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Witness Testimony of Adrian Atizado, Disabled American Veterans, Assistant National Legislative Director

Mr. Chairman, Ranking Member Miller and other Members of the Subcommittee—

Thank you for inviting the Disabled American Veterans (DAV) to testify at this important legislative hearing of the Subcommittee on Health of the Committee on Veterans’ Affairs.  DAV is an organization of 1.4 million service-disabled veterans, and along with its auxiliary, devotes its energies to rebuilding the lives of disabled veterans and their families.

You have requested testimony today on ten bills primarily focused on health care services for veterans under the jurisdiction of the Veterans Health Administration (VHA), Department of Veterans Affairs (VA).  Your staff indicated two additional draft bills would be considered but we did not receive those two bills in time to include them in this testimony.  With exception to the aforementioned draft legislation, this statement outlines our positions on all of the proposals before you today.  The comments are expressed in numerical sequence of the bills, and we offer them for your consideration.

H.R. 1448 — The VA Hospital Quality Report Card Act of 2007

H.R. 1448 would establish a "hospital report card" covering a variety of activities of inpatient hospital care occurring in the medical centers of the Department.  We support this bill, because it is consistent with trends occurring in private sector health care.  We believe that veterans under VA care have the same rights as private sector patients to review the quality and safety of the care they receive while hospitalized.  We do note, however, that the purposes of this bill do not cover the grand majority of overall patient care workload in VA health care, namely primary (outpatient) care and extended care services provided in VA's nursing home care units and its various contracted programs.  Nevertheless, this is a good bill and one that is supported by DAV.  We do note for the Committee's purposes, that the term "VA hospital" was supplanted by the term "VA medical center" in prior legislation.  You may wish to consider conforming this bill accordingly, should the Committee decide to approve and report it.

H.R. 1853 — The Jose Medina Veterans Affairs Police Training Act of 2007

H.R. 1853 would require the Secretary of Veterans Affairs to ensure that officers of the VA police service be trained with respect to officers’ interactions with veterans possibly suffering from mental illnesses.  While DAV does not have a resolution dealing with this issue, we consulted with the National Alliance for Mental Illness (NAMI) and its NAMI Veterans Council, an advocacy group that, like DAV, is deeply concerned about VA mental health programs and veterans who benefit from them.  NAMI fully supports the concept of adequate training being provided to VA police, who are sworn federal police officers charged with providing physical and personal security at all VA health care facilities.  We concur with NAMI’s views on this issue.  We would suggest that the bill be amended, however, to ensure that properly credentialed mental health practitioners (principally those whom VA employs within the VHA to care for veterans with mental illnesses) be designated as training resources for the purposes of this bill.

H.R. 1925 — To direct the Secretary of Veterans Affairs to establish a separate Veterans Integrated Service Network for the Gulf Coast region of the United States

H.R. 1925 would establish a 22nd Veterans Integrated Service Network (VISN) in the western Panhandle of Florida, far south Alabama, and eastern Mississippi, within one year of date of enactment.

DAV does not have a resolution from our membership addressing this issue.  It should be noted however, that the bill raises valid questions on the relevance and effectiveness of current VISN boundary alignments.  These VA jurisdictional lines have been in place with only one adjustment for the past 12 years.  These boundaries were generally formed based on veteran patient care referral patterns established in the 1980s, and it should be recalled that VA has revolutionized its patient care system over the past dozen years. 

It is unclear if VA has reviewed whether the current alignment is optimal or may need adjustment.  Also, it should be noted that some parts of the geographic area encompassed by the bill’s intent is still in transition in terms of VA physical assets, with no major affiliated VA medical centers and only one significant VA facility in Florida, the Pensacola Outpatient Clinic, one in Alabama, the Mobile Outpatient Clinic and one Mississippi VA medical center, in Jackson.  Distances and access to these facilities is challenging for the veterans of the region, especially for specialized VA services that had generally been provided by the New Orleans, Louisiana VA facility until Hurricane Katrina destroyed it in 2005.  It is also important to note that the Florida Panhandle area is not a part of VISN 8, constituting the remainder of the State of Florida excepting a few counties along its northern border.  With most of this area now embedded within VISN 16, the VA system’s largest VISN (encompassing parts of eight States), the proponent of this bill makes a valid argument that perhaps a new alignment is in order.

H.R. 2005 — Rural Veterans Health Care Improvement Act of 2007

Section 2 of this bill would improve reimbursement rates for veterans for their travel expenses related to VA medical care.  It would reimburse veterans at the same rate paid to federal employees, by increasing it from 11 cents per mile to 48.5 cents per mile.

For several years, we have urged VA to correct the inequity in its travel reimbursement program and include a line item in the budget to make a fair adjustment in travel pay while retaining sufficient funding for direct medical care.  Given the cost of transportation in 2007, including record-setting gasoline prices, a reimbursement rate unchanged since 1977 pales in comparison to the actual cost of travel.  Adequate travel expense reimbursement is directly tied to access to care for many veterans and not a luxury. 

The VA beneficiary travel program is intended by Congress to assist veterans in need of VA health care to gain access to that care.  While the mileage reimbursement rate is currently fixed, actual reimbursement is limited by law with a $3.00 per trip deductible capped at $18.00 per month.  The mileage reimbursement rate has not been changed in almost 30 years, even though the VA Secretary is delegated authority by Congress to make rate changes when warranted.  The law also requires the Secretary to make periodic assessments of the need to authorize changes to that rate.  Unfortunately, no Secretary has acted to make those changes, despite the obvious need to update the rate of reimbursement to reflect rises in travel and transportation costs.

 DAV Resolution No. 212 is a long-standing resolution supporting repeal of the beneficiary travel pay deductible for service-connected veterans and to increase travel reimbursement rates for all veterans who are eligible for reimbursement.  Additionally, we support legislation that has been introduced in Congress to repeal the mandatory deductible and increase the rate veterans are reimbursed for their authorized travel to and from VA services.  We believe the House and Senate bills titled the “Veterans Travel Fairness Act,” offer a fair and equitable resolution to this situation which we have been concerned for many years.  We urge this Subcommittee to approve and enact legislation this year to reform the VA beneficiary travel program. 

Section 4 of this measure would establish a grant program to provide innovative transportation options to veterans in remote rural areas.  The bill tasks the Director of VA’s Office of Rural Health to create a program that would provide grants of up to $50,000 to veterans’ service organizations and State veterans’ service officers to assist veterans with travel to VA medical centers and to improve health care access in remote rural areas.  The bill authorizes $3 million per year for the grant program through 2010.

In 1987, the DAV, in coordination with VA’s Voluntary Service program, began buying and donating vans to VA for the purpose of transporting veterans to receive VA medical care.  Since that time, the DAV National Transportation Network has become a very significant and successful partnership between VA and DAV.  We have donated 1,959 vans to VA facilities at a cost exceeding $39 million.  Since its inception, these vans, their DAV volunteer drivers and medical center volunteer transportation coordinators have transported more than 10 million veterans over 397 million miles.  We plan to continue and enhance this program, not only because the VA beneficiary travel rate is so low, but also we have found our transportation network serves as a truly vital link between rural veterans and crucial VA health care.  Its absence would equate to the actual denial of care for eligible veterans because many of them have no means to substitute.  Although as an organization, the DAV does not accept federal funds such as the grant program; however, knowing first hand the value and effectiveness of such a program, we would not oppose this section of the bill.

Section 3 of this bill would establish at least one and no more than five Centers of Excellence to research ways to improve care for rural veterans.  The centers would be based at VA medical centers with strong academic connections.  The Office of Rural Health would establish between one and five centers across the country with the advice of an advisory panel.

Existing VA research, education clinical centers, and various centers of excellence have proven to be a valuable resource to educate sick and disabled veterans as well as VA health care providers on new and effective treatment regimes.  We are hopeful the proposed Rural Health Research, Education and Clinical Care Centers will strive to strike the balance we seek when providing better outreach and high quality VA medical care to veterans residing in rural and remote areas. 

To examine alternatives for expanding care for rural veterans, section 5 of this measure would require the VA to conduct demonstration projects through the recently created VA Office of Rural Health to establish partnerships between the VA, Centers for Medicare and Medicaid Services, and the Department of Health and Human Services to coordinate care in critical access hospitals and community health centers.  In addition, VA would be required to expand coordination with Indian Health Service for Native American veterans, and a report to Congress on these test projects would be due in two years.

While these initiatives are laudable, we recommend the VA office of Rural Health be given ample opportunity to discharge the responsibilities specified by Congress in Public Law 109-461 which would include developing, refining, and promulgating policies, best practices, lessons learned, and innovative and successful programs to improve care and services for veterans who reside in rural areas of the United States.  In addition, we urge this Subcommittee to provide oversight and urge the Department of proceed with expeditious implementation by the Department.

H.R. 2172 — The Amputee Veteran Assistance Act

This measure seeks to improve VA’s prosthetics programs by requiring all VA orthotic/prosthetic laboratories and clinics to be certified by either of the two leading boards in these fields, the American Board for Certification in Orthotics and Prosthetics or the Board of Orthotics and Prosthetic Certification, within five years of the enactment of this bill, and allow disabled veterans to obtain new devices and seek care for the repair and servicing of their existing prosthetic devices from outside the VA system when VA facilities are unable to perform the required service or repairs due to a lack of technology or capability or when a suitable VA facility is not within a 55 mile radius.

The bill would also require a complete review and a report to Congress by VA of its prosthetic laboratories and clinics to determine the need to modernize such facilities to ensure that the VA is capable of servicing and repairing the most technologically advanced prosthetic devices.  Also, VA would be required to complete a review and a report to Congress on VA prosthesists to determine what kinds of training and education will be needed to ensure that its prosthesists have the required knowledge to service and repair the latest prosthetic devices. 

The DAV agrees that the Department’s prosthetics program should be able to provide all necessary prosthetic services, devices, and supplies for the proper treatment of service-connected disabled veterans.  We believe much of the bill’s requirements are already being addressed and implemented by VA.  We are concerned however, with the bill’s requirement for VA to enter into one contract with one non-VA entity to repair and service prosthetic devices in certain circumstances.  In addition to the arbitrary nature of a 55-mile radius as a requirement to contract for the service and repair of prosthetic devices, VA currently utilizes numerous service and repair contractors to allow a more personalized and convenient care to veteran in need of prosthetic and orthotic devices.

H.R. 2173 — To amend title 38, United States Code, to authorize additional funding for the Department of Veterans Affairs to increase the capacity for provision of mental health services through contracts with community mental health centers, and for other purposes

This measure would allow the VA to provide mental health services through contracts with community mental health centers, and authorizes appropriations of $150 million from fiscal years 2008 through 2010 for such contracts.

First and foremost, DAV’s position on contracted or fee-based care is well known.  We believe that VA purchased care is an essential tool in providing timely access to quality medical care.  Current law limits the indiscriminant use of VA purchased care to specific instances so as not to endanger VA facilities’ ability to maintain a full range of specialized inpatient services for all enrolled veterans and  to promote effective, high quality care for veterans, especially those disabled in military service and those with highly sophisticated health problems such as blindness, amputations, spinal cord injury or chronic mental health problems.

Second, as VA’s contract workloads have grown significantly at a cost of about $3 billion each year, it has not been able to monitor this care, consider its relative costs, analyze patient care outcomes, or even establish patient satisfaction measures for most contract providers.  This measure does not include provisions to address our concerns that VA has no systematic process for contracted care services to ensure that:

  • care is safely delivered by certified, licensed, credentialed providers;
  • continuity of care is sufficiently monitored, and that patients are properly directed back to the VA health-care system following private care;
  • veterans’ medical records accurately reflect the care provided and the associated pharmaceutical, laboratory, radiology and other key information relevant to the episode(s) of care; and
  • the care received is consistent with a continuum of VA care.

Any bill seeking to contract for care outside VA without addressing these concerns would essentially shift medical resources and veterans from VA to the private sector to the detriment of the VA health care system and eventually sick and disabled veterans themselves.  VA operates under constant pressure to do more with less and we believe the expansion of the current form of VA contracted care would benefit some veterans at the cost of eroding VHA’s patient resource base, undermine the Department’s ability to maintain its specialized service programs, and endanger the well being of veteran patients under care within the system.

We are concerned that this bill does not provide any consideration for judicious use of contract care nor does it address our concerns regarding the lack of a systematic process for contract care.  Such a measure could place at risk VA’s well recognized qualities as a renowned and comprehensive direct provider of health care.

H.R. 2192 — To amend title 38, United States Code, to establish an Ombudsman within the Department of Veterans Affairs

This measure would require VA to assign an Ombudsman to act as a liaison for veterans and their family members to navigate the VA health care and benefits system.  We appreciate the intent of this bill; however, we believe VA has taken actions to address these issues by providing assistance and outreach to newly returning veterans through a cadre of case managers, transition patient advocates, patient representatives, peer counselors, suicide prevention coordinators, and other special purpose assistance to guide veterans through the VA health care benefit systems. 

VA’s actions noted above raise questions concerning the purposes of the proposed Office of the Ombudsman, given the fact that some of these positions have only recently been filled or that VA is in the midst of recruiting or training personnel to fill these positions.  We urge the Subcommittee to provide oversight on the effectiveness of these new programs before authorizing the additional Office as proposed by this legislation.

H.R. 2219 — Veterans Suicide Prevention Hotline Act of 2007

This measure would require the VA to award a grant to a private, nonprofit entity to establish and operate a national toll-free suicide prevention hotline.  It would establish a three-year authority for this program, at a cost of $7.5 million, to be paid from VA’s Medial Services Appropriation.

There is already in existence a federally funded 24-hour, toll-free suicide prevention service comprised of over 120 individual crisis centers across the country.  This service is available to all persons in need or in suicidal crisis.   Individuals seeking help can call the National Suicide Prevention Lifeline (NSPL) at 1-800-273-TALK (8255).  From the toll free number, they will be seamlessly routed to the certified provider of mental health and suicide prevention services nearest to the call of origination.

We agree with testimony provided by Mr. Jerry Reed, Executive Director of Suicide Prevention Action Network USA (SPAN USA), before the Senate Committee on Veterans’ Affairs on May 23, 2007, that we could build upon what Congress has already funded with the NSPL.

As it was pointed out during that hearing, once a veteran in need calls the number, an option could be provided for that veteran to be transferred to a VA call center if the individual wants the services and support of the VHA.  We also agree that the VA should be providing up-to-date information to non-VA crisis centers on all VA suicide prevention counselors, hospitals, medical centers, outpatient clinics, and peer support groups and, where appropriate, this national network of crisis centers should reliably transfer cases to the VHA call center.  It is our understanding that VHA’s mental health program office is discussing the possibility of joining the existing system rather than mounting an independent VA suicide prevention service.  We concur with that concept and urge VA to move forward in lieu of Congress passing this bill.

H.R. 2378 — Services to Prevent Veterans Homelessness Act

This bill would direct the VA to provide financial assistance for supportive services for very low-income veterans’ families in permanent housing. Under the bill VA would provide grants to certain eligible entities such as private nonprofit organizations or consumer cooperatives to provide various supportive services.

The DAV supports the intent of the bill to better address homeless veterans’ needs, and to help them move toward independent living.  Furthermore, unlike the companion bill in the Senate, this measure authorizes appropriation and does not divert resources from VA’s medical care account.  However, as well-intentioned as this measure may be, we are concerned that a grant under which health care and counseling services would be provided by private providers versus VA providers raises questions about cost, quality, continuity and safety similar to our views on other proposals with these goals.

H.R. 2623 — To amend title 38, United States Code, to prohibit the collection of copayments for all hospice care furnished by the Department of Veterans Affairs

VA is the only public health care system that charges co-payments to hospice patients, and the DAV is greatly concerned particularly as the number of veteran deaths has been increasing to a current average of 1,800 per day.  Congress initially addressed this issue, but only to a limited extent.  Section 204 of Public Law 108-422, the Veterans Health Programs Improvement Act of 2004, exempted veterans who receive hospice care from the requirement to pay copayments, but only if the hospice care were being provided at a nursing home.

The DAV recommends the fulfillment of Congress’s original intent in Public Law 108-422 by exempting veterans from paying co-payments when they receive VA hospice care in any authorized setting.  We thank Ranking Member Miller for introducing this measure and Chairman Michaud for including it in today’s hearing, which seeks to prohibit the collection of copayments for all hospice care furnished by the VA. 

Veterans are subject to inpatient copayments if they seek inpatient hospice care at facilities without nursing home beds, or if the hospice care must be provided in an acute care setting as a result of clinical complexity.  Moreover, veterans choosing to remain at home for their hospice care are subject to outpatient primary care copayments.  While the DAV supports H.R. 2623, we recommend that its scope be broadened to include exempting veterans from copayments for hospice care provided in any treatment setting by amending section 1710 of Title 38 United States Code.

Mr. Chairman, again, the members and auxiliary of DAV appreciate being represented at this hearing today, and I appreciate being asked to testify on these bills. Mr. Chairman, this concludes my testimony.  I and other members of the DAV Legislative Staff will be pleased to make ourselves available to you and your staffs for further discussion of our positions on any of these issues, in hopes of working toward compromise on measures that we can eventually support. I will be pleased to respond to any of your or other Committee Members’ questions.