WOUNDED WARRIOR PROJECT
COMMITTEES ON VETERANS AFFAIRS
U.S. SENATE AND HOUSE OF REPRESENTATIVES
MARCH 4, 2010
Chairmen Akaka and Filner; Ranking Members Burr and Buyer; and Members of the Committees:
Thank you for inviting Wounded Warrior Project (WWP) to present our 2010 legislative agenda for the Committees at this joint session. Wounded Warrior Project was founded on the principle of warriors helping warriors, and we pride ourselves on outstanding service programs that advance that principle. Building on the rich legacy of veterans’ advocacy in this country, Wounded Warrior Project has a simple goal – to ensure that this is the most successful, well-adjusted generation of veterans in our nation’s history. We ask you to embrace that goal and help us achieve it.
Historically, the experience of war and the recognition of its toll on our warriors have prompted a grateful nation not only to honor the combatants but – through the Congress – to establish special benefits and programs to help those new veterans readjust, rehabilitate, and rebuild their lives.
We are very fortunate that both houses of Congress have committees dedicated to veterans’ affairs and committee members dedicated to that mission. The Senate and House Veterans Affairs Committees have done extraordinary work on behalf of America’s veterans. And yet that work is not complete.
Wounded Warriors’ Needs
I am Andrew Kinard, and I am testifying this morning not only as a Member of the Board of Directors of Wounded Warrior Project but also as one of the many young Americans whose lives have been irrevocably altered in service to their country. Some of us have come to terms with our wounds and successfully readjusted. I myself am a member of the class of 2011 at Harvard Law School, which I’m attending through the Department of Veterans Affairs’ vocational rehabilitation program. But many others are readjusting much more slowly.
As you know, large numbers are struggling with Post-Traumatic Stress Disorder (PTSD), often accompanied by depression or other mental health disorders. Often, these brave men and women are not finding the kind of help they need at VA; may be reluctant or fearful of pursuing care; or VA facilities may simply be too distant or too inconvenient to be helpful. Many still experience considerable pain, from physical as well as psychological injuries. Some are self-medicating. Far too many returning veterans are struggling economically. Too many young men and women who demonstrated outstanding leadership in uniform are now unable to find employment, let alone a job that taps their leadership skills. Others face insurmountable barriers to needed vocational training and rehabilitation. Still others, with severe traumatic brain injury, may never be gainfully employed again, and yet seek far greater independence.
I’m among the lucky ones. I survived. In 2006, while leading Marines on a foot patrol in al Anbar Province, Iraq, an IED exploded beneath me. It ripped through my body resulting in amputations of both legs at the hip and massive abdominal wounds, and left me comatose for a month. I endured more than 60 surgeries and went through a year and a half of rehabilitation.
Three experiences stand out in distinguishing my recovery from that of many other wounded warriors. I had the benefit of an outstanding college education at the U.S. Naval Academy. Then, while awaiting medical retirement from the Marine Corps, I had the opportunity to intern in the Office of Legislative Counsel at the Pentagon, and to serve as a military fellow in the office of Senator Lindsey Gra¬ham.
Very few of my brothers and sisters in uniform have had these kinds of advantages. Many are struggling with a constellation of potentially overwhelming problems – pain, depression, nightmares, anger, unemployment, lack of permanent housing and more. Well-intentioned efforts to improve VA services for our warriors have made a difference. A generally robust VA budget for the coming fiscal year is encouraging. But far more fundamental changes are needed to provide the kind of help wounded warriors need and deserve.
While VA administers an array of programs targeted at specific problems, there is little in the way of a holistic, coordinated approach to help a severely injured veteran to thrive again. Much more must be done to achieve the critically important goal of making VA and VA programs truly veteran-centered. One important program that is truly veteran-centered is the Federal Recovery Coordination Program, which assists servicemembers and veterans who were severely injured in Iraq and Afghanistan, and their families, gain access care, services, and benefits. Established in 2007, the FRC program has proven an exceptional initiative, effectively coordinating care and facilitating re-integration. Yet only about 460 warriors have FRCs. Clearly, a significant need remains.
The FRC program CAN make a difference in the lives of wounded warriors and their families. But on a more fundamental level, VA must change its management, organization, coordination, and business practices with the aim of improving outcomes for veterans, as the National Academy of Public Administration has advised. We urge you to press VA to make those kinds of changes. But we also implore you to re-examine the statutory framework of key VA programs that must serve our wounded warriors better.
Yesterday’s Statutory Programs and Today’s Wounded Warriors
There is certainly much to celebrate in the rich array of veterans’ benefits and services created by Congress over many decades. But prior Congresses could not have anticipated that thousands of servicemembers could have survived the kinds of grievous injuries warriors have sustained in Iraq and Afghanistan. Nor would they have imagined that young women would be among those severely wounded warriors. Finally, few would have anticipated that as tens of thousands of combat-injured veterans struggle to reintegrate, those veterans would face the most serious economic downturn since the Depression.
With the high survival rate of those injured in Operation Enduring Freedom and Operation Iraqi Freedom, unprecedented numbers are returning home with severe polytraumatic injuries -- amputations, extensive burns, blindness, spinal cord and traumatic brain injury, as well as severe mental injuries. These complex injuries have sparked needs -- like family caregiver assistance -- that were just not foreseen.
Last year, WWP was honored to testify before both Committees on the need to enact comprehensive legislation to meet the needs of family members who have become caregivers of their severely injured loved ones. We applaud both Committees for the high priority each gave to our legislative recommendations, and for the thoughtful deliberation in crafting strong provisions. We deeply appreciate the care with which you have been working to reconcile the respective caregiver-assistance bills.
Enactment, and successful implementation, of caregiver-assistance legislation will fill a critical gap in the array of important VA programs. But our wounded warriors have other clinical and rehabilitative needs that must be met. In some instances -- particularly, as they involve PTSD and traumatic brain injury, the signature wounds of this war -- our warriors' needs require not only new programmatic responses, but statutory changes. Our testimony today aims to highlight the importance of closing other gaps and eliminating barriers that confront too many wounded warriors on what should be a smooth road, not simply to recovery from their wounds but to thriving – physically, psychologically and economically. Certainly, the signature wounds of this war alone compel us to re-examine statutory provisions that were designed to address the needs of veterans with very different kinds of disabilities. This war surely challenges us to reassess – as Congresses have in the past – whether the statutory benefits and services codified in title 38 of the US Code fully meet the needs of this generation of warriors and their families.
We appreciate your openness to making those needed changes.
Needed Mental Health Legislation
The Department of Veterans Affairs (VA) reports record high levels of returning OEF/OIF veterans being seen, diagnosed and treated for mental health problems. Applying lessons learned from earlier wars, VA has aimed to identify those with war-related mental health problems and provide treatment early-on to arrest problems and avoid conditions becoming chronic.
Unquestionably, VA has mounted earnest efforts to identify and treat mental health problems experienced by returning veterans – instituting systemwide mental health screening, expanding mental health staffing, integrating mental health and primary healthcare, adding new counseling and clinical care sites, and conducting trainings on treatment techniques. WWP does not believe these steps, laudable as they are, have gone far enough. In fact, we question whether VA is winning the war for the mental health of this new generation, or whether it even has an optimal strategy in place to do so.
VA has certainly conveyed the impression that it’s doing the job. Of the approximately 945,000 reported to have become eligible for VA health care after deployment to Iraq or Afghanistan, VA has stated that through 2008 some 400 thousand (42 percent) had obtained VA health care since FY 2002, and of that number nearly 93 thousand had been diagnosed with PTSD. Observing that this level of utilization of VA health care is historically high, researchers have reported that 37% of veterans who used the VA health system for the first time from April 1, 2002 to April 1, 2008, received a mental health diagnosis.
VA cautions that the 400 thousand OEF/OIF veterans who have accessed VA health care constitute some 24% of the approximately 1.7 million who have been deployed and are not a representative sample. Moreover, while as many as 45% of patient encounters among OEF/OIF veterans were coded as related to a mental health disorder, VA’s analysis advises that this “does not indicate that approximately 2/5 of all recent war veterans are suffering from a mental health problem.” Beyond that, however, we know little about the more than half a million OIF/OEF veterans who have not sought VA care. For example, women in the military are at a significantly higher risk of developing PTSD than men. But VA has no data, to our knowledge, regarding the prevalence of PTSD, depression or anxiety among those who have not sought its care, or data on those who might have sought, or would even have access to, mental health care elsewhere. And, in acknowledging the limitations of the most recent prevalence study, researchers stated that they “lacked data on clinical outcomes.”
In 2008, VA undertook to reach by telephone the approximately 500,000 OEF/OIF veterans who had not sought VA health care and to encourage them to enroll for care. This unprecedented initiative was apt recognition that we must be concerned not just about those returning veterans who come to VA’s doors, but about the entire OIF/OEF population. Given the long-term health consequences associated with PTSD, depression and other mental health conditions so common among returning veterans, VA must take a public health approach to addressing this health risk. In that regard, far more aggressive measures than a single telephone reach-out, or routine efforts to encourage enrollment are needed. We must recognize the many factors that make returning veterans reluctant to seek help for psychological problems, and develop a strategy accordingly. Certainly, VA must fully articulate and evaluate the effectiveness of outreach efforts – and future outreach efforts should be accompanied with appropriate tracking metrics or reports.
In our view, VA’s approach is largely passive – relying on veterans to seek care. And even for those who seek care for psychological problems, we see little to assure that the treatment is ultimately effective. To illustrate, considerable emphasis is placed on screening. VA performance measures direct, for example, that 97% of eligible veterans are to be screened for PTSD at specified intervals in 2011. Yet a far lower performance bar is set for provision of optimal treatment – with only 25% of OEF/OIF veterans who have a primary diagnosis of PTSD expected to receive a minimum of 8 psychotherapy sessions within a 14 week period next year, far below the 60% strategic target. Too often, treatment is simply aimed at medically (and indeed, pharmaceutically) managing the symptoms of mental health conditions – rather than on helping this generation of veterans to be mentally healthy and to thrive, which must be the ultimate goal.
Returning veterans still face difficulty in getting needed mental health treatment. Many factors contribute to the wide gap in access:
• veterans with mental health needs are generally less willing to travel as far for needed treatment as veterans with other health problems;
• facilities in closest proximity to most veterans (community-based outpatient clinics) often lack specialized mental health treatment capacity;
• those facilities that have such expertise (like Vet Centers ) do not offer comprehensive clinical services;
• those that do have comprehensive services are often distant and do not provide the often critical supports (particularly peer support and family support) that Vet Centers provide;
• VA generally does not afford veterans who live far from its facilities access to community-based care despite a policy that requires it do so; and
• there are currently only very limited community-options that have expertise in war-related trauma treatment.
We note that VA’s budget for FY 2011 has won praise for proposing an approximately 8 per cent increase in funding for mental health care. While such plans are welcome, increased funding alone – without more fundamental programmatic and qualitative changes to achieve far greater and more effective outreach, access and effective care -- will not go nearly far enough.
We urge Congress not only to press for a far-more veteran-centric approach to mental health care, but to pursue that objective through legislative action, to include:
• directing VA to employ, and harness the power of peers (namely OEF/OIF veterans who have themselves battled PTSD) to conduct one-on-one outreach and to mentor and support returning veterans who have PTSD through the course of their treatment;
• bringing screening to the veteran – through community-based evaluations (conducted by primary-care providers under fee-arrangements) to identify those at risk and in need of treatment;
• bringing services to veterans who live far from VA facilities by partnering with, and training (as necessary), community-based providers; and
• keeping the veteran’s support system healthy by providing the veteran’s spouse access to mental health care to enable the veteran to get needed support.
Rehabilitative and Long-term Supported-Care Options
As with PTSD, VA continues to learn through the experience of caring for veterans with severe traumatic brain injury and cognitive impairments. Surviving these and other grievous battlefield wounds, young men and women may well require life-long assistance, ranging from total care for their most basic needs to supports for semi-independent living. While DoD and VA facilities have focused substantial treatment resources on saving these warriors’ lives, their facilities and programs are not consistently geared to helping the individual achieve the fullest possible rehabilitation and highest possible level of functioning. These can be achievable goals, but they require access to the right therapy, at the right time, to maximize the outcome. They also require the least restrictive, individualized, long-term supports to allow reasonable access to the community and the fullest quality of life.
While some veterans are served well by existing programs, others are not. Under current law, the Veterans Health Administration (VHA) may provide rehabilitative services – a term defined in law as “such professional, counseling, and guidance services and treatment programs as are necessary to restore, to the maximum extent possible, the physical, mental, and psychological functioning of an ill or disabled person.” Our experience, however, is that while VA furnishes services to restore function, wounded warriors are not necessarily assured -- under VA’s statutory framework -- of continued therapy to sustain function and to prevent loss of the gains achieved. The distinction is critically important to the well-being of a warrior with severe traumatic brain injury, for example. In addition, VHA’s authority to provide rehabilitative services (as defined above) suggests the provision of services under a medical model. But a traditional medical model may not best meet the range of rehabilitative needs of a profoundly injured young warrior. It is vital that rehabilitative care and services for very severely injured warriors be individualized and holistic in nature, and that these warriors have reasonable access to, and a choice of options geared to their age and injury, whether through government facilities, private, or a combination.
Mr. Chairmen, we urge you, accordingly, to take up legislation to enable VA to provide individualized rehabilitative services (not limited to a restrictive medical model) and patient-centered supports to permit the severely wounded warrior to live as normal a life as possible in whatever setting is most appropriate, to include in-home or in home-like residential options. Such legislation would be a step toward moving VA to pioneer new approaches to rehabilitation and community living for young veterans learning to live with traumatic brain injury, and to educating and training a new generation of specialists in traumatic brain injury rehabilitation.
Vocational Rehabilitation and Employment
Whatever their injuries, it is fundamental that each warrior should have the opportunity to achieve his or her full potential. Employment and independent living in the community are central to that vision. Optimally structured, the vocational rehabilitation and employment program, anchored in chapter 31 of title 38, is critical to paving the way for returning disabled veterans to adapt to their “new normal” and achieve a productive life. But significant obstacles prevent that program from fully realizing its important mission. We look forward to working with you this year to win enactment of legislation to establish a 21st century vocational rehabilitation and employment program.
Such a program would provide the financial support necessary for veterans who are often married and may be largely dependent on VR&E subsistence income. Today, however, VR&E’s very spartan monthly subsistence stipend (which is limited to those in the VR&E training track and which is not adjusted for geographic cost of living) often makes it impossible for an individual with family-support needs to participate in the program. Instead, more generous financial support under the new GI bill may encourage veterans to opt for that program, and forego the specialized counseling and employment assistance VR&E was created to afford. A program aimed at helping service-disabled veterans gain employment should not provide a lower subsistence allowance than an education program open to non-disabled veterans. Yet WWP field staff has encountered recent instances of VR&E counselors using the disparity in payments between the two programs to aggressively push VR&E-eligible veterans into the GI bill program, with the apparent aim of lowering caseloads. There is no justification for such practices, or for the disparity in payments. VR&E must be modernized to provide participants sufficient financial support – to include necessary expenses in searching for employment -- to realize the program’s goals and free the veteran to focus on his or her rehabilitation rather than on personal finances.
To Congress’ credit, the VR&E program is sufficiently flexible that it can accommodate a range of needs, and today’s program has five different tracks. Its Independent Living track – serving those whose disabilities preclude engaging in gainful employment – has taken on increased importance for a generation that has experienced severe traumatic brain injury in unprecedented numbers. We have some concern, however, that the program operates under an annual statutory cap that now limits VA to 2600 new cases annually, a bar that could impede some warriors from benefiting from this important rehabilitation program in the future.
VR&E holds the potential to be a life-changing program for this generation of wounded warriors, and we urge the Committees to make VR&E modernization a top priority this year. We ask that you not only address its statutory limitations, but work to ensure that the program realizes its enormous potential. In essence, the VR&E program is short-staffed and under-funded, and as such, is not optimally positioned to have the impact it should in helping this generation of disabled veterans to thrive economically. Given how important it is that wounded warriors be economically empowered, VR&E should be a premier VA program, not an impoverished stepchild.
But statutory changes, and increased staffing and funding alone will not ensure that the program becomes the model it should be. VA must work to make the program one of its “crown jewels.” The program has certainly improved in recent years, and both leadership and oversight have been critical catalysts. In that regard, we were disappointed to learn that VA had recently terminated a contract for an evaluation of the VR&E program. With much at stake for many wounded warriors, a thorough, independent program evaluation is vital.
Ultimately, of course, the success of the VR&E program is also significantly dependent on the availability of jobs. A 2007 research study for the Department of Labor found that young, recently separated veterans experience high unemployment immediately after transition and may take up to 9 months to find a job. One can reasonably infer that the nation’s severe economic downturn has not seen a decline in unemployment among new veterans, and particularly not among wounded warriors. We urge the Committees to work with your respective leaderships to foster specific employment measures for service-disabled young veterans, and look forward to working with you on this critically important subject.
Compensation for the “Signature” OEF/OIF Disabilities
While some wounded warriors may require more time than others to be ready to pursue vocational rehabilitation, virtually all need compensation and related benefits-assistance early on in their recovery and transition. Yet, current benefits’ law -- keenly focused on physical injury and loss -- does not equitably compensate and support certain severely wounded warriors, particularly those warriors with moderate to severe traumatic brain injury.
By way of illustration, current law limits eligibility for specially adapted housing to service-connected veterans who are totally disabled due to physical conditions such as blindness, severe burns, and loss or loss of use of the lower extremities or the upper extremities. A warrior who has survived a severe traumatic brain injury (but has little or no physical impairment) may be as, or even more, profoundly disabled as those now eligible for adaptive housing. And home adaptations may be critically important to ensure his or her safety. Under current law that same warrior would also not be eligible for a VA grant for the purchase of an automobile, a benefit to which veterans who are service-connected for loss or loss of use of one or both feet or hands, or bilateral loss of vision are entitled.
These and other benefits are important to reintegrating a profoundly disabled wounded warrior in his or her community. Congress must re-examine these provisions and give high priority to erasing unwarranted distinctions based on physical impairment alone. We urge that you also re-examine and increase the levels of monetary and ancillary benefits, which have failed to keep pace with much-increased costs. Such adjustments are long-overdue.
Finally, we welcome VA’s focus on streamlining and improving its claims-processing system. The problems with VA claims-adjudication are, of course, more complex than simply the oft-cited existence of a “claims backlog” and the unreasonably long time still spent in adjudicating a claim. Importantly, the system must not only become timely, but accurate and veteran-centric. It must take account of, and institute special measures to ensure effective adjudication of the often complex cases associated with polytrauma and the signature disabilities of this war. Ultimately, though, the goal should not simply be to improve a set of processes and operating systems, but to provide fair, timely benefits to veterans. Changes in processing that are not accompanied at the same time by changes in a too-adversarial culture -- that focuses more on quantity of claims adjudicated than the quality of the adjudication -- will not achieve that goal.
Transition Assistance Program
While acknowledgement of their entitlement to, and receipt of, veterans’ benefits is an important aspect of honoring the service of our wounded warriors and fostering their reintegration, such benefits cannot replace the importance of employment. As discussed above, young, recently separated veterans are experiencing high unemployment after transition. Research also suggests that the transition from military to civilian workforce is a turbulent period for all veterans. But it is even more turbulent for those warriors who have sustained serious injuries, including PTSD and TBI. Recognizing the need for transition assistance, Congress in 1995 required the Department of Defense, in collaboration with other departments, to mount a Transition Assistance Program (TAP) for members of the armed forces and their spouses about to separate or retire. Transition assistance services prepare separating servicemembers with skills, tools, and self-confidence to overcome barriers to employment. Participation in these TAP services varies widely by military service and installation. We urge the Committees to work with your respective committees on armed services to make TAP mandatory.
Finally, while our policy agenda this year is principally focused on needed legislative changes, we intend to work with VA and other departments, as needed, on critical administrative issues. We certainly envision working intensely to ensure that a family caregiver-assistance law is fully and successfully implemented, and that caregivers receive the supports which Congress has worked hard to establish.
That legislation does not, however, address an issue that has been problematic for numbers of family caregivers. In circumstances where the wounded warrior is deemed unable to handle his or her finances, VA may appoint a family member to serve as a fiduciary and manage his or her benefits. While the VA fiduciary program aims to protect vulnerable beneficiaries, its administration can be rigid and intrusive. From the perspective of the family periodically subjected to inspections and audits, the process can be demeaning, disrespectful, and confusing. Family members who have altered their lives to become full-time caregivers find themselves viewed with suspicion rather than recognized for their dedication. We have begun a dialogue with the Veterans Benefits Administration with an eye to program changes to provide families greater respectfulness, greater consistency in decision making, and greater clarity with regard to families drawing on a veteran’s benefits when they are living in the same household as the veteran, and have little or no income of their own because they have given up jobs to become the veteran’s caregiver. VBA has taken first steps toward revising the fiduciary program to better accommodate wounded warriors and the devoted family members with whom they live. We hope we can avert any need to ask you for help on this issue but will not hesitate to do so if it becomes necessary.
In closing, Mr. Chairmen, we look forward to the coming session, and to working with the Committees to realize the changes needed to help our wounded warriors achieve the goals to which we all aspire.
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