Mr. Chairman and Members of the Subcommittee:

Thank you for inviting the Disabled American Veterans (DAV) to testify at this hearing, and for the opportunity to present the views of our organization on health care legislation before the Subcommittee today.  DAV is an organization of 1.3 million service-disabled veterans, and devotes its energies to rebuilding the lives of disabled veterans and their families. 

The measures before the Subcommittee today cover a range of issues important to DAV, to veterans and their families.  My testimony includes a synopsis of each of the bills being considered, along with DAV’s position or other commentary.  Our comments are expressed in numerical sequence of the bills. 

H.R. 2818—To amend title 38, United States Code, to provide for the establishment of Epilepsy Centers of Excellence in the Veterans Health Administration of the Department of Veterans Affairs

This measure would require the Secretary to designate not less than six Department of Veterans Affairs (VA) health care facilities as epilepsy centers of excellence.  The bill would intend these sites to function as centers of excellence in research, education, and clinical care in the diagnosis and treatment of epilepsy, and would include training of medical residents and other VA specialized providers to ensure improved access to state-of-the art treatment throughout the VA health care system. 

The bill would establish a peer review panel, consisting of experts on epilepsy and complex multi-trauma associated with combat injuries, including post-traumatic epilepsy, to assess the scientific and clinical merit of proposals submitted by VA facilities for consideration to be designated as Epilepsy Centers of Excellence under this bill.  The peer review panel would be required to report its assessment of such proposals to the Under Secretary for Health, presumably to strengthen the Secretary’s decision to designate Centers on the basis of merit (but the bill does not specify this peer review as a precursor to the Secretary’s designations).  The Subcommittee may wish to make that minor modification to the bill to ensure the best proposals are considered by the Secretary as determined by the peer review panel. 

Finally, the bill would require the Secretary to consider appropriate geographic distribution when making site selections, and would authorize $6 million for each of fiscal years 2008-2012 to establish and operate these Centers. 

While DAV has no adopted resolution from our membership on this matter, we have been briefed by professional associations concerned about the decline of availability of epilepsy services in the VA, and we share their concerns.  Also, literature is emerging to suggest the incidence of co-morbid epilepsy in veterans with traumatic brain injury.  Therefore, we believe this timely legislation addresses a real need, and DAV would have no objection to its passage. 

H.R.5554—Veterans Substance Use Disorders Prevention and Treatment Act of 2008

This measure would amend section 1720A of title 38, United States Code, to mandate that VA provide eligible veterans system-wide access to a full continuum of care for substance use disorders.  The bill would require substance use screening in all VA settings; detoxification and stabilization services; intensive outpatient care services; relapse prevention services; outpatient counseling services; residential substance abuse services for severe disorders; pharmacological treatments to reduce cravings, including opioid substitution therapy when needed; coordination with peer counselors; short term, early interventions when needed; and, marital and family counseling.  Additionally, the bill would require the Secretary to provide outreach to veterans who served in Operations Enduring and Iraqi Freedom (OEF/OIF), to increase awareness within that population about availability of these VA specialized services for substance use disorders. 

H.R. 5554 would attempt to ensure more equitable access to VA substance use disorder treatment by allocating funding to assure that the full continuum of substance use disorder care was provided to all veterans in need, irrespective of their residences.  Also, to that end it would require an annual report on the number of veterans who used care within the substance use disorder continuum as a proportion of all veterans who used care at the facility, the number of veterans who were screened and the number of veterans who were identified as having a substance use disorder, the number of veterans who were referred for substance use disorder treatment, and the number of veterans who received such care.  The report would also address the availability of substance use disorder care at each VA facility.  Under the terms of this bill, this report would be reviewed by the Committee on Care of Severely Chronically Mentally Ill Veterans.  That Committee would analyze and further report the availability of care along the continuum, the barriers to access such services and the quality of services provided. 

Finally, the bill would require a pilot program specifically designed to offer worldwide web-based options for self-assessment, education and specified treatment of substance use disorders.  The program would include, on a voluntary basis, any OEF/OIF veteran, and would be accessible from remote, particularly rural, areas.  In designing the pilot program, the Secretary would be required to consider similar pilot programs of the Department of Defense for the early diagnosis and treatment of post traumatic stress disorder (PTSD) and other mental health conditions, and carry out such programs in VA medical centers that have established Centers of Excellence for Substance Abuse Treatment and Education, or that have established a Substance Abuse Program Evaluation and Research Center. 

DAV fully supports the Veterans Substance Use Disorders Prevention and Treatment Act of 2008.  As noted in prior testimony, DAV has a growing concern about the reported effects of combat deployments in Iraq and Afghanistan on our newest generation of war veterans, a steadily rising proportion of whom are serving multiple deployments and long separations from family.  There is converging evidence that substance abuse is a significant problem for many OEF/OIF veterans—and that the incidence of this problem will likely continue to rise.  Although substance abuse is a complex problem, there is clear evidence that treatment can be brought to bear to reduce some of the negative consequences of overuse of substances.  This comprehensive measure would ensure the unique services necessary to address substance use disorders are provided consistently throughout the VA health care system.  Untreated substance abuse can result in severe physical consequences for the veteran, additional stress on the veterans’ families, and a marked increase in preventable health and social costs. 

We owe our nation’s disabled veterans access to timely and appropriate care, including specialized treatment programs for those suffering with post deployment mental health and related substance use disorders.  We applaud the Chairman and cosponsors for advancing this timely bill that would aim effective VA substance use disorder programs at prevention, early intervention, outreach, education and training, for veterans and their families, to close the current gaps in VA’s existing efforts.  We support its passage and offer no recommendations for amendments. 

H.R. 5595—Make Our Veterans Smile Act of 2008

H.R. 5595 would amend section 1712(a)(1)(G) of title 38, United States Code to extend eligibility for outpatient dental services and treatment, and related dental appliances, to all veterans with service-connected disabilities.  Current law limits such services to veterans with a service-connected disability rated permanently and totally disabling; former prisoners of war; to a veteran who sustained a dental trauma during military service; and in other very limited circumstances related to necessary, ongoing or completion of VA treatment or care.  It would further allow VA to provide these services through contract providers. 

DAV recognizes that oral health is integral to the general health and well being of a patient, and is part of comprehensive health care.  For these reasons, we support this measure to provide dental services to all veterans with service-connected disabilities—a reasonable corollary to DAV Resolution No. 178, which supports legislation that would provide dental services to all veterans enrolled in VA health care.  Consequently DAV would have no objection to the passage of this bill. 

H.R. 5622—Veterans Timely Access to Health Care Act

This bill would establish a five-year pilot program in Veterans Integrated Service Network (VISN) 8 (primarily the State of Florida minus most of the Panhandle, but including several Georgia and Alabama counties) to ensure a standard of access to primary care for enrolled veterans in need of primary health care from VA.  Under the bill the standard for access to care would be 30 days from the date the veteran contacted the VA facility seeking an appointment, until the date the primary care visit was actually completed.  This measure would require VA to conduct periodic performance reviews of the access standards in all facilities within VISN 8 and provide Congress an annual report to outline the Department’s performance in meeting the established standard of access to care. 

In the case of any enrolled veteran for whom VA facilities were unable to meet the 30-day access standard, the bill would require VA to contract for private health care using its existing contracting authority (Section 1703(a), title 38, United States Code).  Additionally, payment for contracted services under this procedure would not be permitted to exceed the Medicare reimbursement rate for similar services, and under the bill the private provider involved could not require the veteran to defray any difference between the provider’s invoiced charge and that paid by VA. 

H.R. 5622 includes additional quarterly reports to identify the number of newly enrolled veterans in VISN 8 after enactment, versus the numbers of veterans enrolled in that VISN before

October 1, 2001, who fall within specified waiting time ranges for primary and specialty care.  The reports would also include the number of veterans who enroll in VA, but who had not sought care in a VA facility since enrollment. 

Finally, the bill would require any veteran whose care were contracted out under the terms of this bill who wished to return to a VA facility’s care to submit a written notice of intent to return, but only after expiration of a 30-day period receiving non-VA care.  Such a veteran would then be authorized to return to VA-provided care, if capacity within the VA facility were available to accommodate that return. 

DAV appreciates the bill’s intent to ensure timely access to health care services for veterans in VISN 8.  However, in our judgment contracting for care is not the best option for addressing this problem.  DAV has maintained this principle in commenting on other bills, and we do so here.  To guarantee access to care, VA must receive sufficient, timely and predicable funding.  Over the past several budget cycles Congress has provided increased discretionary appropriations for veterans’ medical care, but at the same time there have been even higher increases in demand for services.  Additionally, the budget has been late arriving every year, and as a consequence, VA’s ability to effectively plan and properly manage its resources was greatly hampered. 

VA currently spends more than $2 billion annually on contract health care services.  Unfortunately, VA does not routinely monitor this care, consider its relative costs, analyze patient care outcomes, or even establish patient satisfaction measures for most contract providers.  VA has no established 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.

Currently, VA is implementing a Congressionally authorized pilot project titled “Project HERO”—Healthcare Effectiveness through Resource Optimization.  The VISN 8 network is one of the demonstration sites participating in this project.  According to VA, the purpose of Project HERO is to better manage private health care services VA purchases, and to ensure that community providers meet the quality standards of VA care in caring for participating veterans.  As noted by VA, one expected benefit of Project HERO is improvement in access to specialty care services by veterans living in underserved areas.  Given the early stages of this initiative, it is unclear what benefits Project HERO will yield in providing more timely access to VA health care services.  In a similar vein, we question whether Congress should authorize two competing pilot projects in the same VISN purportedly aimed at solving the same problem.  Thus, aside from our principled opposition to contracting as a primary means of solving access shortages in VA, we are concerned about the potential confusion enactment of this bill would spur in VISN 8 as it implements the Project HERO program.

DAV is a strong supporter of a robust, viable VA health care system, sustained to provide highly specialized health care resources—some of them unique—to wounded and ill war veterans.  DAV supports contract care options when needed services are unavailable in VA facilities, and in other circumstances authorized by law; however, contract care should be used judiciously and VA coordination of outside care is essential to ensure high quality, safety and cost effectiveness.  While we appreciate that enactment of this bill would seem to be helpful in the short run for some veterans, it potentially could damage the VA system by eroding funding needed to sustain VA’s viability to continue providing specialized resources to service-disabled veterans.  For these reasons we are unable to support this measure, but we appreciate the sponsor’s intentions to improve access to care. 

H.R. 5729—The Spina Bifida Health Care Program Expansion Act

This bill would amend the language of section 1803(a), title 38, United States Code.  This section provides basic authority for health care services for Vietnam veterans’ children afflicted with spina bifida.  The current language states these individuals receive “such health care as the Secretary determines is needed by the child for the spina bifida or any disability that is associated with such condition.”  Under the bill, this language would be stricken and replaced with “health care under this section.”  Such simplification of authority would ease determinations on eligibility to specific health care services, eliminate concerns that arise on the definition of “child”, and moot the need for an association of a specific condition with spina bifida.  Consequently this amended language would likely save administrative costs for VA and improve the quality of life for these children and their parents.  Finally, this measure includes a provision to include domiciliary care as part of the health care services available to these individuals. 

DAV does not have a resolution in support of the specific changes outlined in this bill; however, we believe the goals of the bill are in accord with the intent of the law to provide comprehensive health care services to Vietnam veterans’ children with spina bifida.  Thus, we have no objection to enactment of this measure. 

H.R. 5730—To direct the Secretary of Veterans Affairs to display in each prosthetic and orthotic clinic of the Department an Injured and Amputee Veterans Bill of Rights. 

This bill would require VA to establish and prominently display, in each VA health care prosthetic and orthotic clinic, a Bill of Rights for veterans who are injured or have amputations. 

The Bill of Rights enumerated in the bill would include the right to:

• access the highest quality prosthetic and orthotic care including the most appropriate technology and qualified practitioners

• continuity of care in the transition from the Department of Defense to the VA health care system, including comparable benefits relating to prosthetic and orthotic services

• select a practitioner that best meets their needs

• consistent, portable and comparable health care services and technology across the VA system of care

• timely and efficient prosthetic and orthotic care

• patient-centered care with the option to request a second opinion regarding prosthetic and orthotic treatment options

• receive a primary and functional secondary prosthetic and orthotic devices

• respectful treatment and the ability to readjust to civilian life through access to VA vocational rehabilitation, employment programs and housing assistance

DAV does not have a specific resolution from our membership on this proposal; however, it is consistent with providing patient-centered, comprehensive, high quality health care services for our nation’s sick and disabled veterans.  Thus, DAV would have no objection to its enactment.

Mr. Chairman, thank you for requesting the views and recommendations of DAV on these bills.  This concludes my testimony and I would be pleased to address your questions and those from other Members of the Subcommittee.