Good Morning Mr. Chairman and Members of the Subcommittee:

Thank you for inviting me here today to present the Administration’s views on several bills that would affect Department of Veterans Affairs (VA) benefits programs and services.  Joining me today are Walter A. Hall, Assistant General Counsel; Brian McVeigh, Chief Consultant, Human Resources Management; and Patricia Vandenberg, Assistant Deputy Under Secretary for Health for Policy and Planning.  Unfortunately, we do not yet have views and costs for H.R. 84, H.R. 1075 and a draft bill regarding performance pay and collective bargaining.  We will forward them as soon as they are available.

H.R. 949?Repeal of 38 U.S.C. § 7422 Collective Bargaining Exclusions; Adverse Action Decisions and Appeals; Disciplinary Appeals Board Transcripts

When Congress first authorized VA clinicians to engage in collective bargaining in 1991 it did so acknowledging that clinical decisions and clinical management decisions should not be decided through the collective bargaining process.  Congress provided that only the Secretary, and by delegation the Under Secretary for Health may decide when one of the statutory bargaining exclusions in section 7422 applies.  However they did provide that, if a party believes that the Under Secretary for Health has acted arbitrarily or capriciously in issuing a 7422 decision, the party may seek judicial review of the decision pursuant to section 7422(e).

The key provision of H.R. 949 would make matters relating to direct patient care and the clinical competence of clinical health care providers subject to collective bargaining.  It would repeal the current restriction on collective bargaining, arbitrations, and grievances over matters that the Secretary determines to concern or arise out of the professional conduct or competence, peer review, or compensation of Title 38 employees.  In addition, the bill would impose a very tight time limit on the issuance of final agency decisions on employee grievances and would make such decisions subject to judicial review.  Finally, the bill would require VA to provide employees who appeal adverse actions under section 7462 with a full and correct copy of the Disciplinary Appeals Board transcript at least 21 days before post-hearing briefs are submitted, despite the existence of a 120-day deadline for the issuance of Disciplinary Appeals Board decisions.

We appreciate the many positive contributions collective bargaining and labor-management partnership make to VA’s mission.  H.R. 949 would have an adverse impact on VA’s ability to deliver quality patient care.  Consistent with our views on a similar Senate bill, we strongly oppose it.  Section 1 of H.R. 949, if enacted, would imperil VA’s ability to furnish timely and quality care for Veterans.  H.R. 949 would open VA’s responsibility under Title 38 to 1) make direct patient care and clinical competency decisions, 2) assess Title 38 professionals’ clinical skills, and 3) determine discretionary compensation for Title 38 professionals, to review other non-clinical third parties who lack the clinical training and health care expertise to make such determinations. 

In September 2009, following extensive discussions with the American Federation of Government Employees (AFGE) regarding friction over differences of interpretation over collective bargaining authorities, VA and its labor partners signed a charter for a 38 U.S.C. 7422 Workgroup, with the purpose of formulating recommendations for the Secretary to improve knowledge, understanding, and consistent use of the authorities and limitations in section 7422.  The Workgroup consists of representatives from VA’s five national unions (AFGE, National Federation of Federal Employees, National Association of Government Employees, Service Employees International Union, and United American Nurses). VA’s team is headed by the Assistant Secretary for Human Resources and Administration, Mr. John Sepulveda, and includes subject matter experts from the Veterans Health Administration, Office of General Counsel, and Office of Labor Management Relations.  The Workgroup charter charged its members with: (1) establishing a dialogue about the meaning of the 7422 bargaining and grievance exclusions; (2) making recommendations to the Secretary regarding consistent use of section 7422; (3) developing joint training about the section 7422 exclusions and decision process; (4) identifying strategies for enhancing collaborative efforts to resolve disputes at all levels; (5) recommending approaches for capturing data reflecting informal and formal efforts to resolve section 7422 disputes; and, (6) developing a strategic communication plan for the results of the Workgroup.  Over the past 6 months, the 7422 Workgroup has held a series of multi-day face-to-face sessions, conducted in a partnership manner, where the parties engaged in a productive dialogue.  We are hopeful this process, when concluded, will result in actions and understandings that will address many of the unions’ concerns about the manner in which section 7422 exclusions are applied.

H.R. 949 would create a number of significant problems that would impede VA’s ability to operate a safe, effective and responsive healthcare system.  The rules for collective bargaining often lead to protracted negotiations and third-party proceedings.  On average, it takes 120 days to negotiate national Memorandums of Understanding (MOU) with VA’s largest union, the AFGE.  The 120-day average does not include local level bargaining over facility-specific aspects of a change, which can add another 30-60 days.  While this kind of timeline may be acceptable for most workplace matters, it is not when it comes to patient-care matters.  If H.R. 949 is enacted, critical changes in patient care, safety procedures, and policies could not be implemented until national and local bargaining had been completed.  This could result in less than optimal care for Veterans.  Such delays, and the very practice of negotiating clinical matters, are inconsistent with patient-centered medicine. 

H.R. 949 would allow Title 38 professionals to grieve matters or file unfair labor practice charges on clinical matters currently exempted from collective bargaining.  Grievances not resolved at the informal stage are decided by a third-party arbitrator and may be subsequently appealed to the Federal Labor Relations Authority.  Labor grievance arbitrators, the Federal Labor Relations Authority, and the Federal Service Impasses Panel would have considerable discretion to impose a clinical or patient care resolution on the parties.  VA would have limited, if any, recourse if such an external party erred in its consideration of a clinical or patient care issue; VA would be bound by that third-party’s decision.  VA opposes this change in the strongest possible terms - clinicians must be able to make the clinical decisions to ensure care is furnished in compliance with VA and prevailing medical practice standards.  Actions concerning direct patient care and the clinical competence of VA providers must be made and reviewed by clinicians, not arbitrators. 

Moreover, non-clinical third-parties are not accountable for ensuring the health and safety of the Veterans receiving their care through the Department.  If the Secretary and the Under Secretary for Health are going to be held responsible and accountable for the quality of care provided to Veterans, they must be able to make decisions relating to patient care and the clinical competence of VA providers. Decisions must be based on what is best for our Veterans from a medical perspective rather than what is the best that can be negotiated through collective bargaining, or on what a non-clinical arbitrator or the Federal Labor Relations Authority decides is appropriate in the context of collective bargaining.  Our Veteran patients cannot be expected to understand why their VA providers—a group of highly qualified, trained, and trusted professionals—have no option but to follow the decisions of third-parties with whom they disagree on matters affecting patient care. 

This provision would also require collective bargaining related to VA’s Peer Review process by which VA assess the clinical skills of Title 38 health care professionals and assesses whether our patients are receiving the high-standard of care they deserve.  Matters relating to peer review are now expressly exempted from collective bargaining under section 7422.  H.R. 949 would change that, again subjecting  the process of assessing the clinical skills of Title 38 professionals and determining whether they are clinically competent in their area of practice to review by non-VA, non-clinical third-parties. 

In addition to clinical-care issues, H.R. 949 would permit unions to bargain over, grieve, and arbitrate subjects that are even exempted from collective bargaining under Title 5, including the determination of the amount of an employee’s compensation.  Permitting Title 38 staff to negotiate the discretionary aspects of their compensation would be at complete odds with a basic premise of federal labor management relations. 

Section 2 of the bill would establish a new section 7463(f)(1), which would require VA to decide grievance appeals no later than 60 days after a grievance is filed and would subject such decisions to judicial review.  VA opposes Section 2 of H.R. 949.  In many cases, because of the complexity of the issues, the need to develop and review evidence, or secure the availability of witnesses, a grievance examiner's review can take most or all of those 60 days, leaving no time for a VA higher level official to review, and decide upon, the grievance examiner's findings and recommendations as called for in section 7463(d)(3).  Sixty days is not sufficient for this process. 

Finally, section 3 of the bill would amend the Disciplinary Appeals Board or DAB statute in section 7462 to require the provision of a full and correct copy of a DAB transcript to an employee at least 21 days before the submission of post-hearing briefs.  DABs are conducted when a Title 38 employee appeals a major adverse action arising out of a question of professional conduct or competence.  VA opposes Section 3 of H.R. 949 because it would unnecessarily constrain the time available to DABs to make their decisions, which by law must be rendered within 45 days of the DAB hearing and no later than 120 days after commencement of the appeal.  There may be instances where it will be impossible to provide the transcript to an employee within 21 days and meet the 120-day statutory time limit because of the timing of the oral hearing or the length of time it takes to prepare a full and complete transcript.  Cases can involve complex clinical issues and extensive medical and expert testimony and evidence.  Moreover, post-hearing briefs are neither necessary for nor required by many DABs because the issues are sufficiently fleshed out in the DAB’s oral hearing, the written notices provided to the employee, and the employee’s written reply, oral reply, and DAB appeal.

In sum, VA’s ability to manage its health care facilities and to monitor the professional conduct and competence of its employees must be reserved for the VA professionals and clinicians who are responsible for delivering quality patient care.  Current law provides the appropriate balance between rightful subjects for collective bargaining and clinical need, and, as noted above, VA and its unions are engaged in a productive dialogue to resolve issues of interpretation of the contours of how 7422 is applied.

H.R. 2698?“Veterans and Survivors Behavioral Health Awareness Act”

VA does not support section 2 of H.R. 2698 which would direct VA to provide scholarships to individuals pursuing education or training in behavioral health care specialties in order to recruit and retain individuals for service in Vet Centers.  In exchange for the scholarship, an individual would be required to fulfill a service obligation with VA.  The total amount available for scholarships could not exceed $2,000,000 in any fiscal year. 

VA appreciates the concept of using scholarships to enhance succession planning.  However, this section is unnecessary.  Under existing authority, VA can establish a special scholarship program to identify, educate and hire individuals for difficult-to-recruit and difficult-to-retain health care positions including individuals pursuing degrees in mental health specialties.  Additionally, implementation of section 2 of H.R. 2698 would result in substantial costs to VA over a long period of time with little short-term benefits.  It takes 2 to 7 years of education to qualify to become a VA behavioral health specialist.  Congress has authorized and VA has taken other actions to promote recruitment and retention of qualified health professionals, including the Education Debt Reduction Program and the Employee Incentive Referral Initiative.  VA takes this opportunity to again endorse reauthorization of the Health Professional Educational Assistance Scholarship Program.  This program would be a more effective and broader program to support recruitment and retention efforts in a variety of career fields, including mental health counselors.

VA has not had difficulties hiring new counselors, and in the past 3 years, VA has hired more than 5,800 additional mental health workers.  VA has also expanded funding for mental health training by supporting the expansion of training positions in psychology by 206 positions.  Seventy percent of current VA psychologists participated in a VA training program, demonstrating that these initiatives are an exceptional resource for addressing future recruitment needs.  The legislation also appears to duplicate provisions from the Montgomery GI Bill and the Post-9/11 GI Bill, which already provide mechanisms for funding graduate and post-graduate degree programs for eligible Veterans.  These measures do not include a specific service obligation, but do allow Veterans to pursue an advanced education in the behavioral health sciences.

We have not formulated costs at this time, but will provide them for the record when they become available.

VA supports section 3 of H.R. 2698, which would direct VA, on receipt of a request for counseling from an individual who has been discharged or released from active service but who is not otherwise eligible for such counseling, to: (1) provide referrals to assist the individual in obtaining mental health care and services outside VA; and (2) if pertinent, advise such individual of the individual's rights to apply for review of the discharge or release. 

This provision would allow VA to provide referral services to Veterans with problematic discharges by referring them to services outside VA and by advising such veterans of their right to apply for a discharge upgrade.  There are no significant costs associated with enactment of this section.

Section 4 of H.R. 2698 would direct VA to carry out a program to award grants to nonprofit organizations that provide emotional support services (i.e., bereavement counseling) for survivors of deceased members of the Armed Forces and deceased Veterans through the survivors' peers.  

VA currently has authority to provide bereavement services to the surviving military family members of service members who die while on active duty, and to family members of Veterans who die while receiving VA treatment for a service connected condition in a VA facility.  Section 4 would expand bereavement services to family members of all veterans.  VA has not had time to develop costs for this section, but will provide our views and costs as soon as they are available.   With regards to bereavement services provided to families of service members, Vet Centers have adopted standards of care to ensure that family members are contacted the same day as the referral is received, and to schedule an appointment with a counselor at the nearest Vet Center within 24 to 48 hours of receiving the referral.  Through February 2010, Vet Centers have assisted the families of 1,939 fallen service members; 1,152 (60 percent) were in-theater casualties in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF). 

H.R. 2699?“Armed Forces Behavioral Health Awareness Act”

Section 2 of H.R. 2699 would make members of the Armed Forces, including the Reserve components, who are deployed in support of OEF/OIF eligible for readjustment counseling and related mental health services operated by VA as authorized under 38 U.S.C. § 1712A.  The Department will provide its views and the cost estimate for section 2 soon.

VA defers to the Department of Defense concerning section 3 of H.R. 2699 and to the Department of the Army concerning section 4 of H.R. 2699.

H.R. 2879?“Rural Veterans Health Care Improvement Act of 2009”

Section 2 of H.R. 2879 would amend 38 U.S.C. § 111 by setting the beneficiary travel allowance rate at 41.5 cents per mile and repealing the requirement that allowances be determined using the mileage reimbursement rate under 5 U.S.C. § 5707(b) for the use of privately-owned vehicles by Government employees on official business.  In addition, this section would repeal VA’s authority to modify the allowances or reimbursement amounts in excess of the rate determined by 5 U.S.C. § 5707(b).  This section would also repeal the requirement that certain beneficiaries must be unable to defray the expenses of such travel pursuant to regulations; repeal the requirement that payments may not exceed the cost of such travel by public transportation if accessible and not medically inadvisable; and repeal the requirement that payments must not exceed the actual expense incurred as certified in writing by the person.  Last, this section would require that the Veterans Health Administration (VHA) Handbook on beneficiary travel be revised to clarify that a travel allowance based on mileage may exceed the cost of such travel by public transportation regardless of medical necessity.

VA does not support section 2 of H.R. 2879.  While 41.5 cents per mile is the current reimbursement rate, VA would lose the authority to decrease or increase the rate using the mileage reimbursement rate under 5 U.S.C. § 5707(b). VA would also lose the flexibility to exceed the section 5707(b) rate should funding and circumstances warrant.  The requirement to allow for mileage reimbursement greater than the cost of travel by public transportation regardless of medical necessity would eliminate VA’s authority to pay only for the most cost-effective available and appropriate mode of transport.  As a result, in some cases VA would reimburse more than the Veteran actually expended for transport.

VA estimates the cost of implementing this section to be $16.24 million over 5 years, and $35.56 million over 10 years.  

Section 3 would require the establishment of one to five centers of excellence for rural health research, education, and clinical activities, through the Director of the Office of Rural Health.  The centers would be required to conduct research, develop specific models for furnishing health services, provide education and training for health care professionals, and develop and implement innovative clinical activities and systems of care.

VA does not support section 3 of H.R. 2879 because the “Centers of Excellence” proposed in this provision would be duplicative of the Veterans Rural Health Resource Centers (VRHRC) and of the efforts of VA’s Veterans Rural Health Advisory Committee.

VA established the VRHRCs to improve care and services for Veterans residing in geographically-isolated areas.  The VRHRCs conduct policy-oriented studies and analyses; function as field-based clinical laboratories for policy-relevant pilot projects and evaluations; serve as regional rural health experts organizing and sharing information within and across Veterans Integrated Service Network (VISN) boundaries; and serve as an educational repository and academic and clinical information clearinghouse.  The VRHRCs are operational and conducting important work, such as a pilot project designed to develop a simulation tool for modeling rural health care access; telephone-based telehealth initiatives for diabetes, hypertension, and chronic pain; rural workforce development; utilization of mobile clinics as an alternative care delivery model; and a study on clinical practice intensity to compare VA to private sector physicians in urban and rural settings.   VA’s Veterans Rural Health Advisory Committee membership includes affected Veterans, rural health experts in academia, state and federal professionals who focus on rural health, state-level Veterans affairs officials, and leaders of Veterans Service Organizations.  The purpose of the Advisory Committee is to examine ways to enhance VA health care services for Veterans in rural areas by evaluating current programs and identifying barriers to health care.

VA estimates the minimum cost of implementing section 3 to be $10.76 million over 5 years and $23.67 million over 10 years.  

Section 4 would require the establishment of a grant program to provide innovative transportation options to Veterans in rural areas.  Under this section, grants awarded could be used by State Veterans’ service agencies and Veterans service organizations to assist Veterans in highly rural areas with travel to VA medical centers, or otherwise assist in providing medical care to these Veterans.  A grant awarded under this section could not exceed $50,000.

VA agrees with the intent of this legislation and agrees that Veterans in rural areas need more transportation options when seeking VA health care, but VA does not support section 4 of H.R. 2879.  The specific provisions of this legislation are unnecessary, and VA already has efforts underway that will address this problem more quickly than new legislation would.  VA is currently developing pilot programs to implement innovative transportation services at various rural health care facilities.  Funds that would be spent for grants would be more effectively and efficiently used by VA to develop these initiatives that would include but not be limited to integrating the services of networks of volunteer, community, state and other transportation providers with Veteran transportation services offered in its health care facilities.  Furthermore, the administration of the grant program proposed in this section would be costly, diverting resources from either supporting new transportation options or health care for rural Veterans. 

VA estimates the cost of this section to be $3 million per year, and $15 million over 5 years.

Section 5 would require demonstration projects to examine the feasibility and advisability of alternatives for expanding care for Veterans in rural areas, through the Director of the Office of Rural Health, at facilities that are geographically distributed throughout the United States.  The required projects would include (1) a partnership between VA and the Centers for Medicare and Medicaid Services of the Department of Health and Human Services (HHS) to coordinate care for Veterans in rural areas at critical access hospitals, (2) a partnership between VA and HHS to coordinate care for Veterans in rural areas at community health centers, and (3) expanding coordination between VA and the Indian Health Service (IHS) to expand care for Indian Veterans.  It would authorize the appropriation of $350,000,000 for each of fiscal years 2009 through 2011 to carry out the projects.

VA does not support section 5 of H.R. 2879 for three reasons.  First, VA already is encouraging and examining strategies to improve collaboration to increase service options for Veterans in rural areas; examples include the Patient Navigator Pilot in VISN 5 that is focusing on expanding and developing public-public collaborations, and the community-based outpatient clinic (CBOC) partnership for improving rural mental health in VISN 16 that is focused on establishing collaborations within the rural health community.  Second, additional legislation would impose burdens and specific restrictions upon our ability to explore these opportunities and may impede us from pursuing the best health care options for Veterans.  Finally, VA already is undertaking pilot programs at the direction of Congress in sections 107 and 403 of Public Law 110-387, and VA believes it is more appropriate to evaluate the results of these pilot projects before beginning new initiatives so that we can ensure resources are best used to serve Veterans.  Section 107 of that law requires VA to carry out a pilot program to assess the feasibility and advisability of providing peer outreach, peer support, readjustment counseling, and other mental health services to Operation Iraqi Freedom and OEF/OIF Veterans, with readjustment counseling and other mental health services provided to certain rural Veterans through community health centers, IHS, or other appropriate entities.  Section 403 requires VA to conduct a pilot program under which VA provides covered health services to certain highly rural Veterans through qualifying non-VA health care providers.  These pilots will be exploring opportunities for collaboration. 

VA estimates the cost of implementing section 5 to be $3.04 billion through fiscal year (FY) 2011, as indicated in the legislation.

Section 6 would require a program to provide peer outreach, peer support, readjustment counseling, and mental health services to OEF/OIF Veterans, particularly Veterans who served in OEF/OIF while in the National Guard and Reserves, to be established no later than 180 days after enactment.  The program would also provide education, support, counseling, and mental health services to immediate family members of OEF/OIF Veterans during the 3 years after the Veteran’s return from deployment.  The services provided to immediate family members would assist in the readjustment of the Veteran to civilian life, the recovery of the Veteran (if the Veteran incurred an injury or illness during deployment), and the readjustment of the family following the return of the Veteran.

In carrying out this program, this section would require contracts with community mental health centers and other qualified entities only in areas not adequately served by VA health care facilities.  In addition, this section would require a training program for clinicians of those community mental health centers or entities to ensure that the clinicians recognize the unique experiences of OEF/OIF Veterans, and utilize best practices and technologies when providing services under this section.  This section would also require a contract with a national not-for-profit mental health organization to carry out a national training program for OEF/OIF Veterans to be trained to provide peer outreach and peer support services. Finally, this section would require reports to the House and Senate Committees on Veterans’ Affairs.

VA opposes section 6 of H.R. 2879 because this provision duplicates existing authorities and is unnecessary.  Section 107 of Public Law 110-387 requires VA to carry out a pilot program to assess the feasibility and advisability of providing OEF/OIF Veterans with peer outreach, peer support, readjustment counseling, and other mental health services, with readjustment counseling and other mental health services provided to certain rural Veterans through community health centers, IHS, or other appropriate entities.  VA is implementing this pilot.  Section 6 proposes a plan similar to that outlined in Section 107.  VA believes that results from the section 107 pilot will provide experience and information on how best to serve the mental health needs of the rural OEF/OIF Veteran population. 

In addition, VA’s authority to furnish readjustment counseling services already includes authority to furnish limited mental health services to family members necessary for effective treatment of Veterans’ readjustment issues.  The Vet Center program is also taking steps to enhance access for Veterans’ families.  Within the context of the Vet Center mission, family members are central to combat Veterans’ readjustment.  VA is implementing a plan to enhance its capacity to serve families by hiring the additional staff necessary to place a qualified family counselor in every Vet Center.  

Vet Centers provide professional counseling for combat-related PTSD and co-morbid conditions such as depression and substance abuse.  When necessary for the treatment of more complex mental health conditions, Vet Centers refer Veterans to VA medical facilities.  For Veterans leaving a VA facility after receiving care for an injury or illness sustained during deployment, VA provides education and training prior to the Veteran’s discharge from care to ensure that family members can tend capably to the needs of the Veteran.  As a result, the authority to provide readjustment counseling and education to family members is unnecessary.

Further, VA is expanding access to mental health care to assist rural Veterans.  VA is integrating mental health into all of its primary care clinical settings and is significantly expanding the number of Vet Centers to almost 300 by the end of the fiscal year.  VA has already deployed 50 Mobile Vet Centers to provide services and outreach to Veterans, including rural Veterans.  Moreover, VA continues to expand the use of telemental health to connect Veterans in rural areas with clinical experts from across the country.  In addition, VA contracts for mental health treatment and for readjustment counseling and related readjustment services, as needed with private-sector community mental health agencies and other qualified professional entities.  Most of these contract providers are located in rural areas.  Section 6 is also duplicative and unnecessary because the Vet Center’s model for Veteran-centric services already utilizes Veteran peer outreach and counseling.  Almost 70 percent of all Vet Center staff members are Veterans, and more than 30 percent of Vet Center staff members are OEF/OIF Veterans. 

VA estimates the cost of implementing section 6 to be $115.58 million over 5 years and $253.46 million over 10 years.

Section 7 would address improving care for American Indian Veterans.  Because section 7 is almost identical to H.R. 4006, VA views on this bill are addressed under our discussion of H.R. 4006 (which follows below).

Section 8 would require an annual report to Congress on the implementation of the provisions of this bill and the establishment and function of VA’s Office of Rural Health.  VA does not support section 8 of H.R. 2879.  VA already provides a number of periodic reports (including quarterly and annual reports) to Congress on the status of our programs for rural and highly rural Veterans. For example, Senate Report 110-428, which accompanied the Military Construction and Veterans Affairs and Related Agencies Appropriations Act, 2009 (Division E of Public Law 110-329), directed VA to provide a quarterly report to Congress on rural health initiatives funded through rural health appropriations.  A Conference Report (H. Rept. 110-424), accompanying the Consolidated Appropriations Law, 2008, required a report to Congress on access to health services in rural areas.  If the Committee would like additional information on any of our programs, VA staff members are available to conduct a briefing at your request. 

VA estimates the cost of implementing section 8 to be $70,596 over 5 years, and $155,173 over 10 years.

H.R. 3926?“Armed Forces Breast Cancer Research Act”

H.R. 3926 would direct the Department of Defense (DoD) and VA to conduct a joint study on the incidence of breast cancer within the armed forces and among veterans.  VA supports the objective of H.R. 3926, but cannot support the bill as proposed. H.R. 3926 would provide only an estimate of incidence of one disease at one point in time.  A broader study of health care outcomes would be much more cost effective and useful.  A broader study would provide information regarding the frequency of occurrence of breast cancer as well as other illnesses and chronic disease outcomes of interest to Veterans.  For less than the costs required to conduct such a study we could support a longitudinal study that considers breast cancer as one condition among many.  This would be accomplished by collecting information on a representative sample of Veterans, including demographic variables such as age, gender, era of service, and frequency of occurrence of various health outcomes of concern to Veterans.  Establishing a survey mechanism of this type would allow VA to repeat the study and identify trends over time, such as increases or decreases in the occurrence of various diseases, such as breast cancer.

In order to satisfy the complex requirements of H.R. 3926, the study requirements currently proposed in the bill would demand much more time than the 18-month time frame envisioned.  We estimate it would take 3 to 5 years to accomplish this work. 

The total cost of this study is estimated to be $6.34 million.

H.R. 4006?“Rural, American Indian Veterans HealthCare Improvement Act of 2009”

Section 2(a) would require that an Indian Veterans Health Care Coordinator be assigned at each of the ten VA medical centers that serve communities with the greatest number of Indian Veterans per capita.  The Coordinators would be responsible for improving outreach to tribal communities; coordinating the medical needs of Indian Veterans on Indian reservations with VA and IHS; expanding the access and participation of VA, IHS, and tribal members in the VA Tribal Veterans Representative program; acting as an ombudsman for Indian Veterans enrolled in VA for health care; and advocating for the incorporation of traditional medicine and healing in the VA treatment plans for Indian Veterans.  This section would define “Indian” as defined in 25 U.S.C. § 450b (“‘Indian’ means a person who is a member of an Indian tribe”).

VA does not support section 2(a) of H.R. 4006 because VA’s Office of Rural Health (ORH) is already providing support to American Indian/Alaskan Native (AI/AN) Veterans specifically as it relates to ongoing rural health initiatives.  VA is also working to address the unique health care needs of all enrolled Veterans residing in rural areas, including AI/AN Veterans.  VA encourages cooperation and resource sharing between IHS and VA to deliver quality health care services and enhance the overall health of AI/AN Veterans.  Most VISNs are engaged in a variety of outreach activities including: meetings and conferences with IHS program and tribal representatives; VA membership in the Native American Healthcare Network; VA participation in traditional Native American ceremonies; and transportation support to AI/AN.  The Veterans Rural Health Resource Center, Western Region, established a partnership with IHS and is currently working on several fronts to support expanded benefits and services, such as tele-psychiatry clinics for AI/AN Veterans on rural reservations, infrastructure focused on the needs of AI/AN Veterans, and a Memorandum of Understanding with IHS concerning telemental health services for AI/AN Veterans. 

VA estimates the cost of implementing section 2(a) to be $5.30 million over 5 years, and $11.65 million over 10 years.

Section 2(b) would require an MOU no later than one year after enactment, between VA and the Department of the Interior to ensure that the health records of Indian Veterans may be transferred electronically between IHS and VA facilities.  VA agrees with the objectives of section 2(b), but notes that implementation would not be possible without legislative changes to 38 U.S.C. § 7332.  That law restricts the ability of VA to provide health information concerning human immunodeficiency virus (HIV), sickle cell anemia and drug abuse or alcohol abuse.  VA does not object in principle to requiring a MOU, but notes that VA and IHS have already taken the position that sharing of VA and IHS electronic health records should be done through the Nationwide Health Information Network (NHIN).  As a result, the MOU would be unnecessary, because each party participating in the NHIN will be required to be a signatory to the Data Use and Reciprocal Support Agreement.  We note that section 2(b) of H.R. 4006 refers to the Secretary of the Interior, rather than the Secretary of Health and Human Services.  VA believes this is a clerical error, since IHS is responsible for providing federal health services to AI/AN. 

VA estimates there will be no costs associated with this provision.

Section 2(c)would permit VA to transfer surplus VA medical and information technology equipment to IHS as is considered appropriate for IHS purposes by the Secretaries of VA and HHS jointly.  VA does not object to the authority to provide surplus medical and information technology equipment, but notes that VA generally only surpluses equipment when it can no longer reasonably be used; IHS is unlikely to find such equipment of practical use.  While the title of the section refers to Medical Equipment per se, the text of the section refers to both medical and information technology equipment.  VA estimates there would be negligible costs associated with this provision.

Section 2(d) would require a report to Congress, no later than one year after enactment, jointly submitted by VA and HHS on the feasibility and advisability of VA and IHS jointly establishing and operating health clinics on Indian reservations to serve the populations of those reservations, including Indian Veterans.  VA does not support this requirement because it is unnecessary.  VA would welcome the opportunity to provide a briefing to address current collaborations with IHS and efforts to support AI/AN Veterans. 

VA estimates that the cost of implementing this section would not be substantial.

Draft Bill?“Expanding VA Reimbursement of Continuing Medical Education Expenses to VA Health Professionals”

This bill would require VA to reimburse any full-time board certified health professional for expenses, up to $1,600 per year, for continuing professional education, but prohibits VA from reimbursing for education provided by a Department medical center. 

VA opposes this draft bill because of the cost of implementation and because our current programs are sufficient to address this need.  There are currently over 170,000 health care professionals in VHA.  The total cost of implementing this legislation would be $282,000,000 per year for the next 10 years.  Moreover, VA’s Employee Education Service provides continuing education credits (those needed to maintain current licensure or certifications) through on-line learning, content distribution network and face-to-face sponsored training.  In addition, medical centers host on-site training to provide continuing education credits and purchase on-line products that allow health care professionals to gain needed continuing education.  Medical Centers also have a mechanism in place for all employees (not just health care professionals) to request funding or reimbursement for training and education.

The potential cost to provide up to $1,600 to each health care professional would be $272 million. 

Draft Bill?“Authority to Waive Requirements for Mental Health Counselors”

This bill would create an exception to the statutory requirements for eligibility for employment of licensed professional mental health counselors by allowing the Secretary to waive the licensure or certification requirement for a reasonable period of time recommended by the Under Secretary for Health.  VA does not oppose the legislation.  VA currently has a parallel statutory authority to appoint psychologists and clinical social workers for up to 2 years before they have completed their licensure or certification.  These employees are closely supervised by a licensed mental health professional when administering care.  These are temporary, conditional appointments, and VA believes a similar model would be appropriate if this legislation is enacted. 

This proposal would be cost neutral.

This concludes my prepared statement.  Mr. Chairman, we would be pleased to respond to whatever questions you may have.