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C O N T E N T S
September 9, 2008

Legislative Hearing on H.R. 3051, H.R. 6153, and H.R. 6629

OPENING STATEMENTS

Chairman Michael Michaud
    Prepared statement of Chairman Michaud
Hon. Jeff Miller, Ranking Republican Member, prepared statement of
Hon. Phil Hare
    Prepared statement of Congressman Hare

WITNESSES

U.S. Department of Veterans Affairs, Gerald M. Cross, M.D., FAAFP, Principal Deputy Under Secretary for Health, Veterans Health Administration
    Prepared statement of Dr. Cross

American Legion, Joseph L. Wilson, Deputy Director, Veterans Affairs and Rehabilitation Commission
    Prepared statement of Mr. Wilson
Disabled American Veterans, Joy J. Ilem, Assistant National Legislative Director
    Prepared statement of Ms. Ilem
Johnson, Hon. Eddie Bernice, a Representative in Congress from the State of Texas
    Prepared statement of Congresswoman Johnson
Salazar, Hon. John T., a Representative in Congress from the State of Colorado
    Prepared statement of Congressman Salazar
Shea-Porter, Hon. Carol, a Representative in Congress from the State of New Hampshire
    Prepared statement of Congresswoman Shea-Porter
Vietnam Veterans of America, Thomas J. Berger, Ph.D., Senior Analyst for Veterans' Benefits and Mental Health Issues
    Prepared statement of Dr. Berger

SUBMISSIONS FOR THE RECORD

American Veterans (AMVETS), Raymond C. Kelly, National Legislative Director, statement
Brain Injury Association of America, Susan H. Conners, President/Chief Executive Officer, statement
Hodes, Hon. Paul W., a Representative in Congress from the State of New Hampshire
National Military Family Association, Barbara Cohoon, Deputy Director, Government Relations, statement
Paralyzed Veterans of America, statement
Schraa, James C., Psy.D., Neuropsychologist, Licensed Psychologist, State of Colorado, Craig Hospital, Englewood, CO
Veterans of Foreign Wars of the United States, Christopher Needham, Senior Legislative Associate, National Legislative Service, statement
Wounded Warrior Project, Anna Frese, Family Outreach Coordinator for Brain Injury, statement

LEGISLATIVE HEARING ON H.R. 3051, H.R. 6153, AND H.R. 6629

Tuesday, September 9, 2008
U. S. House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, DC.

The Committee met, pursuant to notice, at 10:00 a.m., in Room 334, Cannon House Office Building, Hon. Michael Michaud  [Chairman of the Subcommittee] presiding. 

Present: Representatives Michaud, Snyder, Hare, Berkley, Salazar, Miller, and Brown of South Carolina.

OPENING STATEMENT OF CHAIRMAN MICHAUD

Mr. MICHAUD.  I would like to call this hearing to order.  And I would like to thank everyone for coming today.  Today’s legislative hearing is an opportunity for Members of Congress, veterans service organizations (VSOs), the U.S. Department of Veterans (VA), and other interested parties to provide their views and discussion on the legislation that has been introduced within the Subcommittee’s jurisdiction.  I do not necessarily agree or disagree with these bills before us today, but I believe that this is an important part of the legislative process that will encourage frank discussion of new ideas. 

We have three bills before us today.  Congressman Salazar’s bill, H.R. 3051, the "Heroes at Home Act of 2007," H.R. 6153, Congresswoman Johnson’s bill, the "Veterans' Medical Personnel Recruitment and Retention Act of 2008," and H.R. 6629, Congresswoman Shea-Porter’s bill, the "Veterans Health Equity Act of 2008."  I look forward to hearing the views of our witnesses on these bills before us.  Due to the late inclusion of H.R. 6629 we do not expect to have written testimony today.  However, I would ask the witnesses if they would submit their views in writing on H.R. 6629 within ten legislative days after the ending of this hearing. 

[The statement of Chairman Michaud appears in the Appendix.]

Mr. MICHAUD.  I would like to ask Mr. Hare if he has an opening statement. 

OPENING STATEMENT OF HON. PHIL HARE

Mr. HARE.  I do.  Thank you, Mr. Chairman.  First, let me thank you and Ranking Member Miller for holding this hearing today.  The three bills before us today address important issues, all of which have huge impacts on the welfare of our Nation’s veterans. 

Secondly, I would like to thank the sponsors of these bills, the three Members that are testifying before the Subcommittee today.  Mr. Salazar is a fellow Committee Member and I know from sitting next to him over the past two years that he is a tireless advocate for veterans, especially the many rural veterans that live in his large district in the State of Colorado.  His bill addresses family caregivers of veterans suffering from traumatic brain injuries (TBI), and also telehealth services.  These are crucial matters that are directly in line with Mr. Salazar’s passion for improving the lives of veterans and their families. 

Ms. Johnson is also a big supporter for veterans.  For fifteen years she worked at the Dallas VA Medical Center (VAMC) as a medical and psychiatric nurse.  Appropriately, her bill aims to help VA recruit and retain more nurses and other healthcare professionals.

Ms. Shea-Porter and I came into Congress at the same time, and I know without a doubt that there is nobody more dedicated to serving our veterans than she is.  It is a paradox then that her home State, the great State of New Hampshire, does not have a VA Medical Center.  Her bill attempts to resolve this injustice.

Third, I would like to thank all of our witnesses for testifying today, including Dr. Cross of the VA, and each representative of the three VSOs present.  I would also like to congratulate the Disabled American Veterans (DAV) for recently electing Raymond Dempsey, a fellow Illinoisan, as National Commander.  Speaking on behalf of this great State of Illinois I take pride in knowing that such a well respected organization is under the leadership of Mr. Dempsey. 

Mr. Chairman, thank you again for holding this important hearing.  I look forward to our witnesses testifying this morning.  Thank you. 

[The statement of Congressman Hare appears in the Appendix.]

Mr. MICHAUD.  Thank you very much, Mr. Hare, for your opening statement.  Mr. Miller?

Mr. MILLER.  Thank you very much, Mr. Chairman.  I apologize for being late.  I would like to just submit my opening statement for the record. 

[The statement of Congressman Miller appears in the Appendix.]

Mr. MICHAUD.  Without objection so ordered.

Now I would like to thank our first panel for coming here this morning.  I look forward to your testimony.  We will start off, in the order that you arrived, with Congresswoman Johnson of Texas to introduce her piece of legislation first.  Thank you. 

STATEMENTS OF HON. EDDIE BERNICE JOHNSON, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS; HON. JOHN T. SALAZAR, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF COLORADO; AND HON. CAROL SHEA-PORTER, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW HAMPSHIRE

STATEMENT OF HON. EDDIE BERNICE JOHNSON

Ms. JOHNSON.  Thank you very much, Mr. Chairman, and other distinguished Members of the panel.  I will submit my written statement and try to summarize. 

As has been said, I worked as a professional psychiatric nurse at the Veterans Administration Hospital for fifteen years before entering public office, and I opened the psychiatric unit.  And I know how important the psychiatric unit became day after day as veterans started coming back from active wars.  Recently there were four suicides of psychiatric patients at the VA hospital that made the front page of the paper.  The VA hospital is in my district so I went to visit to see what the problem was.  And they explained that the real problem is they are not attracting enough professional nurses to do what they need done to observe psychiatric patients.  As you know, psychiatric patients are supposed to be observed at least every fifteen minutes.  It is also very important for consistency.  It is important that they develop a relationship with the nurses.  And the nurses remain the profession with the most trust of the public. 

They are using part-time nurses because the work in the VA hospital for nurses is a little more stringent than in other facilities.  And they identified their problem as not having nurses in the Medical Personnel Recruitment and Retention Act.  And it actually came out because nurses were so tight, there was such a shortage, that they thought that this would give more even distribution of nurses to other facilities as well.  But they found that they lost many, many nurses because of the work.  It is just hard in facilities like the VA. 

It does not take much to observe that.  You can go into a private facility and if you find a professional nurse they are usually seated at the desk.  You go into a VA hospital and they are usually walking, taking care of patients.  So it is really a difference, and I can tell you that from experience.

So I came back to see what I could do.  They specifically asked for this type of legislation.  And I saw where Senator Akaka had introduced a bill, it is Senate Bill 2969, that address the same problem.  And so this simply is a companion bill to his.  It is an urgent need.  Very early I put an amendment on one of the bills to see that when patients admitted to psych, admitted, coming directly from war, that they got a psychiatric evaluation by professionals right away because most of them come back with post traumatic stress disorder (PTSD) even if they do not have head injuries, and many are coming back with head injuries.  The earlier they are diagnosed, the earlier the intervention, the better the outcome. 

When I worked at the VA hospital, there were long-term patients because at the time the modality was not experienced enough to have very early intervention.  Consequently, we had a number of long-time, chronic patients.  The approach has changed now.  But in order to make it successful, the professionals must be available.  And this legislation directly addresses that issue by placing nurses in the same category of physicians and dentists, and other therapists, so that their pay rate pays them back into it.  So that their pay will be on the scale that it had been on the professional level. 

I know that this is asking for additional money, probably not right away but in the scale as it comes.  But if we want to give the appropriate attention to those people that have given much of their lives in defending this country, I think it is only right to make sure that they have adequate care, and a large enough and professionally qualified staff; especially nurses, who spend more time with the patient than any other professional.  They are in their care, they are there 24 hours.  And especially on a psychiatric ward you cannot depend on people coming in part-time, hitting it one time this week and another time next month.  You have got to have consistency.

I see that my time is up and I will be available for any questions. 

[The statement of Congresswoman Johnson appears in the Appendix.]

Mr. MICHAUD.  Thank you very much, Congresswoman.  Congressman Salazar, thank you for introducing your piece of legislation and for your ongoing commitment to our veterans.  I open it up for your comments.

STATEMENT OF HON. JOHN T. SALAZAR

Mr. SALAZAR.  Well, thank you Mr. Chairman, Ranking Member Miller and Members of the Subcommittee.  I surely enjoy being a Member of this wonderful Committee and all the work that we all do for veterans.  I appreciate the trip that we took to Iraq.  That was a very enlightening trip.

Mr. Chairman and Ranking Member Miller, first I would like to thank Dr. Jim Schraa, a neuropsychologist at Craig Hospital, and Anna Frese, with the Wounded Warrior Project, who submitted testimony for the record on the bill that I introduced, H.R. 3051, the "Heroes at Home Act," on July 17, 2007. 

The purpose of this bill is to improve the diagnosis and treatment of traumatic brain injury in current and former members of the armed forces.  The program will be located in VA healthcare centers across the Nation.  This is especially important in rural districts like mine where making healthcare accessible is a constant challenge.  H.R. 3051 addresses the needs for access to care by expanding the U.S. Department of Defense (DoD) and VA telehealth, and telemental health programs.  Ultimately the bill will ease the burden on our veterans suffering from TBI and the families who care for them.

Our Committee has heard testimony from many veterans, VSOs, and the VA on mounting cases of TBI, PTSD, and other invisible wounds of war.  I think that many of us agree that veterans are often worse off with those unseen injuries than those with visible, physical injuries.  Unlike injuries that can heal, brain injuries are often permanently disabling.  In addition, TBI can sometimes take years to develop and diagnose.  Even when discovered, the road to recovery is long and is born by families of our brave men and women in uniform. 

We have also heard of the link between TBI and other mental conditions such as epilepsy.  A DoD study after Vietnam found that 15 percent of soldiers with a penetrating TBI developed epilepsy soon after their injury.  H.R. 3051 creates a program to train family members of the TBI patients to become their personal care attendants.  Participants going through the program would also become certified and receive compensation from the VA so that they can focus their energy on caring for their loved one. 

By taking place at home with family, the healing process is made more comfortable for our veterans.  The cost to the VA for having someone cared for at home is less than having them at a medical facility and allows the VA to allocate the resources they have to serve more veterans.  We have soldiers in Iraq and Afghanistan spending longer periods of time in harm’s way and away from the their families, and with this in mind we need to ensure that there are programs in place to care for them when they return home.

A program that provides quality care for our veterans and a financial benefit for the family seems appropriate for the difficult economic times our country is facing.  Most importantly, the bill will help us reach our goal of ensuring our veterans the best care.

Mr. Chairman, I still have two minutes and I anticipated some of the questions that you might have.  If you do not mind, I would like to address some of those.  I know that one of the questions is how much is this going to cost?  The Congressional Budget Office has not scored this bill.  However, the cost of having someone cared for at home is much less than having them at a medical institution.  In fiscal year 2006, San Diego VAMC spent $825,000 for Personal Care Attendants (PCA) services for 52 veterans.  This year they expect the service’s cost to be $1 million.  They are currently providing home care services to 56 individuals.  I believe that it is much less expensive to take care of these veterans at home with family members.  We must keep in mind that a family member rate is less than $16 per hour versus a professional at a medical facility that may be charging $30 or more. 

The training will actually take place at home.  Currently the Department operates a similar PCA training and certification program for the spinal cord injury (SCI), SCI population out of San Diego.  Senate Bill 3421, the "Veterans Benefits Healthcare and Information Technology Act of 2006," includes a provision which, in Section 214, requires the establishment of a pilot program to improve caregiver assistance.  I think that the language specifically mentions caregiver training and certification a part of the pilot and authorizes $10 million over the next two years.

With that, Mr. Chairman, I think my time is up.  I do appreciate your time.

[The statement of Congressman Salazar appears in the Appendix.]

Mr. MICHAUD.  Thank you very much, Mr. Salazar.  Ms. Shea-Porter, I want to thank you for coming this morning and presenting your piece of legislation, and thank you for fighting for our veterans as well. 

STATEMENT OF HON. CAROL SHEA-PORTER

Ms. SHEA-PORTER.  Mr. Chairman, thank you for the opportunity to speak to your Subcommittee about a critical inequity facing New Hampshire veterans, the lack of full service in State healthcare.  New Hampshire has not had a full-service veterans hospital since 2001.  New Hampshire is the only State without a full-service VA hospital or comparable facility.  Veterans in Alaska and Hawaii receive care at military hospitals on base.  While New Hampshire may be a small State, it has a veteran population of 130,000.  Unlike many New England States whose populations are declining for veterans, New Hampshire’s veterans population is projected to grow over the next ten years.

Because New Hampshire does not have a full-service veterans hospital, our veterans are forced to travel out of State for some medical care.  Veterans traveling from the most northern parts of the State can travel for three hours to Manchester and then be forced to travel another hour to Boston if referred there for care.  Then they have to wait while everybody on that van receives their care.  So we are sending our sickest and our most vulnerable to Boston to wait all day after traveling several hours to get to the central meeting point.  This routinely happens.  In 2007, 704 of our veterans were transferred out of State for acute care.  Three-hundred forty-six of those veterans were sent to Boston. 

I have been calling for the VA to either restore the Manchester facility to full-service hospital care, or allow New Hampshire vets to receive care locally since I came to Congress.  I have been working with both the VA and my colleagues to realize that goal.  Chairman Filner visited the Manchester facility earlier this year and held a series of events, including a round table hearing in which we heard about the serious burdens place on the New Hampshire veterans and their families simply because we do not have a full-service hospital.  And again, I would like to emphasize, the only State in the country. 

Despite these efforts, the administration refuses to either provide local access to care or restore the full-service hospital care to New Hampshire.  I met with Secretary Peake at the Manchester VA Medical Center in June to express my interest in working with him to either restore the facility to a full-service hospital or provide local access.  Unfortunately, after our meeting, Secretary Peake told the local press that there would be no full-service hospital in Manchester. 

The administration’s failure to act is just unacceptable.  New Hampshire veterans deserve the best care possible and the current system is not delivering that.  That is why I introduced H.R. 6629, the "Veterans Health Equity Act of 2008."  This legislation will ensure that veterans have access to at least one full-service VA hospital, or that they can receive care locally.  That would mean that the VA would have to do one of two things, either restore the facility to a full-service hospital or provide more local care providers.  The men and women in our local VA facility have done a herculean job caring for these vets despite the limits placed on them.  The administration has recently shown some willingness to allow radiation therapy to be provided locally, but this is not enough.  Our veterans, regardless of whether they need radiation therapy, mental health services, acute care, or anything else, need and deserve the care their counterparts in every other State receive.  It is unconscionable that we deny them this full-service care and instead we offer ad hoc services.

Mr. Chairman, I appreciate your leadership in providing the best healthcare for our Nation’s veterans.  I am sure you and other members of your Subcommittee appreciate the challenges created by the lack of the full-service hospital.  I look forward to working with you and the Subcommittee to address these challenges.  Again, thank you for the opportunity to come and speak to you about this important issue and I look forward to answering any questions that you might have.  Thank you.

[The statement of Congresswoman Shea-Porter appears on p. ]

Mr. MICHAUD.  Thank you very much, Congresswoman.  And once again I would like to thank our first panel for your willingness to come before us this morning.  Mr. Miller?

Mr. MILLER.  Thank you, Mr. Chairman.  Ms. Shea-Porter, you only talk about the 48 contiguous States and you do not talk about Alaska.  You talk about Hawaii, but what about the territories as well?  Is there a reason—

Ms. SHEA-PORTER.  Well my understanding, and again we were just looking at the ones coming from our States, but they can receive access at military bases.  And so when we looked at just the 50 States, and because that was the best comparison that we could make, we are the only State without it.  And the others have access to military base hospitals.  And so, it has really created a tremendous burden on these vets, especially as I indicated the oldest and the sickest.  Because they are the ones who are being sent the furthest.  And up until now, the families were not properly reimbursed for the travel.  And when you look at who generally has to travel, it is an extra burden on the family and the community.  If an 80-year-old man, for example, needs to go to the VA and he has got a 5-hour trip, that means his wife is probably about 80 years old herself, needs to find help to bring him at least to the first part where the Manchester VA, where they can then head off to Boston. 

So the burden is awful and is unfair.  And New Hampshire veterans are aware of this.  And here is the other problem.  We need people to enlist in the service.  And we have young men and women in New Hampshire looking at that and saying, “You know, that just does not seem fair.”  And so, if we also want to make sure we recruit and bring our fine New Hampshire men and women into the service, we need to make sure that they know we will keep our promise to them and our commitment, and care for them when they return.

Mr. MILLER.  So, it is your understanding that veterans in American Samoa and the Virgin Islands have access to military hospitals?

Ms. SHEA-PORTER.  Well, I do not know what they do.  I am just looking at the 50 States.  And as I said, we are looking strictly at our 50 States and saying, “What do they do in every other State?” 

Mr. MILLER.  Actually, you said the 48 contiguous States.

Ms. SHEA-PORTER.  Well, that is because the other two have comparable care.  And what I am asking for is either or.  I am just asking for comparable care.  I am not saying it has to be a full-service VA hospital as long as they allow contracts locally so that our servicemen and women are not forced to take on an undue burden.

Mr. MILLER.  Thank you.  That is all. 

Mr. MICHAUD.  Mr. Hare?  Questions?  Mr. Brown?  Ms. Berkley?  Okay.  I just have one.  Thank you, Mr. Salazar, for answering the question I had for you.  I appreciate that. 

Ms. Shea-Porter, you had mentioned that Secretary Peake said no hospital.  Did Secretary Peake at least acknowledge that there is a concern with veterans accessing healthcare?  Is he willing to do some type of comparable care, whether it is contracting our services in different regions of New Hampshire?

Ms. SHEA-PORTER.  Well, actually I could not get an answer from him.  I finally said to him, “Mr. Secretary, are you saying yes or no?” and he said, “Neither.”  And so, you know, I could not get an answer.  But I do know that shortly thereafter they talked about providing radiation care in the community.  But this really has been a long festering problem.  And when we looked at the numbers of veterans from other States, and we looked at their ability, there cannot be any explanation for it.  You know, we have looked at the stats and there is just no explanation for New Hampshire being without some kind of care there. 

And, again, I am not insisting that they build a full-service VA hospital.  I want to do whatever is the most economical and practical.  But we have to keep our commitments to our veterans and that is why I am sitting here today.  We owe it to these New Hampshire vets.

Mr. MICHAUD.  Now, you mentioned the time it takes for veterans to travel to Boston.  My concern is access to healthcare and Maine, as you know, is a very rural State and we have to travel long distances.  Normally, when we say it is going to take four hours to travel from one end to Togus, that is at, the speed limit.  When you say it is going to take four hours, how does that traffic affect your veterans traveling?  Is it four hours because of congestions?  Or is it four hours depending on what time they go during the day?

Ms. SHEA-PORTER.  Right.  Well, when they start off, and the furthest point from my district could be an hour and a half to two hours from the tip of the district down.  And it is not that heavy.  I mean, it is New Hampshire.  It does not look like Washington traffic for sure, but the roads are slower, because if you get in front of a car.  So you add that time.  And then when they get to Manchester and they have to take a van, and that is when the traffic really becomes very difficult.  And so many of our older vets simply must travel in a van for a number of reasons.  Their unfamiliarity with the roads and with urban districts and driving in cities, they are elderly, and they are ill.  And it is pretty hard to find people in your neighborhood who are happy about driving four hours to Boston, you know, and going through, and picking their way through that traffic in that very heavily congested area in an area that they are not familiar with. 

So that means they have to come to Manchester and be loaded on the van.  And there are other people who are receiving services as well.  And so they come to an urban VA, which is very busy, and they have to wait all day.  And so these trips are absolutely exhausting them.  They can go, you know, for hours and hours and hours.  From Manchester to the VA can take an hour and a half.  It does take an hour and a half, it can take two hours.  Add that in addition to the two to three hours, you know, each way, five hours, and then the wait.  And you get a sense of what we are putting them through.  And again, they are our oldest and our sickest that are being sent down. 

Mr. MICHAUD.  Thank you very much.  Once again, I would like to thank our first panel for your testimony this morning.  I look forward to working with you as we work to make sure our veterans get the adequate healthcare that they need.  Once again, thank you very much. 

I would like to welcome the second panel.  As they come, it is Joy Ilem who works for the Disabled American Veterans (DAV), Joseph Wilson from the American Legion, and Dr. Thomas Berger from the Vietnam Veterans of America (VVA).  I would like to thank our second panel for your willingness to come today and to give your testimony on the bills that we have heard from our first panel. 

I would like to start off with Ms. Ilem. 

STATEMENTS OF JOY J. ILEM, ASSISTANT NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS; JOSEPH L. WILSON, DEPUTY DIRECTOR, VETERANS AFFAIRS AND REHABILITATION COMMISSION, AMERICAN LEGION; AND THOMAS J. BERGER, PH.D., SENIOR ANALYST FOR VETERANS' BENEFITS AND MENTAL HEALTH ISSUES, VIETNAM VETERANS OF AMERICA

STATEMENT OF JOY J. ILEM

Ms. ILEM.  Thank you Mr. Chairman and Members of the Subcommittee.  Thank you for inviting the Disabled American Veterans to testify at this legislative hearing.  We appreciate the opportunity to provide our views on the bills under consideration by the Subcommittee today. 

DAV supports the provisions in H.R. 3051, which would establish a program for training and certification of family caregivers of servicemembers and veterans with traumatic brain injury, and authorize these personal care attendants to receive compensation for such services.  This program would allow these family members to have standardized and consistent training and to receive compensation that recognizes their efforts that will help to ensure the stability of the family at an extremely difficult and vulnerable time.  We note, however, this section of the bill only addresses veterans with traumatic brain injuries but could also benefit other catastrophically injured veterans with long-term personal assistance needs, such as veterans with spinal cord injuries or severe physical trauma without brain injury.  If successful, we would like to see this provision related to training and support for caregivers expanded to other catastrophically disabled veterans requiring caregiver assistance.

DAV also supports provisions in the bill requiring outreach to educate and make veterans and the public aware of the symptoms of PTSD and TBI, and make available best practices for these conditions to non-VA healthcare providers.  Often a family member is the first to notice cognitive changes in the veterans’ behavior and mood.  Thus informing the general public is an important element of this bill.  Likewise, we appreciate the dissemination of best practices on TBI and PTSD to non-VA providers to help ensure that veterans who may seek care outside the VA and DoD systems benefit from their expertise. 

Mr. Chairman, DAV also supports but with some concerns Section 4 of this bill to assess the feasibility of using telehealth technology to assess cognitive functioning of military members and veterans who have sustained TBI, with a priority in rural areas.  We support efforts to assess new web-based diagnostic tools for the prevalent cognitive conditions that are emerging among our returning veterans.  However, we ask the Subcommittee to ensure that any partnership with the private sector to expand telemedicine in rural areas include coordination through VA’s Office of Rural Health and be supplemented by appropriate resources.

On a final note, we ask the Subcommittee to also consider expanding this measure to include a standardized and more comprehensive package of support services for caregivers, including financial support, health and homemaker services, respite, education, training, and other necessary relief services.  Family members of severely injured veterans often shoulder and great and lifelong responsibility as home and institutional caregivers, giving up or severely restricting their own employment and educational advancement, and social opportunities.  Not surprisingly, family caregivers often suffer severe financial and personal hardships as a consequence of providing care to a severely disabled veteran.  Yet, in their absence, an even greater burden of direct care would fall to VA and DoD at significantly higher cost to the government and reduced quality of life for these veterans who have sacrificed so much. 

H.R. 3051 would provide welcome relief to family caregivers of severely disabled veterans and is consistent with DAV Resolution 165 and recommendations of the fiscal year 2009 Independent Budget.  Therefore, we support this measure and urge the Subcommittee to work towards its enactment. 

The next bill for discussion is H.R. 6153, the "Veterans Medical Personnel Recruitment and Retention Act of 2008."  Along with our partners in The Independent Budget, DAV has called for improvements in VA policies and procedures used to recruit and retain highly qualified VA clinical staff.  VA needs new authority to achieve and sustain its goal to be competitive with private sector providers and become a preferred employer for physicians, nurses, dentists, and other medical personnel needed to care for our enrolled veterans. 

This bill aimed at providing meaningful financial and professional incentives to encourage VA medical personnel to pursue full careers in the VA healthcare system is timely and appropriate given all of the challenges VA faces to maintain delivery of timely, high quality, comprehensive healthcare services to our Nation’s veterans.  The Independent Budget conveys a series of recommendations that are fully consistent with the intent of this bill.  Therefore, DAV has no objection to its enactment. 

Mr. Chairman, on the final bill under consideration, since we did not have a chance to really review that thoroughly, we will be happy to submit in writing our views on that final bill.  Thank you.

[The statement of Ms. Ilem appears in the Appendix.]

Mr. MICHAUD.  Thank you.  Mr. Wilson?

STATEMENT OF JOSEPH L. WILSON

Mr. WILSON.  Mr. Chairman and Members of the Subcommittee, thank you for this opportunity to present the American Legion’s views on these three important pieces of legislation.

H.R. 3051, the "Heroes at Home Act of 2007."  This bill seeks to improve the diagnosis and treatment of traumatic brain injury in members and former members of the armed services, to review and expand telehealth and telemental health programs of the Department of Defense and Department of Veterans Affairs, and for other purposes.  Section 2 of H.R. 3051 requests the Secretary of VA to establish a program on training and certification of family caregivers of veterans and members of the active-duty armed forces with traumatic brain injury as personal care attendants. 

Pursuant to Section 744(a)(2) of Public Law 109-364, the Veterans Traumatic Brain Injury Family Caregiver Panel was established in 2007.   The 15-member panel was created by the DoD to operate under the Department of Health as a subcommittee to advise and specifically provide DoD and VA with independent advice and recommendations on the development of training curricula to be utilized by the above mentioned family members on techniques, strategies, and skills for care and assistance for such individuals with TBI, or traumatic brain injury.  The panel was convened on occasions, to include a recent town hall meeting to discuss matters related to the development of this curriculum and to hear from the public about the issue. 

Now, the American Legion asserts that the advice of this subcommittee, incorporated into the provisions of this piece of legislation, is vital and that its absence may deprive such a bill of an effective stance and approach to treatment and care of TBI.  The American Legion, in its continuing efforts to increase access and quality of care to all eligible and potentially eligible veterans, supports this proposal as it would help to accomplish this ongoing challenge.

H.R. 6153, the "Veterans Medical Personnel Recruitment and Retention Act of 2008."  This bill seeks to amend Title 38 of the United States Code to enhance the capacity of VA to recruit and retain nurses and other critical healthcare professionals in addition to addressing other issues.  The American Legion applauds this proposal to amend the methods of hiring and retain an additional medical personnel of various disciplines to adequately equip VA medical facilities to ensure the adequacy and quality of treatment and care.  The American Legion supports the proposal requested in Section 2(j), which seeks to amend 7451(c)(2) to allow critical fields such as nurse anesthesiologists to exceed rate limitations on authorized competitive pay. 

Although VA has various anecdotal programs in place to include recruitment, relocation, and retention incentives for these hard to fill positions, there remains a shortage of such nurses and specialty medical physicians.  The overall response to the question of shortage indicated that salaries and delays in appointments were key causative factors.  The American Legion, during its VA Medical Center site visits to 49 facilities in 2008, encountered various recruitment issues, including such delays in the appointment of nursing assistants.  Management attributed these delays to the three- to four-month hiring process.  By the time management completed the hiring process, applicants had accepted a position in the private sector. 

Also in their site visits, the American Legion representatives ascertained other areas with difficulty recruiting.  These included mental health positions, specifically psychologists and psychiatrists, dermatology, gastroenterology, orthopedics, and anesthesia.  A study published in the New England Journal of Medicine ascertained there were shorter inpatient delays and lower complication rates in hospitals with higher staffing levels while there were longer inpatient stays and increased urinary infections, gastrointestinal bleeding, pneumonia, and shock or cardiac arrest in hospitals with lower staffing levels. 

We hereby urge Congress to act on this piece of legislation by incorporating it into the VA system to prevent the healthcare system from being included in the casualties of the projected shortage of medical professionals through the year 2020. 

And I will briefly comment on H.R. 6629, the "Veterans Health Equity Act of 2008."  The bill seeks to amend Title 38, United States Code, to ensure that veterans in each of the 48 contiguous States are able to receive services in at least one full-service hospital of the Veterans Health Administration (VHA) in the State or receive comparable services provided by contract in the State.  The American Legion wholeheartedly concurs with one proposal portion of this bill, which urges the Secretary of VA to allow veterans equal access to full-service hospitals.  However, in Section 2, the terminology, “certain States,” leaves question of an alternative or adverse motive unfavorable to proposals to further enhance access and quality of care across the board within the VA healthcare system.  In addition, under Section 2 the proposal to insert the language, “access to full-service hospitals in certain States,” once again does not warrant unanimous support for this piece of legislation.  The term “certain” implies some States as opposed to all. 

The purpose of this piece of legislation, which is also the leading opening statement of the bill, seems to be contradicted by Section 2, which includes such language as stated in the above mentioned paragraph.  The uncertainty of this legislation leads the American Legion to avoid a position on this bill. 

Mr. Chairman and Members of the Subcommittee, the American Legion sincerely appreciates the opportunity to submit testimony.  Thank you. 

[The statement of Mr. Wilson appears in the Appendix.]

Mr. MICHAUD.  Thank you very much.  Dr. Berger? 

STATEMENT OF THOMAS J. BERGER, PH.D.

Mr. BERGER.  Mr. Chairman, Ranking Member Miller, and distinguished Members of this Subcommittee and guests, the Vietnam Veterans of American, VVA, thanks you for the opportunity to present our views on these important pieces of legislation affecting the healthcare of America’s troops and veterans.  With your permission, I shall try and keep my remarks brief and to the point.

In general, Vietnam Veterans of American supports the intent of H.R. 3051.  But remember, medical experts say that traumatic brain injuries are the signature wound of the Iraq War in particular and in fact TBIs have become so commonplace that we are yet again focused on them today in this hearing.  Certain TBI symptoms, such as seizures, can be treated with medications.  But the most devastating effects, such as depression, agitation, and social withdrawal are difficult to treat with medication, especially when there is loss of brain tissue.  In troops with documented TBIs, the loss of brain function is often compounded by other serious medical conditions that affect physical coordination and memory functions.  These patients need a combination of psychological and physical treatment that is difficult to coordinate in a traditional medical setting, even when properly diagnosed at an early date.  And we must remember that both concussive and contusive brain injuries are never just isolated injuries.  Over time, without proper diagnoses, care, and treatment, TBI can affect nearly everything about the survivor, including one’s cognitive, motor, auditory, olfactory, and visual skills, perhaps ultimately resulting in behavioral modifications and definitely not a mental illness.  Families say that they struggle with the military and the VA medical systems that were unprepared for these wounded.  In some cases, new equipment and specially trained staff needed for the most catastrophic cases are not available, or have not kept pace with the advances in battlefield medicine that kept these servicemembers alive.  In addition, there are issues about intensity and drain of needed family support that will be hard to sustain, as well as the significant issues regarding the complexity of the medical and other specialized needs that need to be addressed with TBIs.  Of all the War’s medically challenging injuries, brain injuries require the most personal involvement, dedication, and cost over time. 

As you are well aware, one of the recommendations of the Dole-Shalala Commission was to significantly strengthen support for families.  This will not be an easy task, but VVA believes that H.R. 3051 can be a key step in achieving this recommendation and providing a mechanism for empowering the families of brain-injured servicemembers if, and only if, the VA can develop effective implementation strategies for certification, competency evaluations, and meaningful outcome measurements to carry it out.  As they say, the devil remains in the details.  And part of our concern, of course, lies with the fact that there is so much variation amongst the States’ regulations relative to training, certification, outcome measurements, etcetera, for brain-injured persons.  It will be a difficult task.  But if the VA can pull it off ,it certainly holds hope for family members. 

Regarding H.R. 6629, we certainly, we did not submit any written testimony but we certainly support equitable pay and hiring processes that will permit our professional staff at the VA facilities to at least achieve comparable pay and salaries with those in the private sector to provide the care that is needed by our veterans. 

Regarding the, excuse me, that was not H.R. 6629.  That was H.R. 6153.  On H.R. 6629, we just got that on Friday and we have not had an opportunity.  Now we have heard some background information and we will submit written testimony in ten days.  Thank you very much for the opportunity to do this. 

[The statement of Dr. Berger appears in the Appendix.]

Mr. MICHAUD.  Thank you very much, doctor.  Once again, I would like to thank the panel.  A couple of questions.  Ms. Ilem, you had raised concerns with implementing the caregivers’ training program in each of the VA Medical Centers due to the lack of capacity, and recommend that the program be limited to polytrauma centers and other units within the Defense and Veterans Brain Injury Network to ensure the training is high quality.  Do you have any suggestions on how we can address, the challenges you highlighted so that the program can be implemented in all VA Medical Centers?

Ms. ILEM.  Well, we did note that so that, you know, initially because we felt that probably that is where the families would be.  You know, where those patients would be and have the initial opportunity to work with those families.  So to keep consistency, you know, hopefully to be able to develop some best practices to make sure it is consistent, standardized training, to do that, and then to, you know, be able to press that out, if necessary, you know, depending on, you know, the need for that.  But since so many of those veterans are either going to the Veterans Integrated Services Network (VISN) area, one of the polytrauma, you know, level one polytrauma centers, or then, you know, to their VISN level polytrauma center we felt that would be the most appropriate place to start just to maintain that high quality and consistency of training.

Mr. MICHAUD.  Mr. Wilson, I did not expect you to comment on the Congresswoman’s legislation, but since you did and did not take any position on it, would you, having heard her testimony, agree that it is important for veterans, regardless of where they live, to have access to healthcare?  I can understand the concern with building a brand new hospital.  I want to make sure that veterans get the services they need versus bricks and mortar.  But it appears that the concern is that there is a large number of veterans who have to travel four hours to get the care that they need.  Would you agree that it is important that, if there is care that is needed, whether it is fee-for-service or otherwise, that that be provided?

Mr. WILSON.  Well, in terms of access, and from my experience in traveling throughout various VISNs in this Nation, and even to include Puerto Rico, there is an issue with access in addition to New Hampshire.  The American Legion does not exclude any one particular VA Medical entity within the VA healthcare system.  That's where we have concerns regarding the overall piece of legislation itself.  However, there were portions, in regards to the access of care, level of care, and quality of care at New Hampshire.  And I am sure someone can attest to access as an issue.  Let's use Nevada, because with Nevada has a large catchment area.  There is an issue with traveling to various VA medical facilities in Nevada.  And I can name quite a few, actually, in regards to access.  We have "A System Worth Saving" booklet, our annual publication that we disseminate to Congressional Members.  You can read it in the 2008 publication, regarding access issues.  So we do support the issue of improving access to care.  However, regarding that it is not a competition here.  We would like to take all VA medical facilities to that level of quality access and care. 

Mr. MICHAUD.  Thank you.  Mr. Miller?  Mr. Hare? 

Mr. HARE.  Thank you, Mr. Chairman, I just have a couple of quick questions here on, for the VVA on H.R. 3051.  You highlight the need to ensure that VA develop effective implementation strategies for certification, competency, evaluation, and meaningful outcome measurements.  I wonder if you could expand on that point?  And then, is there additional legislative text that you would recommend adding to the bill to ensure that the provisions in the bill are implemented effectively?

Mr. BERGER.  Thank you, sir.  In regard to the first part of the question, I refer to my comment that there is a great deal of variation amongst the States relative to private and not-for-profit institutions or agencies that offer these kinds of services, particularly in rural areas across the country.  And I am not hinting that they are bad in this State or they are better in this State, I am just saying there is no standardization across the country. 

My own personal experience in working both with Easter Seals of Illinois and United Cerebral Palsy brings this to the forefront.  The standards for caregivers for brain-injured persons in these organizations in two parts of the country were extremely different.  I think that if the VA were to develop a standardized process, for lack of a better term, not to run through everything that I said, this would help greatly.  And then the family members could take advantage of this.

We are going to have a problem down the road, particularly in rural areas, with family caregivers taking care of folks if they do not receive proper, standardized training. 

Mr. HARE.  I just wanted, maybe all three of you could comment on this, on H.R. 6153, supporting the legislation.  Are there other health professionals who are not included in H.R. 6153 who face recruitment and retention challenges and would benefit from flexibilities provided in the bill?  For example, I know the Paralyzed Veterans of America (PVA) in their statement for the record identified a shortage of spinal cord injury disease nurses and the need to apply the specialty pay provisions to the groups.  So I guess what I am asking you, are there other health professionals that ought to be included in the bill, or concerns that you may have with that?

Mr. WILSON.  In regards to specialty medical positions, I do not want to, I cannot specify further than what I have recorded on paper.  However, speaking from our various site visits I can; we will soon disseminate the "System Worth Saving" publication in which you could actually read for yourself from the horse’s mouth, if I can say in retards to the various shortages.  The concern, in discussion, comes from management within each respective VA medical facility. 

Mr. BERGER.  Mr. Hare, I would certainly add those specialized social workers that deal with brain injury and seizure disorders.

Ms. ILEM.  I would agree with PVA’s statement and I am not, any other ones have not been brought to our attention, that have been missed.  But if we are made aware of any of those we will certainly forward those on. 

Mr. HARE.  Thank you very much.  Thank you, Mr. Chairman.

Mr. MICHAUD.  Thank you, Mr. Hare.  Mr. Snyder? 

Mr. SNYDER.  Thank you, Mr. Chairman.  Mr. Wilson, I wanted to follow up a little bit on this issue that Mr. Michaud asked about with regard to Carol Shea-Porter’s bill.  Because I think we are all in agreement, you know, we want access for all veterans.  It is just, I guess it is the reality of the human condition is we tend to nibble off things that we can, you know, bite-sized morsels and move on.  I mean, we have got a bill coming out on the floor I think tomorrow, or this week, or something, Jerry Moran’s bill.  It came out through this Committee and it, what do we call it, highly rural areas because we recognize that distances in rural areas are, can make it prohibitive.  So I, while I understand we are trying to equalize everything, I would also hope we would recognize there may well be a peculiar nature of New Hampshire. 

I have traveled in Nevada a fair amount.  I have traveled some in New Hampshire.  It can be hard to get around New Hampshire some times of the year.  I had trouble walking in New Hampshire at certain times of the year.  I just want us to appreciate that driving 100 miles in certain parts of the country is probably a whole lot different than driving 100 miles in New Hampshire in the wintertime.  And so I do not think we should be afraid of doing something that helps one State that for probably historical reasons never got themselves a VA hospital for whatever reasons in years ago in the past.  I do not think we should not be willing to deal with that problem hoping that somehow we are going to correct all of the problems of access to healthcare before we deal with New Hampshire.  That does not seem a very good approach.  And I use as a model as somebody already did the highly rural area we are trying to, as a pilot, that Jerry Moran’s bill, which I think you all supported.  I think the American Legion did support Jerry Moran’s bill and it does not deal with nationally.  So thank you, Mr. Chairman. 

Mr. MICHAUD.  Thank you, Dr. Snyder.  Ms. Berkley? 

Ms. BERKLEY.  I have no questions of the witnesses but I want to thank you for taking time out and coming to testify. 

Mr. MICHAUD.  Mr. Salazar?

Mr. SALAZAR.  Thank you, Mr. Chairman.  Mr. Berger, do you believe that H.R. 3051 actually begins to implement the provisions of the Dole-Shalala recommendations?

Mr. BERGER.  I think that particular recommendation about support for the family is contained in the bill, yes, sir. 

Mr. SALAZAR.  Let me just read you a little bit of the statement that was submitted for the record by Anna Frese, who is with the Wounded Warrior Project.  She talks about her brother, Retired Army Sergeant Eric Edmundson, who was seriously injured in Iraq in October 2005 and is currently living at home receiving 24/7 care from her father, Edgar Edmundson.  This is what the father experienced.  “Upon learning of Eric’s lifelong challenges, our father resigned his position at work in order to provide Eric the full-time care that he needed.  This decision did leave him and our mother with one less income, and in times of need they had to dissolve their personal and retirement savings.  Just as importantly, now at 53 years old, my father is no longer covered by health insurance.”  So these are the kinds of issues that families face—

Mr. BERGER.  Yes, sir.

Mr. SALAZAR.  —especially in rural communities where they do not have facilities close by.  It seems to me that soldiers or patients who have gone through some kind of traumatic brain disorder can actually recover better and have a better quality of life by having family caregivers.  Is that correct?

Mr. BERGER.  That is absolutely correct, sir.

Mr. SALAZAR.  Thank you.  I would ask for Mr. Wilson and Ms. Ilem to comment on that as well?

Mr. WILSON.  I have no comment currently.  Please refer to our book, "A System Worth Saving."

Ms. ILEM.  We would agree that the family caregiver issue, just as you have noted, in talking with family members you see how their lives are impacted and DAV is very supportive of doing everything we can to support the caregiver to make sure veterans have the best care possible, and in the best environment for those veterans.

Mr. SALAZAR.  Well as