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Submission For The Record of Mr. John Rowan, et. al., Vietnam Veterans of America, National President

Chairman Michaud, Ranking Member Miller and distinguished Members of the Subcommittee, on behalf of all of our officers, Board of Directors, and members, I thank you for allowing Vietnam Veterans of America (VVA) the opportunity to submit this statement for the record regarding the President’s fiscal year 2008 budget request for the Veterans Health Administration of the Department of Veterans Affairs. VVA looks forward to working with you and all of your distinguished colleagues to address the needs of the unique system created to serve our Nation’s veterans. 

Mr. Chairman, several years ago, Vietnam Veterans of America developed a White Paper in support of the need for assured funding for the veterans health care system, which I hope you have read and shared with others. We hope that you will remain a strong supporter of legislation to achieve assured funding. There is a clear and urgent need for such a mechanism to correct the problems in the current system of funding.  As we have this discussion in regard to the FY’08 budget for VHA, the readily apparent need for this legislation has never been more pressing.  We look forward to working with you to ensure its enactment.

VVA does wish to recognize that this year’s request from the President for the VA Budget, while lacking in many other respects, is relatively free of “budget gimmicks” that have so plagued discussions in the past. VVA believes that this is due to the strong efforts of Secretary Nicholson in doing battle to strip out the favorite “gimcrackery” of that permanent staff over at the Office of Management & Budget (OMB). VVA commends the Secretary of Veterans Affairs in this regard for seeking to have an honestly presented budget proposal.

Veterans Health Administration

VVA is recommending an increase of $6.9 billion to the expected fiscal year 2007 appropriation for the medical care business line. We recognize that the budget recommendation VVA is making this year is extraordinary, but with troops in the field, years of under-funding of health care organizational capacity, renovation of an archaic and dilapidated infrastructure, updating capital equipment, and several cohorts of war veterans reaching ages of peak health care utilization, these are extraordinary times.   It’s past time to meet these needs.

In contrast to what is clearly needed, we believe the Administration’s fiscal year 2008 request for $2 billion more than the expected 2007 appropriation in the continuing resolution is inadequate.  Unfortunately, we still are unsure of the bottom line for fiscal year 2007.  While we certainly appreciate that the Congress is planning to restore funding for veterans health care in the continuing resolution (and it is essential that it does so to ensure the Department’s ability to meet ongoing obligations), the fact that VA is still uncertain about the amount of funding it will receive a third of the way through the fiscal year does, virtually in and of itself, make the case for assured funding. 

The $2 billion increase the Administration has requested for medical care may almost keep pace with inflation, but it will not allow VA to enhance its health care or mental health care services for returning veterans, restore diminished staff in key disciplines like clinicians needed to care for Hepatitis C, restore needed long-term care programs for aging veterans, or allow working-class veterans to return to their health care system.  VVA’s recommendation does accommodate these goals, in addition to restoring eligibility to veterans exposed to Agent Orange for the care of their related conditions.

The Veterans Health Administration of the Department of Veterans Affairs has had many successes, and been recognized by numerous prestigious awards in recent years.  The veterans’ service organizations are often seen as critics of the Department, but while it’s true that we sometimes take exception to its policy decisions we are, in fact, also its most stalwart champions.  Over the last decade the Veterans Health Administration (VHA) at VA has taken steps to become a higher quality, more accessible health care system.  It has demonstrated great efficiency by almost doubling the number of veterans it treats while holding per capita costs relatively constant. (Unfortunately, they have gone way too far in staff reductions through attrition, which now urgently needs correction.)  It has developed hundreds of Community Based Outreach Clinics (CBOCs). VHA has received many prestigious awards for excellence and innovation. While VVA remains extremely concerned about recent breaches that compromised veterans’ personal data to the outside world, and we remain equally concerned regarding the privacy of a veterans’ personal health and other information within the VA structure, VVA does appreciates the fact that VA has put together a computerized system of medical records that sets the standard for modern health care delivery.  These achievements are to be celebrated.

Yet, these advances have not come without a cost.  For years, the veterans’ health care system has been falling behind in meeting the health care needs of some veterans.  At the beginning of 2003, the former Secretary of Veterans Affairs made the decision to bar so-called Priority 8 veterans from enrolling.  In most cases, these veterans are not the well-to-do—they are working-class veterans or veterans living on fixed incomes as little as $28,000 a year.  It’s not uncommon to hear about such veterans choosing between getting their prescription drug orders filled and paying their utility bills.  The so-called “temporary” decision to bar these veterans is still standing and is reflected now in the long term planning for the VHA. This is still troubling to thoughtful Americans. 

In addition to the current bar on health care enrollment, in recent years VA has sent Congress a budget that requires more cost-sharing from veterans, and eliminates options for their care—particularly long-term care.  We appreciate that VA’s proposal this year has not presumed enactment of some of the cost-sharing legislative proposals Congress has opposed in the past.  This may allow Congress more leeway to augment its request in concrete ways rather than merely filling deficits left by the Administration presuming that revenues and savings from these unpopular initiatives will be realized.  

Congress is to be commended for turning back many legislative requests for enrollment fees and outpatient cost increases in the past, which would have jeopardized hundreds of thousands of veterans’ access to health care.  Hard-fought Congressional add-ons, such as the $3.6 billion for fiscal year 2007 currently being debated as part of the continuing resolution, have kept the system afloat.  The budget recommended by VVA in addition to the enactment of some assured funding mechanism will enable a robust health care system to meet the needs of all eligible veterans—now and in the future.

Medical Services

For medical services for fiscal year 2008, VVA recommends $34.5 billion, including collections.  This is approximately $5 billion more than the Administration’s request.  VVA is making its budget recommendations based on re-opening access to the millions of veterans disenfranchised by the Department’s policy decision of early 2003 that was supposed to be “temporary.”  The former ranking member of the House Veterans’ Affairs Committee, Lane Evans, discovered that a quarter-million Priority 8 veterans had applied for care in fiscal year 2005.  Similar numbers of veterans have likely applied in each of the years since their enrollment was barred.  Our budget allows 1.5 million new Priority 7 and 8 veterans to enroll for care in their health care system.  While this may sound like too great a lift for the system, use rates for Priority 7 and 8 veterans are much lower than for other priority groups. Based on our estimates, it may yield only an 8% increase in demand at a cost of about $1.5 billion to the system for additional personnel, supplies and facilities.

The budget axe has fallen hard on long-term care programs in VA.  About a decade ago, there was a major policy shift throughout the health care industry, including with VA, which encouraged programs to deliver as much care as possible outside of beds.  In many cases this has been a productive policy.  Veterans value the convenience of using nearby community clinics for primary care needs, for example. 

However, the change took a great toll on the neuro-psychiatric and long-term care programs that housed and cared for thousands of veterans, often keeping them institutionalized for years.  Instead of developing the significant community and outpatient infrastructures that would have been necessary to adequately replace the care for these most vulnerable veterans, the resources were largely diverted to other purposes.

Where have these vets gone?  The fiscally challenged Medicaid program supports many of those who need long-term care, adding an additional burden to the states.  State homes play an important role in remaining the only VA-sponsored setting that provides ongoing, rather than rehabilitative or restorative, long-term care.  VA’s mental health programs—some of the finest in the nation—as well as significant advances in pharmaceutical therapies continue to serve and allow many veterans to recover.  However, what are in fact increasing waiting times for mental health programs and the lack of treatment options often contribute to incarceration and homelessness for the most vulnerable of these veterans.  Sadly, we hear increasing numbers of stories of veterans of Iraq and Afghanistan whose inability to deal with readjustment post-deployment have lead them to the streets or even suicide. 

Mental Health, PTSD, and Other Needs Under-estimated

Mr. Chairman, Vietnam Veterans of America’s founding principle is: “Never again will one generation of veterans abandon another.”  This is why we are imploring this committee to ensure that VA has the imperative and the resources to bolster the mental health programs that should be readily available to serve our young veterans from Iraq and Afghanistan.  Experts from within the Department of Defense estimate that as many as 17% of those who serve in Iraq will have issues requiring them to seek post-deployment mental health services and recent studies have shown that four out of five of the veterans who may need post-deployment care are not properly referred to such care. There is good reason to believe that even the rates forecast by DoD may be too low.  

VA has not made enough progress in preparing for the needs of troops returning from Iraq and Afghanistan—particularly in the area of mental health care and Traumatic Brain Injury (TBI).  Its own internal champions—the Committee on Care of the Seriously Mentally Ill and the Advisory Committee on Post-Traumatic Stress Disorder, for example – have expressed doubts about VA’s mental health care capacity to serve these newest vets.  As recently as last March, VHA’s Undersecretary for Health Policy Coordination told one commission that mental health services were not available everywhere, and that waiting times often rendered some services “virtually inaccessible.”  The doubts about capacity to serve new veterans have reverberated in reports done by the Government Accountability Office (GAO).  In addition, one recent working paper by Linda Bilmes of the John F. Kennedy School of Government at Harvard University estimates that in a “moderate” scenario in 2008 VA will require $1.8 billion to treat the veterans returning from Iraq and Afghanistan—much of this funding would be used to augment mental health care to properly serve these veterans.  VA has projected that approximately 260,000 Global War on Terrorism (GWOT) veterans will use the VA health care system in FY’08. VVA and others believe that well more than 300,000 “new” veterans will use the VHA system in FY’08.

Poor Projection Formula Inappropriate for Military Veterans Health Care Needs

A further reason that VA has underestimated the need for medical services is that they continue to use the same formula that they use for CARES, which is a civilian-based model. Mr. Chairman, VVA has testified many times that the VHA must be a “veterans’ health care system” and not a general health care system that just happens to see veterans if the VHA is to properly and adequately address the needs of veterans, particularly veterans who are sick or injured in military service. The model developed by Millman & Associates that VA uses was designed for middle-class people who can afford HMOs or other such programs. It projects only one to three presentations (things wrong with) per patient as opposed to the five to seven per veteran patient that is the average at VHA. Some adjustment to this is done on the basis of clinic stops or visits, but it still under estimates the total usage rate per individual veteran that is actually needed. Obviously one using the VA model will continually underestimate overall resources needed to care for the veterans who come to the system by using this civilian formula. Further, VHA has been consistent in underestimating the number of GWOT returnees who will seek services from the system in each of the last four years. VVA has corrected these errors in our projections.

In addition to the funds VVA is recommending elsewhere, we specifically recommend an increase of an additional billion dollars to assist VA in meeting the long-term care and mental health care needs of all veterans.  These funds should be used to develop or augment with permanent staff at VA Vet Centers (Readjustment Counseling Service, or RCS), as well as PTSD teams and substance use disorder programs at VA Medical Centers and CBOCs, which will be sought after as more troops (including demobilized National Guard members and Reservists) return from ongoing deployments.  In addition, VA should be augmenting its nursing home beds and community resources for long-term care, particularly at the State veterans’ homes.  

Improperly High Doctor - Patient and Nurse- Patient Ratios Must Be Addressed

To assist in developing these programs and augmenting all areas of veterans’ care, VVA recommends funding to accommodate the staff-to-patient ratio VA had in place before VA had dismantled so much of its neuro-psychiatric and long-term care infrastructure.  This would allow VA to better ensure timely access to care and services.  Studies have shown that inadequate staffing—particularly of nurses involved in direct care—is correlated with poorer health care outcomes in all medical disciplines.   To allow the staffing ratios that prevailed in 1998 for its current user population, VA would have to add more than 20,000 direct-care employees—MDs and nurses—at a cost of about $2.2 billion. 

The $2.2 billion funding for the staff shortfalls identified by VVA all too closely corresponds to the funding from unspecified (so called) “management efficiencies” VA has had to shoulder throughout this Administration for this to be a coincidence.  It is important to realize that the effect of leaving these funding deficiencies unfulfilled is cumulative.  That is, each year VA is forced to live with a greater hole in its budget.  GAO has joined VSOs and Congress in questioning the extent to which VA has been able to identify and realize the so-called savings created by such proposed efficiencies.  VA officials have advised GAO that the efficiencies identified in at least two recent budget proposals—FY’03 and ‘04—were developed to allow VA to meet its budget guidance rather than by detailed plans for achieving such savings (GAO-06-359R).  In other words, the savings were justified only by the need to meet the Administration’s “bottom line.” The cuts (and they were indeed budget cuts) were met by reductions in staff. (This was done primarily through attrition and then just not filling positions, although some RIFs and buyouts probably occurred during this timeframe as well.) through attrition. These so-called management efficiencies have resulted in staff deficiencies across the spectrum of medical disciplines, and across the country.  VVA hopes Congress will agree that this is no way to fund our veterans’ health care system. 

Further, the staff cuts referenced above have caused VA to often rely on contracting out using such gimmicks as the inaptly named “Project HERO” that VHA is about to use to further contract out services instead of hiring full time staff clinicians and properly training them in the wounds and maladies particular to military service, depending on what branch one served, when they served, where they served, their military occupational specialty, and what actually happened to them (e.g., SHAD biological and chemical exposures). While the VHA has created such curricula, as part of the Veterans Health Initiative (www.va.gov/vhi), most clinicians and no contractors even know of the existence of these curricula.

The extensive use of contracting out medical services by VHA is both the result of under funding, and a costly, wasteful solution to the problem created by the staff shortages resulting from the same under funding. This is not a rational or proper way to run a health care system, much less one for our nation’s veterans, who have already given so much.

Agent orange Health Care

For our last point under Medical Services, VVA believes Congress did a grave injustice to Vietnam-era veterans.  For decades, veterans exposed to Agent Orange and other herbicides containing dioxin had been granted health care for conditions that were presumed to be due to this exposure.  This special eligibility expired at the end of 2005. Despite VVA’s repeated requests, Congress did not reauthorize it.  Had Congress simply reauthorized existing authority, VA would have realized no new costs.  Now we understand that the Congressional Budget Office estimates that it will cost more than $300 million to restore this eligibility.  Why this eligibility was allowed to expire seems more a matter of dollars than sense to VVA, given the ever-mounting body of research that clearly points to conditions such as diabetes being linked to dioxin exposure. However, the pressing issue now is to reinstate veterans with these conditions for the higher priority access to services that they deserve.

Vet Centers (Readjustment Counseling Service)

VVA believes that announced expansion of the Readjustment Counseling Service by opening 23 new Vet Center is great, and a much needed move on the part of the VA. However, this will be a great thing only if the Readjustment Counseling Service (RCS) is accorded at least another 300 (+) FTEE. The RCS already needs at least another 250 full time professional staff members to provide one family counselor cross trained in PTSD and bereavement counseling at each of the 209 existing Vet Centers, and to provide 40 more staff members RCS-wide, so that the Director of RCS does not have to juggle vacancies just in order to keep operating. That is the case today, before the addition of these 23 new Vet centers.

In addition to these needed additional FTEE, VVA strongly encourages changing Chapter 41 of Title 38 to require a full time DVOP be permanently out stationed at each VA Vet Center, with the appropriate computer support, travel allowance, etc. to be able to develop jobs in the community for the vets utilizing that Vet Center. The best of the Vet Centers around the country have some sort of arrangement like this, but the state work force developments in many cases are ending that support, even where it exists.

Helping a veteran get to the point where he or she can obtain AND sustain meaningful employment at a living wage is still the central event in the readjustment process. We have not paid sufficient attention to this fact in the past, and we need to ensure insofar as possible that we provide sufficient resources for employment for those coming home today.

If the U.S. Department of Labor and the workforce development agencies that actually employ the DVOPs wont do this properly (as is currently the case), then there must be new VA Vocational Rehabilitation specialists, skilled in job placement as well as education and training issues, who are located one counselor in each Vet Center.

Medical Facilities

For medical facilities for fiscal year 2008, VVA recommends $5.1 billion.  This is approximately $1.5 billion more than the Administration’s request for fiscal year 2008.  Maintenance of the health care system’s infrastructure and equipment purchases are often overlooked as Congress and the Administration attempt to correct more glaring problems with patient care.  In FY’06, in just one example, within its medical facilities account VA anticipated spending $145 million on equipment, yet only spent about $81 million. (The rest of the funds went just to meet costs to keep the facilities open and operating.) However, these projects can only be neglected for so long before they compromise patient care, and employee safety in addition to risking the loss of outside accreditation.    The remainder of the funding was apparently shifted to other more immediate priority areas (i.e., keeping facilities operating in the short run).

VA undertook an intensive process known as CARES (Capital Asset Realignment to Enhance Services) to “right-size” its infrastructure, culminating in a May 2004 policy decision that identified approximately $6 billion in construction projects. While for the reasons noted above the VA has consistently underestimated future needs by using a fatally flawed formula, thus far Congress and the Administration have only committed $3.7 billion of this all too conservative needed funding. 

We believe the CARES estimate to be extremely conservative given that the models projecting health care utilization for most services were based on use patterns in generally healthy managed care populations rather than veterans and that the patient population base did not include readmitting Priority 8 veterans, or significant casualties from the current deployments.  Notwithstanding our concerns about the methods used in CARES, very few of the projects VA agrees are needed have been funded since this time.  Non-recurring maintenance and capital equipment budgets have also been grievously neglected as administrators have sought to shore up their operating funds.   

In a system in which so much of the infrastructure would be deemed obsolete by the private sector (in a 1999 report GAO found that more than 60% of its buildings were more than 25 years old), this has and may again lead to serious trouble.  We are recommending that Congress provide an additional $1.5 billion to the medical facilities account to allow them to begin to address the system’s current needs.  We also believe that Congress should fully fund the major and minor construction accounts to allow for the remaining CARES proposals to be properly addressed by funding these accounts with a minimum of remaining $2.3 billion. 

Medical and Prosthetic Research

For medical and prosthetic research for fiscal year 2008, VVA recommends $460 million.  This is approximately $50 million more than the Administration’s request for fiscal year 2008.  VA research has a long and distinguished portfolio as an integral part of the veterans’ health care system.  Its funding serves as a means to attract top medical schools into valued affiliations and allows VA to attract distinguished academics to its direct-care and teaching missions. 

VA’s research program is distinct from that of the National Institutes of Health because it was created to respond to the unique medical needs of veterans.  In this regard, it should seek to fund veterans’ pressing needs for breakthroughs in addressing environmental hazard exposures, post-deployment mental health, traumatic brain injury, long-term care service delivery, and prosthetics to meet the multiple needs of the latest generation of combat-wounded veterans.

 Agent Orange Research

VVA brings to your attention that VA Medical and Prosthetic Research is not currently funding a single study on Agent Orange or other herbicides used in Vietnam, despite the fact that more than 300,000 veterans are now service-connected disabled as a direct result of such exposure in that war.

When VVA pressed VA last Fall in this regard, they for the first time made available the results of some mortality studies done by VA’s Public Health & Environmental Hazards staff member Dr. Han Kang. (VVA has supplied your staff with copies of the results of these studies as we have received them from VA.)

VA tried to say that this was sufficient for research into the deleterious health care effects of Agent Orange, other herbicides used in the Vietnam War, and all of the other toxins that were rife in Vietnam during the war. With the permission of the Committee, Mr. Chairman, I ask that the results of these studies be entered into the record, as VA has never made any effort to publicize or follow up on the results which indicated that there are many more maladies that should be service connected presumptive for those who served in Vietnam, but which are not so today. This is largely the function of there not being enough studies in this area, and VA is not funding even internal research, much less outside studies that the veterans’ population is more inclined to believe would be objective and scientifically valid research. I have submitted these studies to the Subcommittee under separate cover for your consideration, Mr. Chairman.

VVA unequivocally takes the position that this total lack of funding further research that is indicated as needed by the VA’s own mortality and morbidity studies by Dr. Kang is simply unacceptable, and urges the Subcommittee to demand to know why this is the case

Women Veterans and Mental Health

 In the Iraq and Afghanistan wars “combat support troops” are just as likely to be affected by the same traumas as infantry personnel.  This has particularly important implications for our female soldiers, who now constitute about 16 percent of our fighting force.  Returning female OIF and OEF troops face ailments and traumas of a different sort.  For example, studies conducted at the Durham, North Carolina Comprehensive Women’s Health Center by VA researchers have demonstrated higher rates of suicidal tendencies among women veterans suffering depression with co-morbid PTSD.  And according to a Pentagon study released in March 2006, more female soldiers report mental health concerns than their male comrades, 24 percent compared with 19 percent.  In addition, roughly 40 percent of these women have musculoskeletal problems that doctors say likely are linked to lugging too-heavy and ill-fitted equipment.  A considerable number - 28 percent - also return with genital and urinary system infections. 

There are also gender-related social issues that make transitioning tough for women.  For example, women are more likely to worry about body image issues, especially if they have visible scars, and their traditional roles as caregivers in civilian life can set them back when they return.  In other words, they are the ones who have traditionally had the more nurturing role within our society, not the ones who need nurturing.  And lastly, female veterans now number 1.7 million.  The VA projects that by 2010, 10 percent of all veterans will be women, compared with 2 percent in 1997.  And although the VA's budget for women's health-care service has also grown, from $21 million in 2000 to an estimated $43.5 million in 2006, services are not evenly distributed throughout the VA system.

While the VA has made vast improvements in treating women since 1992, especially in treatment of PTSD and the other after effects of Military Sexual Trauma (MST) at VA Medical Centers; there are very few clinicians within the VA who are prepared to treat combat situation-induced PTSD as opposed to MST-induced PTSD. Additionally, there are already cases where returning women service personnel have a combination of the two etiologies, making it extremely difficult for the average clinician to treat, no matter how skilled in treating either combat-incurred PTSD in men, or MST-induced PTSD in women.

 Because of the number of women who are now de facto combat veterans based upon the nature of the conflicts in Afghanistan and particularly Iraq, Vietnam Veterans of America (VVA) believes there is an immediate need for research on effective, evidence-based, integrated dual diagnosis treatment modalities for women veterans suffering from PTSD and related mental health disorders.

National Vietnam Veterans Longitudinal (Readjustment) Study

No one really knows how many of our troops in Iraq and Afghanistan have been or will be affected by their wartime experiences.  Despite the early intervention by psychological personnel, no one really knows how serious their emotional and mental problems will become, nor how chronic both the neuro-psychiatric wounds (particularly PTSD) will be or how these wounds will impact their physiological health.  However, reports from researchers at Walter Reed have suggested that troops returning from service in Afghanistan and Iraq are suffering mental health problems at rates comparable to or higher than the levels seen in Vietnam War veterans. 

In fact, Vietnam Veterans of America (VVA) has no reason to believe that the rate of veterans of this war having their lives significantly disrupted at some point in their lifetime by PTSD will be any less than those estimated for Vietnam veterans by the National Vietnam Veterans Readjustment Study.

Results from the original NVVRS demonstrated that some 15.2 percent of all male and 8.5 percent of all female Vietnam theater veterans were current PTSD cases (i.e., at some time during six months prior to interview).  Rates for those exposed to high levels of war zone stress were dramatically higher (i.e., a four-fold difference for men and seven-fold difference for women) than rates for those with low-moderate stress exposure.  Rates of lifetime prevalence of PTSD (i.e., at any time in the past, including the previous six months) were 30.9 percent among male and 26.9 among female Vietnam theater veterans.  Comparisons of current and lifetime prevalence rates indicate that 49.2 percent of male and 31.6 percent of female theater veterans, who ever had PTSD, still had it at the time of their interview.  Thus the NVVRS was a landmark investigation in which a national random sample of all Vietnam Theater and era veterans, who served between August 1964 and May 1975, provided definitive information about the prevalence and etiology of PTSD and other mental health readjustment problems. The study over-sampled African-Americans, Latinos, and Native Americans, as well as women, enabling conclusions to be drawn about each subset of the veterans’ population.

The NVVRS enabled the American public and medical community to become aware of the documented high rates of current and lifetime PTSD, and of the long-term consequences of high stress war zone combat exposure.  Because of its unique scope, the NVVRS has had a large effect on VA policies, health care delivery and service planning.  In addition, because the study clearly demonstrated high rates of PTSD and strong evidence for the persistence of this disease, it was generally accepted that the VA would pursue a follow-up or longitudinal study of the original participants in this seminal research project.

Thus in 2000 the Congress, by means of Public Law 106-419, mandated the VA to contract for a subsequent report, using the exact same participants, to assess their psychosocial, psychiatric, physical, and general well being of these individuals.  It would enable it to become a longitudinal study of the mortality and morbidity of the participants, and draw conclusions as to the long-term effects of service in the military period, as well as about service in the Vietnam combat zone in particular. The law requires that VA use the previous report as the basis for a longitudinal study.

Shortly after enactment of the law, in early 2001 the VA solicited proposals for non-VA contractual assistance to conduct a longitudinal study of the physical and mental health status of a population of Vietnam era veterans originally assessed in the NVVRS.  It is apparent that a longitudinal follow-up to the NVVRS is necessary in order to meet the requirements of the law, and to adequately satisfy policy and scientific questions.  However, not only has the VA failed to meet the letter of the law, there has been no effort to build upon the resources accumulated from this unique and comprehensive study of Vietnam veterans in a highly cost-efficient and scientifically compelling manner. 

Such a longitudinal study would provide clues about which VA health care services are effective and about ways to reach the veterans who receive inadequate services or do not seek them at all.  And this has important consequences for America’s current and future veterans.

At that same hearing on Research & Development on June 7, 2006, the VA also said that they could not do the study because they could only find 300 of the original more than 2,500 persons in the statistically valid random sample chosen by the Gallup Organization at a public cost of more than $1 million in 1984 dollars. VVA suggest that a more intensive effort to locate these veterans be undertaken before the VA is allowed to scuttle a longitudinal study for this reason. If that were true (which strains credulity at best) that all but 300 are dead, then that would mean that 85% of that valid national sample has died in the past 25 years.  VVA would suggest that this is unlikely.

 The VA has tried to claim they would be better off using the widely discredited and failed “Twins” study data base now controlled by the Institute of Medicine, that has no women at all, and not nearly enough African-Americans, Hispanics or Asian-Americans in the data base to make valid conclusions about each of these important sub-groups in the Vietnam veteran population. Furthermore, the “twins” database is even so small that it is not a statistically valid random sample for anybody. One can speculate that the VA refuses to obey the law because they do not want a longitudinal study, or perhaps they do so because they do NOT want to have validated the results of what the NVVLS may demonstrate in regard to very high mortality and morbidity of Vietnam veterans, especially those most exposed to combat.

It is now clear that the VA is ignoring the law and the Congress and plain refusing to do the study. It also seems clear that they intend to continue thumbing their nose at the Congress, and regarding laws they do not like as cute ideas put forth by the Congress that can be ignored anytime and in any way they choose.

The VA has said in Congressional testimony that “the Inspector General stopped the study”, when in fact the IG has no line authority at all to do any such thing. The Undersecretary and the Secretary stopped the study. The only real criticism by the IG was for VHA failing to follow proper contract procedures or exercise proper oversight. Certainly the specious to the point of being just plain silly reasons that the Director of Medical Research and others from VA convince no one that this is anything but politically motivated and ordered to try and minimize possible future costs to the VA.

 Because the VA has still not moved forward and contracted to finish the National Vietnam Veteran Readjustment Study (NVVRS), Vietnam Veterans of America (VVA) strongly urges that the VA follow the law, and contract to get this study completed as soon as possible, as it will provide both the medical community and America’s veterans’ community valuable insight into chronic PTSD and other socio-psychological readjustment problems of combat theater veterans and when and how these problems will be likely to manifest themselves in the current generation. However, VVA frankly does not anticipate that VA will do the right thing, or even obey the law, unless they are compelled to so by means of the power of the purse.

It has now come to our attention that VA, though their contract officer, is demanding of the Research Triangle Institute (RTI) to know the names and social security numbers of the participants in the original study, who had been assured anonymity. The previous, and some of the current VHA leadership not only has tried to besmirch the reputation of this respected research institution by citing things in a report by the Inspector General (IG) at VA that the report did not contain, but now they are threatening RTI with legal and or other punitive action, through the contract officer, if they don’t violate privacy rights of the human participants in this study. This unconscionable effort to compromise the study population, to violate basic scientific principle of protection of human subjects, as well as violate the privacy rights of the individuals concerned, must be stopped by the Congress before the VA totally foils efforts to conduct a proper follow up study ever being done on this population.

Mr. Chairman, finally VVA urges this Subcommittee the to compel VA to obey the law (Public Law 106-419) and conduct the long-delayed National Vietnam Veterans Longitudinal Study. VVA asks that you specifically request of VA to advise the Subcommittee on steps it will take to complete this study properly within two years, as a comprehensive mortality and morbidity study.

Traumatic Brain Injuries

Medical experts say traumatic brain injuries (i.e., TBIs) are the “signature wound” of the Iraq war, a by-product of improved body armor that allows troops to survive once-deadly attacks. Unfortunately, the armor does not fully protect against the blast effects of roadside explosive devices and suicide bombers.  These injuries have become so common that both Army and the VA have set up special traumatic brain injury centers. For this both the VA and the Army are to be commended.  Symptoms include slowed thinking, severe memory loss, and coordination and impulse control problems. 

TBI shares some symptoms with, but is markedly different than Post Traumatic Stress Disorder (PTSD), which is triggered by extreme anxiety and permanently resets the brain’s fight-or-flight mechanism.  Battlefield medics and medical supervisors often miss traumatic brain injuries, and many troops don’t know the symptoms or won’t discuss their problems for fear of being sent home with the stigma of mental illness.  In this war, it is the blast waves themselves that cause the most damage and have proven the most problematical, the most disabling, and the most difficult to treat, primarily because they severely damage a soldier’s nervous system. 

Primary injuries to the brain include concussions which can result in the loss of consciousness and what neurologists used to call “coup-contra-coup” injuries, a term formerly restricted to central nervous injuries resulting from severe blows to the head. 

Indeed, soldiers walking away from blasts have later discovered that they suffer from memory loss, short attention spans, muddled reasoning, headaches, confusion, anxiety, depression, and irritability. 

In a 2004 article in The Journal of Brain Injury entitled “Depression, Cognition and Functional Correlates of Recovery Outcome after Traumatic Brain Injury,” neurologists acknowledge that patients with mild to traumatic brain injuries are more affected by their emotional problems than by their residual physical disabilities.  The article ends with an admonition that it is important to screen blast injury patients for depression and to conduct neuropsychological testing as soon as possible after the head injury in order to initiate treatment and ensure successful re-entry back into civilian life.  Yet to date the Pentagon has been unwilling to fund a screening program for returning soldiers for mild brain injuries, arguing that the long-term effect of brain injuries needs more research. Researchers have found that up to 10% of the troops suffer from concussions during their tours, a figure that rises to 20% for those in combat units.  One thing is clear:  subtle TBIs can and do result in PTSD like symptoms, even if actual PTSD due to combat stressors is not present.

Certain TBI symptoms, such as seizures, can be treated with medication, but the most devastating effects of TBIs – depression, agitation and social withdrawal – are difficult to treat with medications, especially when loss of brain tissue occurs.  In troops with documented TBIs, the loss of brain function is often compounded by other serious injuries that affect physical motor coordination and memory functions.  These patients need a combination of psychological, psychiatric and physical rehabilitation treatment that is difficult to coordinate in a traditional hospital setting, even when it is properly diagnosed at an early date.

Furthermore, as more and more troops return home with even mild brain damage, their families must contend not only with the shock of seeing the physical and psychological destruction to their loved ones, but also with how their own lives change dramatically.    In addition, there are issues about the intensity and drains of vitally needed family support that will be hard to sustain, as well as significant issues regarding the complexity of the medical and other specialized needs that have to be addressed. 

A TBI to a thirty-five-year-old with two children at home is a wound that also affects the future of the whole family.  For the majority of head injuries there is the inability to concentrate, the mood swings, depression, anxiety, even the loss of a job.  The economic and emotional instability of a family can be as terrifying and as real as any difficulty focusing or simply waking and crying in the middle of the night. 

But Vietnam Veterans of America’s (VVA) real concern is that many significant closed head injuries are going undiagnosed, and we fear that subtle but real neurological and related psychological problems are missed in soldiers who are exposed to blasts, but who are not visibly injured enough to enter the medical evaluation chain.  The limited medical research on blast injuries clearly shows that such injuries are notorious for their delayed onset.

Vietnam Veterans of America (VVA) strongly urges this Subcommittee to push for more R&D funds, and push hard that part of these funds be used to foster enhanced research efforts to determine the relationship and long-term impacts of TBIs, especially so-called “mild” brain injuries, to the delayed onset of Post Traumatic Stress Disorder (PTSD).

Assured Funding for Veterans’ Health Care

Once this Congress provides a budget that shores up VA medical services and facilities, it will need to assure that VA continues to be funded at a level that allows it to provide high-quality health care services to the veterans that need them. That is where enactment of assured funding will come in.  Once enacted, an assured funding mechanism will ensure that, at a minimum, annual appropriations cover the cost of inflation and growth in the number of veterans using VA health care.  It will allow VA administrators some predictability in both how much funding it will receive and when it will be received, resulting in higher quality and ultimately more cost-effective care for our veterans.

Accountability at VA

So much of what VVA and the Congress on both sides of the aisle find wrong or disturbing at the VA revolves around the general and all-pervasive issue of little or no accountability, or imprecise fixing of authority commensurate with accountability mechanisms that are meaningful (and vice versa) in all parts of the VA.

Within the past year, VA has finally made significant progress in meeting the minimum goal of at least 3% of all contracts and 3% of all subcontracts being let to service-disabled veteran business owners. Secretary Nicholson and Deputy Secretary Mansfield are to be commended on setting the pace for the Federal government. It is instructive in this discussion, however, that the action directed by the Secretary to put achievement or substantial real progress toward meeting or exceeding the 3% minimum into the performance evaluation of each Director of the 21 Veterans Integrated Service Networks (VISNs) was a key element enabling VA to be the first large agency to reach the goal mandated by law.  Some 85% of all VA procurement is through VHA, primarily through the VISNs is the key factor in this achievement. 

There is an expression that “what is measured, matters.” Hard-working people with many responsibilities will understand the priority their leaders give certain policy by whether it is measured and has consequences. Putting procurement from service disabled veteran owned businesses in the performance evaluations means that those managers who ignore a requirement do not get an outstanding or superior rating, and hence no bonus. VVA, and now the VA in at least this one instance, have found that it is amazing how reasonable almost all people can be when you have their full attention.

There is no excuse for the dissembling and lack of accountability in so much of what happens at the VA. It can be cleaned up and done right the first time, it there is the political will to hold people accountable for doing their job properly.

Lastly, there is no excuse for allowing the continuation of the practice of VHA to “lose” tens of millions (sometimes hundreds of millions) of taxpayer dollars that are appropriated to VHA for specific purposes, whether that purpose be to restore organizational capacity to deliver mental health services, particularly for PTSD and other combat trauma wounds, or to conduct outreach to GWOT veterans as well as de-mobilized National Guard and Reserves returnees from war zone deployments. There is a consistent pattern of VA, particularly VHA, to either really not know what happened to large sums of money given to them for specific reasons, or they7 are not telling the truth to the Congress and the public. In either case, it is unacceptable and cannot be tolerated any longer.

In the proposed budget submittal, VVA struggled with accounting for the dollars footnoted in the President’s submittal as “Adjusted for IT.” We could not find an accurate accounting. When we asked, it turns out that no one that we have spoken to, including VA officials, can fully explain at least $200 million-plus of this “adjustment” either. And this is before they get their hands on the dollars.

VVA urges this Subcommittee, and your colleagues on Appropriations, to make this the year that this sloppy nonsense and dissembling is stopped once and for all. Accountability will only come about when Congress absolutely demands that these folks be fully accountable for performance, and for accounting for each and every taxpayer dollar.

Thank you again, Mr. Chairman, for allowing Vietnam Veterans of America (VVA) to submit this statement for the record regarding the level of resources necessary for the veterans’ health care so vitally needed by veterans of every generation. We hope these thoughts and recommendations prove to be of some use to you in the vital work of helping to ensure that the resources, and the accountability mechanisms, are in place to get the job for every generation of veterans that has earned the right to medical care by virtue of their service.

VVA urges you to leave no veteran behind.

We look forward to working with you and the distinguished Members of this Subcommittee to obtain an excellent budget for VA in FY’08, and to ensure the next generation of veterans’ well being by enacting assured funding. 

VVA will be happy to answer any questions you and your colleagues may wish to tender to us in writing.

MEDICAL SERVICES (in millions $)
   
FY 2007 Est. Baseline (Includes Projected Collections)

27612

   
Medical Services Payroll  
Annualization costs for 136,000 FTE (FY 07 and FY 08)

959

Address 8% Increase in Demand

1088

Restore and Enhance LTC and MH Services

1000

Restore Adequate Staff to Patient Ratio to Address
    Timeliness and Assure Quality of Care

2200

 

5247

Other Inflation and Increase in Demand
Drugs

543

Other Med. Products

211

Contracted Medical Services

488

CPI (non medical)

84

 

1326

New Initiatives  
Restore Services for Agent Orange exposed Veterans

300

 

300

   
Subtotal, Medical Services

6873

 

[ The following attachments are being retained in the committee file: Watanabe, Kevin K., Kang, Han K., "Military Service in Vietnam and the Risk of Death from Trauma and Selected Cancers," Elsevier Science Inc. (1995); Watanabe, Kevin K., Kang, Han K., "Mortality Patterns among Vietnam Veterans, a 24-Year Retrospective Analysis," American College of Occupational and Environmental Medicine; "Health Status of Army Chemical Corps Vietnam Veterans Who Sprayed Defoliant in Vietnam," American Journal of Industrial Medicine; Dalager, Nancy A., Kang, Han K., Thomas, Terry L., "Cancer Mortality Patterns Among Women Who Served in the Military: The Vietnam Experience," American College of Occupational and Environmental Medicine.]