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Witness Testimony of Carl Blake, National Legislative Director, Paralyzed Veterans of America

Chairwoman Buerkle, Ranking Member Michaud, and Members of the Subcommittee, Paralyzed Veterans of America (PVA) would like to thank you for the opportunity to submit our views today on the proposed legislation. Our statement will examine H.R. 198, the “Veterans Dog Training Therapy Act;” H.R. 1154, the “Veterans Equal Treatment for Service Dogs Act;” H.R. 1855, the “Veterans Traumatic Brain Injury Rehabilitative Services Act of 2011;” H.R. 2074, the “Veterans Sexual Assault Prevention Act;” H.R. 2530; the draft “Veterans Health Care Capital Facilities Improvement Act of 2011;” and, the draft “Honey Sue Newby Spina Bifida Attendant Care Act.” 

H.R. 198, the “Veterans Dog Training Therapy Act”

While PVA has no specific position on this proposed legislation, we believe that it could be beneficial therapy for veterans dealing with Post-Traumatic Stress Disorder (PTSD) and other mental health issues. A model program for this service was created in 2008 at the Palo Alto VA Medical Center in conjunction with the Assistance Dog Program. This program, maintained by the Recreational Therapy Service at the Palo Alto VAMC, is designed to create a therapeutic environment for veterans with post-deployment mental health issues and symptoms of PTSD to address their mental health needs. Veterans participating in this program train service dogs for later placement with veterans with hearing and physical disabilities. As we understand it, a similar, privately-funded, pilot program is currently underway at Walter Reed Army Medical Center (WRAMC) where service dogs have been used in therapeutic settings since 2006.

In these programs, training service dogs for fellow veterans is believed to be helping to address symptoms associated with post-deployment mental health issues and PTSD in a number of ways. Specifically, veterans participating in the programs demonstrated improved emotional regulation, sleep patterns, and sense of personal safety. They also experienced reduced levels of anxiety and social isolation. Further, veterans’ participation in these programs has enabled them to actively instill or re-establish a sense of purpose and meaning while providing an opportunity to help fellow veterans reintegrate back into the community. Given the apparent benefit to veterans who have participated in similar programs as the one proposed by H.R. 198, we see no reason to oppose this legislation.

H.R. 1154, the “Veterans Equal Treatment for Service Dogs Act”

PVA supports H.R. 1154, the “Veterans Equal Treatment for Service Dogs Act of 2011.” 

While we believe this legislation should be unnecessary based on the provisions of Section 504 of the Rehab Act, the actions of the VA clearly demonstrate the need for this legislation. If the VA is unwilling to make the regulatory change to accomplish the intent of H.R. 1154, then we hope Congress will move quickly to enact this important legislation.

H.R. 1855, the “Veterans Traumatic Brain Injury Rehabilitative Services Act of 2011”

PVA fully supports H.R. 1855, the “Veterans Traumatic Brain Injury Rehabilitative Services’ Improvement Act of 2011.” If enacted, H.R. 1855 would ensure that long-term rehabilitative care becomes a primary component of health care services provided to veterans who have sustained a Traumatic Brain Injury (TBI).  Specifically, this legislation would change the current definition of “rehabilitative services” to include maintaining veterans’ physical and mental progress and improvement, as well as maximizing their “quality of life and independence.” 

As we have testified on previous occasions, TBI is one of the most common and complex injuries facing veterans returning from the current wars in Afghanistan and Iraq. Today, we still do not fully understand the impact or gravity of TBI. In April 2008, the RAND Corporation Center for Military Health Policy Research completed a comprehensive study titled Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. RAND found that the effects of TBI were poorly understood, leaving a gap in knowledge related to how extensive the problem is or how to handle it. RAND found 57 percent of those reporting a probable TBI had not been evaluated by a physician for brain injury. Military service personnel who sustain catastrophic physical injuries and suffer severe TBI are easily recognized, and the treatment regimen is well established. In recent testimony, PVA has raised continuing concerns about servicemembers who do not have the immediate outward signs of TBI getting appropriate care. The military has implemented procedures to temporarily withdraw individuals from combat operations following IED attacks for an assessment of possible TBI, creating a significant military impact, but believing it necessary for soldier health even if it reduced combat forces.

On July 12, 2006, the VA Office of the Inspector General (OIG) issued Health Status of and Services for Operation Enduring Freedom/Operation Iraqi Freedom Veterans after Traumatic Brain Injury Rehabilitation. The report found that better coordination of care between DOD and VA health-care services was needed to enable veterans to make a smooth transition. While VA and DOD have done extensive improvements of coordination since that report, the OIG Office of Health Care Inspections conducted follow-on interviews to determine changes since the initial interviews conducted in 2006. The OIG concluded that three years after completion of initial inpatient rehabilitation, many veterans with TBI continue to have significant disabilities and, although case management has improved, it is not uniformly provided to these patients.

Because all the impacts of TBI are still unknown, this legislation to expand services and care, providing for quality of life and not just independence, and emphasizing rehabilitative services, is important to the ongoing care of TBI patients. It is imperative that a continuum of care for the long term be provided to veterans suffering from TBI. This bill will address the intricacies associated with TBI and help veterans and their families sustain rehabilitative progress.

H.R. 2074, the “Veterans Sexual Assault Prevention Act”

PVA fully supports H.R. 2074, a bill that would require a comprehensive policy on reporting and tracking sexual assault incidents and other safety incidents that occur at VA medical facilities. PVA believes policy mandates that specifically outline how sexual assaults within the VA should be handled are long overdue. The implementation of polices involving sexual assault will reinforce veterans’ confidence in the VA’s ability to provide a safe environment for care.

H.R. 2074 will require VA to develop and implement a centralized and comprehensive policy on the reporting and tracking of sexual assaults and safety incidents that occur at each medical facility. While the proposed legislation provides clear examples and definitions of the types of assaults and incidents that are to be reported, further detail and interpretation is need for the term “centralized.”

Although daily management of VA medical facilities is under the supervision of Veteran Integrated Service Networks (VISNs), PVA recommends that the proposed legislation require the leadership of each VISN to be responsible for the centralized reporting, tracking, and monitoring system, while also requiring the VISNs to provide the tracking reports to VA’s Veterans Health Administration (VHA) central office.  Such information sharing will enhance accountability and case management, and make data readily available when monitoring incidents or conducting assessments of the newly implemented system. Additionally, PVA recommends that VA provide clear and concise policy guidance that includes a specific time frame in which front-line VA personnel responsible for the initial processing of assault claims must begin processing the report. 

PVA also believes that a major component of preventing and appropriately handling sexual assaults and other incidents is ensuring that all occurrences of such events are reported by not only VA personnel, but veterans and other visitors as well.  VA medical facilities must provide safe and secure environments for veterans and their families seeking care and services. Therefore, PVA recommends that the proposed legislation include language that requires VA medical facilities to post clear and precise guidance on ways in which individuals visiting VA facilities can safely report sexual assaults and safety incidents.

H.R. 2530

PVA generally supports H.R. 2530 to allow for increased flexibility in establishing rates for reimbursement for State veterans’ homes, but believes greater understanding of the problem is needed. The State Veterans Home Program is examined in great detail in The Independent Budget for FY 2012. Those comments are reflected here in our statement for H.R. 2530. The VA State Veterans Home Program currently encompasses 137 nursing homes in 50 States and Puerto Rico, with more than 28,000 nursing home and domiciliary beds for veterans and their dependents. State veterans homes provide the bulk of institutional long-term care to the nation’s veterans. The GAO has reported that State homes provide 52 percent of VA’s overall patient workload in nursing homes, while consuming just 12 percent of VA’s long-term care budget. VA’s authorized average daily census (ADC) for State veterans’ homes was 19,208 for FY 2008 and was projected to be approximately 19,700 for FY 2010.

VA holds State homes to the same standards applied to the nursing home care units it operates. State homes are inspected annually by teams of VA examiners, and VA’s Office of Inspector General (OIG) also audits and inspects them when determined necessary. State homes that are authorized to receive Medicaid and Medicare payments also are subject to unannounced inspections by the CMS and announced and unannounced inspections by the OIG of the Department of Health and Human Services. VA pays a small per diem for each veteran residing in a State home, currently at a rate of $77.53 per day. This is less than one-third of the average cost of that veteran’s care. The remaining two-thirds is made up of a mix of funding, including State support, Medicaid, Medicare, and other public and private sources. In contrast, VA pays Community Nursing Homes over $200 per day with the cost of care in VA Community Living Centers (VACLC) at almost $800 per day.

Service-connected veterans should be the top priority for admission to State veterans’ homes, but traditionally they have not considered State homes an option for nursing home services because of lack of VA financial support. To remedy this disincentive, Congress provided authority for full VA payment. Unfortunately, veterans with severe disabilities may be put at a disadvantage in gaining access to State veterans’ homes. As part of P.L. 109-461, the “Veterans Benefits, Health Care, and Information Technology Act of 2006,” Congress approved payment of different per diem amounts by VA to State veterans’ homes which provide nursing home care to veterans with service-connected disabilities, a program dubbed “the 70 Percent Program.” VA issued regulations for this program in April 2009 and granted a higher per diem rate for veterans with service-connected disabilities. Unfortunately, PVA is hearing reports that these rates have resulted in lower payments to many State veterans’ homes and in some cases are less than the actual cost of care.

PVA believes VA made a good faith effort in establishing the original rates, but may not have taken into consideration the significantly greater cost of care for those with severe disabilities, in particular those service connected veterans with 70 percent or greater rating. As a result, we are concerned that many severely disabled veterans who would choose to use the State veterans’ homes will be denied access simply because the veterans’ home cannot afford the cost of their care. This will cause a significant impact on our veterans most in need at a time when VA is continuing to reduce their capacity to provide long-term care facilities.

PVA has been informed by representatives of the National Association of State Veterans Homes (NASVH) that VA seems resistant to modifications of the per diem rate or alternatives that may provide greater reimbursement rates. There is a sense that the VA believes the lower rate is appropriate because VA shoulders a great financial burden when it helps cover the cost of construction, rehabilitation, and repair of State veterans’ homes, providing up to 65 percent of the cost, with the State providing at least 35 percent. If true, PVA believes this argument is invalid.

In FY 2011 the construction grant program was funded at only $85 million, the same amount Congress had provided in multiple previous fiscal years. Based on a current backlog of nearly $1 billion in grant proposals, and with thousands of veterans on waiting lists for State beds, The Independent Budget for FY 2012 recommends no less than $200 million for this program. Unfortunately, Congress seems poised once again to only provide $85 million for the State homes grant program. The VA is using this grant program as an incentive to build more capacity to avoid the greater cost of building it themselves. PVA firmly believes that construction costs should not be mixed with healthcare costs. The per diem rate should be independent of any quid pro quo VA may believe exists with the State veterans’ homes due to construction funding. State veterans homes can provide high quality care at a rate cheaper than VA and should be rewarded for doing so, not punished.

Draft “Veterans Health Care Capital Facilities Improvement Act of 2011”

VA’s significant inventory of real property and physical infrastructure is a truly remarkable asset in the provision of health care and benefits delivery to veterans.  At the same time, these facilities must be properly managed and cared for to ensure that the investment made in the use of these buildings and properties coincides with the benefits derived from their use.

In the same manner, as the VA begins with the manipulation, sale or leasing of its infrastructure, great care must be taken to ensure that the value and equity in VA’s physical property is not squandered. That equity does not belong to the VA or the Federal Government; it belongs to the veterans of the nation for their future good. With any rearrangement of VA facilities great care should be taken to make certain present as well as future needs of veterans are fully accounted for.

With that caveat, we believe the legislation before the Subcommittee does provide the VA with improved flexibility in leasing unused or underused properties.  VA enhanced use lease authority is almost unique among other federal departments and agencies. Unfortunately, however, the process has been called cumbersome and time consuming, discouraging VA Administrators from wanting to expend the effort to use this route in dealing with a property.  Such a lengthy process also greatly discourages potential private sector entities from considering VA properties as a potential investment asset. PVA is pleased to see that the legislation retains the Capital Assets Fund to serve as the repository for the proceeds from the sale or lease of VA properties and then act as the conduit for the reinvestment of those proceeds for the improvement of other VA facilities. We also find it interesting that the Committee calls for these proceeds to be reinvested into Major and Minor Construction, rather than the Medical Care Collections Fund.

However, we have two areas of caution as the Committee moves forward.  First, VA, with proper Congressional oversight, must ensure that it receives fair market value and appropriate leases for these properties. This is particularly important in light of the current real estate market climate.  Second, Congress must ensure that proceeds reinvested into Major and Minor Construction are not looked upon by the Office of Management and Budget, as well as the Budget and Appropriations Committees, as an alternative to, and not over and above regular funding for needed specific construction appropriations. Ultimately, we do not want to see VA major and minor construction funding or non recurring maintenance budget line items offset by Capital Asset Fund disbursements.

PVA is particularly pleased that the Subcommittee has chosen to reauthorize a number of programs targeted at assisting homeless veterans.  However, we would encourage the Subcommittee to include reauthorization of the Homeless Veterans Reintegration Program (38 U.S.C. §2021) managed by the Department of Labor.  The HVRP is a valuable program focusing on employment of homeless veterans. This program has achieved wonderful success since its inception approximately 25 years ago. The HVRP provides help for those veterans with significant problems including substance-use disorder, severe PTSD, serious social problems, legal issues and HIV. The specialized services needed for these veterans and provided by HVRP are often their only hope.

Draft “Honey Sue Newby Spina Bifida Attendant Care Act”

This legislation would amend Title 38 U.S.C., to provide additional benefits for children with spina bifida of veterans exposed to herbicides while serving in the Armed Forces during in Vietnam. PVA supports this legislation as it would simply improve upon the benefits that already exist for this beneficiary population. 

Madame Chairwoman and members of the Subcommittee, once again PVA would like to thank you for the opportunity to offer our views on the legislative matters pending before the Subcommittee. We look forward to working with you to ensure that meaningful reforms that best benefit veterans are made to the health care services provided by the VA.

This concludes our official statement. I would be happy to answer any questions that you may have.

Information Required by Rule XI 2(g)(4) of the House of Representatives

Pursuant to Rule XI 2(g)(4) of the House of Representatives, the following information is provided regarding federal grants and contracts.

Fiscal Year 2011

Court of Appeals for Veterans Claims, administered by the Legal Services Corporation—National Veterans Legal Services Program—$300,000 (estimated).

Fiscal Year 2010 Court of Appeals for Veterans Claims, administered by the Legal Services Corporation—National Veterans Legal Services Program—$287,992.

Fiscal Year 2009

Court of Appeals for Veterans Claims, administered by the Legal Services Corporation—National Veterans Legal Services Program—$296,687.