Vietnam Veterans of America
Executive Director for Policy & Government Affairs
Committee on Veterans Affairs
United States Senate
The Department of Veterans' Affairs
Fiscal Year ‘10 Budget Request
March 10, 2009
Chairman Akaka, Ranking Senator Burr, and distinguished Senators on the Committee, on behalf of Vietnam Veterans of America (VVA) National President John Rowan and all of our officers, Board of Directors, and members, I thank you for giving Vietnam Veterans of America (VVA) the opportunity to testify today regarding the President's fiscal year 2010 budget request for the Department of Veterans Affairs. VVA thanks each of you on this distinguished panel, on both sides of the aisle, for your strong leadership on issues and concerns of vital concern to veterans and their families.
I want to thank you for recognizing that caring for those who have donned the uniform in our name is part of the continuing cost of the national defense. Caring for veterans, the essential role of the VA and, for specific services other federal entities such as the Department of Labor, the Small Business Administration, and the Department of Health and Human Services, must be a national priority. This is poignantly clear when we visit the combat-wounded troops at Walter Reed Army Medical Center and Bethesda Naval Hospital.
Mr. Chairman, VVA thanks you for sponsoring advanced Appropriations legislation in the Senate (S. 423). As you know, VVA and other major veterans' service organizations have been long-time supporters of legislation to achieve assured funding. When the VA budget is late 19 or of the last 22 times, it is clear that there is a need for a new mechanism to correct the problems in the current system of funding. While VVA remains committed to the assured funding concept, we currently strongly support the Advanced Appropriations legislation contained in S. 423 as being so much better than what we currently have in place. As we have this discussion in regard to the FY'10 budget for the VA, the readily apparent need for this legislation has never been more pressing. We look forward to working with you to ensure its enactment, as it will move us toward our common goal of predictable, fully adequate, and timely funding for VA health care that is sufficient to truly meet the needs of all veterans in vital need of such care.
Concerning the proposal at hand, the President's FY'10 budget for the VA, VVA is pleased with the overall amount of the request, which is for a $5.5 Billion overall increase over the FY 2010 budget. It is unclear how much of that is slated for the Veterans Health Administration (VHA), and how much for other purposes given the sketchy outline of the VA budget thus far available. However, it is clear that the bulk of those funds needs to VHA to meet the rising needs of medical inflation continue the process of adding needed organizational capacity as the population served expands, and for modernizing equipment and facilities.
Using the Center for Medicare & Medicaid Services (CMS) figure of 3.6% inflation, that would mean that the Congress needs to add a minimum figure of about $1.4 Billion to VHA just to keep up with increases in fixed costs, even if no more veterans entered the system. Further, there is a need to "front load" staff to increase organizational capacity to be ready to handle additional numbers of veterans allowed to seek health care from the VHA as the system is re-opened to those who were frozen out of the system by the actions of the previous Administrations beginning in January of 2003. There will be further increases of our youngest veterans from the current conflicts seeking services from VHA as well as more older veterans seeking services, particularly Vietnam veterans whose medical problems are now coming to the fore due to age and manifestation of long term effects of exposure to Agent Orange and other herbicides and toxins in Vietnam and elsewhere during their military service.
While VVA is adamant that VA needs to allow these veterans to register and to receive health care, it needs to be done in a manner that avoids overwhelming the system all at once leading to long delays in receiving care. The system is in many cases too "thin" to be able to accommodate more people for more than a brief amount of time. VVA believes that these staff enhancements and increases in organizational capacity will require at least another $2 Billion for VHA to increase the size of permanent staff.
This would include significantly increasing the number of staff in the highly successful VA Vet Center (Readjustment Counseling) program to not just open and provide staff for new centers and to do rural outreach, as important as these two efforts are, but to enlarge the size of existing teams. Perhaps the most pressing need, beyond ensuring that staff members at Vet Centers are not so over-worked that they "burn out," is the need for more certified family counselors and more counselors professionally trained and certified to deal with military sexual trauma in veterans of both genders. The Vet Centers are our first line of defense against suicides, and we must make sure they have the organizational capacity to continue doing what they do so well on a long term sustainable basis.
.VVA calls for an increased outlay for Research and Development. Traumatic Brain Injuries, or TBI, needs to be better understood for treatment to be more effective. Other mental health issues, too, that are afflicting too many of our returning troops, need to be better understood. Research, for which VA scientists and epidemiologists can be justifiably proud, benefit not only troops who are forever changed by their experiences in combat but the general populace as well. VVVA believes that we must become more serious about research at the VA, given that the National Institutes of Health (NIH) continues to totally ignore veterans and the long term health effects of military service. Other than one head injury study, we know of no other NIH research project that even tangentially asks about military service and uses that as a variable (and possible confounder). VVA recommends that Research & Development be provided at least $ 750 million for FY 2010 and commensurately large increases in the out years, so that over five years this activity is funded at least at the $1 Billion level.
For the first time in many years, VVA has NOT signed on to the Friends of VA Health Care & Medical Research (FOVA) although we strongly believe that there needs to be a significant increase in R&D funding. VVA did not sign on to FOVA because of a required pledge not to push for any earmarks in Research & Development funds. It would be irresponsible of VVA to sign this pledge and not seek ear marks given that we have been unable to discover ANY research programs into the long term health effects of Agent Orange and other toxins, despite repeated inquiries to the current Undersecretary for Health and the current occupant of the office of Director of Research & Development, as well as the previous two occupants of the office of Secretary of Veterans Affairs. Obviously we need ear marks for research into the environmental wounds of Vietnam, as well as into the deleterious health effects of service in other periods of time and theaters of operation, such as the first Gulf War. It would be a betrayal of our members and their families if we did not urgently seek ear marks for further research into the terrible health long term effects of exposure to the herbicides and other toxins (including pesticides, PCBs, etc.) used in Vietnam during the war.
This lack of such research projects is compounded by VHA's adamant refusal to obey the law and complete the replication of the "National Vietnam Veterans Readjustment Study" (NVVRS) as a robust mortality and morbidity study from the only existing statistically valid random sample of Vietnam veterans in existence. Frankly, this study in needed not only to document the long term course of post traumatic stress disorder, but also to document physiological problems in this population (which we know to be many). Their refusal says a great deal about their bias and determinedly continued willful ignorance.
Mr. Chairman, VVA thanks this Committee and the Appropriations Committee for using the power of the purse in the FY 2008 and FY2009 Appropriations act to compel VA to obey the law (Public Law 106-419) and conduct the long-delayed National Vietnam Veterans Longitudinal Study. VVA asks that you schedule a hearing and/or a Members briefing for the second half of March for VA to outline their plan as to how they are going to complete this much needed study for delivery of the final results to the Congress by April 1, 2010, as a comprehensive mortality and morbidity study of Vietnam veterans, the last large cohort of combat veterans prior to those now serving in OIF/OEF.
VVA is concerned that previous leadership at VA felt they were above the law and ignored this mandate, and were unapologetic about being scofflaws. We hope this provision will again be included in the Appropriations act and that General Shinseki will see to it that VA obeys the law and gets this done on his watch.
Further, VVA strongly urges the Congress to mandate and fund longitudinal studies to begin virtually immediately, using the exact same methodology as the NVVRS, for the following cohorts: a) Gulf War of 1991; b) Operation Iraqi Freedom; and, c) Operation Enduring Freedom.
Please take action now so that these young veterans are not placed into the same predicament Vietnam veterans find ourselves today.
Further, the continued refusal of VHA to take a complete military record as part of the electronic medical records means that there is no way to do needed epidemiological research on veterans who use the VA system that looks into exposures they may have been subject to in military service, depending on the branch of service, when, where, and MOS. Further, this would enable mortality studies based on when and where one served for those who have already died. It's almost as if our government does not want to know about these ailments so that it won't be burdened with Dependency Indemnity Compensation (DIC) payments.
VVA asks that $25 million be specifically designated for replication of the NVVRS, $20 million for research into the health care effects of Agent
Orange and other toxins, $15 million to the Medical Follow Up Agency (MFUA) at the Institute of Medicine (IOM) at the National Academies of Sciences, to finish translating all of the data from the now closed Ranch Hand Study into modern computer language and properly catalogue it to make this data accessible to credentialed researchers. This potentially enormously valuable trove of research data should not be allowed to perish for want of these minimal funds.
In 2009, VA and DOD is supposed to complete the pilot of a new disability evaluation system for wounded returnees at major medical facilities in the Washington, D.C. area, and expand it to most other large military medical centers. We hope that what results from this effort "to eliminate the duplicative and often confusing elements of the current disability process of the two departments" will lead to less confusion and a single, viable disability rating determined by the VA. However the process is currently not working as it is supposed to work. VVA repeatedly brought this to the attention on the former Secretary of Veterans Affairs and the current Undersecretary for Benefits and his staff since last November. There is a real need for joint oversight of this process by the Veterans Affairs Committee and the Armed Services Committee to ensure that wounded and ill soldiers are treated fairly in their waning days of military service.
We are also concerned that there still will not be enough resources to deal with the flood of troops and veterans returning to our shores and presenting with a range of mental health issues. The VA ramped down for several years the numbers of mental health professionals it employed. Now, seeing the error of its ways, it is hurriedly hiring clinicians. The question is: Will there be enough of them to meet the challenge? Will those staff be properly trained to deal with the needs of veterans with heavy combat trauma and other problems?
Much more attention needs to be devoted to continuing medical education, particularly for mental health providers and for primary care physicians and other clinicians. One of the best kept secrets at VA is the existence of the Veterans Health Initiative (VHI) curricula about the wounds, maladies, illnesses, and conditions endemic to military service depending on when and where one served. (www.va.gov/vhi) VHA apparently makes no systematic effort to utilize this tool to better educate these clinicians who can and will do an even better job if properly trained and supported. As Secretary Shinseki has repeatedly stated, what is lacking is primarily a matter of leadership and accountability. We hope and trust that he can and will meet that lack, particularly if the rest of his team gets on board quickly.
Mental Health -Need to Restore Organizational Capacity for Substance Abuse Treatment
VVA urges that language be inserted in the Appropriations bill the Congress to express concern that substance use disorders among our nation's veterans is not being adequately addressed by the Veterans Health Administration (VHA). The relatively high rate of drug and alcohol abuse among our nation's veterans (much of which is self-medication to deal with untreated PTSD), especially those returning from service in Operation Enduring Freedom and Operation Iraqi Freedom, is causing significant human suffering for veterans and their families.
These folks can and will be stronger for their experience if we only will deliver the effective care they need when they need it in a way they will accept.
Further delay in moving to restore effective mental health and substance abuse services will lead to poorer health and more acute health care utilization in the out years, not to mention economic opportunity cost to the nation and needless suffering by these veterans, and their families.
Last year, VVA urged the Congress to direct the Secretary to make concerted efforts to reduce the overall incidence of drug and alcohol abuse and dependence among enrollees in the Veterans Health Administration by meeting the performance measurements included in "A Comprehensive VHA Strategic Plan for Mental Health Services," VA's current and adopted plan to reform its mental health programs, with the hallmark of recovery. To its credit, VA has developed a strategy to "restore VHA's ability to consistently deliver state of the art care for veterans with substance abuse disorders," as a milestone within that reform plan, but to date has yet to fulfill the promise of its commitment to recovery, and establishing the goal of every veteran being able to obtain and sustain meaningful employment at a living wage as the ultimate goal for all VA mental health programs, including its substance use disorder programs. It should now no longer be a case of lacking resources, so we need much better oversight and accountability in the coming year. In addition it is clear that we need new leadership in the Mental Health area, as the Chairman has noted on several occasions. We hope Secretary Shinseki will heed the Chairman and others in this regard.
VVA urges the Congress to direct the Secretary to provide quarterly reports beginning with a baseline report by each Veterans Integrated Service Network (VISN) on the initiatives set forth in the VHA Strategic Plan for Mental Health Services, specifically to improve VA's treatment of substance use disorders. These reports will provide an ongoing indication of VHA's progress in the implementation of its adopted Strategic Plan as described in section 1.2.8 of "A Comprehensive VHA Strategic Plan of Mental Health Services", May 2, 2005. In addition to baseline information, at minimum these reports should include: the current ranking of networks on their percentage of substance abuse treatment capacity along with plans developed by the lowest quartile of networks to bring their percentage up to the national average; and, the locations of VA facilities that provide five days or more of inpatient/residential detoxification services, either on site, at a nearby VA facility, or at a facility under contract to provide such care; and, the locations of VA health care facilities without specialized substance use disorder providers on staff, with a statement of intentions by each such facility director of plans to employ such providers or take other actions to provide such specialized care.
The decade long diminishment of VA mental health programs that we experienced in the 1990s did level out by 2001, and VA all too slowly started to rebuild capacity that has been accelerated in recent years. However, we must continue to restore capacity to deal with mental disorders, particularly with Post Traumatic stress Disorder and the often attendant co-morbidity of substance abuse. In particular, substance abuse treatment needs to be expanded greatly, and be more reliant on evidence based medicine and practices that are shown to actually be fruitful, and be held to much higher standards of accountability, as noted above. The 21 day revolving door or the old substance abuse wards is not something we should return to, but rather treatment modalities that can be proven to work, and restore veterans of working age to the point where they can obtain and sustain meaningful employment at a living wage, and therefore re-establish their sense of self-esteem.
VVA also urges that additional resources explicitly be directed in the appropriation for FY 2009 to the National Center for PTSD for them to add to their organizational capacity under the current fine leadership. The signature wounds of this war may well be PTSD and Traumatic Brain Injury and a complicated amalgam of both conditions. VVA believes that if we provide enough resources, and hold VA managers accountable for how well those resources are applied, that these fine young veterans suffering these wounds can become well enough again to lead a happy and productive life.
Up until recently, VA has not made enough progress in preparing for the needs of troops returning from Iraq and Afghanistan-particularly in the area of mental health care. In addition to the funds VVA is recommending elsewhere, we specifically recommend an increase of an additional $500 million dollars over and above the $3.9 Billion that VA now says they will allocate to assist VA in meeting the mental health care needs of all veterans. These funds should be used to develop or augment with permanent staff at VA Vet Centers (Readjustment Counseling Service or RCS), as well as PTSD teams and substance use disorder programs at VA Medical Centers and clinician who are skilled in treating both PTSD and substance abuse at the CBOC, which will be sought after as more troops (Including demobilized National Guard and Reserve members) return from ongoing deployments. VVA also urges that the Secretary be required to work much more closely with the Secretary of Health and Human Services, and the states, to provide counseling to the whole family of those returning from combat deployments by means of utilizing the community mental health centers that dot the nation. Promising work is now going on in Connecticut in and possibly elsewhere in this regard that could possibly be a model. In addition, VA should be augmenting its nursing home beds and community resources for long term care, particularly at the state veterans' homes.
To allow the staffing ratios that prevailed in 1998 for its current user population, VA would have to add more than 15,000 direct care employees-MDs, nurses, and other medical specialists-at a cost of about $2 billion. This level, because the system can and should be more efficient now, would allow us to end the shame of leaving veterans out in the cold who want and are in vital need of health care at VA, and who often have no other option.
Blind and Low Vision Veterans Need Much Greater Resources and Attention
The President's request contains a significant reduction in the efforts to strengthen services for blind veterans. With the number of blind and very low vision veterans of the nation's latest wars in need of services now, VVA strongly recommends the Congress explicitly direct an additional $35 million for FY 2010 to increase staffing and programming at the VA's Blind and Visually Impaired Service Centers, and to add at least one new center.
Further, VVA recommends that the Congress directs the Secretary to implement an employment and independent living project modeled on the highly successful "Project Amer-I-Can" that so successfully placed blind and visually impaired veterans into work and other situations that resulted in them becoming much more autonomous and independent. That program was a cooperative venture of the New York State Department of Labor, the Veterans Employment & Training Service (VETS), and the Blind Veterans Association.
In a system in which so much of the infrastructure would be deemed obsolete by the private sector (in a 1999 report GAO found that more than 60% of its buildings were more than 25 years old), this has and may again lead to serious trouble. We are recommending that Congress provide an additional $1.5 billion to the medical facilities account to allow them to begin to address the system's current needs. We also believe that Congress should fully fund the major and minor construction accounts to allow for the remaining CARES proposals to be properly addressed by funding these accounts with a minimum of the remaining $2.3 billion.
As we all know, homelessness is a significant problem in the veterans' community and veterans are disproportionately represented among the homeless population. While many effective programs assist homeless veterans to become productive and self-sufficient members of their communities and Congress must ensure that the Department of Veterans Affairs has adequate funding to meet the needs of the over 154,000 homeless veterans who served this country so proudly in past wars and veterans of our modern day war. VVA recommends the following in VA FY2010 budget for homeless programs.
Homeless Provider Grant and Per Diem Program
The Department of Veterans Affairs Homeless Grant & Per Diem Program has been in existence since 1994. These programs address the needs of homeless veterans and support the development of transitional, community-based housing and the delivery of supportive services. Because financial resources available to HGPD are limited, the number of grants awarded and the dollars granted are restrictive and hence many geographic areas in need suffer a loss that HGPD could address.
The Consolidated Appropriations Act of 2008, Public Law 110-161 provides $130 million, the fully authorized level, to be expended for the GPD program. Based on GAO's findings and VA's projected needs for additional GPD beds, VVA that for FY2010 a $200 million authorization is required. An increase in the funding level for the next several years would help ensure and expedite VA's program expansion targets. It would provide critical funding for service, or drop-in, centers - the primary portal that links veterans in need with the people who can help them. It would guarantee continued declines in veteran homelessness, and provide for scaling back the funding as warranted by the VA's annual Community Homelessness Assessment, Local Education and Networking Group (CHALENG) reports
The VA provides grants to VA health care facilities and existing GPD recipients to assist them in serving homeless veterans with special needs including women, women who have care of dependent children, chronically mentally ill, frail elderly and terminally ill veterans. Initiated in FY 2004, VA has provided special needs funding to 29 organizations totaling $15.7 million. The VA Advisory Committee on Homeless Veterans 2007 report states the need and complexity of issues involving women veterans who become homeless are increasingly unexpected. Recognizing women veterans are one of the fastest growing homeless populations, the Committee recommended future notices of funding availability target women veteran programs including special needs grant offerings. P.L. 109-461 authorizes appropriations of $7 million for FY 2007 through FY 2011 for special needs grants.
VVA estimates approximately $45 million will be needed to adequately serve 7,500 or more clients in HUD-VASH housing units. Rigorous evaluation of this program indicates this approach significantly reduces the incidence of homelessness among veterans challenged by chronic mental and emotional conditions, substance abuse disorders and other disabilities.
VVA also strongly urges you to actively help us seek an appropriation for the full $50 million authorized for the Homeless Veterans Reintegration Program (HVRP) for FY 2010.
Veterans Benefits Administration
The Veterans Benefits Administration (VBA) continues to not only need additional resources and enhanced accountability measures, but a total paradigm shift and re-tooling of the business processes.
Compensation & Pension
VVA recommends adding one hundred staff members above the level requested by the President for the Compensation & Pension Service (C&P) specifically to be trained as adjudicators. Further, VVA strongly recommends adding an additional $80 million dollars specifically earmarked to create "express lines" at all VARO and not just the ten pilot sites, for additional training for all of those who touch a veterans' claim, institution of a competency based examination that is reviewed by an outside body that shall be used in a verification process for all of the VA personnel, veteran service organization personnel, attorneys, county and state employees, and any others who might presume to at any point touch a veterans' claim.
Last year (and the year before that), VVA recommended adding an additional two hundred specially trained vocational rehabilitation placement specialists to work with returning service members who are disabled to ensure their placement into jobs or training that will directly lead to meaningful employment at a living wage. VA only added 60 such counselors. It still remains clear that the system funded through the Department of Labor simply is failing these fine young men and women when they need assistance most in rebuilding their lives.
It is clear VA needs to add several hundred of these employment placement specialists for disabled veterans specifically called for in past years' funding measures, and there is clearly a need for additional training to ensure they are effective in assisting disabled veterans, particularly profoundly disabled veterans, to obtain decent jobs.
VVA has always held that the ability to obtain and sustain meaningful employment at a living wage is the absolute central event of the readjustment process. Adding additional resources and much greater accountability to the VA Vocational Rehabilitation process is essential if we as a nation are to meet our obligation to these Americans who have served their country so well, and have already sacrificed so much.
Computerization of the Claims Process
VVA agrees with Secretary Shinseki's statement that computerization in and of itself will not fix the mess in the Compensation & Pension program, but rather to re-think and straighten out the business processes first before we "put garbage in to get garbage out." While the Secretary and his new team figure that out, VVA also believes that Congress needs to set aside funds for putting all of the VBA records into digital form. This is essentially an investment in computer infrastructure every bit as important as buildings. We do not know what that figure is, but we have to believe there are existing platforms that can be adapted for this use that are already successfully being used in other branches of the Federal government.
Accountability at the VA
There is no excuse for the dissembling and lack of accountability in so much of what happens at the VA. It is certainly better than it used to be, but there is a long way to go in regard to cleaning up that corporate culture to make it the kind of system that it can be with existing resources, and even largely the same personnel as they currently have on board. It can be cleaned up and done right the first time, if there is the political will to hold people accountable for doing their job properly.
The almost quarter of a million VA personnel consist of fine hard working people who are by and large committed to doing a good job for the veterans whom they serve. What is needed is leadership that is worthy of those fine workers, and a better system of accountability (especially for managers) and the system will work much better.
Thank you again, Mr. Chairman, for allowing VVA to be heard at this forum. We look forward to working with you and this distinguished Committee to obtain an excellent budget for the VA in this fiscal year, and to ensure the next generation of veterans' well being by enacting S. 423 at the earliest possible time. I will be happy to answer any questions you or your colleagues may have.
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