Chairman Sanders and Chairman Miller; Ranking Members Burr and Michaud; and Members of the Committees:

Thank you for inviting Wounded Warrior Project (WWP) to discuss our 2013 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.  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 - illustrated powerfully by our logo of a warrior carrying his wounded brother in service.

The Senate and House Veterans Affairs Committees have done extraordinary work on behalf of America's veterans.  We are especially grateful for the enactment of legislation just in the last year to expand the scope of required rehabilitative care for veterans with traumatic brain injury (TBI), and to improve veterans' mental health care through such steps as including peer-outreach and peer-support services as an integral part of VA mental health care. We commend both Committees for your strong record of accomplishment. 

Many of our Wounded Warriors and their families continue to face challenges on their path to recovery.  WWP's policy agenda remains focused on closing gaps and eliminating barriers to improved mental health of warriors and their families and caregivers, providing optimal, long-term rehabilitative care that maximizes community reintegration and independence, and fostering the economic empowerment of Wounded Warriors.  In instances where progress has been made, such as the enactment of the TBI legislation, it is incumbent upon both committees to provide strict oversight for full and timely implementation of the law.  Yet, there are also areas where progress has been slow, where gaps and barriers remain, and there is still much work to be done. 

Let me emphasize, though, that WWP is not simply here to cite problems.  Rather, we strive to propose solutions, as well as develop programs of our own to meet warriors' and caregivers' needs.  These solutions are informed directly from warriors, caregivers and from staff - who interact daily and work closely with warriors and caregivers through our programs which are specifically structured to engage them, nurture their minds and bodies, and encourage their economic empowerment.  We are eager to work with your Committees as well as the VA and other Executive Branch Departments to continue our work to help Wounded Warriors overcome these barriers and to thrive.

Mental Health

With that objective, our highest priority is to close the gaps in VA's mental health system.  As has been well documented, 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. 

Mental health issues have taken a very real toll on our Wounded Warriors, as evidenced by the following findings from our most recent annual survey of over 13,000 alumni:

• 69 percent screened positive for PTSD;
• An alarming 62 percent indicated they were currently experiencing symptoms of 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).
• 49 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 more than two thirds reported that emotional problems had interfered with work or regular activities during the previous four weeks.
• More than 37 percent of respondents said "yes" when asked if they had difficulty getting mental health care, put off getting care or did not get the care they needed.

Our warriors' descriptions of what they are facing are in some respects even more powerful than the data we have compiled.  Consider the following examples, drawn from our survey:

"I'm anxious, depressed, and feel trapped and on guard constantly.  I still have no idea how to make this stop and feel as though no one can help."

"The most challenging part has been the emergence of my PTSD.  I did not realize what was going on until a couple years after I separated.  My anxiety increased and I had a lot of trouble with my anger and my dealing with the outside world.  My family life has been very stressful due to my symptoms."

"The hardest part has been the detached feeling from family, friends, and co-workers.  I know I should have feelings for these people including my wife and child but I feel nothing so I find myself acting the part for their sake instead of actually mentally participating."

Some warriors acknowledged finding help from VA therapists and clinics.  But more than one in three reported difficulties in accessing effective care for mental health services.    Frustrations run deep, as illustrated by the following warrior comments:

"The VA is overwhelmed...The advice I received from my clinic was to go to the main VA clinic and wait for an appointment.  I have a job and I have to keep it.  I can't wait a whole day just to see a doctor."

"There is a complete and total failure at the VA for providing PTSD treatment outside major metro areas.  In my location there is nothing available..., essentially you're on your own to figure it out.  If they offer you something there is a 4-6 hour drive and 2-3 days off work to attend."

Others report that the VA was quick to provide medications,  but that it was difficult to get therapy.  Still, others have been resistant to seeking professional help.  Overall, our warriors' battles with mental health issues - coinciding with alarming rates of suicide among service members - underscore the urgency and importance of taking action.

With the drawdown of forces in Afghanistan, more service members will be transitioning to veteran status and the challenge of engaging warriors and providing effective mental health care will continue to grow.  We applaud the oversight and focus your Committees have provided, particularly regarding access to timely treatment, and we welcome such initial steps as VA hiring additional mental health providers.  But increased staffing alone will not close all the gaps we see in VA's mental health system.

Earlier this month VA testified to the progress it has made to date in filling mental health vacancies and in meeting the target of hiring an additional 1600 clinical staff.  Even with the additional staffing medical centers have received, residual problems remain. 

For example, we continue to hear reports of warriors encountering troublingly long waits for needed mental health services.  The following is but one example:

While on active duty, a warrior with PTSD had standing appointments three times a week with a DoD psychiatrist.  Yet, when he retired in 2010, bureaucratic deficiencies delayed VA intake and treatment as his claim took over a year to adjudicate.  After finally receiving his rating of 100% for PTSD, his first appointment with a VA psychiatrist was not until over 20 months post-retirement.  Instead of providing a combination of therapy and medication, which is 'best practice,' the VA only provided the warrior an ineffective cocktail of medication and even after admitting this warrior was in bad shape, failed to schedule a follow-up appointment.  When the warrior attempted to make a follow up appointment, the next available was five months away, and only with a physician's assistant (PA), not his previous psychiatrist.  The PA was able to get his medication under control, but that's it.  VA cancellations have deferred subsequent appointments.  Today, several months since seeing the PA, and out of medication, with no refills and no physician, the warrior waits for his next appointment- in mid-March - with no prospect of more consistent care or enrollment in therapy.      

Consider also the case of a major metropolitan VA medical center where even with a 10% increase in mental health staffing a clinician has told us that "not ONE of those positions went to the PTSD Clinic," whose clinicians remain overworked.  He also reported that "it remains just as difficult as ever...to secure for a combat veteran...weekly individual contacts with a provider who knows how to treat trauma," and "too many veterans are not seen frequently enough, or in sessions that are long enough, to permit...successful trauma treatment."   If this is the case at a major urban VA teaching hospital, what is the situation at centers where it is more difficult to recruit and retain highly qualified clinicians?

The scope of VA's challenge is perhaps best captured in the findings of one of the leading researchers in the field, Dr. Charles 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.

Clearly, the challenge is not simply one of improving access.  One must ask, for example, "access to what?"  Mental health care also has to be effective!  At a minimum, that requires building a relationship of trust between provider and patient.   And that trust can be quickly broken when a veteran who needs one-on-one therapy is simply given medication, or is put into group therapy prematurely, or is only offered therapy that requires reliving the painful trauma of war when he or she is not yet ready for such intense treatment.  Such experiences lead warriors to drop out of treatment.

But we also see evidence of frustration among VA mental health staff, when VA system-requirements interfere with their exercising their best clinical judgment.  As one VA psychiatrist told us recently, "the number of required clinical reminders I get keeps growing.  I have a patient who is homeless and whose wife died, but I have to take time away from treatment to administer a depression-screening test even though I know he is depressed." She continued: "I need to be able to spend enough time addressing the veteran's wife's recent death, rather than being required to urge him to stop smoking."  

We see no objection, in principle, to mental health performance requirements, but VA's measures only track processes.   And even at that, these performance requirements can be, and have been "gamed," as prior hearings have documented.  Even more troubling, VA is not measuring whether patients are actually getting better.  Yet those requirements dictate the way clinicians must practice, and a mental health provider who puts his or her patients' needs ahead of performance requirements can incur financial repercussions as a result.   As one described it, "The reality is that the VA is a top-down organization that wants strict obedience."

It bears emphasizing that PTSD and other war-related mental health conditions can be successfully treated - and in many cases, VA clinicians and Vet Center counselors are helping veterans recover and thrive.  Wounded Warrior Project is proud to play a part through our Combat Stress Recovery Program in fostering warriors' recognizing and recovering from the trauma of war.  Our Project Odyssey program, for example, brings warriors together with other combat veterans on outdoor rehabilitative retreats that promote healing.  Such peer-connection is often a first step toward engagement in treatment.

Ultimately, if warriors are to overcome combat-related mental health issues and thrive, the VA must close critical gaps in its mental health care system - and work seamlessly with DoD.  In the recent past, congressional oversight has been a critical catalyst in identifying the need for major system improvements in the provision of mental health care for Wounded Warriors and in effecting needed reforms.  Such vigilant oversight must continue in order to realize still-needed transformative changes.  Among these, we urge that congressional oversight include focusing on the following:

• Given new statutory requirements to work with the National Academy of Sciences (NAS) to establish new staffing guidelines and measures to assess timeliness and effectiveness of mental health care, the VA must give high priority to expeditiously contract with NAS to conduct the necessary assessments and establish the framework for reforms required by law;
• VA must work collaboratively with DoD, both to improve access to mental health care, and to identify and further research the reasons for - and solutions to - warriors' resistance to seeking such care;
• As provided for in law and Executive Order, the VA in 2013 must carry out large-scale training and employment of at least 800 returning warriors (who have themselves experienced combat stress) to provide peer-outreach and peer-support services as part of VA's provision of mental health care to Wounded Warriors;
• The VA should partner with and assist community entities or collaborative community programs in providing needed mental health services to Wounded Warriors, to include providing training to clinicians on military culture and the combat experience;
• The VA must implement provisions of law that require it to provide needed mental health services to immediate family members of veterans whose own war-related mental health issues may diminish their capacity to support those warriors;
• The VA should improve coordination between its medical facilities and Vet Centers, and increase both Vet Center staffing and the number of Vet Center sites, with emphasis on locating new ones near military facilities; and
• The VA should provide for Vet Center staff to participate in VSO-operated recreational programs that are designed to encourage veterans' readjustment, as provided for by law.

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.   Permit us, however, to highlight several of the other issues that merit special attention this session and on which your Committees have already taken important steps.

Long-term Rehabilitation for Traumatic Brain Injury

With recent statutory changes, Congress has required the VA to set a far higher bar in providing rehabilitative services for veterans with TBI.  Specifically, in section 107 of Public Law 112-154 (the Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012), Congress required that VA rehabilitative care for TBI must focus not only on achieving functional gains, but on sustaining them, and that rehabilitative services and supports can contribute to maximizing an individual's independence. 

Studies have found that as many as 45% of individuals with a severe TBI are poorly reintegrated into their community, and social isolation is reported as one of the most persistent issues in follow up studies of such patients.   However, individuals with severe TBI who have individualized plans and services to foster independent living skills and social interaction are able to participate meaningfully in community settings.   It is critical that these warriors not be denied the promise of the fullest recovery possible.  The VA, accordingly, must fully implement the requirements of this new law to ensure that warriors with severe TBI achieve the fullest possible lives in the community.

WWP itself has gone an extraordinary distance to demonstrate the kinds of support warriors with severe TBI should be getting to achieve maximum independence.  With that goal, we created the Independence Program (IP), which now assists 40 warriors and is slated to more than double that number by year's end.  I can think of no better way to describe the program than to tell you about Shane Parsons:

Shane suffered severe traumatic injuries when his Humvee hit a roadside bomb in Iraq in 2006 and he became dependent on his mother, Cindy for his most basic needs.  Shane lost both legs above the knee, and the resulting blood loss caused a severe anoxic TBI and multiple cardiac arrests.  The TBI robbed Shane of some basic cognitive skills, including the ability to read and write, and it took ongoing, long-term rehabilitative care and a year at a brain injury assisted-living facility after that before he was able to return home.  But that lengthy rehab didn't really answer the question of "rehab to what?"  Just being home isn't enough of an answer.

Getting to that next step requires much more than traditional rehab provides.  For Shane, it was first about identifying his interests and goals, and then helping him realize them.  The Independence Program is a team-effort that includes family members and caregivers, medical providers and treatment teams, community support professionals, and WWP staff.  A full assessment of an individual's needs and interests is conducted and results in a personalized plan to enlist the support of community resources and move the warrior on the road to recovery.  In Shane's case, the program not only helped him identify a life-changing personal goal - coaching football - but opened a door to his realizing that dream.  It wasn't easy.  It required Shane - who'd essentially lost the ability to read - to pass two exams, a coaching license and a Red Cross CPR test.  Through the IP, WWP got him both a literacy tutor - with whom he re-learned basic reading and other cognitive skills - and a community-support worker.  Shane's hard work with these two paid off.  He's now an assistant junior high football coach for a local team. 

Through this program, WWP is helping severely Wounded Warriors - who might otherwise simply "stay home" with a risk of social isolation and inactivity - achieve real community reintegration.  VA can, and should, be providing full rehabilitative services to warriors like Shane, to help them reintegrate and thrive in their communities.  Recovery is possible with sufficient support and enlisting community resources is often a critical step to sustaining success.

Amputee Care

Amputee care is another critical concern among our warriors.  Historically, VA has been a leader in this field.  DoD, however, has surpassed the VA in providing state of the art rehabilitation for this generation of combat-injured amputee service members and veterans.   We are concerned that VA's leadership role in prosthetics has declined and that prosthetics no longer holds the priority for VA as it did in the past.   It is particularly distressing that VA prosthetics research - an area of real strength in the past and so important to serving Wounded Warriors tomorrow - has lagged, even as the numbers of new veteran-amputees climb steadily.

Today, some 39% of the OEF/OIF amputee population returns to DoD to receive prosthetic care.  While DoD is currently able to shoulder that demand, WWP is concerned that, as the current conflicts draw down, DoD facilities will ultimately scale back their services and associated funding with the decline in combat injuries.  The VA must be ready to meet this need; but it is not yet there.  There are pockets of excellence within the VA's prosthetic system, but that level of expertise is not consistently available to veterans across the VA system.

Congressional oversight is needed to ensure both preservation of the prosthetics system's strengths and VA progress in improving the quality of its prosthetics and orthotic care.  Together, oversight and VA adoption of recommendations made in our more-detailed policy agenda would go a great distance toward improving the lives of those who have lost limbs in our ongoing war, and enhancing the care of veteran-amputees of all generations.

Caregiver support

Nearly three years ago, your Committees crafted historic legislation that established the framework for a VA caregiver-assistance program that now provides critical supports to family caregivers of seriously Wounded Warriors.  A year after the law was enacted VA finally implemented the program with the adoption of interim final regulations.  Although we raised concerns about those implementing regulations in formal comments, VA has yet to promulgate final regulations.   Several of these unresolved issues are sources of real frustration for caregivers.  Caregivers continue to experience flawed clinical decision-making, based on regulations that give clinicians far too much discretion to deny needed assistance. 

To illustrate the point, just this month I was startled to hear about a decision involving a caregiver of a veteran who is rated 100% disabled for PTSD and who needs his wife's assistance because he cannot manage safely on his own, cannot drive, and cannot manage his own funds (the Veterans Benefits Administration (VBA) has designated his wife his guardian and the fiduciary for his funds).  Yet a VA psychiatrist, apparently with no input from any other VA staff, unilaterally determined that the veteran's wife is not eligible for caregiver-assistance because the clinician's goal for the veteran is to become more independent.  That would certainly also be his wife's goal, but the issue is that the warrior needs caregiver-assistance now, and the possibility that he might one day achieve greater independence cannot be a basis to deny a family caregiver the support she and the veteran need now. 

VA's regulations also include deeply flawed criteria for assessing the extent of needed caregiver-assistance.  In a WWP-conducted survey of caregivers last year, more than one in four (28%) respondents expressed disagreement with the VA's assessment of the number of hours of caregiver-assistance their veteran required.  

As the lead advocate for the caregiver-assistance law, WWP will continue to press for regulatory change, or pursue other avenues as needed.  WWP will also work to ensure that the support provided to caregivers under this new law is not compromised (in the case of caregivers who serve as fiduciaries for a wounded warrior) by unreasonable demands under the VA's fiduciary program.  There is an appropriate place for fiduciary oversight.  From the perspective of a family member who for years has sacrificed to care for a loved one and also takes on responsibilities as a fiduciary, oversight under that program can be not only confusing, but demeaning.  WWP will work to ensure that the VA's fiduciary program better accommodates the needs of these warriors and their families.

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 the major warrior survey we conducted last year, 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.   While employment is paramount to a warrior's sense of personal and economic empowerment, more than 17 percent of our responding alumni are unemployed, though actively seeking employment.   Asked to list factors making it difficult to obtain a job, one in three cited mental health issues, 23% physical limitations, 23% felt they weren't qualified, and almost 14% believed they were behind their civilian peers due to their deployments.

Let me share the words of one of our warrior survey-respondents, whose experience is in many ways emblematic:

"When I was discharged, I could not find a job...Civilian companies did not care about the helicopter, weapons, or tactical experience I had.  Eventually, I was able to work my way through the challenge and gain the experience I needed to compete in the job market with my peers, but it was a long and difficult journey."  

For many Wounded Warriors, it is critical that they are afforded the tools, skills, resources, education, and support needed to secure employment and develop fulfilling careers in ways that matter to them and their families.  Education is often the first step on this path and the two primary benefits warriors are using to finance their education are the Post 9/11 GI Bill and the VA's Vocational Rehabilitation and Employment (VR&E) program.  More than twice as many school-enrollee warriors in our survey are using the Post 9/11 GI Bill than VR&E.   Only 21 percent of school-enrolled respondents reported using the VR&E program, while 53 percent are using the Post 9/11 GI bill, up from 46 percent in 2011.    Given that the VR&E program (unlike the GI bill) provides counseling and other support and is limited to service-connected disabled veterans, the marked decline since 2010 in warrior enrollment among survey participants is striking.

VA's VR&E program should be a key transitional pathway for Wounded Warriors and should provide the supportive services needed by those with service connected disabilities to thrive in the classroom and beyond.  The prevalence of TBI and PTSD among this generation's warriors underscores the importance of ensuring that programs like VR&E are responsive to the unique circumstances associated with those conditions.  Wounded warriors' experiences with VR&E services reflect wide-ranging variability in counselor skills, experience, understanding of TBI and PTSD, and interpretation and knowledge of the program's services.  Warriors report delays in receiving VR&E services, difficulty communicating and scheduling with their counselors, and reduced opportunities to achieve successful and timely rehabilitation.

In short, a program that should be a prized benefit has failed many Wounded Warriors.  Too often, warriors enrolled in the program have simply not received the skilled counseling and support that is so central to successful rehabilitation, and that should be a program hallmark.  Program leadership must focus more sharply on this generation's needs and tailor support accordingly.  Counselors need to understand the struggles, but also the strengths, of these warriors so that they, in turn, can help warriors recognize that they are not "broken," but continue to have great potential.  They must be partners in the warriors' rehabilitation, not critical gatekeepers who too readily dismiss "unrealistic" aspirations.  In working with this generation, counselors must also understand the very profound disorientation experienced by warriors whose lives and life-plans have been upended.  As one put it, the "military was my life and my purpose and now I don't have it and it kills me inside every day, because...that identified me as a person, and now I just feel worthless and without a purpose in life...."   A VR&E counselor must have the sensitivity, training and experience to help that warrior find new purpose, or to link him to appropriate professional help.  But even the most capable, empathetic counselor - challenged with 150 other "cases" to manage - is unlikely to have sufficient time to provide that warrior the needed level and kind of support.  More appropriate staffing levels must be a component of refocusing and re-energizing this important program.  In all, WWP urges Congress and VA to make the VR&E program a greater priority through legislative, budgetary, programmatic, and outcomes-based action.

While the GI Bill is another critical pathway for Post-9/11 warriors, those who are enrolled in school may face hurdles.  Many 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.   Too few institutions of higher education have offered meaningful assistance, including providing accessible on-campus mental health staff trained in military culture, counseling and tutoring services for warrior-students; full-time staff to assist student-warriors; training for faculty on TBI and PTSD; and peer-support services.  While model programs exist, they represent the exception, not the rule.

Congress can play a critical role today in helping this generation of wounded student-warriors make that transition from combat zone to campus.  As discussed more fully in our policy agenda, the objective would be to enable student-warriors to thrive - not struggle - on campus. 

Mental Health Disability:

With the high percentage of Wounded Warriors dealing with combat-related mental health conditions, we see daily the importance of VA disability compensation in providing needed income support.  Yet, the VA mental health rating criteria that provide the framework for determining the amount of that income-support are deeply flawed.  While the VBA has been working to revise those criteria, its initial attempt was highly unsuccessful.  At this point, given the complexity of the issues and a process that has largely been carried out behind closed doors, we are no longer confident of seeing fair, reliable, accurate criteria emerge.  With that concern, we urge your continued focus on VA's process and progress.

 We urge as well examination of the disincentive to employment inherent in VA compensation-policy based on "individual unemployability" (IU).  This policy - which has affected many warriors 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.  Our policy agenda offers guidance aimed at restructuring the IU benefit to encourage pursuit of employment.

Finally, as your Committees have ably demonstrated, successful reintegration of our returning wounded also requires a focus on the DoD-VA handoff and a successful warrior transition from combat to civilian roles.  There remain concerns regarding the support warriors receive at Warrior Transition Units; the operation, efficiency and effectiveness of the medical retirement process and the Integrated Disability Evaluation System (IDES); and DoD-VA coordination in the operation of the Federal Recovery Care Coordination program.  Your work on these and related issues would make a difference toward achieving the still-unrealized goal of affording Wounded Warriors a seamless transition.

In closing, we acknowledge that some may see ours as 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 thrive.