I would like to thank Chairman Filner and members of the committee for inviting Veterans for Common Sense to testify about the Department of Veterans Affairs’ budget request for Fiscal Year 2009.  VCS especially thanks this Committee for the dozens of hearings you held last year, and for the prompt passage of the “Dignity for Wounded Warriors Act,” a bill strongly supported by our VCS members.

As Associate Supreme Court Justice Thurgood Marshall said, “Justice too long delayed is justice denied.”  With that quote in mind, VCS believes VA’s 2009 budget request falls far short because it does not adequately seek to address what we believe should be VA’s four highest budget priorities:

1. Zero tolerance for homelessness.  VA’s budget does not provide enough funding to reduce the number of homeless from 200,000 to as close to zero as possible. 
2. Zero tolerance for VA turning away suicidal patients.
3. Zero tolerance for turning away Afghanistan and Iraq war veterans from free and prompt VA healthcare within five years of their discharge from active duty.
4. Zero tolerance for VA claim delays and claim errors. 

VCS believes VA suffers from a capacity crisis, and that our veterans are unduly denied prompt access to VA services.  Our veterans earned and need prompt and high-quality medical care as well as prompt and accurate claim decisions.  VCS is outraged that government lawyers argued against the new law mandating five years of free VA medical care for our Iraq and Afghanistan war veterans.

VCS is concerned about three statements VA made about VA’s 2007 budget:

VA Statement #1: Former VA Secretary Jim Nicholson said: “The President’s 2008 budget request provides the resources necessary to ensure that service members’ transition from active duty military status to civilian life continues to be as smooth and seamless as possible.”

- Reality: VA’s 2008 budget failed to meet this goal.  The Walter Reed scandal broke a few days after VA’s comments, revealing the military and VA were woefully under funded and unprepared for unanticipated patients.  We thank this Congress for ignoring the Administration’s chronic under funding and increasing VA’s 2008 budget.

VA Statement #2: Current VA Under Secretary for Health Mike Kussman said: “With the resources requested for medical care in 2008, the Department will be able to continue our exceptional performance dealing with access to health care – 96 percent of primary care appointments will be scheduled within 30 days of patients’ desired date…”

-  Reality: While VA’s Kussman claimed only four percent of patients waited more than 30 days to see a doctor, VA’s Inspector General reported that 25 percent waited more than 30 days.  This is six times more than VA’s claim.  In Charleston, South Carolina, the Charlottesville Observer reported that 93 percent of Iraq and Afghanistan war veterans waited more than 30 days for medical care for serious conditions such as TBI.
VA Statement #3: Former VA Secretary Nicholson said: “We expect to improve the timeliness of processing these claims to 145 days in 2008…. In addition, we anticipate that our pending inventory of disability claims will fall to about 330,000 by the end of 2008….”   In VA’s press release dated February 4, 2008, VA once again promised to cut the backlog to 300,000 claims and process claims in an average of 145 days.

- Reality: While VA would lead Congress to believe that VBA can improve, the pending inventory of rating-related claims is 400,000, and veterans wait an average of 183 days. 

Important Facts: VCS used the Freedom of Information Act to obtain documents providing incontrovertible evidence that VA’s capacity crisis requires more funding.

• VA expects to treat 5.8 million patients this year, yet VA’s IG reported 25 percent, or nearly 1.5 million veterans, will wait more than one month to see a VA doctor.
• VA regional offices are still working on 650,000 claims of all types, yet 26 percent, or 169,000 veterans, have already waited more than six months.
• Here are salient facts regarding Iraq and Afghanistan war veterans:
• DoD already reports 68,000 non-fatal battlefield casualties from the two wars, and VA expects to treat 333,000 veteran patients during 2009.
• VA hospitals already treated 264,000 unanticipated patients, yet 33 percent, or 87,000 veterans, wait more than one month to see a VA doctor. 
• VA’s budget proposal spends more than $7,100 per veteran on medical care, yet VA budgets only $3,900, for Iraq and Afghanistan veterans, or 55% of the cost.
• VA regional offices received 245,000 unanticipated disability claims, yet 16 percent, or 39,000 veterans, are still waiting, on average six months, for a VA claim decision.
• DoD reported 20 percent, or potentially as many as 320,000, of our new war veterans are at risk for Traumatic Brain Injury, or TBI.
• A recent West Virginia survey identified 36 percent, or potentially as many as 600,000, of our veterans as having post traumatic stress disorder, or PTSD.
• Veterans who served in the National Guard and Reserves are nearly three times as likely to have their claim denied than veterans from regular Active Duty (14% v. 5%).
• VA diagnosed 56,246 veterans with PTSD, yet approved only 61 percent of the claims, or 34,138, for PTSD.

VA’s failure to submit a budget to increase capacity and rectify other systemic problems needlessly increased suffering among our veterans. According to published reports, the number of broken homes, unemployed veterans, drug and alcohol abuse, suicides, and homelessness all rose – problems expected to worsen without immediate VA action.

As the Rev. Martin Luther King, Jr. said, “Injustice anywhere is a threat to justice everywhere.”  Our veterans earned and deserve better from our government.  The Administration’s VA budget request is dead on arrival because it does not deliver justice for our veterans in a complete and timely manner.

Additional VA Budget Suggestions

VCS believes that VA should follow the role model of General Omar Bradley, VA’s Administrator after World War II.  He said, "We are dealing with veterans, not procedures – with their problems, not ours."   With that in mind, VCS solicited suggestions from our members, and they were incorporated in the following additional VA budget suggestions.

VCS believes that VA’s failures are caused by this Administration’s myopia at saving money and its inability to evolve.  VA should not be able to hide behind its failures to follow the law for decades as an excuse not to begin a massive reform program to eliminate homelessness among veterans, guarantee prompt and high-quality medical care, and process disability claims accurately within one month.

VCS remains especially concerned that VA’s inflexible leaders continue to be unable to provide justice to our Nation’s veterans, especially during war when the needs of our veterans are most acute.   Here are some items that would bring justice to our veterans.

• Patient Backlog.  There is no Administration request for mandatory full funding for all priority groups, thereby excluding millions of uninsured veterans from VA hospitals and clinics.  Currently there is an unlimited military budget for bullets and bombs for our military.  Logically, there must also be mandatory full funding of VA’s budget for hospital beds and benefits for our veterans.  In addition, VA needs to stay open longer each weekday and consider being open on weekends in order to increase capacity and thus meet the increase in demand. 

• New Patients: The VA did not request additional funding to provide the five years of mandatory free healthcare for our returning Iraq and Afghanistan war veterans recently signed into law.  Similarly, there is no VA funding request to provide PTSD and TBI screening for all 1.6 million service members deployed to the war zone.  In January 2008, a U.S. District Court ruled that our class action lawsuit against VA will move forward.  The Court ruled the two years of free medical care is a spending mandate and rejected VA’s view that spending on healthcare for Iraq and Afghanistan war veterans was discretionary.  Congress should codify this ruling with mandatory full funding so no future veterans wait for VA care.

• Polytrauma.  In 2007, VA planned more than 20 polytrauma centers.  VCS believes every VA medical center should be capable of treating polytrauma patients in order to meet the growing demand that more than six years of on-going warfare requires.  All VA medical centers should have this ability so veterans can be treated near their homes where family members and friends can provide comfort and support.

• Suicide Epidemic.  VA should fund a state-of-the-art suicide data collection, reporting, and analysis office.  The national office should identify local, state, and federal data about veterans who attempted or committed suicide so VA can implement the best policies to reduce suicide among all veterans, especially recent war veterans.  This should include monitoring of specific cohorts of veterans by period of war, gender, race, number of deployments, length of deployments, and use of VA healthcare.

• Claims Backlog.  In order to expedite claims and reduce the backlog, the VA budget submitted by the President should have sought new rules designed to create a presumption for a concussive blast and/or a psychological stressor so that VA can more accurately and quickly adjudicate claims for TBI and PTSD.  Congress should mandate automatically approving all VA claims within 30 days, for a period of up to one year for deployed veterans’ claims.  VCS supports this bold recommendation initially made by Harvard University Professor Linda Bilmes.

• Disability Claims. VA should make sure that VA employees stationed at military facilities are authorized to assist with both military and VA healthcare and claims paperwork, thus ending the turf war preventing VA employees from assisting soon-to-be veterans.  While VA recently signed a contract to review adding “quality of life” to the list of items considered when determining the amount of compensation payments, VA has not sought additional authority to pay such benefits.

• Long-Term Planning. While there is increased funding for information technology, there does not appear to be any funding for increased staffing for data collection, reports, and analysis.  These are necessary so that VA does not repeat prior mistakes when VA requested insufficient funding.  Congress should enact HR 1354, introduced by Rep. James Moran and Rep. Ray LaHood, which directs VA to define the war zones, collect data, and prepare cost and benefit use reports about the Iraq and Afghanistan wars.  VCS also supports a longitudinal study of Iraq and Afghanistan war veterans that starts now.  The Congress and the public must be fully and regularly informed about the human and financial costs of the two wars.

• Overhauling VA.  VA does not appear to request money for a desperately needed agency-wide overhaul, as recommended by the Veterans Disability Benefits Commission.  VCS believes that our veterans and VA employees will continue to suffer as long as VA fails to plan for mandatory full funding and to plan to significantly expand timely access to VA healthcare and claims.  One component would be to implement 38 USC Section 5106, and thus require the military to automatically provide VA full military and medical records on all service members.  Another component would be to automatically enroll all service members into VA the first day the new service member enters the military.

• Education Benefits.  Transition and readjustment assistance in the form of educational benefits are a meager fraction of what they were when compared to the Post - World War II GI Bill.  That is why VCS strongly supports S 22, introduced by Senator Jim Webb, “The Post - 9/11 Veterans Educational Assistance Act of 2007,” that substantially increases payments to veterans.

• Personality Disorder Discharges.  There does not appear to be any funding so VA can review the applications for healthcare and disability benefits denied by VA on the basis of a personality disorder discharge given by the military.

• Ending Stigma.  There is no funding to reduce the stigma against people with mental health conditions.  Military studies confirm this stigma hinders many of our war veterans from seeking mental healthcare.

• Ending Employment Discrimination. Similarly, there is no funding for public service announcements to combat illegal job discrimination against veterans.

• Vet Centers. Congress should enact legislation expanding VA’s highly successful Vet Centers so they can provide mental health services to active duty service members, either at existing facilities or at new offices on military bases.  This expanded service might first be targeted at military installations that have shortages of mental healthcare providers and bases expecting large redeployments from the war zones.  Congress should allow families to participate in the readjustment counseling process at all Vet Centers.

• Executive Bonuses.  Congress should allow only modest bonuses for VA executives, and these should be approved outside the agency’s normal chain of command.  Furthermore, VCS strongly supports performance-based incentives and bonuses for VA’s rank-and-file employees for ideas and actions made to improve the delivery of healthcare and benefits to veterans.

• Gulf War Veterans.  Years of denial of the problem of chronically ill Gulf War veterans is a tragic stain on the record of the United States government in caring for our veterans.  VCS strongly supports research to identify treatments for the 175,000 veterans of the 1991 Gulf War that VA estimates remain chronically ill, especially the $75 million for VA’s program at the University of Texas Southwestern Medical School.  Another project that deserves close Committee attention and support is actually funded by the military: VCS supports adding $30 million to the Department of Defense budget for competitive research in the Congressionally Directed Medical Research Program since the military has historically provided the majority of funding for this research, but refuses to put it in its budget.

• Vietnam War Veterans.  VCS continues to support research and treatments for Vietnam War veterans poisoned by dioxin contained in Agent Orange.  VCS also supports outreach to veterans with diabetes, prostate cancer, and other war-related medical conditions so they are aware of new VA healthcare and disability benefits for those conditions.  VA must be prohibited from expending funds to block claims by “Blue Water” veterans for VA healthcare and benefits related to agent orange.

• TSGLI.  VA’s Traumatic Servicemembers’ Group Life Insurance program office should hire additional staff to analyze significant discrepancies in the outcomes of TSGLI claims.  According to VA, only half of the TSGLI claims were approved (2,075 approved out of 3,979 applications, or 52%).   Furthermore, Active Duty veterans were 65 percent more likely to have their TSGLI approved than National Guard and Reserve veterans (66% v. 40%).  Currently, TSGLI is available only to service members deployed to the Iraq and Afghanistan war zones.  VCS believes Congress should expand TSGLI staffing and make TSGLI benefits available to service members involved in training-related accidents, regardless of their location.

• Travel Reimbursement.  VCS believes people in our country should be treated equally, and veterans should receive the full 70 cents per mile reimbursement for travel, the same amount that Representatives and Senators receive, and not the 28 cents approved by Congress that includes a deductible that increased from $6 to $15.

• Due Process. VCS believes all veterans should be able to retain an attorney at the initial stages of a VA healthcare or disability benefit application in order to expedite and improve the process as well as to save VA money developing the claim; as it stands a veteran must wait until the initial VA determination is made and the veteran filed a Notice of Disagreement.  VCS wishes to strongly emphasize the need for competent, unbiased, non-government legal advice for veterans and family members when a veteran has a serious injury (such as TBI or PTSD), as the most serious cases of VA healthcare and claims negligence and difficulties often involve veterans with these conditions.

• Outreach.  VCS supports lifting the current ban on VA advertising and outreach, as described in the July 2002 memo authored by the former VA official Laura Miller.    VCS believes VA should broadcast public service announcements describing VA services, especially for members of the National Guard and Reserve, who are using VA services less than their Active Duty peers.   VCS believes Congress should fund VA training and outreach to universities so law students are encouraged to learn about laws designed to assist veterans, plus ongoing education to remain current on changes in the laws.  If the military can spend billions recruiting new soldiers, then VA should be able to spend some money making sure veterans and their families know what they earned and making sure they can quickly receive it.

VCS respectfully requests the following documents be entered into the hearing record:

• "VA Facility Specific OIF/OEF Veterans Coded with Potential PTSD,” Aug. 27, 2007.
• “VA Benefits Activity: Veterans Deployed to the Global War on Terror,” Nov. 14, 2007.
• VA “Analysis of Healthcare Utilization Among U.S. Global War on Terror Veterans,” Oct.  2007.
• DoD “Contingency Tracking System Deployment File for Operations Enduring Freedom & Iraqi Freedom,” Oct. 31, 2007.
• VCS “VA Fact Sheet,” Feb. 4, 2008 and VCS “DoD Fact Sheet,” Jan. 12, 2008.
• “The Elusive 'Seamless Transition',” Proceedings, February 2008.

VA Facility Specific OIF/OEF Veterans Coded with Potential PTSD
Through 3rd Qt FY 2007

I. Background:

The Government Accountability Office (GAO) has requested VA to enumerate the total number of OIF/OEF veterans who were diagnosed with PTSD by VISN and VAMC using VA inpatient and outpatient records. GAO also asked for this information is to be aggregated with Vet Center utilization data. VHA prepared an initial report in October 2004 for the healthcare utilization during FY 2004. This eleventh report covers the VA healthcare data from FY2002 through 3d Qt FY 2007.

II. Data Sources:

OIF/OEF veteran roster:

Since October 2003, the Department of Defense (DOD) Defense Manpower Data Center (DMDC) has sent the Department of Veterans Affairs (VA) Environmental Epidemiology Service (EES) a periodically updated personnel roster of troops who participated in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) who had separated from active duty and become eligible for VA benefits. The roster was originally prepared based on the pay records of individuals but in more recent months it was based on a combination of pay records and operational records provided by each branch of service. Based on the latest DMDC file received on July 27, 2007, there are a total of 751,273 unique OEF/OIF veterans (excluding 3,638 who died in theater), who have been separated as of May 2007 from active duty following the deployment. For each veteran, his/her demographic (SSN, name, DOB, gender, education, etc) and military service specific data (branch, rank, unit component, deployment dates, etc) were included in the record.

VHA health care utilization records:

The roster was checked against VA’s inpatient (PTF) and outpatient (OPC) electronic patient records available through June 30, 2007 to determine those who had sought treatment in VA facilities as well as the ICD-9 diagnostic codes used to describe the visits.  Thus, the data we have was administrative data and not based on a careful review of each patient record. For the purpose of this report, we searched his/her health care utilization records during FY 2002, 2003, 2004, 2005, 2006 and through  FY 2007 3rd Qt ending June 30, 2007 following his/her first deployment in Iraq or Afghanistan theater. For identification of a potential PTSD patient, we used ICD-9CM, 309.81.

The Vet Center counts were based on the data provided to EES on August 17, 2007 by the Readjustment Counseling Service (RCS). The RCS staff matched the same DMDC roster with Vet Center users’ records through FY 2007 3rd Qt.                         .

III. Distribution of Veterans by Diagnostic Code and Facility

• A veteran is counted only once in any facility specific category. For example, a veteran, who received health care from two or more medical centers within the same VISN, was counted once for that VISN. Likewise, a veteran who used services across two or more VISN facilities and a Vet Center was counted only once for the national overall total.
• The number for “Primary” indicates the total number of unique veterans whose primary reason for the inpatient or outpatient visit was for treatment or evaluation of PTSD.
• The number for “Any” indicates the total number of unique veterans coded with PTSD, whether or not the primary reasons for the inpatient or outpatient visit was for treatment or evaluation of PTSD.
• Both “Primary” and “Any” categories may include a suspected diagnosis.

IV. Summary:

Recognizing the limitations of DMDC deployment roster and the uncertainty of the final diagnostic data based on VHA’s electronic patient records, a query of VHA health care utilization databases using the May 2007 DMDC separation roster yielded a total of 48,559OEF/OIF veterans coded with PTSD at a VA medical center and 14,655 veterans who received Vet Center service for PTSD. Of these, 41,591were seen only at a VAMC; 7,687 only at a Vet Center; and

6,968 were seen at both facilities. In summary, based on the electronic patient records available through June 30, 2007, a grand total of 56,246 OEF/OIF veterans were seen for potential PTSD at VHA facilities following their return from Iraq or Afghanistan Theater.

Han K. Kang, Dr.P.H.
August 27, 2007

Number of unique OEF/OIF veterans with PTSD utilizing VA facilities during FY 2002 – 3d Qt FY 2007