TESTIMONY OF
DAWN HALFAKER
WOUNDED WARRIOR PROJECT

BEFORE THE
COMMITTEES ON VETERANS AFFAIRS
OF THE
SENATE AND HOUSE OF REPRESENTATIVES

MARCH 21, 2012

Chairman Murray and Chairman Miller; Ranking Members Burr and Filner; and Members of the Committees:

Thank you for inviting Wounded Warrior Project (WWP) to discuss our 2012 policy priorities at this joint session.  WWP was founded on the principle of warriors helping warriors, and we pride ourselves on outstanding service programs that advance that principle.  We are driven by our mission to honor and empower wounded warriors and our vision to foster the most successful, well-adjusted generation of veterans in our nation’s history.

I am Dawn Halfaker, and I am testifying this morning not only as the President of WWP’s Board of Directors, but also as a Wounded Warrior myself.  Thanks to a strong support network I have made a successful readjustment.  Because of that, I am deeply committed to WWP’s ideal of warriors supporting one another.  

At a governmental level, there is still much to be done to help my fellow veterans and servicemembers, who continue to face barriers on their path to recovery and reintegration. Importantly, WWP’s policy priorities and agenda address the daily challenges wounded servicemembers and their families experience.  We are committed not only to identifying the barriers and gaps they encounter on the road to recovery, rehabilitation and reintegration, but to proposing solutions and working with your Committees and with Executive Branch departments to topple those barriers and close those gaps.

Many Wounded Warriors have sustained severe physical injuries – amputations, burns, spinal cord injury, loss of vision, and more.  But many more suffer from invisible wounds.  These have taken a very real toll on our alumni, as evidenced by the following findings of our most recent annual survey, with more than 2300 of 5800 wounded warriors responding:
• 78 percent self-identified as having symptoms of a combat-related mental health condition; 
•  51 percent reported having experienced a traumatic brain injury; 
• One in three respondents reported that mental health issues made it difficult to obtain employment or hold jobs,  and almost two in three reported that emotional problems had substantially interfered with work or regular activities during the previous four weeks.  
• An alarming 62 percent indicated they were experiencing current depression (compared to a rate of 8.6 percent in the general population, and RAND’s projection of nearly 14 percent among OEF/OIF veterans generally).  
• More than 36 percent of respondents said “yes” when asked if they had had difficulty getting mental health care, or put off getting such care or did not get the care they needed.

WWP’s experience is that PTSD and other invisible wounds can affect a warrior’s readjustment in many ways – impairing health and well-being, compounding the challenges of obtaining  employment, and limiting earning capacity.  VA does provide benefits and services that are helping some of our warriors overcome such problems: but VA, and the Department of Defense (DoD) as well, have much more to do.

Current budget numbers do suggest record levels of support.  But it’s not necessarily just about reaching particular funding levels.  It’s about outcomes -- ultimately honoring and empowering warriors, and, in our view, about making this the most successful generation of veterans. It’s not enough for VA administrators to set performance metrics for timeliness or other process-measures (especially when those metrics may not adequately reflect the true situation), they must establish performance measures that recognize and reward successful treatment outcomes.  Many of our warriors benefit greatly from the counseling and peer-support provided at Vet Centers, but VA leaders are failing other warriors when they resist implementing a nearly two-year-old law that requires VA to provide peer-support to OEF/OIF veterans at VA medical facilities as well.   Certainly VA’s workforce employs many, many dedicated individuals.  But the Department fails a warrior any time a vocational rehabilitation counselor discourages that warrior’s vocational goal based solely on a PTSD or a TBI diagnosis.  It shortchanges a warrior when critical judgments about the degree of disability associated with service-connected PTSD is based on a VA clinician’s superficial 20-minute meeting with that claimant.  Success is not possible when VA shortsightedly terminates a warrior’s TBI rehabilitative services because “he’s not making enough progress.”  And it fails warriors when it allows fiscal considerations to trump patient-centered services in planning to reverse longstanding prosthetics procurement practice.
 
Timely, effective care, services and benefits for Wounded Warriors cannot be just one among many other “priorities;” it must be a real imperative.

VA Mental Health Care
In our view, the most compelling issue before us – and our deepest concern -- is VA mental health care.  We applaud the oversight and focus your Committees have provided, particularly regarding access to timely treatment, and we welcome the initial step VA has taken of implementing site visits to each of its medical centers.  But VA site-visiting alone falls well short of a commitment to solve what we see as serious gaps in the system, and we have yet to see or hear of a credible remedial plan.  There is a critical need for such a plan, and WWP hopes to contribute to the dialogue that must be a part of its formulation.
To that end, WWP recently initiated a survey of VA mental health staff which is already both confirming and further informing much of what  VA’s own cursory poll of its mental health providers revealed.  Initial responses from VA mental health providers to our survey, including the following six respondents, suggest that significant additional mental health staffing must be a critical element of a needed effort to catch up to, and keep pace with, the ever-growing numbers in need of mental health care:
“There is increasing pressure [on clinicians] to ‘cure’ PTSD and most veterans are funneled into monthly groups…Most of the clinicians on our team have more than 150 patients and some have more than 200.  Most treatment is simply managing the caseload, rather than providing specialized and individualized care.” 

“I would say that far more than half of the time, our patients are seen less frequently than they need to be, and this is PRIMARILY due to insufficient number of clinicians to handle these caseloads.  My colleagues are generally very well trained and are good at what they do; many of us are feeling distressed and demoralized due to this.”

“I have lost count of how many veterans have required hospitalization at my VAMC or elsewhere, or have required referral to a crisis program, when simply receiving more regular outpatient care would likely have made this unnecessary.”

“We need more therapists…Our therapists are not permitted to NOT take yet another patient.  Our therapists are mandated to see some patients weekly and mandated to see some in very time-consuming therapies like prolonged exposure.  It is an impossible situation.  Many of our best therapists are quitting and none are replaced in a timely fashion.”

“The most important issue is lack of adequate staffing.  I work at an inner city VA and our patients present with very complex issues – childhood trauma, impulsivity, suicidality, chronic medical problems, chronic pain, TBI, poverty, racism, military trauma, joblessness, poor coping skills, poor social support, addiction, inadequate housing, dangerous living conditions, violence.  These are issues that are not easily or quickly resolved and take longer term therapy to resolve.  Many of these veterans are very volatile and need more robust treatment and attention.  I routinely feel like I have patients who are on the brink of disaster (suicide or dangerous relapse), but I do not have time to attend to their needs properly.” 

“We have so many more incoming veterans that the push is to get patients to end therapy with their therapist, which is not appropriate." 

While budgets alone are not the be-all and end-all, the Secretary’s recent acknowledgement that VA’s proposed mental health budget increase for FY 2013 is “unimpressive” but adequate with regard to staffing is at odds with what both clinicians and our warriors are reporting.

The scope of the problem is not limited to timely access. We see evidence that veterans at many VA facilities are not getting the kind of mental health care they need or the appropriate intensity of care.  VA is pushing therapies that – without adequate support -- are too intense for many veterans, with the result that a high percentage drop out of treatment altogether.  VA is also not reaching large numbers of returning veterans.  As described by one of the leading mental health researchers on the mental health toll of the conflict in Afghanistan and Iraq, Dr. Charles W. Hoge,
“…veterans remain reluctant to seek care, with half of those in need not utilizing mental health services.  Among veterans who begin PTSD treatment with psychotherapy or medication, a high percentage drop out...With only 50% of veterans seeking care and a 40% recovery rate, current strategies will effectively reach no more than 20% of all veterans needing PTSD treatment.

Hoge urges a strategy of expanding the reach of treatment, to include greater engagement of veterans, understanding the reasons for veterans’ negative perceptions of mental health care, and “meeting veterans where they are.”

Hoge’s insights are important, including his admonition that we must meet veterans where they are.  To illustrate, many warriors experiencing PTSD are just not ready for the intense experience of prolonged exposure therapy or other trauma-focused treatment, and experts acknowledge that such treatment may not be beneficial for everyone.   Yet VA performance measures demand increasing reliance on these therapies, with clinical practice being decisively shaped by performance measures rather than by individual warriors’ clinical needs and preferences (even leading in some instances to administrators eliminating effective therapies).

WWP’s prescription for improving VA mental health care would include several different elements.   Among those steps, we urge VA to:
• implement section 304 of the Caregiver Law, which calls for VA medical facilities to employ returning veterans who have themselves experienced combat stress to provide both direct one-on-one peer-outreach to OEF/OIF veterans who might not otherwise seek treatment and peer-to-peer support to help sustain veterans in treatment;
• implement fully its own longstanding directive calling for use of community-care options when VA mental health resources are so limited and taxed that a warrior in need cannot be seen within a reasonable timeframe;
• better utilize and allocate more resources to its more than two hundred Vet Centers, and take steps to ensure close cooperation and coordination between VA medical facilities and its Vet Centers, which too often operate as though they are wholly separate systems; and
• ensure that clinicians have the means to provide effective treatment (including adequate staffing and support) rather than relying on performance measures that too often cannot be met and lead to gaming the system to meet required numbers rather than improved patient outcomes.
In offering that assessment, we would concede that significant work must be done to identify the right mix of what is needed (and what is feasible) by way of adding new staffing; making greater use of community providers; determining the right number of peer-support specialists VA should train and hire; the precise outcome measures VA should institute in lieu of using process-focused metrics that can and are being “gamed;” and other important elements, discussed above.   Such an analysis can and must be undertaken without regard to any pre-judgment that VA’s mental health budget is “adequate.”  We urge your Committees to require VA to conduct that analysis in concert with key stakeholders  – or to contract with the Institute of Medicine to do so -- and to develop and submit an implementation plan to you.

To its credit, VA has embraced an all-out effort to end homelessness; it must do no less to address needed mental health service care for our returning warriors! 

Ensuring that our Wounded Warriors have access to timely, effective mental health care is our top priority this year.  But the reality is that our warriors also face other challenges that cannot be ignored.  Our policy proposals to address those barriers are fully set out in our more detailed WWP policy agenda.  Below are the highlights of a number of pressing issues that we believe merit special attention this session and on which – in several instances -- your Committees have already taken important steps.

Long-term Rehabilitation for Traumatic Brain Injury
As you know, key provisions of still-pending bipartisan legislation – House-passed H.R. 2074 and S. 914, as reported -- would close critical gaps in long-term VA rehabilitative care of warriors with severe traumatic brain injury.  These provisions would help ensure that needed rehabilitative supports are not prematurely terminated, and would enable VA to provide individualized rehabilitative services (not limited to a restrictive medical model) and patient-centered supports to permit these veterans to live as normal and independent a life as possible in the community.  WWP has taken first steps of our own in developing an Independence Program that now provides these community supports to ten warriors who had suffered severe TBIs.  We look forward to briefing you on the remarkable developments we’ve already seen in some of these veterans – one of whom, for example, is now successfully tutoring children in math.  WWP’s initiative is modest in scope relative to the numbers who could benefit from such services. Enactment of this legislation is critical to warriors and families whose lives have been forever changed by severe traumatic brain injury.  Please do not delay further the passage of this widely supported and important legislation.

Vital Oversight
Economic Empowerment:  Whatever their wounds, it is clear that our warriors’ paths to successful reintegration must include access to the tools and skills they will need to obtain and maintain employment, a key to successful transition and productive lives.  Yet in trying to get past their injuries and rebuild their lives, many face stark employment and education challenges.  As evidenced by the findings of a major survey we conducted, our warriors reported that their financial situation did not improve over the last year.   Nearly 40 percent responded that they are worse off than a year ago.   High unemployment and a staggering economy have created additional challenges.  While employment is paramount to a warrior’s sense of personal and economic empowerment, only 48.8% of our survey respondents were employed full-time or part-time.   Those who were unemployed reported having been actively job-searching for an average of 32.6 weeks, with about half searching for up to 100 weeks.   Asked to list factors making it difficult to obtain a job, 33% cited mental health issues, 22.6% physical limitations, and 21.5% felt they weren’t qualified. 

Many Wounded Warriors are addressing these economic challenges through education.  Some 75 percent of respondents in WWP’s recent survey of wounded warriors have less than a bachelor’s degree, and 33 percent of respondents were enrolled in school.   Of those enrolled, 60 percent were pursuing a bachelor’s degree, 25 percent are pursuing an associate’s degree, and approximately 4 percent were pursuing a technical degree or certificate.

The two primary benefits warriors are using to finance their education are the Post 9/11 GI Bill and VA’s Vocational Rehabilitation and Employment (VR&E) program, with a higher percentage using the Post 9/11 GI Bill.   Even when enrolled in school, Wounded Warriors face additional hurdles.  They report difficulty assimilating on campus and adapting to student-life; insufficient or non-existent accommodations to their physical and mental limitations; and lack of understanding of needs arising from PTSD and TBI on the part of faculty and fellow students. Family issues, finances, and health problems often compound these school-related stresses.    

Vocational Rehabilitation and Employment: Too often, the programs designed to give disabled veterans the help they need to gain success in the workforce are failing them. The VA Vocational Rehabilitation and Employment (VR&E) benefits program should be a key transitional pathway for wounded warriors.  But, as your committees’ have documented, VA has not given the program the priority and resource support needed to assure required services are actually available and that this new generation of wounded warriors is getting the kind of help they need. 

To illustrate, WWP still hears of VR&E counselors blocking warriors’ employment aspirations by denying them access to their program choice and pressing them instead to pursue “any job” as a goal. Too often, warriors who enroll in VR&E encounter problems, or even drop out.  Warriors cite frustration with inadequate numbers of counselors or counselors without adequate training, program inflexibility, and the failure of VA to provide necessary supportive services such as tutoring and accommodations for disabilities as serious obstacles.  With warriors continuing to report that they are effectively denied the skilled counseling and support they need because of inadequate VR&E staffing and counselors who too often are not sufficiently trained to understand their most prevalent wounds, we urge the committees’ continued oversight.

Supporting Warriors Using the Post-9/11 GI Bill:  The Post-9/11 GI Bill is the most robust veterans’ educational benefits package in a generation, offering comprehensive, generous education and subsistence benefits.   But while this program has provided our warriors much-improved educational access, it does not address the unique campus-related challenges that many face.  WWP sees troubling signs that schools of higher education are not providing the support to help this population succeed, even as it has become apparent that warriors who pursue higher education are no more insulated from reintegration challenges than their brothers and sisters who defer education or return to the workforce.  But colleges and other institutions of higher education do not often recognize the unique transitional challenges facing a wounded veteran embarking on a new educational journey. Fewer still have appropriate supports in place to help these student-warriors.  While post-9/11 GI bill expenditures are projected to total $9.9 billion in FY 2013,  most schools receiving these funds are not providing the kinds of supports student-warriors, and especially wounded warriors, need.  According to the American Council on Education report “From Soldier to Student: Easing the Transition of Service Members on Campus,” only 22 percent of postsecondary institutions with student-veterans provide transition services; approximately 40 percent of postsecondary institutions with student-veterans provide training opportunities for staff to better assist the student-veterans; 23 percent of college and universities with student-veterans have staff trained to assist students with brain injuries; 33 percent of those same institutions have staff trained to assist students with other physical disabilities; and only 32 percent of institutions with student-veterans have a club to foster peer support.   Model programs exist, but they represent the exception, not the rule.

We share the concerns voiced by Secretary Shinseki that warriors face a steeper climb than their fellow students and that high numbers of Post-9/11 veterans who begin using their education benefits are not completing their courses of study.   Given the importance of higher education to warriors’ achieving economic and other life goals, such warnings are cause for concern, both for our warriors and the effectiveness of the post-9/11 GI bill.

Wounded warriors who return to school under the Post-9/11 GI Bill are not simply grappling with adjustment to the demands of higher education, but often with PTSD, traumatic brain injury, and other often-severe disabilities.  In our view, institutions of higher education that receive significant funding from the Post-9/11GI bill should provide reasonable supports and services to accommodate the special needs of their wounded warrior students.   We urge your Committees to work to make the promise and the investment of the post-GI Bill real for these warriors, and to begin that work with oversight hearings. 

Prosthetics:  Many of our warriors will continue to need rehabilitative support long after the war effort winds down, and with the high number who have suffered limb loss – many with multiple amputations -- prosthetic services will remain critical.   But it is important to recognize that this war has challenged the VA health care system, which for some time had principally served a generally older patient population whose prosthetic needs were most often linked to diabetes and post-vascular disease.   More than three years have passed since VA received the recommendations of a 27-member expert panel (on which WWP was represented) that comprehensively reviewed VA amputee prosthetic care and research.  Many of its recommendations have yet to be fully implemented, and no steps have been taken on others.  While VA has charted a course-shift toward a new amputee-care paradigm, that course-correction is still underway.  VA’s challenge here is multi-faceted.  War zone injuries that result in amputations are often complex and can prove difficult for later prosthetic fitting because of length, scarring, and additional related injuries such as burns.   VA has instituted an amputation system of care and initiated the development of amputee centers of excellence which can become important components of needed changes, but WWP’s experience is that much more progress is needed to realize the underlying vision.  In fact, major DoD health centers have surpassed VA in providing state of the art rehabilitation for this generation of combat-injured amputees.  Yet we cannot assume that DoD will continue to sustain that effort as the ongoing wars wind down. 

While these issues alone offer compelling reason for oversight, we are concerned to see VA moving to achieve economies in the prosthetics arena, which may not be in the best interests of the warrior.  It is our understanding, for example, that VA plans to institute a policy change this summer under which prosthetics-equipment purchases of items over $3,000 – now routinely made by Prosthetics Service under specific statutory authority -- could only be made by a VA contracting officer under the auspices of an entirely different organizational entity.  While this might seem an innocuous step, it could in fact put highly individualized purchasing-decisions in the hands of officials who lack prosthetics expertise or supervision thereof, with very high likelihood of warriors experiencing substantial delays in receiving needed limbs and other equipment, and the risk that needed items would be inappropriately ordered or even denied. 

We urge your Committees to institute early oversight this year into the VA prosthetics program, which could include an independent study and assessment of steps taken and additional measures that may be needed to assure VA leadership in providing state of the art service to our wounded warriors.

Caregiver-assistance: The Veterans Affairs Committees played a pivotal role last year in successfully pressing VA to rectify the most glaring flaws in its implementation of the Caregiver-Assistance program.  WWP, and more importantly Wounded Warrior caregivers, are deeply grateful.   Approaching the one-year anniversary of that program’s start-up, questions still remain as to the resolution of the concerns voiced on VA’s interim final regulation.  While many caregivers are getting much needed help, we ask the Committees to review the program and ensure that the implementation regulations do indeed meet Congress’ intent.

On a related front, we hope you will also continue to press the Veterans Benefits Administration regarding its Fiduciary Program to resolve concerns experienced by family caregivers.  A devoted family member who provides consistent, high-quality daily care for a severely wounded veteran has, over time, surely earned VA’s trust and should not be treated as an object of VA suspicion simply because the individual serves as the veteran’s fiduciary.  Families who have already earned that trust should not be subjected to rigid budgeting, unnecessarily detailed accounting, ongoing intrusive scrutiny, or threatening warnings without substantial cause.  Finally, VA should work to achieve more uniform standards and greater consistency in its application of fiduciary oversight policy. 

Mental health disability evaluation: Re-emphasizing the psychological trauma so many warriors have experienced, we urge your continued focus on the deep flaws in VA’s procedures for evaluating, and its criteria for rating, disability due to mental conditions.  We certainly recognize that the Veterans Benefits Administration is working to revise its clearly outdated mental health rating criteria.  In that regard, there is likely wide consensus that the existing rating criteria do not provide a fair or accurate basis for evaluating average impairment of earning capacity resulting from mental health disability.  But we cannot assume, given the complexity of the issues and a process largely being carried out behind closed doors, that proposed changes to the rating criteria will ultimately meet VA’s clear obligation in law.   

In our view, simply modernizing the mental health rating schedule will not alone result in fair, accurate compensation awards, given VA’s heavy reliance on often superficial compensation and pension examinations to assess degree of disability. Currently, the claims-adjudication process relies heavily on an examination conducted by a psychologist or psychiatrist who typically has never met (let alone treated) the veteran before.  In addition, C&P examinations of mental health conditions are often very brief and superficial.  Hurried, or less than comprehensive, C&P examinations heighten the risk of adverse outcomes, additional appeals, and long delays in veterans receiving benefits.  In contrast, meaningful evaluation of a mental health condition requires a painstaking inquiry that often depends on developing a trusted relationship with a client, on probing inquiry, and on sustained dialogue.   A brief, one-time office visit with a stranger is hardly conducive to such an encounter, and provides only the most distant impression of the extent of disability. VA mental-health compensation determinations should be based on the best evidence of a veteran’s functional impairment associated with that service-connected condition.   We believe that objective study would demonstrate that giving much greater weight to the findings of mental health professionals who have been treating a veteran, and who are necessarily far more knowledgeable about his or her circumstances would result in fairer and more accurate disability ratings.  We urge your Committees to press VA to contract for the conduct of such study with an eye to revising current policy based on strong study results.   

Other critical compensation issues certainly also demand attention.  DoD-VA coordination in evaluation of disability has not lived up to the expectations associated with developing the Integrated Disability Evaluation System (IDES).  We welcome the oversight on that system soon to begin in the House.  We urge as well examination of the disincentive to employment inherent in VA compensation-policy for “individual unemployability.” This policy – which has particular significance for veterans with PTSD and other combat-related mental health conditions – provides for awarding a veteran a 100% rating based on being unable to pursue substantially gainful employment due to severe disability.  But, given that an effort to return to the work force carries risk of a steep decline in compensation, many are understandably reluctant to take those important first steps.

Finally, as your Committees have ably demonstrated, successful reintegration of our returning wounded also requires a focus on DoD initiatives and the DoD-VA handoff.  There remain concerns regarding the support warriors receive at Warrior Transition Units; the operation, efficiency and effectiveness of the medical retirement process; and DoD-VA coordination in the operation of the Federal Recovery Care Coordination program.  Your work on these and related issues will make a difference toward achieving the still-unrealized goal of affording wounded warriors a seamless transition.

Ours is an extensive agenda, but that is fitting given that so many of our warriors  have not only suffered multiple wounds – physical and emotional – but face multiple challenges, including uneven access to care, gaps in treatment, and barriers to achieving economic empowerment.  We look forward to working with your Committees on these and other issues to make real the changes needed to help our Wounded Warriors achieve their goals of success.