defeat the 
purpose of capital granting for new and existing community partners to 
make the necessary changes to provide services to Veterans.
    The legislation appears to require meeting not only life safety 
requirements but it also outlines ``any other requirements in the 
jurisdiction in which the project is located regarding the condition of 
the structure and the operation of the supportive housing or service 
center.'' This could be construed as requiring an applicant to have 
existing permits or licenses to provide services prior to being an 
eligible applicant for a capital grant.
    Furthermore, by amending subchapter I of chapter 20 of title 38, 
this legislation would apply to every specialized homeless program 
operated under chapter 20 of title 38, including the Supportive 
Services for Homeless Vets program found in 38 U.S.C. 2044, and could 
require mandatory housing code upgrades in existing structures even 
when Veterans are not cared for in these structures. For example, under 
38 U.S.C. 2044, VA provides grants to community partners to provide 
prevention and rapid re-housing services to homeless Veterans. In 
general, community partners operating under these types of grants would 
use existing structures for the administration of services; Veterans 
are not ``cared for'' in these structures, but services are 
administered and provided out of these structures. Certainly, these 
community partners would be expected to meet the necessary state and 
local housing codes, but in many cases, the Life Safety Code imposes 
much more rigorous requirements. This legislation would likely require 
costly upgrades to meet the Life Safety Code. In short, this 
legislation could impose onerous remodeling and upgrade costs on 
community partners' administrative buildings even though the services 
they are providing are wholly unrelated to the conditions of the 
building the entity occupies.
    For the reasons stated above, we do not support this bill. It has 
the potential to be unduly burdensome and therefore would undermine the 
original congressional intent to encourage new partners to provide 
services to Veterans. The proposed law could also have a chilling 
effect upon the entry of new providers into the market. There are no 
Federal- level costs associated with this bill.
    This concludes my prepared statement. Thank you for the opportunity 
to testify before the Subcommittee. I would be pleased to respond to 
any questions you or Members of the Subcommittee may have.

                                 
                       Statements For The Record
              PREPARED STATEMENT OF INSTITUTE OF MEDICINE
    Mr. Chairwoman and members of the Subcommittee on Health, my name 
is Harvey V. Fineberg. I am the President of the Institute of Medicine 
of the National Academies. The Institute of Medicine (IOM) is an 
independent, nonprofit organization that works outside of government to 
provide unbiased and authoritative advice to decision makers and the 
public.
    Established in 1970, the IOM is the health arm of the National 
Academy of Sciences, which was chartered under President Abraham 
Lincoln in 1863. Today, the National Academy of Sciences has expanded 
into what is collectively known as the National Academies, which 
comprises the National Academy of Sciences, the National Academy of 
Engineering, the National Research Council, and the IOM.
    I have been asked by your subcommittee to submit a statement for 
this hearing on the topic of H.R. 3337, the Open Burn Pit Registry Act 
of 2011. Our service men and women have long indicated concern that 
their health may have been adversely impacted by the burning of solid 
waste in open pits at US bases overseas where they were or are 
stationed. This concern has been echoed by Congress and the Department 
of Veterans Affairs. In 2009 the IOM was asked by the Department of 
Veterans Affairs to assess the long-term health risks from open pit 
burning at bases in Iraq and Afghanistan, using Joint Base Balad (JBB) 
near Baghdad, one of the largest military bases in Iraq, as an example.
    IOM convened an expert committee to study this matter and the 
committee completed their report in 2011. A PDF download of this report 
is available to the public at no charge from the National Academy Press 
at the following web address: [ http://www.nap.edu/catalog.php?record--
id=13209].
    I am submitting a copy of the summary of this IOM report for the 
record here. Briefly, the IOM collected data on environmental releases 
and concentrations of combustion products at JBB, considered 
information on possible human exposures at the base and elsewhere, and 
assessed the potential for long-term health effects of those exposures. 
The Department of Defense provided raw air-sampling data from JBB taken 
when the burn pit was in operation (it has since been replaced by 
incinerators), which were used to determine which chemicals were 
present at JBB. Based on these data, the committee found that levels of 
most pollutants at the base were not higher than levels measured at 
other polluted sites worldwide.
    However, insufficient evidence prevented the IOM committee from 
developing firm conclusions about what long-term health effects might 
be seen in service members exposed to burn pits. Along with more 
efficient data-gathering methods, the report recommends that a study be 
conducted that would evaluate the health status of service members from 
their time of deployment to JBB over many years to determine the 
incidence of chronic diseases, including cancers, that tend to show up 
decades after exposure. Given the many hazards to which military 
personnel are exposed in the field, service in Iraq and Afghanistan in 
general, rather than exposure to burn pits only, might be associated 
with long-term adverse health effects.
    In addition to instructing the Department of Veterans Affairs to 
establish a health registry, the proposed H.R. 3337 instructs the 
Secretary, Department of Veterans Affairs to enter into an agreement 
with an independent scientific organization to accomplish tasks 
outlined in Section 3 of the legislation. I will offer brief comments 
about those tasks. The three tasks are appropriate and feasible for an 
independent scientific organization to accomplish. For example, the 
first task is to assess of the effectiveness of actions taken by the 
Secretaries (Defense and Veterans Affairs) to collect and maintain 
information on the health effects of exposure to toxic chemicals and 
fumes caused by open burn pits. The independent organization could 
invite the Secretaries to review with the external independent 
organization in a public venue, their plans and programs for carrying 
out the legislation's requirements. That review would include assessing 
the completeness of a toxic agents inventory that the Secretary, 
Department of Veterans Affairs, believes is associated with the open 
burn pits, how and where the information is being derived and 
maintained, and how accessible it is to veterans included in the 
registry. This assessment would naturally lead to a set of 
recommendations (the second task) to improve the collection and 
maintenance of such information. Finally, the third task requires an 
independent organization to review epidemiological studies, established 
and previously published, and to offer recommendations regarding the 
most effective and prudent means of addressing the medical needs of 
eligible individuals with respect to conditions that are likely to 
result from exposure to open burn pits. An independent scientific 
organization would be able to scour the world literature for relevant 
articles relating to this topic.
    Depending on the nature of the information discovered, the 
independent organization could ascertain which exposures might present 
the most significant potential long-term health risks. That, in turn, 
would lead to recommendations about how best to prevent or clinically 
manage these potential effects. If little or no information could be 
obtained from a comprehensive literature review, the independent 
organization could suggest new research, epidemiological and otherwise, 
to inform the health risks.
    In sum, the tasks outlined in section 3 of H.R. 3337 can be 
accomplished by a credible independent organization. Thank you for the 
opportunity to submit a statement for the record.

                                 
                  PREPARED STATEMENT OF BURN PITS 360
    Honorable Chairman Jeff Miller and Honorable Members Of The 
Committee On Veterans' Affairs
    It is an honor to have the opportunity to submit a statement for 
the record regarding Bill H.R. 3337. I am the wife of Captain Leroy 
Torres and founder/Executive Director of Burn Pits 360. ``The War That 
Followed Us Home'' is the slogan on t-shirts worn by many service 
members, veterans, and families affected. They are also the 6 words 
that describe the health and lives stolen from thousands of soldiers 
who served in the OEF/OIF war campaign where they were exposed to 
environmental toxins.
    My husband, Captain Leroy Torres served a dual role to his 
community as a State Trooper in the State Of Texas and a Captain in the 
U.S. Army Reserves. He served a one-year tour at Camp Anaconda, a 
forward operating base that contained the largest burn pit. As he 
walked down the airport terminal with both arms and both legs, I sighed 
with relief thinking that we had accomplished a mission and our life 
would resume back to normal. It was his bulletproof vest in his 
civilian job that confirmed our biggest fear, returning from a war zone 
with life threatening injuries, everytime he put on the vest it 
restricted his breathing leaving him gasping for air. Since then he has 
been diagnosed with an irreversible lung disease, pulmonary 
hypertension, memory loss, parasitic infections, etc. . . . He has lost 
both of his careers at the age of 39 due to toxic inhalation and the 
effects this has had on him and on our family has been devastating. The 
once healthy father of 3 and husband that served on the SWAT police 
tactical squad and ran circles around his children is now a patient to 
over a dozen specialty doctors including: cardiology, neurology, 
pulmonary, GI, etc. . . .
    Gasping for air and searching for answers we felt alone and 
confused. What was causing the coughing spasms, fatigue, memory loss, 
headaches, Gastric pains and were we the only ones out there 
experiencing these unexplained symptoms. Our prayers were answered the 
night that I googled the words, `` soldiers returning sick from Iraq''. 
It was at that moment that we discovered a community of soldiers and 
their families that had lost the battle to toxic exposure and many that 
were still fighting the battle to toxic exposure.
    Like the names listed on the Vietnam Memorial Wall, we discovered 
name after name of individuals that were suffering from brain tumors, 
cancer, lung diseases, etc. . . . One of those names is SSG. Steven 
Ochs, 32 yrs. old, who's story of battling cancer after 3 tours in Iraq 
was told at the October 8, 2009 testimony before the United States 
Senate Committee On Veterans' Affairs. The lists of Fallen Soldiers 
that have lost the battle to toxic exposure include: Amanda Downing 24 
yrs. old, Sgt. William Mc Kenna, Major Kevin Wilkins 51 yrs. old, SSG. 
Matthew Bumpus 31 yrs. old, Christopher Sachs 36 yrs. Old, Andy Rounds 
22 yrs. Old, Jessica Sweet, SSGT Danielle Nienajadlo, and many more.
    Since organizing Burn Pits 360, we are currently the only 
organization that manages a registry for those affected by toxic 
exposures from the Burn Pits In Iraq and Afghanistan. Our registry 
consists of over 600 self-reported entries. Over 90 % of the registries 
represent those suffering from pulmonary symptoms and others from 
Parkinson's, low testosterone levels, skin rashes, fatigue, joint pain, 
memory loss, crohn's disease, parasites, h-pylori, colon cancer, t-cell 
lymphoma, AML-acute myeloid leukemia, lung cancer, throat cancer, brain 
tumors, CML-chronic myelogenous leukemia, renal cell carcinoma, and 
several other illnesses.
    Burn Pits 360 was developed as a pathway of advocacy by 
constituents and military families affected by toxic exposure. It was 
the only answer to avoid from becoming the next Agent Orange. This 
became a passion and a mission for my husband, my family, and for 
myself. The service members, veterans, families of the fallen, 
children, spouses, mothers, fathers, husbands, wives to those affected 
ask each and every one of you to support H.R. 3337. We have traveled to 
Washington at our own expense, walked the halls of Capitol Hill, 
visited the gravesites of those that have lost the battle, and built 
life long friendships with one thing in common, Burn Pits. As a 
military family our patriotism is shown by the American Flag that hangs 
over our front porch, as a caregiver to a wounded warrior, a twenty one 
year employee of the Department Of Veteran Affairs, and executive 
director to Burn Pits 360, it is my hope that each and everyone of you 
will show your patriotism by supporting a bill that will serve as a 
platform to those affected by toxic exposure.

    Respectfully,

    Rosie Torres

                                 
                PREPARED STATEMENT OF HUMANA GOVERNMENT
    Chairwoman Buerkle, Ranking Member Michaud, and members of the 
Subcommittee:

                              Introduction
    Thank you for the opportunity to present Humana Veterans' views on 
H.R. 3723, the Enhanced Veteran Healthcare Experience Act of 2011, 
which would provide much needed improvements to the Department of 
Veterans Affairs' (VA) Fee program for Veterans who are authorized to 
receive medical care from non-VA providers.
    Through the congressionally-directed pilot Project HERO (Healthcare 
Effectiveness through Resource Optimization), Humana Veterans 
Healthcare Services, Inc. (Humana Veterans), a Humana Government 
subsidiary, provides Veterans with access to non-VA healthcare when the 
Department determines that specific medical resources are not available 
within the VA healthcare system in VISNs 8, 16, 20, and 23. In these 
VISNs, we provide access to a competitively priced network of 
physicians, institutions and ancillary providers to supplement the VA 
healthcare system while adhering to high quality and access to care 
standards. With the HERO pilot scheduled to end on September 30, 2012, 
we would like to provide the Subcommittee our perspective on what key 
pilot program elements should be adopted and incorporated into a 
follow-on national program to replace the current VA Fee process.
    Humana strongly supports H.R. 3723 because the bill addresses the 
fundamental flaws of the VA's non-HERO Fee program where Veterans 
receive fragmented care with little or no coordination between VA and 
non-VA healthcare systems. The bill ensures that VA would adopt the 
successful elements of the HERO pilot program, along with additional 
improvements to create a fully integrated healthcare delivery system 
where Veterans receive well-coordinated, patient-centric care. This 
bill enables VA to track and monitor all Veterans with Fee care 
authorizations, requires proper care coordination to positively impact 
Veterans' health outcomes, and will lead to cost savings by minimizing 
duplicative healthcare services and tests. Because of the care 
coordination elements in this bill, its adoption will also result in 
greater empowerment for VA to recapture as much of the Fee workload 
into the VA healthcare delivery system as they can absorb.
                     Challenges in VA's Fee Process
    As currently implemented, the Fee process is not integrated with 
VA's healthcare delivery system and there is no coordination or care 
management of Veterans with Fee care authorizations, except in certain 
congressionally-directed pilot programs such as Project HERO and 
Project ARCH (Access Received Closer to Home). VA's Fee process fails 
to ensure that Veterans are seen by credentialed and qualified non-VA 
providers and does not guarantee the return of pertinent clinical 
information to the VA primary care provider in a timely manner. With 
the exception of Veterans participating in Project HERO and Project 
ARCH, VA has no way of tracking and monitoring if and when Veterans 
schedule and receive care in the community. This means that VA loses 
track of Veterans and the care they receive once they leave the VA 
system for Fee care. Veterans are also left with the daunting task of 
navigating the very confusing VA and non-VA healthcare systems on their 
own without a single point of contact who will be the integrator of all 
care. This process is not Veteran-centered nor structured to allow VA 
to determine if and how a Veteran can be brought back to the VA for 
follow- up care and treatment, if appropriate.
    In addition, the problem of erroneous Fee payments is well 
documented. Despite VA's best efforts to automate the Fee claims 
process through various pilot programs over the past 10 years, claims 
are still not automated today and the current manual claims process 
places VA at high risk for improper payments. For example, a March 2012 
report by the VA Office of Inspector General identified the Fee 
program's improper payment rate at 12.4 percent \1\, and the Government 
Accountability Office's February 2012 report placed the Fee program 
among the top 10 Federal programs with the highest reported improper 
payment rates \2\. These findings are consistent in the September 2011 
report by the National Academy of Public Administration (NAPA). The 
NAPA study also discusses the Fee program's use of ``antiquated systems 
and technology'' and points to private sector payors who provide ``much 
more efficient and accurate claims processing'' \3\.
---------------------------------------------------------------------------
    \1\ VA Office of Inspector General. Department of Veterans Affairs: 
Review of VA's Compliance with the Improper Payments Elimination and 
Recovery Act. Mar. 14, 2012. Web. 6 Apr. 2012, /www.va.gov/oig/
pubs/VAOIG-12-00849-120.pdf>
    \2\ U.S. Government Accountability Office. Improper Payments: 
Moving Forward with Government-Wide Reduction Strategies. Feb. 7, 2012. 
Web. 6 Apr. 2012 /www.gao.gov/assets/590/588228.pdf>
    \3\ National Academy of Public Administration. Veterans Health 
Administration Fee Care Program. Sept. 2011. Web. 6 Apr. 2012 /
www.napawash.org/wp-content/uploads/2011/11/White--
Paper11012011webposting.pdf>
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    To address these problems, VA and Humana Veterans worked in a close 
partnership to implement the HERO pilot program. The result of this 
experience has allowed us to capture the positive outcomes and lessons 
learned, and we can identify the ideal core elements that should be 
incorporated into the Fee program. However, instead of leveraging the 
lessons learned from this pilot program, VA's plan for the follow-on 
HERO program that they are calling Patient Centered Community Care 
(PCCC), would only result in the creation of a sub-specialty provider 
network. Care coordination is not possible under PCCC, because it 
excludes a number of health care services that will end up being 
provided in the community separately from PCCC. This will not yield 
meaningful improvements in the existing Fee program. Instead, PCCC will 
maintain the status quo of the current Fee program and the re-pricing 
contract that only gives VA a discount in price, but does not include 
Veteran-facing services.
    In addition, under PCCC the contractor would not be able to provide 
the administrative services that exist in the HERO pilot and which were 
instrumental to the contractor's care coordination role. In its current 
design, PCCC would significantly limit the contractor's role to one of 
establishing and managing a provider network. Concurrently, VA is also 
creating and building new in-house capacity to handle administrative 
functions associated with the Fee care authorizations, visits and 
treatment through the Non-VA Care Coordination (NVCC) program. Instead 
of tapping the capacity that already exists in industry, NVCC will 
require significant resource investments, both in staff and the 
necessary tools (including IT) to properly handle the ``back-office'' 
administrative functions. It is not clear why VA would want to build 
internal capacity to become an insurance payor, when their expertise 
and experience is in delivering excellent healthcare as a provider. An 
unintended consequence of removing contractor-provided administrative 
services under the PCCC proposed model is the threat to the 
contractor's ability to maintain a provider network responsive to VA's 
changing needs. It also means that VA will not be able to get the best 
price, since the contractor cannot negotiate a better price with their 
network providers in the absence of a predictable minimum workload and 
without the ability to guarantee a low no-show rate, and timely, 
predictable payments.
    The current flawed Fee program operates much like a fee-for-service 
program, which has perpetuated and magnified the risk for poor health 
outcomes, improper payments, and has resulted in unnecessary 
duplicative healthcare services and tests. These problems will persist 
if VA moves forward with PCCC in its current design, and NVCC that will 
excise the back-office functions that contributed to the success of 
HERO. In today's challenging budget environment, VA cannot afford to 
support and expand ineffective and efficient programs. VA must make 
fundamental changes to the traditional Fee program to address the 
current program challenges. This is possible with the enactment of H.R. 
3723, since this bill provides a sound foundation of core Fee program 
elements that can be used to guide VA as they develop the requirements 
for PCCC. The purpose of the congressionally directed HERO pilot 
program was to test ways to improve the broken Fee process. As 
discussed below, the HERO pilot program data point to key positive 
outcomes. H.R. 3723 builds on the integrity and basic successful 
elements of HERO to create meaningful improvements to the traditional 
Fee program.
                               H.R. 3723
    H.R. 3723 ensures that Veterans with Fee authorizations receive the 
same high-quality care and protections that the VA healthcare system 
provides through the following HERO elements:

      Fully credentialed and certified network of specialty 
providers: Humana Veterans provided a network of 39,443 providers in 
the four HERO pilot VISNs. This network made it possible for Veterans 
to travel a median appointment distance of only 13 miles, even though 
45 percent of the HERO appointments were in rural or highly rural 
areas.
      Clinical information exchange: Under Project HERO, Humana 
Veterans returned 94 percent of clinical information to the VA within 
30 days with a median return of 9 days. This helped to improve clinical 
decision-making, and minimized duplicate care and services.
      Care coordination: Humana Veterans' care coordinators 
helped each Veteran in Project HERO navigate the care that they receive 
in the community. For example, Humana Veterans assisted Veterans in 
identifying a network community provider, scheduling the appointment, 
and following up to ensure that the Veteran made the doctor's visit. As 
a result, Humana Veterans achieved a no-show rate of 5 percent, which 
is significantly below the industry average that ranges between 14 
percent and 24 percent. Humana Veterans also provided VA direct access 
to the Authorization and Consult Tracking (ACT) system, which is our 
proprietary IT tool for care coordination that allowed VA to track and 
monitor Veterans with Fee authorizations for the very first time.
      Clinical quality management to respond to patient safety 
events: Under Project HERO, Humana Veterans operated a clinical quality 
management program, which provided a structured way for identifying and 
addressing possible patient safety events. The clinical quality 
management program has reviewed all identified potential quality 
indicators and investigated 100 percent of confirmed quality issues, as 
well as discussed outcomes with the VA through the jointly operated 
Patient Safety Peer Review Committee.
      Accurate and timely claims payment: Project HERO required 
Humana Veterans to handle Fee related administrative services, 
including claims processing for our network providers. Using our 
automated claims process and contracted rates that minimize the risk 
for improper payments, we made 99 percent of claim payments to our 
providers within 30 days and maintained an extremely low payment error 
rate in FY 2011.

    In addition, H.R. 3723 provides for stronger care coordination by 
requiring a VA-provided and a contractor-provided care coordinator to 
work together in managing the care that Veterans receive. The bill also 
attempts to eliminate variation by requiring VA to make consistent 
determination of Fee authorizations for Veterans, while leaving the 
Department with the flexibility to define the standards for referrals 
and authorizations. This means that VA retains the decision-making 
control of if and when they use Fee care as a tool to supplement the 
care that Veterans receive in the VA. In summary, H.R. 3723 provides 
necessary changes to the Fee program and incorporates the successful 
elements from HERO that will enable the VA to work in partnership with 
community providers to provide Veterans with not only patient-centric 
and coordinated care, but also ensures continuity of care across VA and 
non-VA provided healthcare systems.
                               Conclusion
    In order to enhance the Veteran's healthcare experience, VA should 
do what they do very well (i.e., delivery of excellent healthcare) and 
partner with an administrative services contractor to provide services 
they do very well in the marketplace (e.g., care coordination, 
maintaining credentialed provider networks, payments, etc.). For the 
reasons outlined above, Humana Veterans strongly supports H.R. 3723 and 
encourages its enactment. Eligible Veterans for whom VA provides Fee 
authorizations will benefit greatly from a fully integrated care 
coordinated Fee program that will also ensure VA's ability to bring 
these Veterans back into the VA if and when follow-up care is needed. 
We look forward to working with the Committee to make the necessary 
transformational changes to the Fee program so that Veterans receive 
more effective and efficient care when they must go outside of the VA 
system for care.

                                 
     PREPARED STATEMENT OF NATIONAL COALITION OF HOMELESS VETERANS
    Chairwoman Ann Marie Buerkle, Ranking Member Michael Michaud, and 
distinguished members of the House Committee on Veterans' Affairs, 
Subcommittee on Health:
    The National Coalition for Homeless Veterans (NCHV) is honored to 
present this Statement for the Record for the legislative hearing on 
April 16, 2012. On behalf of the 2,100 community- and faith-based 
organizations NCHV represents, we thank you for your commitment to 
serving our nation's most vulnerable heroes.
    For the purposes of this statement, NCHV would like to formally 
indicate its support for the following three bills:

      H.R. 4079, Rep. David McKinley's ``Safe Housing for 
Homeless Veterans Act.''
      H.R. 3723, Rep. Bobby Schilling's ``Enhanced Veteran 
Healthcare Experience Act of 2011.''
      H.R. 1460, Rep. Bill Owens' bill to provide for automatic 
enrollment of veterans returning from combat zones into the VA medical 
system.

         H.R. 4079, ``Safe Housing for Homeless Veterans Act''
    Among the homeless veteran programs that would be affected by this 
legislation is the Homeless Providers Grant and Per Diem Program (GPD) 
- which provides transitional housing with supportive services, and is 
a staple of the Department of Veterans Affairs' Five-Year Plan to End 
Veteran Homelessness.
    A vast majority of homeless veterans must address mental illnesses, 
substance abuse disorders, physical disabilities, or co-occurring 
disorders. The road to recovery for GPD participants often results in 
triumph, but it is not without tribulation. A safe environment is 
critical to ensure this rehabilitation can happen.
    Existing GPD capital grant regulations require compliance with the 
Life Safety Code of the National Fire Protection Association, as well 
as local and state codes and licensing requirements. The ``Safe Housing 
for Homeless Veterans Act'' would establish these policies as federal 
law.
    Numerous homeless shelters across the country have witnessed fatal 
fires. We have the technology, however, to prevent these tragedies from 
happening. H.R. 4079 would signal to VA's community-based service 
provider partners the importance of meeting these safety measures.
    As Congress works to protect homeless veterans and their families, 
it must not create undue obstacles for those who wish to serve them. 
The ``Safe Housing for Homeless Veterans Act'' offers a short-term 
safeguard for homeless veteran programs currently receiving federal 
funds - those that do not already meet the required certification would 
have up to two years to come into compliance.
    We believe the essential components of the Five-Year Plan to End 
Veteran Homelessness are in place and advancing - these include access 
to safe housing, health services, income stability and prevention 
strategies. Without ensuring the safety of veterans in rehabilitative 
housing programs, however, our efforts to end their homelessness will 
be incomplete. This bill takes a sensible approach to help protect 
America's former service members.
H.R. 3723, ``Enhanced Veteran Healthcare Experience Act of 2011''
    Homeless veteran service providers have long recognized the need 
for an ``open door'' policy that ensures veterans have access to 
immediate primary and mental health services. This legislation would 
promote this policy by replacing VA's fee-based care system with the 
contract-based ``veterans enhanced care program.''
    At present, it is incumbent upon the veteran - no matter his or her 
disability level - to travel potentially hundreds of miles to the 
nearest VA medical facility to apply for fee-basis care. H.R. 3723 
would remove this unnecessary burden by allowing qualified service 
providers to enter into contracts with VA to serve eligible veterans in 
areas that are underserved by VA facilities.
    The provisions in this bill cover primary medical care, mental 
health services, and long-term rehabilitative care - all of which are 
critical to the overall health and well-being of veterans, particularly 
those who have served in combat and combat support operations.
    For vulnerable veterans in highly rural and underserved areas, the 
``Enhanced Veteran Healthcare Experience Act of 2011'' will provide 
much-needed relief, and enhance the responsiveness of the VA. NCHV 
supports this bill's patient-centered approach to providing medical 
care.
H.R. 1460, to provide for automatic enrollment of veterans returning 
        from combat zones into the VA medical system
    Although combat exposure is not definitively linked to 
homelessness, it is a high predictor of later difficulties in life. The 
full scope of this relationship remains unclear, however. By 
automatically enrolling veterans returning from combat zones into the 
VA medical system, H.R. 1460 would enable our nation to build a 
comprehensive record of the health care services required by these 
veterans. This is critical to the VA's full understanding of the health 
issues related to combat exposure, and the agency's ability to 
effectively plan for the services it will have to provide to combat 
veterans in the long term.
    This bill protects service members' autonomy by including an option 
not to enroll during their discharge or separation process. 
Additionally, all veterans would have the option to ``disenroll'' for a 
period of up to six months after their initial enrollment.
In Summation
    Thank you for the opportunity to submit this Statement for the 
Record. We look forward to working with this subcommittee to help 
advance H.R. 4079, H.R. 3723, and H.R. 1460 to the full committee and 
House of Representatives.

    John Driscoll
    President and CEO

    National Coalition for Homeless Veterans
    333 \1/2\ Pennsylvania Avenue SE
    Washington, DC 20003
    202-546-1969

                                 
          PREPARED STATEMENT OF PARALYZED VETERANS OF AMERICA
    Chairwoman Buerkle, Ranking Member Michaud, and members of the 
Subcommittee, Paralyzed Veterans of America (PVA) thanks you for the 
opportunity to submit a statement for the record regarding the proposed 
legislation being considered today. PVA appreciates the fact that you 
are addressing these important issues that affect the health and well-
being of our nation's veterans. We support your effort to improve the 
health care and benefit services that these men and women have so 
honorably earned and deserve.
                               H.R. 1460
    PVA generally supports the intent of H.R.1460, a bill that would 
require the Department of Veterans Affairs (VA) to automatically enroll 
veterans returning from combat zones into the VA health care system. 
This bill would also provide veterans with information on job training 
and educational programs that may benefit veterans as they transition 
back into their civilian lives. PVA believes that automatic enrollment 
in the VA health care system immediately after veterans are discharged 
or separated from service will help make veterans more aware of the 
health care services, benefits, and veterans programs available to them 
through the VA. However, we recognize that as a result of automatic 
enrollment there will be a significant increase in utilization, which 
will require additional resources and funding for VA facilities. 
Therefore, PVA's full support for this bill is contingent upon 
providing the VA with the additional resources and funding that will be 
necessary to meet the growth in health care demand.
    PVA also has concerns that if this legislation is enacted the 
current generation of veterans who are discharged or separated from 
military service will be granted enrollment in the VA health care 
system when they may not otherwise be eligible. As written, this bill 
is unclear if the targeted population of veterans will be enrolled in 
the VA health care system in accordance with current enrollment 
policies; or if veterans discharged or separated from military service 
after the bill is enacted will be eligible to enroll regardless of 
restrictions that may be in place for other veterans. PVA believes that 
veterans entering the VA health care system must meet the VA 
eligibility requirements that are in place during the time of automatic 
enrollment.
    PVA would also like to ensure that a veteran's decision not to 
enroll does not preclude him or her from enrolling in the future. The 
VA must also be certain to continue its outreach to inform veterans of 
the many services and benefits that the VA has to offer. Educating 
returning service members on the many benefits of enrollment in VA's 
health care system is an essential element of veterans consistently 
seeking VA services.
    Lastly, PVA believes that it is imperative that this legislation 
recognizes and includes our mobilized National Guard and Reservists as 
they are demobilized from wartime service. The period when a member of 
the Reserves demobilizes is an extremely hectic time and the focus of 
the service member is to get back home to their family. They are no 
less deserving of automatic enrollment and it may be even more 
important as they do not have the long period of preparation often 
afforded to those being discharged from active service.
H.R. 3016
    PVA supports H.R. 3016, legislation that would mandate both the VA 
and the Department of Defense (DoD) to jointly operate the Federal 
Recovery Coordination Program (FRCP). PVA believes that the FRCP is an 
excellent program and has the potential to help severely injured, ill, 
or wounded service members and veterans navigate through the various 
benefits and services for which they are eligible through the VA or 
DoD. However, in order for the FRCP to succeed, both VA and DoD must 
take joint responsibility for its administration.
    As identified by past hearings held by the Subcommittee, 
communication between the VA and DoD, as well as duplication of 
efforts, continues to be a problem in the administration of the 
program. It is for this reason that PVA believes H.R. 3016, if enacted, 
would not only improve communication between VA and DoD, but also 
encourage coordination between the two departments as veterans enter 
the program.
    Since the VA and DoD both have responsibility for individuals 
enrolled in the FRCP, PVA believes that both departments should equally 
share responsibility for the program. If this bill is enacted, VA and 
DoD must work to ensure that the changes that will occur as a result of 
joint responsibility do not thwart the progress that has been mad thus 
far. Administration of the program must continue to move forward in 
order to provide veterans with the necessary guidance and stability 
that is needed for them to make informed decisions in support of their 
full recovery and rehabilitation.
H.R. 3245, the ``Efficient Service for Veterans Act''
    PVA does not have a position on H.R. 3245, legislation that ensures 
that VA Vet Centers have access to the Defense Personnel Record Image 
Retrieval System and the VA/DoD Identity Repository system.
H.R. 3279
    PVA strongly supports H.R. 3279, a bill that would amend title 38, 
United States Code, to clarify that caregivers for veterans with either 
a serious illness or injury are eligible for assistance and support 
services provided by the VA. PVA has over 60 years of experience 
understanding the complex needs of spouses, family members, friends, 
and personal care attendants that love and care for veterans with life-
long medical conditions. PVA believes the original legislation was 
clearly intended to support populations of veterans that have 
experienced a catastrophic injury or illness.
    Additionally, the Secretary of Veterans Affairs, Eric Shinseki, 
emphasized during the roll-out of the new caregiver program that 
``caregivers are critical partners with VA in the recovery and comfort 
of ill and injured veterans.'' Unfortunately, the law is being 
interpreted very narrowly and thus excluding caregivers who care for 
veterans dealing with catastrophic illnesses. PVA believes that this is 
simply unacceptable and urges the Committee to pass this legislation.
H.R. 3337, the ``Open Burn Pit Registry Act of 2011''
    PVA supports H.R. 3337, which would require the VA to create an 
open burn pit registry for members of the Armed Forces who may have 
been exposed to toxic chemicals and fumes caused by open burn pits 
while deployed to Afghanistan or Iraq. This legislation would provide 
this population of veterans with information regarding burn pit 
exposures, and potentially assist VA with future research and health 
care initiatives. PVA believes that the burn pit registry is a first 
step towards ensuring that veterans returning from Afghanistan and Iraq 
receive the proper medical attention regarding exposure to toxic 
elements.
H.R. 3723, the ``Enhanced Veteran Healthcare Experience Act of 2011''
    PVA does not support H.R. 3723, the ``Enhanced Veteran Healthcare 
Experience Act of 2011.'' This bill would amend title 38, United States 
Code to authorize the VA to enter into contracts with health care 
providers in an effort to increase access to health care for veterans 
who have difficulty receiving treatment at a health care facility of 
the VA. While access is indeed a serious concern for PVA, we believe VA 
is the best health care provider for veterans.
    The veterans enhanced care program as proposed in H.R. 3723 would 
change the veteran eligibility requirements for VA contracted care, as 
well as eliminate VA's current Fee-basis care program and replace the 
federal statute governing contract care within the VA. Currently, 
contracted care services provided through the VA are at the discretion 
of VA leadership; reserved for veterans who have sustained a service 
connected disability, or a disability for which a veteran was 
discharged or released from active duty; and provided when the VA is 
not capable of providing the needed care, or such services are 
geographically inaccessible. Under H.R. 3723 VA leadership will no 
longer have the discretion to choose when to contract with private 
providers for veterans' health care, and all veterans enrolled in the 
VA health care system would become eligible to receive contracted care 
outside of the VA. This policy change has the potential to drastically 
increase the number of veterans seeking care outside of the VA, and PVA 
believes that providing quality care to meet the unique needs of 
veterans is an integral component of the VA fulfilling its mission.
    Additionally, this legislation would also expand the criteria under 
which the VA must provide contracted health care to include personnel 
and resource shortages within VA medical facilities. PVA believes that 
this will only lead to the diminution of VA health care services and 
resources. It is PVA's position that the quality of VA's health care 
and ``veteran specific'' expertise cannot be adequately duplicated in 
the private sector. When VA is not capable of providing timely, quality 
services to veterans, it is the responsibility of VA leadership and 
Congress to work together to ensure that VA is able to meet veterans' 
health care needs. PVA does not believe that contracting health care 
services to private facilities is an appropriate enforcement mechanism 
for ensuring access to care.
H.R. 4079, the ``Safe Housing for Homeless Veterans Act''
    PVA supports H.R. 4079, legislation to amend title 38, United 
States Code, to require recipients of VA grants and other assistance 
for the provision of housing and other services for homeless veterans 
to comply with codes relevant to operations. This bill will help insure 
the safety of facilities that offer services to homeless veterans, as 
well as prevent delays in construction of such facilities by requiring 
that all recipients of VA grants be in compliance with safety housing 
codes or licensing requirements. PVA believes that H.R. 4079 is in 
direct alignment with Secretary Shinseki's goal of eradicating 
homelessness among America's veterans.
    Chairwoman Buerkle, Paralyzed Veterans of America appreciates this 
opportunity to express our views on these pieces of important 
legislation. We look forward to working with the Subcommittee on these 
and other issues in the future.

                                 
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