STATEMENT OF

CHRISTOPHER NEEDHAM, SENIOR LEGISLATIVE ASSOCIATE
NATIONAL LEGISLATIVE SERVICE
VETERANS OF FOREIGN WARS OF THE UNITED STATES

BEFORE THE

COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE

WITH RESPECT TO

PENDING HEALTH CARE LEGISLATION

WASHINGTON, D.C.                                                                     MAY 21, 2008

MR. CHAIRMAN AND MEMBERS OF THE COMMITTEE:
On behalf of the 2.3 million men and women of the Veterans of Foreign Wars of the U.S. and our Auxiliaries, I thank you for the opportunity to present our views at today's important legislative hearing.  There is a broad range of health care legislation before us, ranging from funding the system to expanding care and services to our newest veterans.  Our members appreciate the role you allow us to play in their consideration.
S. 2273
The VFW supports the "Enhanced Opportunities for Formerly Homeless Veterans Residing in Permanent Housing Act." 
This legislation would authorize the VA secretary to create a pilot program to provide grants to a number of entities providing housing for homeless veterans.  Included in it would be grants for support services to low-income formerly homeless veterans residing in permanent housing, and grants for programs that assist veterans with transportation and child-care issues when working with VA's vocational rehabilitation programs.  Both are worthy goals that could positively help these veterans get back on their feet. 
We also strongly support section four of the bill, which would award grants for programs to conduct outreach to elderly and rural veterans and their spouses with respect to VA's pension programs.  There certainly must be a great number of men and women who are not aware of their entitlement to this helpful benefit.  Getting them access to the benefits they deserve and providing full outreach to them is clearly the right thing to do.
S. 2377, the Veterans Health Care Quality Improvement Act
The VFW offers our support to this important bill, which aims to improve the quality of health care practitioners within VA.
It would tighten hiring practices for VA physicians by requiring them to disclose previous malpractice judgments, disciplinary actions and ongoing investigations.  The importance of this issue came to light with the unfortunate incidents at the Marion VA facility.  A doctor practiced medicine there despite agreeing to stop practicing in a different state and having two malpractice settlements and a disciplinary action elsewhere.  If the doctor had had to disclose those facts, VA likely would not have hired him.
The bill would also create a quality assurance officer to oversee a health care quality assurance program.  The program is designed to be an independent reporting system with multiple layers to ensure that any concerns about the quality of care are addressed and vetted independently.
A third part of the bill would create several new programs to help encourage high-quality doctors to work for VA.  It would create loan repayment programs, tuition reimbursement for physician students, and allow part-time physicians to enroll in the federal employee health benefits plan.  These incentives would help VA hire experienced doctors as well as recruit and retain younger physicians.
If approved, this bill would likely mean higher quality physicians in VA, and for that reason, we urge its passage.
S. 2383
The VFW is happy to back this bill, which would create a pilot program to provide mobile health care services to veterans in rural areas.  It would bring VA health care providers and caseworkers directly to veterans in locations where access to a clinic or an office is highly limited.   The mobile services would provide basic health treatments, provide prescriptions, screen for mental health issues as well as providing support and information with respect to the compensation system and other veterans benefits.
The number one issue brought up by rural veterans is the difficulty they have in accessing care.  This is an innovative attempt to find a solution to some of the problems faced by veterans, by bringing them to VA instead of forcing them to travel many hours for even basic health care.  This bill is a good step in addressing some of those problems, and we hope that if passed, the results from the pilot program would allow for the expansion of this program throughout the country.
S. 2573
While we appreciate the effort of the bill to try a new approach at tackling these difficult issues, the VFW does not support the "Veterans Mental Health Treatment First Act."
The aim of the bill is to incentivize treatment for veterans suffering from PTSD and other mental health issues.  While that on its face is a good thing, much of the rationale behind it, we believe, is wrong.  There are two main premises lurking behind the bill: 1) Veterans exaggerate their mental health problems to game the system and get higher levels of compensation; 2) Veterans discontinue their treatment because there is a financial disincentive to not get better, or to even get worse.  Both are wrong.
On the first, we continue to believe that veterans do not exaggerate their symptoms.  While it's true that the number of mental health diagnoses have increased dramatically over the last decade, that is not evidence in and of itself of fraud, nor is it an indication that something is wrong with the system.  To us, it's a sign that veterans are becoming more aware of the terrific range of services and benefits VA provides them, and that these men and women are finally able to come forward with what must certainly be a difficult decision.  Seeking help is not easy, and for many years, we have seen a negative stigma associated with mental health issues - look no further than the stereotypical image of the wacko Vietnam veteran.  Coming forward to seek help is not easy, and rather than looking askance at those who do, we should trust that they are doing what they need to do to become healthy and whole.
The Institute of Medicine's 2007 study, "PTSD Compensation and Military Service" bears this out further.  In the section discussing the trends in PTSD compensation, the study notes several reasons for the increase.  While noting that PTSD diagnoses have gone up while anxiety disorders have decreased, they observe that it is possible that "some of the growth in PTSD was actually a change in diagnostic labeling with, for example, fewer veterans being classified with other anxiety disorders than in the past because these veterans were now being diagnosed with PTSD."  If true, then the problem - if there is truly a problem - lays not with the veteran as this bill assumes, but with VA's ability to diagnose mental health disorders.
In the same section, the study notes some other reasons for the increase.  The information they found "is consistent with the suggestion that the growth in PTSD awards is due to a greater willingness on the part of veterans to apply for PTSD compensation.  It may also, though, reflect in part an increasing tendency for VA to recognize a diagnosis of PTSD and, more generally, to recognize disability resulting from any mental disorder."  Again, the problem - if you can call veterans seeking out the treatment they need a problem - is with VA's diagnosis, not with veterans looking for treatment options.
On the second premise of the bill, the IOM's study found that this is a mistaken belief as well.  In the chapter on "Other PTSD Compensation Issues," they note that most other scientific evidence does not support the 2005 VAOIG report, which claimed to have found evidence that veterans receiving compensation received less mental health treatment.   "Longitudinal studies suggest that disability claim approval results in increased use of mental-health services.  Cross-sectional research shows that veterans with service-connected disability for PTSD do not differ from non-service connected veterans in their levels of participation in treatment, and there is some evidence that service-connected veterans are more likely to participate in treatment."
Overall, with the bill, we have serious problems with asking veterans to forgo their disability compensation.  Even with the payments for treatment that this bill would provide, we cannot support legislation that will require a veteran to give up - even temporarily - one of their entitlements.  This is especially true in the case of a veteran who would ultimately be diagnosed with a high level of PTSD or mental health issue, even after treatment.  The wellness stipend would not come close to that level of compensation, financially harming the veteran.  And since there is no way for a veteran to know what his or her disability rating is ultimately going to be, a number of veterans and their families could be financially harmed by the choice to participate in the program.  The choice is free for them to make, but veterans lack enough information prior to making it to determine whether it is a good decision or not.
Also, because the evidence indicates that the vast majority of veterans are already seeking care, are we sure that this would be the proper incentive to get new patients into treatment?  If most already are seeking some sort of health-care treatment through VA, it stands to reason that a number of those incentive payments would be provided to people already in the system, wasting money that could otherwise be used to bolster VA's mental-health programs.
We certainly support expanding access to health care options for veterans with mental health problems, and we would certainly like to see all veterans using the terrific resources of the VA health care system, but as the bill is written, the VFW cannot support it.
S. 2639

The VFW has had a long-standing resolution in support of amending the current discretionary funding process.  We support the "Assured Funding for Veterans Health Care Act" as it would meet our goal of having a funding mechanism to provide VA with a sufficient, timely and predictable budget.

While great strides have been made in the yearly increases provided to VA, we are concerned that that same political will may not be there in the future once the nation's attention shifts from the overseas conflicts.  Further, we are disappointed with the timeliness of the health care budget.  For 13 of the last 14 years, VA has not had its health care budget when the fiscal year began, forcing VA to make do with insufficient funding under continuing resolutions.  We have also seen in previous years the need to go back to the drawing board halfway through the fiscal year to provide more money for VA through an emergency supplemental appropriation because insufficient money was provided the first time.

Taken together, these all point to a system that is broken and a system badly in need of reform.
VA's hospital managers cannot be expected to efficiently manage and plan for the health care needs of this nation's veterans when they are unsure of their funding level from year to year and when the budget they do receive is months late.  This yearly uncertainty impairs VA's ability to recruit and retain staff - a significant challenge recently with specialty care providers - contract for services and perform proper planning and other administrative functions.
We need an assured funding mechanism that provides VA with a sufficient, predictable and timely funding stream so that VA can efficiently and effectively provide first-rate health care to this nation's veterans.

S. 2796
The VFW supports this legislation, which would create pilot programs for community-based organizations to help veterans better understand the benefits and services available to them.  The grants provided under this program would allow organizations to set up telephone hotlines, assist veterans in applying for benefits, help families adjust to deal with the transition, provide outreach information on benefits and to help coordinate health care and benefits services to veterans.
While VA and the military services have done a better job about informing veterans - especially separating service members - about their benefits and entitlements, we still can do a better job.  As this bill acknowledges, there are gaps in awareness that should be filled so that all veterans equally have access to the full range of benefits.  By working with community-based groups, the bill could better coordinate those groups underserved by VA and who may be less aware of their veterans benefits, and we strongly urge its passage.
S. 2797
The VFW supports this bill, which would authorize the construction and leasing of a number of major medical facilities throughout the country.  Included in the list of projects are the top construction priorities as determined by VA's capital asset prioritization process.  It also extends and increases the authorization for several projects previously authorized but that have not yet been completed.
The VFW hopes that Congress will fully fund VA construction so that we can move beyond the CARES process and address the growing backlog of construction needs throughout the country.
S. 2799
The VFW is pleased to offer our strong support for this legislation, which would expand and improve upon the health care services provided to women veterans.  Female veterans from OEF/OIF are experiencing many types of conflict that previous generations did not.  They are involved in a conflict with no true frontline and in a high-stress situation with almost no relent.
The difficulties they face, and the level of reported mental health issues that all OEF/OIF veterans have is itself a challenge for VA.  It is essential that VA's strategies not be a one-size-fits-all approach, but one that adapts and provides our men and women with tailored programs to give them every chance to return to civilian life fully healthy.  This is especially so for our women veterans, many of whom are facing unprecedented levels of stress and conflict, and who, when they return, enter a VA that is predominantly used to caring for male veterans.
VA has made great strides in the care provided to women veterans, but they can definitely do more.  The Women Veterans Health Care Improvement Act would push VA even further along, and would address some of the most critical issues our female veterans face.
Title I of the bill would authorize a number of studies and assessments as to VA's capacity for care, but also for what the future needs of women veterans will be.  Section 101 would create an essential long-term epidemiological study on the full range of health issues female OEF/OIF veterans face.  This is critical because it is uncharted territory.  With increasing numbers of women veterans in a hostile combat zone, there are higher rates of exposures and incidents that must be studied so that we know what health care issues will come up in the short- and long- term.   There is much we do not know, and lots of essential information that is necessary to study to ensure that VA is meeting their full needs. 
Section 102 would require VA to study any potential barriers to care faced by women veterans to determine any improvements that VA must make so that women veterans can access the care to which they are entitled.  This is especially true of those women veterans who choose not to use VA care.  Is it because of a stigma associated with VA, a previous bad experience or other reasons?  To better prepare for the future, VA must know the answers to these questions and we strongly support this study.  Along those same lines, section 103 would require VA to develop an internal assessment of the services it provides to women veterans, as well as plans to improve where it finds gaps.  We, too, welcome this assessment.  Section 104 would study the health consequences of military service among female OEF/OIF veterans.
We fully support the sections contained in Title II of the legislation, which deal with the improvement and expansion of health-care programs for women veterans.  We especially appreciate the addition of two recently separated female veterans to the VA Advisory Committees on women veterans and minority veterans.
The VFW supports section 204, which would create a pilot program to provide child care for veterans receiving health care through VA.  This is a terrific idea, which has the potential to eliminate a barrier for care, especially for single parents.
We also strongly support section 206, which requires VA to have a full-time women veterans program manager at each medical center.  We have had a long-standing resolution in support of this issue as a number of current program managers are assigned as part-time employees, or given the task in addition to their other duties.  This severely limits their effectiveness and their ability to help the medical facility fulfill its duty to women veterans.
S. 2824
The VFW takes no position on this legislation.
S. 2889, sections 2-6
The VFW approves of the changes in sections two through six of this bill, which was introduced by request of VA.
Section 2 would allow VA to contract for specialized residential and rehabilitation care for certain OEF/OIF veterans.  We have supported contracting for care in specialized circumstances where VA is otherwise unable to adequately provide care.  Ideally, we would like VA to gain the in-house expertise to handle these issues, especially since a number of these veterans are likely to be accessing VA for their health care for many years, but contracting for care is valuable in the short-term.  Ultimately, though, we need VA to have the care of these brave men and women in mind over the long term.
Section 3 would reimburse certain physicians and dentists for their continuing education expenses, which can only help to serve as a recruitment benefit for those seeking to practice at VA.
Section 4 would prevent veterans receiving hospice care from having to pay copayments.  This is a humane thing to do when a veteran is nearing the end of his or her life, and it shows compassion to their families at a most difficult time.
Section 5 would repeal section 124 of PL 100-322, which set out the specific circumstances and requirements under which VA could conduct testing for HIV.  If repealing this section will result in VA being able to provide testing to more at-risk veterans with less inconvenience, then we support it.
We do not oppose Section 6, which would allow VA to permanently use information from the IRS and Social Security Administration for income-verification purposes.
S. 2899
The VFW certainly supports the idea of the "Veterans Suicide Act".  This bill would require VA to study the number of suicides among veterans using information from the Department of Defense, veterans organizations, the Centers for Disease Control and Prevention, and various state offices.
The risk and problems of suicide among service men and women have come to the forefront over the last few months, especially with the increased attention paid to the various mental health issues many OEF/OIF veterans face.  These reports have painted a confusing picture with uncertainty over the quality and accuracy of data, but the bottom line is that even one suicide is one too many.
Understanding the rate, the number of attempts and various other figures is essential for VA to properly implement a successful strategy of suicide prevention.  VA certainly has improved their efforts and treatment is readily available for those who seek it, but more can certainly be done, and fully understanding the size and scope of the problem is one step towards a solution.
We would note that VA recently testified before the House Veterans Affairs Committee on their efforts at data collection, which primarily relies on matching names and information it has with the efforts of the Center for Disease Control's National Death Index.  We believe that they are on the right track with collecting the bulk of this information, but we would urge you to continue oversight to ensure that they remain on the right track and that they yield meaningful results.
To that end, we applaud the recent efforts of Chairman Akaka in requesting more information about suicides from VA, and we hope that this action will help us get closer to the truth.
S. 2921
The VFW urges passage of the "Caring for Wounded Warriors Act."  This legislation would create two pilot programs to improve care for veterans suffering from traumatic brain injuries.  Both pilot programs would provide support for family caregivers, who are increasingly taking on a pivotal role in the health care and day-to-day life of those veterans affected by these disabilities.
The first program would require VA to develop a training and certification program for family caregivers to serve as personal care attendants.  This would qualify them to receive compensation from VA for the services they are rendering to their loved ones.  This compassionate program would absolutely make a positive difference in the lives of those affected.  It would allow more family members to play an active role, ensuring that the veteran receives excellent care from someone who truly cares about their condition.
The second program would test the feasibility of using properly trained graduate students to provide respite care for families serving as caregivers.  This is an innovative approach at managing a difficult problem, and with proper oversight of this program, we would support it.
We think the provisions of this bill would be of real benefit to those veterans suffering from the effects of TBI.  We strongly support its passage, and would hope that the pilot program would yield results that would merit it being expanded nationwide where appropriate.
S. 2926
The VFW endorses the "Veterans Nonprofit Research and Education Corporations Enhancement Act."  This legislation would make several changes, which would strengthen and improve the nonprofit research corporations affiliated with VA.  These NPCs help VA to conduct research and education and assist in the raising of funds for VA's essential projects from sources VA otherwise might not have access to, including private and public funding sources.
Included in the legislation is a section that would reaffirm that these NPCs are 501(c)(3) organizations that are not owned or controlled by the federal government.  This is important to ensure that they are able to receive funding from all intended sources and to clarify their purpose in accordance with various state laws or private foundation regulations.
It would also allow for the creation of multi-medical center NPCs to streamline and make the administration of these important organizations more efficient.  Ultimately, this should make more funds available for critical research purposes.  Additionally, it would improve the accountability and oversight of these corporations, requiring more information in their annual reports and periodic audits of their activities.  As these corporations continue to expand, we urge continued oversight of their actions to ensure that they continue to serve the best interest of America's veterans.
The legislation would address some of the concerns laid out in the recent VAOIG report, "Audit of Veterans Health Administration's Oversight Nonprofit Research and Education Corporations."
S. 2937
The VFW supports this legislation, which would permanently extend treatment for veterans who participated in chemical and biological tests conducted by the Department of Defense through the Deseret Test Center.
Project 112/Project SHAD were programs started in 1962 to test the capability of protecting and defending potential chemical and biological warfare threats.   The tests, conducted through the Deseret Test Center in Utah, involved nearly 6,000 service members as part of 134 planned tests.  These tests sometimes used highly toxic agents, such as sarin and VX, as well as infectious bacteria.
With the uncertainty of their medical conditions as well as the DOD's delays in declassifying essential information, VA has provided cost-free health care to these veterans for conditions that may be related to their exposure.  This has clearly been the right thing to do.  This bill would give these veterans permanent access to health care for the treatment of any potentially related conditions.
Although a May 2007 Institute of Medicine study found no clear evidence of specific long-term health effects related to the participation of these tests, the authors also made it clear that "their findings should not be misconstrued as clear evidence that there are no possible long-term health effects."  With this in mind, giving these service members the benefit of the doubt is sound policy.
S. 2963
This comprehensive legislation would make many needed improvements to the mental health care services provided to veterans, but also to members of the Armed Forces and survivors.  This bill recognizes that many of today's war wounds are invisible wounds - wounds that often take months to appear, making the transition our service men and women face all the more difficult.  The looming crisis necessitates action, and this bill is a strong first step in that direction.
Sections 1 through 3 of the bill concern Vet Centers.  The VFW is a strong supporter of Vet Centers and their approach to providing care - especially mental health care - to veterans.  VA has done a pretty good job expanding their reach, but they are victims of their own success.  We are starting to see Vet Centers struggle with difficult workloads as increasing numbers of veterans turning to them for the essential services they provide.  A report done by the staff of the House Veterans Affairs Subcommittee on Health showed that these centers are nearing a breaking point.  They need more staff to manage the workload.  Section 1 would help this in that it provides a scholarship program for individuals seeking education and training in health care specialties needed by the Vet Centers.  Finding qualified mental health professionals is a challenge for VA, and the more incentive they can provide potential employees, the more likely that these men and women will turn to VA as their employer of choice.
Section 2 would allow OEF/OIF veterans to receive counseling services through Vet Centers, even before they separate.  With the number of these brave men and women diagnosed or likely to be diagnosed with a mental health condition, expanding access to health care services for them is the right thing to do.  This change is important for two reasons.  First, military mental health services come with a stigma.  That stigma has been shown repeatedly to be the biggest impediment to these men and women getting care when they need it.  Allowing them to seek care outside regular military channels can only serve as an incentive for them to get care early, when it is often found to be most effective.  With no fear of reprisal or reporting, they are free to do what they need for themselves, instead of having to worry about their careers or the impressions of others.  The second reason is that the military does not have a sufficient number of mental health care providers.  While this legislation does not absolve the military of their need to properly care for these men and women while in service, it helps fill in the gaps in care that too often swallow up those in need.
We do have some slight concerns about this provision in combination with the issue of the current demand for services, though.  With the anticipated expansion in workload this change would make, we would like to see more resources dedicated to staffing Vet Centers to ensure that those currently utilizing them are not delayed or denied care.
Section 3 would require VA to help seek outside counseling services for veterans who are otherwise not authorized to receive care through VA.  This is clearly the right thing to do.
Section 4 would treat suicides of veterans who have a combat-related mental health issue, PTSD or TBI on their record as being in the line of duty if it occurred within two years of their separation.  This would entitle their family members and beneficiaries to the range of benefits this nation provides to help them deal with the tragedy.  It acknowledges that these invisible wounds of war are often as traumatic and life altering as the physical wounds, even if their impact can occur years after the veteran faces the last shot.
Section 5 would allow DOD to provide grants to non-profit organizations that provide support for survivors of deceased members of the Armed Forces and veterans.  These services would expand and go beyond the limited services provided by the military's casualty assistance officers and can only help ease the burden on these families at a most difficult time in their lives.
S. 2969
The VFW asks the Committee to approve the "Veterans Medical Personnel Recruitment and Retention Act."  We believe that this legislation would dramatically improve VA's ability to recruit and retain high-quality medical professionals and that this would increase the quality of care provided to this nation's veterans.
VA has had difficulty attracting and retaining medical professionals.  Many facilities are understaffed, which is in essence a rationing of health care.  The April 2008 hearing this Committee held on these issues showed a broad range of reasons for why VA has difficulties recruiting and retaining health care employees, and we believe that this legislation addresses the largest of those concerns.
It would increase pay for critical jobs, bringing them in line with what the private sector can pay.  It would create special incentive pays for certain specialties and hard-to-fill positions.  It would create market pay and provide adjustments for localities to bring salaries in line with what local markets bear for similar employees elsewhere.
Beyond compensation, it would make nursing more attractive, by limiting mandatory overtime and providing for flexible work schedules, which are highly attractive to potential recruits in a highly competitive labor market.
It would also improve educational assistance programs, loan repayments and provide education debt reduction for certain employees.
Taken together, these meaningful changes would likely improve VA's ability to recruit and retain employees, making VA the employee of choice for greater numbers of health care professionals.  We strongly support these provisions, and we would urge its swift passage.
S. 2984, Title III
Title III of this legislation, which was introduced at VA's request, deals with various health care matters.
Section 301 adds non-institutional extended care services to the list of medical services VA provides.  Section 302 extends various authorities, including nursing home care through 2013 and research corporations through 2013.  Section 303 gives permanent authority for medical care services to veterans who participated in certain chemical and biological testing.  We strongly support this section.  Section 304 would amend annual reporting requirements and section 305 would change reporting requirements for the annual Gulf War research report; we do not object to either. 
Section 306 would consider would determine that payment by the Secretary for care provided under CHAMPVA would be considered payment in full, eliminating any liability for the beneficiary to pay.  We support this.  Section 307 would allow health care providers who give services to children of Vietnam veterans born with Spina Bifida to seek the full costs of care from third parties.  In that this would likely mean more care providers would provide the often intensive care these children need, we would be inclined to endorse it.
Section 308 would allow VA to share records of patients who lack decision-making capacities with their representatives.  Section 309 would require a veteran to provide third-party insurance information and their social security number for verification purposes when receiving VA health care.  We are not opposed to this, and proper and full collections from third parties can only help free up health care resources that could be better spent elsewhere in the system.
Mr. Chairman, this concludes my statement.  I would be happy to answer any questions that you or the members of the Committee may have.  Thank you.