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Submission For The Record of Paralyzed Veterans of America

Mr. Chairman and members of the Subcommittee, Paralyzed Veterans of America (PVA) would like to thank you for the opportunity to submit a statement for the record regarding the proposed legislation.  We appreciate the continued emphasis on providing the best quality health care for veterans who experience mental illness as well as veterans who live in rural areas—two segments of the veteran population that present the some of the most difficult challenges. 

H.R. 2790, Director of Physician Assistant Services

PVA fully supports H.R. 2790, a bill that would establish the position of Director of Physician Assistant Services within the Veterans Health Administration (VHA) at the Department of Veterans Affairs (VA).  This legislation mirrors the recommendation included in The Independent Budget for FY 2008 and that will be included in the FY 2009 edition as well. 

As explained in The Independent Budget, Physician Assistants (PA) in the VA health care system are the providers for millions of health care visits every year in primary care clinics, ambulatory care clinics, emergency medicine, and in 22 other medical and surgical specialties.  Since the PA Advisor position was authorized by P.L. 106-419, the “Veterans’ Benefits and Health Care Improvement Act of 2000,” the number of PA’s in the VHA have grown significantly.  And yet, four Under Secretaries for Health have all refused to make this position a full-time equivalent employee position.  We appreciate the fact that this legislation will finally correct this senseless decision. 

H.R. 3458, Pilot Program on TBI Care for Rural Veterans

PVA has no objection to the provisions outlined in H.R. 3458.  The proposed legislation would authorize the VA to conduct a pilot program in five rural states.  The program would be coordinated with the VA’s Office of Rural Health.  The goal of the pilot program would be to provide the best available services for veterans who have experienced traumatic brain injury (TBI).  We appreciate the fact that the legislation provides some protections to ensure that properly trained professionals are caring for the needs of this critical segment of the veteran population. 

While we have expressed some concerns in the past with the idea of contract care for different groups of veterans, we understand that the VA must tap into the resources and expertise that private providers can offer.  To that end, we have no objection to the provisions of the legislation that authorize contract care when necessary and appropriate.  It is important that services for veterans who have incurred a TBI be coordinated between the VA and private providers. 

H.R. 3819, the “Veterans Emergency Care Fairness Act”

PVA generally supports the provisions of H.R. 3819, the “Veterans’ Emergency Care Fairness Act,” as the legislation is in accordance with the recommendations of The Independent Budget for FY 2008.  However, we remain concerned about some of the eligibility criteria that determine what veterans are eligible for this reimbursement.  In accordance with The Independent Budget for FY 2008, we believe that the requirement that a veteran must have received care within the past 24 months should be eliminated.  Furthermore, we believe that the VA should establish a policy allowing all veterans enrolled in the health care system to be eligible for emergency services at any medical facility, whether at a VA or private facility, when they exhibit symptoms that a reasonable person would consider a medical emergency.

H.R. 4053, the “Mental Health Improvements Act”

First, I would like to say that PVA generally supports this proposed legislation which improves services provided by the VA to veterans with Post-Traumatic Stress Disorder (PTSD) and substance use problems.  Current research highlights that Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) combat veterans are at higher risk for PTSD and other mental health problems as a result of their military experiences.  In fact, the most recent research indicates that 25 percent of OIF/OEF veterans seen at a VA facility have received mental health diagnoses.

We are pleased with the provisions of Section 102 and 103 of the legislation.  In fact, The Independent Budget is set to recommend that VA provide a full continuum of care for substance use disorders including additional screening in all its health care facilities and programs—especially primary care.  We also believe outpatient counseling and pharmacotherapy should be available at all larger VA community-based outpatient clinics.  Furthermore, short-term outpatient counseling including motivational interventions, intensive outpatient treatment, residential care for those most severely disabled, detoxification services, ongoing aftercare and relapse prevention, self help groups, opiate substitution therapies and newer drugs to reduce craving, should be included in VA’s overall program for substance abuse and prevention. 

Although we support the creation of PTSD Centers of Excellence outlined in Section 105 of the legislation, we wonder whether this step is necessary.  The VA already maintains a broad network of PTSD treatment centers.  Furthermore, in 1989, the VA established the National Center for Post-Traumatic Stress Disorder as a focal point to promote research into the causes and diagnosis of this disorder, to train health care and related personnel in diagnosis and treatment, and to serve as an information clearinghouse for professionals.  The Center offers guidance on the effects of PTSD on family and work, and notes treatment modalities and common therapies used to treat the condition.  This center already functions as a center of excellence.  At the very least, it should be incorporated into this new network of centers of excellence.   

PVA has some concerns with the pilot program outlined in Title II of the bill.  While we certainly support the emphasis placed on peer counseling and outreach, we maintain our concerns about contract services with community health centers.  The VA should be able to provide the services described in the legislation through judicious application of its already existing fee basis authority.  We do, however, appreciate the emphasis on ensuring that the non-VA facilities are compliant with VA standards, particularly through additional training managed specifically by the VA. 

While we also support Title III of the legislation regarding research into comorbid PTSD and substance use disorder, we wonder if this is duplicative with activities already taking place at the National Center for PTSD.  However, PVA has long supported research initiatives into various types of conditions and the treatments associated with them. 

Finally, we recognize the unique challenge associated with providing mental health services to families of veterans.  This is an area that the VA has had little experience with in the past.  Likewise, we see no problem with the VA examining the feasibility of providing readjustment and transition assistance to veterans and their families.  It is certainly an issue that has become more apparent as more men and women return from conflicts abroad broken and scarred.  The impact that this has on the veteran and his or her family cannot be overstated. 

H.R. 4107, the “Women Veterans Health Care Improvement Act”

PVA supports H.R. 4107, the “Women Veterans Health Care Improvement Act.”  This legislation is meant to expand and improve health care services available in the Department of Veterans Affairs (VA) to women veterans, particularly those who have served in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF).  More women are currently serving in combat theaters than at any other time in history.  As such, it is important that the VA be properly prepared to address the needs of what is otherwise a unique segment of the veterans population. 

Title I of the bill would authorize a number of studies and assessments that would evaluate the health care needs of women veterans.  Furthermore, these studies would also identify barriers and challenges that women veterans face when seeking health care from the VA.  Finally, the VA would be required to assess the programs that currently exist for women veterans and report this status to Congress.  We believe each of these studies and assessments can only lead to higher quality care for women veterans in the VA.  They will allow the VA to dedicate resources in areas that it must improve upon.

Title II of the bill would target special care needs that women veterans might have.  Specifically, it would ensure that VA health care professionals are adequately trained to deal with the complex needs of women veterans who have experienced sexual trauma.  Furthermore, it would require the VA to disseminate information on effective treatment, including evidence-based treatment, for women veterans dealing with Post-Traumatic Stress Disorder (PTSD).  While many veterans returning from OEF/OIF are experiencing symptoms consistent with PTSD, women veterans are experiencing unique symptoms also consistent with PTSD.  It is important that the VA understand these potential differences and be prepared to provide care. 

PVA views this proposed legislation as necessary and critical.  The degree to which women are now involved in combat theaters must be matched by the increased commitment of the VA, as well as the Department of Defense, to provide for their needs when they leave the service.  We cannot allow women veterans to fall through the cracks simply because programs in the VA are not tailored to the specific needs that they might have. 

H.R. 4146, Emergency Medical Care in Non-VA Facilities

While we support the intent of this proposed legislation, we believe that this issue is handled in a more comprehensive manner by H.R. 3819.  Therefore, we recommend that the subcommittee table this bill in favor of approving H.R. 3819.

H.R. 4204, the “Veterans Suicide Study Act”

The incidence of suicide among veterans, particularly Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans, is a serious concern that needs to be addressed.  Any measure that may help reduce the incidence of suicide among veterans is certainly a good thing.  As such, PVA supports this legislation.  This bill would require the VA to conduct a study to determine the number of veterans who have committed suicide since January 1, 1997.

It is important to note that VA has made suicide prevention a major priority.  VA has developed a broad program based on increasing awareness, prevention, and training of health care staff to recognize suicide risk.  A national suicide prevention hotline has been established and suicide prevention coordinators have been hired in each VA medical center.  Research into the risk factors associated with suicide in veterans and prevention strategies is underway.

However, it is equally important to point out that suicide prevention is something that can be addressed early on in the mental health process.  With access to quality psychiatric care and other mental health professionals, many of the symptoms experienced early on can be addressed in order to reduce the risk of suicide down the road.  This extends to proper screening and treatment for veterans who deal with substance abuse problems as well. 

H.R. 4231, the “Rural Veterans Health Care Access Act”

PVA opposes this proposed legislation.  H.R. 4231 would establish a pilot program that would require the VA to provide vouchers to veterans who served in OEF/OIF who need mental health services, and who reside at least 30 miles from a VA facility that employs a full-time mental health professional.  These vouchers could then be used to purchase mental health services with private providers.  PVA finds it difficult to comprehend the rationale for establishing a precedent for veterans to seek services outside of the VA health care system, as this proposed legislation would do.    

First, let me say that we are absolutely opposed to any suggestion that veterans be given a voucher to seek health care services outside of the VA.  This step amounts to nothing more than privatization of the VA, turning the VA health care system into an insurer of care instead of a provider of care.  Likewise, The Independent Budget has also taken a position against vouchering in the past.  Veterans who would seek care in the private sector would lose the many safeguards built into the VA system through its patient safety program, evidence-based medicine, electronic medical records and medication verification program.  These unique VA features culminate in the highest quality care available, public or private.  Loss of these safeguards, that are generally not available in private sector systems, would equate to diminished oversight and coordination of care. 

We are also very concerned about the seemingly arbitrary nature with which a veteran’s eligibility for this voucher is established.  The legislation states that if a veteran resides 30 miles or more from a VA medical facility that does not employ a full-time mental health professional, then that veteran is eligible for a voucher.  Given the fact that the definition of rural is very subjective, I would suggest that 30 miles from a facility does not qualify as rural. 

Furthermore, we believe that it is patently unfair to suggest that the VA cannot meet the need if the mental health professional in that local facility is not a full-time employee.  If a VA facility is able to provide a mental health appointment in a timely manner, regardless of the employment status of the mental health professional, then it is unnecessary to allow a veteran to go into the private sector with a voucher.  Otherwise, this represents mandating private care for the sake of convenience and not for the sake of demonstrated need. 

Ultimately, we cannot support vouchering of any health care services in the VA because we believe it will only diminish the quality of care in the VA health care system.  Furthermore, we believe that this pilot program would set a dangerous precedent, encouraging those who would like to see the VA privatized.  Privatization is ultimately a means for the federal government to shift its responsibility of caring for the men and women who served. 

We look forward to working with the Subcommittee to develop workable solutions that will allow veterans to get the best quality care available.  We would like to thank you again for allowing us to submit a statement for record on these important measures.  We would be happy to answer any questions that you might have.