Testimony of

Vietnam Veterans of America

 Presented by

Rick Weidman
Executive Director for Policy & Government Affairs

   Regarding

The President’s FY 2011 Budget Request for Veterans

Before the

Senate Veterans’ Affairs Committee
United States Senate

February 26, 2010

 
Good morning, Chairman Akaka, Ranking Member Burr, and distinguished Members of the committee. Thank you for giving Vietnam Veterans of America (VVA) the opportunity to offer our comments on the President’s Budget Request for FY 2011. All of us at Vietnam Veterans of America (VVA) wish to thank the leadership shown by this committee, by the leadership of the Budget Committee and of the Appropriations Committee, as well as the leadership of the entire Senate for your vision in leading the struggle to enact Advance Appropriations. Further, your extraordinary vision in working with your Senate Budget and Appropriations Committee colleagues to secure the dramatic increases in funding for Department of Veterans Affairs (VA) in both the medical system and in the Veterans Benefits Administration in the last three years has been nothing short of astonishing, and we applaud you for it.

First let me note that VVA is one of the many organizations which have endorsed the Independent Budget of the Veterans Service Organizations (IBVSO). We commend our colleagues at the Veterans of Foreign Wars, AMVETS, Paralyzed Veterans of America, and the Disabled America Veterans for their excellent work on this major undertaking, and thank them for the strenuous effort it takes to produce this excellent document each year.

Further, VVA commends President Obama and his Administration for submitting a budget request that continues to move us toward the goal of full funding of the health care and benefits earned by virtue of military service.  It is a relatively “lean year” in regard to the Federal Budget request, yet the President has recognized that caring for “he - or she - who hath borne the battle” and their survivors is both part of the cost of war as well as the duty of the nation and our citizenry. Therefore the President has exempted programs that serve veterans from the projected budget freeze along with the Department of Defense, Department of Homeland Security, and other programs vital to protecting the country. We also would like to thank the administration for increasing funding for women and homeless veterans in the FY2011 budget.

While VVA does endorse the IBVSO in the main, and lauds the President’s Budget Request, there are a few areas that we must comment where we see some needs that are not included in either the IBVSO or in the President’s Budget Request for VA.
First, VVA strongly supports the need to indicate where some of the appropriations increases need to be focused by VA managers, such as Post Traumatic Stress Disorder (PTSD) services. The reason for this is that all too often in the past Congress has appropriated additional funds to deal with specific needs, and the money has been redirected at other areas of operation. The well documented instance of money specifically directed by the Congress to start to more properly address the scourge of Hepatitis C a decade ago is one glaring incident of this behavior by VA. Even after being pressed hard by the Congress and the General Accounting Office (GAO), VA could not account for the majority of the funds that were supposedly directed toward correcting the deficiencies of the VA health care system in diagnosing and treating Hepatitis C. There is therefore a natural inclination to ensure that this type of thing does not happen again, both on the part of top managers in the Executive branch and in the Congress.

However, because so much of the funding was centrally directed from Washington, VISN Directors and VA Medical Center Directors reported to us last tear that they could not meet certain needs because they only got a small increase of funds from FY’08 to FY’09 and/or FY’09 to FY’10. Usually those reported increases were from 1% to 3%. This of course caused VVA to ask how this could be, given that there was a much larger increase than that in the appropriation of the medical operations account? Where did the money go? We were told that it was in the special accounts, such as for PTSD. However, some of the unmet needs that local VA managers said they could not meet because of tight budgets were for additional clinicians to deal with PTSD problems of young soldiers returned from the current conflicts.

The argument against making medical care part of the mandatory side of the budget as opposed to keeping it where it is now, in the discretionary side of domestic spending was that Congress would not have adequate control over how the funds were spent. That was persuasive to the veterans’ community, so all agreed that we should go to advance appropriations. With the strong leadership here in the Senate, and Chairman Filner and his colleagues in the House, as well as President Obama, we have achieved this important milestone. As you know, VVA’s top legislative agenda item for the 111th Congress was Advance Appropriations for VA health care. Now that this has been achieved, our top legislative agenda item is to assist the Congress in

securing much greater accountability in both the efficiency and effectiveness of how each appropriated dollar is spent.

Essentially what we are saying is that the Director of each Veterans’ Integrated Service Network (VISN) and of each VA Medical Center (VAMC) must be given funds to be able to handle the increased costs of everything from electricity to salary to supplies, and then held accountable for how well they use those dollars to deliver high quality medical care to every eligible veteran. VVA suggest that several billion be added to the pool of funds that is sent out to the VISNs under the allocation model. VVA further suggest that Congress direct VA to re-examine the Veterans Equitable Resource Allocation (VERA) model to make it a more finely tuned instrument for allotting resources. At present the VA medical facilities in the north are being shortchanged because the veterans who have resources move south, leaving generally the veterans who are poorer, sicker, and in need of more medical services than the more affluent ones who move to warmer climates. The two-tiered system currently employed does not sufficiently account for this phenomena, thereby leaving those VISNs in the north without adequate resources to meet the needs of the veterans in their catchment area.

This does not mean that the President’s request should not ask for targeted dollars (e.g., for PTSD, for increased services to homeless veterans, etc.), but that as this is passed down to the local level for actual delivery of services, how much goes where needs to be transparent. VVA National President John Rowan wrote to VA on April 9, 2009 asking for the allocation by VISN and by VAMC of medical care dollars. While it was partly answered within 30 days, the only information provided was for the previous (FY’08) Fiscal Year. It is now almost halfway through the second quarter of FY 2010, and we are still waiting for that answer, despite having made repeated efforts to secure same. This is just not acceptable.

Need for Much Greater Transparency in VHA

It is clear to us that mechanisms to achieve a much higher degree of transparency in all parts of the Veterans Health Administration (VHA) needs to be restored, and the trend toward secretiveness that started in 2003-2004, and has only gotten worse each year since, needs to be sharply reversed. There is no better way of securing the undivided attention of the permanent managers employed in the VHA than to make such mandates part of the appropriations process/language, both in the text of the law and in the report language. VVA encourages the Committee to suggest possible language to the Budget and Appropriations Committees in your views and estimates statement.

Further, there needs to be much more consultation and sharing of information between key officials in the VHA and leaders of the veterans’ community. The fact that much of the meetings of the Seriously Mentally Ill Advisory Committee now meets in secret, and the Advisory Committee on PTSD meets totally in secret should give everyone pause, particularly after the mis-steps and serious problems with these services at VA over the last four or five years.

Outreach and Education to Open the System to ALL Eligible Veterans

VVA encourages the Congress to continue and accelerate the lifting of the restrictions imposed in January 2003, and to allow so-called Priority 8 veterans to register and use the system. As a key element in this effort, VVA strongly urges the Congress to mandate that there be a line item in each division of VA specifically for outreach and education, and that all of these efforts be coordinated through the Office of the Assistant Secretary for Intergovernmental and Public Affairs. Having been turned away one or more times by the VA, many of the veterans they are trying to reach are very skeptical (to say the least) about responding to any letters that VA may send asking them to come in and register for health care services.

If it is to be successful, this effort must be coordinated, done on a media market by media market basis, and involve the Veterans Service Organizations and other key players if it is to be successful in drawing these veterans back to VA.

Homeless Veterans

Homelessness continues to be a significant problem for veterans. Among male homeless veterans those of the Vietnam Era are still of the highest percentage, although it is decreasing. Among women veterans this percentage is highest for those of the peace time era after Vietnam and before Gulf War I.  In part this is due to the fact that until the end of the Vietnam Era women by law were only able to make up 2% of the Active Duty Force.

The VA estimates about one-third of the adult homeless population have served their country in the Armed Services. With the increasing number of new, and younger, veterans who find themselves without a home and with dependent children, it is essential that the agencies of government and the non-governmental entities funded to assist these men and women be given the mandate and the funding necessary to assist these veterans – before their homelessness becomes chronic. Newly released population estimates suggest that about 131,000 veterans are homeless on any given night and perhaps twice as many experience homelessness at some point during the course of a year.

Vietnam Veterans of America supports the VA FY2011 budget proposal submitted by the Administration which includes $4.2 billion for the prevention of homelessness among Veterans, $799 million for specific homeless programs and expanded medical care, and $294 million for expanded homeless initiatives.  VVA is hopefully optimistic that the funding in the proposed budget will provide the necessary resources for state, non-profit and faith based agencies and organizations to achieve the goal VA Secretary Eric Shinseki has set before us – Ending Veteran Homelessness in 5 Years.  We also look forward to VA’s plans for establishing these new proposed initiatives.

Thousands of homeless veterans have availed themselves of the VA Homeless Grant and Per Diem programs provided by community-based service providers.  Community-based service providers are able to supply much needed services in a cost-effective and efficient manner.  The VA HGPD program offers funding in a highly competitive grant round.  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 increased dollars in the HGPD Budget will provide for the creation of thousands of new transitional beds.

However, VVA continues to advocate that VA Homeless Grant and Per Diem funding must be considered a payment rather than a reimbursement for expenses, an important distinction that will enable the community-based organizations that deliver the majority of these services to operate more effectively.  Per Diem dollars received by services centers are not capable of obtaining or retaining appropriate staffing to provide services supporting the “special needs” of the veterans seeking assistance.  Per Diem for Service Centers is provided on an hourly rate, currently only $3.91 per hour.

Vietnam Veterans of America thanks this committee for their support as well as your colleagues on the Appropriations Committee for $75M included in the VA FY2010 budget for 10,000 HUD/VASH voucher and urges your support for continued funding for and expansion of the HUD/VASH voucher program.  As we believe this is a key to ending homelessness among our nation’s veteran population.

Further, VVA requests an oversight hearing on the HUD/VASH program and its processes administered by the Department of Veterans Affairs and the Housing and Urban Development.  Oversight is necessary to ensure these vouchers, and any additional vouchers, will be administered, distributed and utilized to the fullest extent possible. Establishing an annual evaluation of their effectiveness will drive not only those vouchers online, but we believe will demonstrate the need for additional vouchers, and will prove to be an invaluable tool in the continuance and expansion of this program.

VVA urges full funding to the authorized level for the Homeless Veterans Reintegration Program (HVRP) administered by the Department of Labor.  Congressman Lane Evans, in a 1994 statement before the full House of Representatives explained, "Veterans are veterans no matter what else has transpired in their lives. These men and women served our nation. Providing them with their rightful benefits can only remind them of their prior commitment to society, promote their sense of self-worth, and further their rehabilitation."

VVA continues to communicate the importance of transitional residential and supportive service only programs in their approach to placing homeless in permanent housing. Additionally, VVA reiterates the sense of Congress in its proposal process and seeks set aside HUD funding in its McKinney-Vento grant cycle for transitional housing, supportive service only and supportive service dollars within the Shelter Plus Care grant programs.

The current programs that are designed specifically for homeless veterans  in place at the Departments of Veterans Affairs, Housing and Urban Development, and Labor to appear to be working.  These agencies provide outstanding services and programs to veterans and their families.  Enhancing all programs with added supportive services will only add to their success.  Supportive services are the key ingredient in finding a solution to this long ignored problem.

The one over riding issue here is that many times society has the misconception that the VA takes care of all veterans.  Society must be reminded that, first we are citizens, second we are veterans.  Our veterans are due the same services as their non-veteran counterparts, with respect to housing, health and a better life provided through every Federal agency.

Women Veteran Health Care

Vietnam Veterans of America (VVA) believes women’s health care is not evenly distributed or available throughout the VA system.  Although women veterans are the fastest growing population within the VA, there seems to remain a need for increased focus on women health and its delivery. It seems clear that although VACO may interpret women’s health as preventative, primary and gender specific care, this comprehensive concept remains ambiguous and splintered in its delivery throughout all the VA medical centers. Many view women’s health as only a GYN clinic. As you are aware, throughout medical schools across the country and in the current health care environment, women’s health is viewed as a specialty onto itself and involves more that gender specific GYN care.

The new women veterans also need increased mental health services related to re-adjustment, depression, and re-integration, along with recognition of differences among active duty, Guard, and reserve women.  The VA already acknowledges the issue of fragmented primary care, noting that in 67 percent of VA sites, primary care is delivered separately from gender specific health care – in other words, two different services at two different times, and in some cases, two different services, two different times, and two different delivery sites.  VVA also notes that there are too few primary care physicians trained in women’s health, and at a time when medicine recognizes the link between mental and medical health, most mental health is separate from primary care. 
VVA seeks to ensure that every woman veteran has access to a primary care provider who meets all her primary care needs, including gender specific and mental health care in the context of an on-going patient-clinician relationship; and that general mental health providers are located within the women’s and primary care clinics in order to facilitate the delivery of mental health services.
Providing care and treatment to women veterans by professional staff that have a proven level of expertise is vital in delivering appropriate and competent gender-specific care.  It is not sufficient to simply have training in internal medicine.  Women’s health care is a specialty recognized by medical schools throughout the country. Providers who have both a knowledge base and training in women’s health are able to keep current on health care and its delivery as it relates to gender.  In order to maintain proficiency in delivering care and performing procedures, these providers must meet experience standards and maintain an appropriate panel size. This cannot occur if women veterans are lost in the general primary care setting.  It is critical that women receive care from a professional who is experienced in women’s health.  If attention is not given to defining qualified providers, it will be a detriment to the quality of care provided to women veterans.
VVA does, however, feel comprehensive women’s health care clinics are most desirable where the medical center populations indicate because comprehensive consolidated delivery systems present increased advantage to the patients they serve. 
Providing Care for Newborns

VVA asks that particular reflective consideration be given to the following –

As referenced in the Department of Veterans Affairs, Volume II, Medical Programs and Information Technology Programs, Congressional Submission, FY 2011 Funding and, FY 2012 Advance Appropriations Request, the VA addresses the care of a newborn delivered to a woman veteran within the VA policy. 
 
“Amend title 38, United States Code, to authorize VA to provide care for newborns of enrolled women Veterans who are receiving maternity care through the Department of Veterans Affairs. This proposal is to cover costs of newborn hospitalization and is not to exceed 96 hours after delivery. Longer hospitalization or outpatient costs for the newborn, beyond 96 hours post-delivery, would not be authorized in this maternity benefit.”

“VA does not provide care for normal pregnancy and childbirth in its medical facilities pursuant to 38 USC § 1710, which limits the Secretary to providing care and services which the Secretary determines are “needed” for a “disability.” VA’s rationale for not providing this care was that a normal pregnancy did not constitute a disability.”

VVA seeks a change in this section of the proposed legislation that would increase the time for the provision of neonatal care to 30 days, as needed for the newborn children of women veterans receiving maternity/delivery care through the VA.  Certainly, only newborns with extreme medical conditions would require this time extension.

VVA believes that there may be extraordinary circumstances wherein it would be detrimental to the proper care and treatment of the newborn if this provision of service was limited to less than 30 days.  The decision for extended would require professional justification. If the infant must have extended hospitalization, it would allow time for the case manager to make the necessary arrangements to arrange necessary medical and social services assistance for the women veteran and her child.  This has important implications for our rural woman veterans in particular. And this is not to mention cases where there needs to be consideration of a woman veteran’s service-connected disabilities, including toxic exposures and mental health issues, especially during the pre-natal period, multiple births and pre-mature births. This may be especially important as it relates to the ever increasing duty responsibilities of our women in the military and their increasing role in “combat related” service. 
Women Veterans and the Veterans Benefits Administration
VVA is concerned that the investment given by the VA in regard to Women Veteran Program Managers at all VA medical centers is not being given the same level of consideration in the Veterans Benefits Administration.  VVA seeks to have consistent standards established for the time allocated to the position of Women Veterans Coordinators based on the number of women Veterans in the geographic area that the VARO serves.  Additionally we note that there is need for a formalized structure to be established for these WVC in order to provide additional oversight, accountability, and reporting. Frankly, if the Congress does not indicate that this should be done, at least in the Committee report accompanying the Appropriations bill, it is unlikely that VBA will take this much needed enhancement of services for women veterans.
VVA also would seek VA to establish a method to identify and track all outcomes, whether granted or denied, for all claims involving personal assault/trauma.  This should be identified and tracked regardless of whether the claim is for PTSD, depression, or anxiety disorder.
Veterans Economic Opportunity

While VVA supports adding additional claims processors to the Compensation and Pension system, it is equally important to add additional staff to the rolls of VA Vocational Rehabilitation. VVA strongly favors reorganizing VA to create a fourth element of VA that would be known as the Veterans Economic Opportunity Administration, giving the current Secretary the opportunity to establish a new corporate culture in the VEOA that focuses on helping veterans to be as autonomous and as independent as possible. Frankly, getting, and keeping, veterans who are homeless off of the street a major goal of VA should make expansion of the VA Vocational Rehabilitation program a top priority, both for adding rehabilitation specialists, and for adding more employment placement specialists. There are currently less than 100 employment placement specialists for the entire nation. We have excellent leadership at the top of VA Vocational Rehabilitation Service now. It is time to give her the staff and the resources needed to assist veterans to obtain and sustain meaningful employment at a living wage. It is important that the Congress add funding specifically for at least 400 staff members to the VA Voc Rehab staff, with many of those being placement specialist. If we can add 4,000 new staff members to process claims, then we should be able to add 400 staff to help veterans return to work,

VA Extramural Research Into the Wounds, Maladies, Illnesses of War

While VVA supports the request for $590 million for VA Research & Development, we hope that all recognize that this is not nearly enough for the tasks at hand. Frankly, much of these funds go to research projects that keep the medical “stars” at VA in the VAMC that are affiliated with a medical school. This is fine, and a useful function. However, there is a glaring need for funding into the wounds, maladies, injuries, illnesses, and medical conditions that stem from service by American citizens in our Armed Forces. The National Institutes (NIH) does virtually no specific veteran related research. Similarly, the same is largely true of the Center for Disease Control (CDC), the National Academies for the Advancement of Sciences (NAAS), and the Agency for Health Research Quality (AHRQ). While VVA strongly supports the work of all of these fine institutions as the only VSO to be a member of the “Research America!” coalition, we also know that there is an immediate and pressing need for veteran specific research. This vitally needed research would include, but not be limited to, projects such as research into the genochromosonal effects of Agent Orange and other toxins across multiple generations, possibly causing health anomalies in grandchildren and great-grandchildren of veterans exposed. Or, similarly, the consequences in regard to MS or MS-like conditions in veterans or the possible birth defects of children of those exposed to the cloud of chemical and biological weapons detonated in Iraq at the end of Gulf War I.

If it is necessary to create a new branch of VA that would be called the Division of Extramural research in order to make it possible to have such directed research grants available to those inside and outside of VA on a competitive basis, then VVA recommend that we move in that direction, and fund these activities to the level of at least $2 Billion by the year 2015, with commensurate increases of $260 + million each year to reach that level. Frankly this is important both for the health of current and future veterans already exposed, but also as a force health protection activity that will assist in preventing such maladies in the future, which makes it necessary for our national security.

In this regard in the short term, VVA strongly urges the Congress to allocate and additional $30 million for VA to begin to analyze and study the mountains of epidemiological evidence that it has on veterans of every generation, to meet Secretary Shinseki’s desire that we not “wait for an Army to die” but rather get answers about patterns of health care problems now, without for prospective studies in the future.

Automating VA IT Functions and Outreach

VA has an ambitious set of proposals to bring the department into the 21st century, and VVA enthusiastically supports these initiatives. However, we are still troubled that VA wants an electronic medical record system that can communicate with the Department of Defense and the private sector, but which will still not be able to communicate with the Compensation & Pension Service.

Further, while we can all be proud that the VA’s electronic health care record “VistA” is so popular that it is now being exported to the private sector, VVA is still troubled that this is occurring without a field being added for military history, thereby sending an implicit false message to the private sector that exposures and experiences in military service have no significant impact on the long term health care risks for veterans. I think it is safe to say that most of know this to not be the case for all too many veterans.

Clearly the funds directed toward IT must be significantly increased from the Administration request, by at least a 20% plus increase more that the current Fiscal Year.

Mr. Chairman, thank you for this opportunity to share our thinking and recommendations on these matters.