Mr. Chairman and other Members of the Subcommittee:

Thank you for inviting the Disabled American Veterans (DAV) to testify at this legislative hearing of the Subcommittee on Health.  DAV is an organization of 1.2 million service-disabled veterans, and devotes its energies to rebuilding the lives of disabled veterans and their families.

We appreciate the opportunity to offer our views on the bills under consideration by the Subcommittee—specifically two bills focused on mental health care services provided by the Department of Veterans Affairs (VA), a measure focused on women veterans health, and one draft measure—related to expansion of eligibility for reimbursement for emergency treatment in non-VA facilities.  Our comments related to the four measures are expressed in numerical sequence of the bills.

H.R. 784—To amend title 38, United States Code, to direct the Secretary of Veterans Affairs to submit to Congress quarterly reports on vacancies in mental health professional positions in Department of Veterans Affairs medical facilities.

This bill would require the Secretary of Veterans Affairs to report quarterly to Congress to describe each mental health professional vacancy in every medical facility in the Department, and to indicate to which Veterans Integrated Service Network (VISN) the facility is assigned.  The bill would define mental health professionals to include psychiatrists, psychologists, social workers, marriage and family therapists, and licensed professional mental health counselors.  While we appreciate the intended purposes of this bill, we ask the Subcommittee to expand its scope to better account for the current situation in VA mental health services, and to consider our recommendations for an enhanced means of achieving better oversight and accountability in that program.

We recognize the unprecedented efforts made by VA over the past several years to improve the consistency, timeliness, and effectiveness of mental health care programs for disabled veterans.  We are especially pleased that VA has committed through its national Mental Health Strategic Plan (MHSP) to reform VA mental health programs, moving from the traditional treatment of symptoms to embrace recovery potential in every veteran under VA care.  We also appreciate the will of Congress in continuing to insist that VA dedicate sufficient resources in pursuit of comprehensive mental health services to meet the needs of veterans.  One key part of improving mental health services and increasing access to those specialized services is through sufficient staffing levels.  The DAV supports the intent of this measure (H.R. 784) that would attempt to verify the current vacancies in mental health positions in VA facilities and thus the gap in mental health professionals needed to provide timely, high quality mental health services to veterans who need them.  DAV is concerned, nevertheless, that the intended goal of the bill will be unfulfilled unless Congress goes beyond requiring VA to provide simply the number of vacancies but rather requiring VA to adopt and enforce mechanisms to assure its policies at the top are reflected as results in the field. As written, we are concerned that enactment of the bill would not surface the kind of information Congress needs to conduct proper oversight of VA’s results and status in achieving mental health reforms.

The development of the MHSP and the new Uniformed Mental Health Services (UMHS) policy (detailed in VHA Handbook 1160.01, dated September 11, 2008)provide an impressive and ambitious roadmap for VHA’s transformation of its mental health services.  However, we have expressed continued concern about oversight of the implementation phase of these initiatives.  The VA MHSP was developed before the impact of Operations Iraqi Freedom and Enduring Freedom (OIF/OEF) was evident, and we believe a pressing need is emerging for Congress to ramp up the monitoring of VA’s strategies, policies, and operating plans being implemented to deliver on the promise of the current strategic plan.  We believe VHA must also conduct accurate annual needs and gap assessments to take into account the changing needs of the veteran population, including the newest generation of combat veterans.

Historically approximately one fifth (20 percent) of veterans receiving any kind of VA care consumed a mental health service.  This use rate in general is well above the rate for the private sector.  According to VA, the needs of OIF/OEF veterans for mental health services are even greater, with almost 45percent having been evaluated for, or having received, a possible diagnosis of a mental health disorder.  Based on past experience and confirmed in the scientific literature, it is clear that the needs and greater demand for mental health services continue for five to ten years following combat exposure.  In a recent compilation of screening data for service members returning from deployments in Iraq, nearly 40 percent of active duty soldiers and more than 30 percent of active duty Marines screened positive for a psycho-social problem.  The rates for reservists were even higher—over 45 percent for Army reserve, 50 percent for Army National Guard and nearly 45 percent for Marine reserves.  On all surveys of psychological concerns among OIF/OEF service members, these rates rise as they experience repeated deployments.  For some, the pressures become unbearable.  While the wars continue and the number of deployments per service member climbs, rates of suicide in the military are rising.  Given these findings, easily accessible, high quality VA mental health and substance-use disorder treatment is essential to address the post-deployment mental health needs of combat veterans early on, before symptoms become chronic.  Today, VA is challenged to meet these needs, and without meaningful oversight that challenge will grow as time goes along. 

VA has been chronically plagued with wide variation among medical centers on the adequacy of the continuum of care of mental health services offered.  Wide unexplainable variations were documented every year from 1996 when Congress first mandated that VA track whether it was maintaining its capacity to provide mental health services, until the final report from that expired mandate was delivered to Congress.  In February 2004 the VA Capital Asset Realignment for Enhanced Services (CARES) Commission included a special section on mental health services underscoring its assessment that the breadth of services and access to mental health care were unacceptably variable across the system.  In June 2004, a VA mental health task force again documented wide variation in the availability of and access to a full continuum of mental health care services, particularly in substance-use disorder treatment, and in use of evidence-based approaches to the care of post-traumatic stress disorder (PTSD) and other mental disorders. 

In response to the 2003 New Freedom Commission’s call for action, VA developed a national strategic plan for mental health services which was finalized in November 2004.  In showing sensitivity to VA’s commitment to reform, Congress allocated new funds to enhance mental health services and required VA to spend these funds in pursuit of that reform.  Despite these efforts, in May 2007 the VA Inspector General again criticized the consistency and adequacy of mental health services throughout the system.

To address these concerns VA has been provided with targeted mental health funds in more recent years’ appropriations to augment mental health staffing across the system.  This funding was intended to address widely-recognized gaps in the access and availability of mental health and substance-use disorder services that existed prior to the development of the MHSP, to address the unique and increased needs of veterans who served in OIF/OEF and to create a comprehensive mental health and substance-use disorders system of care within VHA that is focused on recovery – a hallmark goal of the New Freedom Commission.  In addition, VHA developed its UMHS policy so that veterans nationwide can be assured of having access to the full range of high quality mental health and substance-use disorder services in all VA facilities and at the time that they are most needed.  Timely, early intervention services can improve veterans’ quality of life, prevent chronic illness, promote recovery, and minimize the long-term disabling effects of undetected and untreated mental health problems.  These funds have been dispersed as part of special initiatives, with a clear mandate that they would be used to augment current mental health staffing, not merely replace older positions as they become vacant.

While the specialized mental health augmentation funding has significantly improved mental health services across VHA, a recent gap analysis conducted by VHA, resulting in the UMHS plan, underscores how much still needs to be done to assure equity of access for all veterans.  Furthermore we understand that this analysis (one that VA has not released to the Congress or the veterans service organization community) does not fully take into account many important factors such as the cost and effort required to provide newer evidence-based treatments for priority conditions such as PTSD.

Supplementary mental health funds were allocated as time-limited, annual “special purpose” funding allocations that occurred outside of the usual Veterans Equitable Resource Allocation (VERA) process.  Although there was a clear expectation by Congress that the services based on these funds would be maintained into the foreseeable future, within VA the continued medical center funding has not been promised or assured.  It is critical that these programs and the UMHS package be maintained, since, as was learned tragically after the Vietnam War, the needs for mental health services are not time-limited, since many veterans of that era first sought care long after the conflict ended.  We understand that VHA now proposes to move funding for these programs into the VERA process.  We are concerned that if all mental health funds moved into VERA and mixed with other medical care funds allocated to the medical centers, mental health and substance-use disorder programs will be again at great risk for erosion.  In fact this has been the case in the past when mental health and substance-use disorder funds were allocated under VERA and were required to compete directly with other acute care programs.

VHA is a large integrated health care system with national policy and program mandates but today is characterized as a largely decentralized management system.  While local flexibility has many strengths, the budgetary discretion granted at the Network and local medical center levels for the use of funds allocated through VERA could have unwarranted consequences for vulnerable veteran populations who have special needs.  Comprehensive and detailed oversight and monitoring is imperative if ongoing progress in filling critical gaps in mental health services across the nation is to be assured and recovery is to be fully embraced. 

We believe the solution to this pressing problem would need two major components: an attentive oversight process, and an empowered organizational structure to inform that oversight responsibility.

The oversight process we envision in mental health would be a constructive one that is helpful to VA facilities, rather than punitive.  It should be data-driven and transparent, and should include local evaluations and site visits to factor in local circumstances and needs.  Such a process could assure that ongoing progress is made in achieving the goal of the VA MHSP and UMHS package to provide easily accessible and comprehensive mental health services equitably across the nation.

Mr. Chairman, the second component necessary to make the first one meaningful would be putting in place an empowered VA organizational structure to assure that this oversight process is robust, timely and utilizes the best clinical and research knowledge available.  Such a structure would require VHA to collect and report detailed data, at the national, network and medical center levels, on the net increase over time in the actual capacity to provide comprehensive, evidence-based mental health services.  Using data available in current VA data systems, such as VA’s payroll and accounting systems, supplemented by local, audited reports where necessary, could provide information down to the medical center level on at least the following for the period fiscal year 2004 to the present fiscal year:

• The number of full-time and part-time equivalents of psychiatrists and psychologists;
• The number of mental health nursing staff;
• The number of social workers assigned to mental health programs;
• The number of other direct care mental health staff (e.g. counselors, outreach workers);
• The number of administrative and support staff assigned to mental health programs;
• As a basis for comparison, the total number of direct care and administrative full-time employee equivalents (FTEE) for all programs, mental health and others; and
• The number of unfilled vacancies for mental health positions that have been approved, and the average length of time vacancies remain unfilled. 

The current practice of reporting only the number of offers made to prospective new mental health staff members, and not the number who are actually on board, should be immediately halted, since we know there are lags of several months in actually bringing these new clinicians on board.

Mr. Chairman, we believe VA should be required to establish a web-based clinical inventory instrument to gather information from the field about existing mental health programs (i.e., PTSD, substance-use disorder, etc.) in each VA facility including hours of operation, case loads and panel sizes, staffing levels and current capacity to provide evidence-based treatments as specified in published VA/DoD Evidence-Based Practice Guidelines. 

VA should also develop an accurate demand model for mental health and substance-use disorder services, including veteran users with chronic mental health conditions and projections for the needs of OIF/OEF veterans.  This model development should be created parallel to the VA mental health strategic planning process.  This model should include estimated staffing standards and optimal panel sizes for VA to provide timely access to services while maintaining sufficient appointment time allotment. 

Assuming the creation of these resource tools, Congress should also require VA to establish an independent body, a “VA Committee on Veterans with Psychological and Mental Health Needs,” with appropriate resources, to analyze these data and information, supplement its data with periodic site visits to medical centers, and empower the committee to make independent recommendations to the Secretary of Veterans Affairs and the Congress on actions necessary to bridge gaps in mental health services, or to further improve those services.  Membership of the committee should be made up from VA mental health practitioners, veteran users of the services and their advocates, including veterans service organizations and other organizations concerned about veterans and VA mental health programs.  The site visit teams should include mental health experts drawn from both within and outside of VA.  These experts should consult with local VA officials and seek consensual, practical recommendations for improving mental health care at each site.  This independent body should synthesize the data from each of the sites visited and make recommendations on policy, resources and process changes necessary to meet the goals of the MHSP. 

In addition to these changes, VA should be directed to conduct specialized studies, under the auspices of its Health Services Research and Development Program and/or by the specialized mental health centers such as the Mental Illness Education, Research and Clinical Centers (MIRECCs) in several sites, the Seriously Mentally Ill Treatment, Research Education and Clinical Center (SMITREC) in Ann Arbor; and the Northeast Program Evaluation Center in West Haven, among others, on equity of access across the system; barriers to comprehensive substance use disorders rehabilitation and treatment; early intervention services for harmful/hazardous substance use; couples and family counseling; and programs to overcome stigma that inhibits veterans, particularly newer veterans, from seeking timely care for psychological and mental health concerns.

As an additional validation, we believe that the Government Accountability Office (GAO) should be directed to conduct a follow-on study of VA’s mental health programs to assess the progress of the MHSP, the UMHS, and to provide its independent estimate of the FTEE necessary for VA to carry out the above-noted initiatives.  Congress should also require GAO to conduct a separate study on the need for modifications to the current VERA system to incentivize its fully meeting the mental health needs of all enrolled veterans. 

While DAV supports the basic intent behind H.R. 784, we ask the Subcommittee to consider a broader scope of oversight of VA’s mental health program than envisioned by the bill.  We believe the ideas above—ideas that we have gleaned from a number of mental health and research professionals in and out of VA, and from the literature, are necessary to fully ensure VA is moving its mental health policy and program infrastructure in a proper direction.  Also, we urge the Subcommittee, which would be the major recipient of this new approach to reporting true VA mental health capacity, to continue its strong oversight to assure VA’s mental health programs and the reforms it is attempting to meet all their promise, not only for those coming back from war now, but for those already here.

H.R. 785—To direct the Secretary of Veterans Affairs to carry out a pilot program to provide outreach and training to certain college and university mental health centers relating to the mental health of veterans of Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF). 

The intent of this bill is to establish a four-year pilot program aimed at improving outreach to OIF/OEF veterans on the campuses of colleges and universities.  The measure would require VA to provide training to clinicians, administrative and other relevant individuals at the selected pilot sites for the purpose of improving access to mental health treatment and services for returning war veterans from Iraq and Afghanistan.  H.R. 785 would require VA to report on the selected pilot sites, the number of OIF/OEF veterans enrolled in each university or college, a description of the services to be made available under the program and assessment and effectiveness of the program.  The bill would authorize appropriations of $3 million annually to carry out its intent for each fiscal year 2010 through 2013. 

Current research findings indicate that combat veterans from OIF/OEF are at higher risk for post traumatic stress disorder (PTSD) and other post-deployment mental health problems.  VA reports that veterans of the current wars have sought care for a wide range of medical and psychological conditions, including depression, anxiety, PTSD and substance-use disorders. 

The VA has a unique obligation to meet the health care and rehabilitative needs of veterans who have been wounded during military service or who may be suffering from post-deployment readjustment problems as a result of combat exposure.  The VA and Congress must remain vigilant to ensure that federal programs aimed at meeting the needs of the newest generation of combat veterans are sufficiently funded and adapted to meet them, while continuing to address the chronic health maintenance needs of older veterans who served and were injured in earlier military conflicts. 

DAV Resolution 166, adopted in general session by our members at DAV’s National Convention assembled in Las Vegas, Nevada, August 9-12, 2008, supports program improvement and enhanced resources for VA mental health programs to achieve adjustment of new combat veterans and continued effective mental health care for all enrolled veterans needing such services.  Therefore, DAV is pleased to support H.R. 785, a bill that would offer an appropriate outreach effort and would attempt to better inform academic centers about VA services and the unique needs our newest generation of war veterans—and specifically about their post-deployment mental health needs.  

H.R. 1211—Women Veterans Health Care Improvement Act

This measure seeks to expand and improve health care services available to women veterans from the Department of Veterans Affairs (VA); especially those serving in Operations Iraqi and Enduring Freedom (OIF/OEF). 

Title I, section 101 would require VA to enter into a contract with an outside entity or organization to perform a comprehensive study and report on the existing barriers that impede or prevent women from accessing health care and other services from VA.  This study would build on the work of the National Survey of Women Veterans in FY 2007-2008, to ensure sufficient sample size and include reporting on such barriers as perceived stigma with seeking mental health services, child care, distance to and availability of care, acceptability of integrated primary care, perception of personal safety and gender sensitivity during care, and effectiveness of outreach. 

The VA would be required to internally review the results of the study and submit findings with respect to the study to specified divisions within VA, and would be further required to submit two reports to Congress.  The report to Congress would include recommendations for administrative and legislative action by the VA Secretary as deemed appropriate.  The bill would authorize appropriations of $4 million to carry out the purpose of this section. 

Section 102 would require VA to contract with an outside entity or organization to perform a comprehensive assessment of existing health care programs for women veterans and report the findings to Congress.  This would include assessment of specialized programs, including those for women with post traumatic stress disorder (PTSD), those who are homeless, require substance-use disorder or mental health treatment, and for women who require obstetric/gynecological care.  The assessment would rate the effectiveness of the VA’s programs based on the frequency with which the services are provided, the demographics of women using these services, the locations of the services, and whether, and to what extent, waiting lists, distance to care, and other factors affect the receipt of services. 

After the assessment is completed, and no later than one year after the enactment of this Act, the Secretary would be required to provide a report to Congress on a plan to improve health care services to women veterans, and project future health care needs to include mental health needs of OIF/OEF women veterans.  The report would also include a list of services available at every medical center in the Department and include recommendations for administrative and legislative action that the VA Secretary deems appropriate.  Within six months of this report, GAO would be required to submit a report to Congress based on the Secretary’s report.  The bill would authorize $5 million to be appropriated to carry out the purposes of this section.

Title II, section 201 would amend subchapter VIII of chapter 17 of title 38, United States Code, to authorize hospital care and services for newborn children of women veterans receiving maternity care at a Department facility or through contract care at VA expense, for a period of 14 days beginning on the date of birth of the child. 

Section 202 would improve VA’s ability to assess and treat veterans who have experienced military sexual trauma (MST) who exhibit symptoms of PTSD by requiring a new tailored training and certification program to ensure VA health care providers develop competencies in caring for these co-occurring conditions.  Section 202 would also mandate that professionals be trained in a consistent manner to include the principles of evidence-based treatment and care for MST and PTSD. 

Under this authority, the Secretary would also be required to provide Congress an annual report covering a number of areas including the number of mental health professionals, graduate medical education trainees, and primary care providers who have been certified under the program, along with the amount and type of continuing medical education that they complete for the required certification; in addition, the report would include the number of graduate medical education, training, certification and continuing medical education (CME) courses that were provided by the program.  The report would also detail the number of veterans who received counseling, care and services from these certified professionals, trainees and other providers, and the number of trained full-time employee equivalents needed to meet the needs of veterans treated for MST and PTSD.  Finally, the report would contain any recommended improvements for treating veterans with co-occurring MST and PTSD.

Section 203 would authorize a two-year pilot program, in at least three VISNs, of reimbursement for the expenses of child care services for certain qualified veterans receiving mental health, intensive mental health or other intensive health care services, whose absence of child care might prevent them from obtaining these services.  The term “qualified veteran” would be defined as a veteran with the primary caretaker responsibility of a child or children.  Following the completion of the pilot, the Secretary would be required to report on the program, including recommendations to Congress for continuing or expanding the program.  The bill would authorize appropriations of $1.5 million for each of fiscal years 2010 and 2011 to carry out the pilot program under this section. 

Section 204 would require recently separated women veterans and minority veterans to be appointed to certain VA advisory committees.

Women veterans are a small but dramatically growing segment of the veteran population.  The current number of women serving in active military service and its reserve and Guard components has never been larger and this phenomenon predicts that the percentage of future women veterans who will enroll in VA health care and use other VA benefits will continue to grow proportionately.  Also, women are serving today in military occupational specialties that take them into combat theaters and expose them to some of the harshest environments imaginable, including service in the military police, artillery, medic and corpsman, truck driver, fixed and rotary wing aircraft pilots and crew, and other hazardous duty assignments.  VA must prepare to receive a significant new population of women veterans in future years, who will present needs that VA has likely not seen before in this population. 

Mr. Chairman, this comprehensive legislative proposal seeking to access, improve and expand VA services for women veterans, is fully consistent with a series of recommendations that have been made in recent years by VA researchers, experts in women’s health, VA’s Advisory Committee on Women Veterans, the Independent Budget, and DAV.  DAV Resolution 238 seeks to ensure high quality comprehensive VA health services for all women veterans, with a special focus on the unique post-deployment needs of women veterans returning from OIF/OEF.  DAVs resolution notes that VA needs to undertake a comprehensive review of its women’s health programs, and seek innovative methods to address barriers to care for women veterans to ensure they receive the treatment and specialized services they need and deserve.  Therefore, we fully support H.R. 1211 and urge the Subcommittee to recommend its enactment.

We note with regard to section 202 of the bill that it specifically references “women” a couple of times.  VA MST and mental health specialists have reported to us that veterans currently under care for MST in VA programs are nearly equally divided by gender.  While we fully support the purposes of the bill, and have no objection to the purposes of section 202 being included in the bill, we would recommend any references in section 202 to “women” be made gender neutral.  Alternately, the bill could be amended to sub-divide the required report for each gender.

Draft Bill—To amend title 38, United States Code, to expand veteran eligibility for reimbursement by the Secretary of Veterans Affairs for emergency treatment furnished in a non-Department facility.

This bill would amend subparagraph (b)(3)(C) of section 1725 of title 38, United States Code, by striking the words “or in part” where they appear in current law.  In subsection (f)(2) the bill would strike subparagraph E.  The bill would also add new language to clarify Congressional intent that VA would be required to assume responsibility as a secondary payer in a case in which an otherwise eligible veteran has private insurance coverage that pays a portion or part of the cost of an episode of emergency care in a private facility.  Under the bill, VA would pay the remainder of the veteran’s obligation, less any required copayments under the associated private insurance coverage.  DAV supports the purposes of this draft bill and appreciates the sensitivity of the Subcommittee leadership in developing an effective solution to a nagging problem plaguing both service-connected and nonservice-connected veterans who rely on VA to meet their primary health care needs. 

In 1999, Congress enacted the Veterans Millennium Health Care and Benefits Act, Public Law 106-117.  That act provided the authority sought by VA at the time to complete its role as a comprehensive health care system for all veterans who are enrolled, by giving VA authority to reimburse costs of emergency private care under certain circumstances.  Prior to passage of the Millennium Act, VA was essentially without authority to pay emergency expenses in private facilities for its own patients, unless generally they were service-connected veterans.  Under prior law VA was authorized to pay for non-VA emergency treatment for a veteran’s service-connected disability, a nonservice-connected disability aggravating a veteran’s service-connected condition, any condition of a veteran rated permanently and totally disabled from a service-connected condition(s), and a veteran enrolled in a VA vocational rehabilitation program. 

The intent of this bill would enable a veteran, enrolled in VA health care, who otherwise is eligible for VA reimbursement of certain private emergency health care expenses under the Millennium Act authority but for the existence of coverage “in part” by a form of private health insurance (no matter how major or minor such private coverage might be), to be reimbursed as otherwise authorized under the Millennium Act’s emergency care reimbursement program.  Rescission of the words “or in part” in section 1725, accompanied by the striking of subparagraph E of subsection (f)(2) of that section, would provide VA a clearer authority.  For a VA-enrolled veteran with minimal insurance coverage (such as a small medical rider on a state-mandated automobile insurance plan) to secure VA reimbursement for emergency care under the intended authority, would be an exceedingly helpful new benefit.      

Today, a number of enrolled veterans routinely are being denied reimbursement, because they are covered “in part,” even if all other eligibility requirements are met.  The bill would be effective as of October 8, 2007, presumably to take into account the circumstances of any individuals who may have recently been denied VA reimbursement because of the current “in part” restriction.

DAV supports the intent of this draft bill. This bill’s purposes are in full accord with the mandate from our membership expressed in DAV Resolution No. 178, adopted at our national Convention assembled in Las Vegas, Nevada, August 9-12, 2008.  Its purposes are also consistent with the recommendations of the Independent Budget to improve reimbursement policies for non-VA, emergency health care services for enrolled veterans. We urge the Subcommittee Chairman to introduce this bill, to gain its further consideration by the Full Committee, and we endorse its enactment into law. The DAV thanks those involved for their efforts to ensure this essential emergency relief benefit originally contemplated in the Millennium Act, and its improvements from this bill, are properly implemented.

With regard to this bill, we note the current renewed discussion of the need for national health reform, a major stated goal of this Administration.  Emergency hospitalization of the uninsured is one of the driving forces for reform in the private sector.  One of the unintended consequences of such reform might well impact on the VA health care system.  In that regard, we ask the Subcommittee for vigilance to ensure that whatever shape reform may ultimately take, that veterans’ rights be protected for continuation of reimbursement of their emergency health care services as authorized by section 1725, title 38, United States Code.

Mr. Chairman, this concludes the testimony of Disabled American Veterans on these important bills.  I would be pleased to respond to questions from you or other members of the Subcommittee on these matters.