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Witness Testimony of Ralph Ibson, National Policy Director, Wounded Warrior Project

Chairman Buerkle, Ranking Member Michaud, and Members of the Subcommittee:

Thank you for inviting Wounded Warrior Project (WWP) to offer our views on legislation pending before the Subcommittee. 

WWP works to honor and empower this generation of wounded warriors – physically, psychologically and economically.  Our policy objectives are targeted to filling gaps in programs or policies -- and eliminating barriers -- that impede warriors from thriving.  Importantly, two of the bills before you this morning, H.R. 3016 and H.R. 3279, would close critical gaps facing warriors and their families and we strongly support their enactment.

H.R. 3016

Among the recommendations in WWP’s policy agenda is that Congress review the operation and effectiveness of the many programs created to improve warriors’ transition from military service to civilian status.  The Federal Recovery Coordination Program (FRCP) may be among the most important of those initiatives to our warriors and their families, and we appreciate the inclusion of H.R. 3016 on your subcommittee’s agenda.  H.R. 3016 would require the Secretaries of Defense and Veterans Affairs to develop a memo of understanding setting out a plan for joint Department of Defense (DoD) and Department of Veterans Affairs (VA) operation of the FRCP in accordance with the bill. As discussed below, a key provision of the bill would require the service secretaries to refer eligible servicemembers to the program at the earliest possible time, but not later than six months before expected retirement or separation from service.

By way of background, the FRCP has its roots in the President’s Commission on the Care of America’s Returning Wounded Warriors (the Dole-Shalala Commission), which found that the system of care, services, and benefits created to assist those who had been injured was too complex to navigate alone.  The Commission recommended the creation of “recovery coordinators” or, in the words of the father of a severely wounded Marine, “a case manager to manage the case managers.”  Ultimately, the National Defense Authorization Act of 2008 (NDAA 2008) directed DoD and VA to develop and implement a comprehensive policy to improve care, management and transition of recovering servicemembers and their families, to include the development of comprehensive recovery plans, and the assignment of a recovery care coordinator for each recovering servicemember.[1]  Early on, DoD and VA entered into a memorandum of understanding establishing a joint VA-DoD Federal Recovery Coordination Program to assist those with category 3 injuries – individuals with a severe or catastrophic injury or illness who are highly unlikely to return to active duty and will most likely be medically separated.  A separate DoD Recovery Coordinator Program was designed for those with category 2 injuries who might or might not return to duty.

In WWP’s view, the services provided warriors and their families through the FRCP represent a too-rare instance of a holistic, integrated effort to help injured veterans successfully transition and adjust to their new normal.  Federal Recovery Coordinators (FRCs) make unique contributions – both medical and non-medical -- in facilitating wounded warriors’ care-coordination and reintegration.  Their invaluable work underscores the importance of ensuring that this program reaches all who need that help, and that it operate as effectively as possible.  But while FRCs provide extraordinary assistance to warriors and their families, overarching systemic problems must be addressed to ensure that the program fully meets its objectives.  We believe H.R. 3016 effectively addresses those systemic problems and we strongly support its enactment.

VA and DoD each share an obligation to severely wounded warriors and their families, but the reality is that they do not now share full responsibility for the FRC program.  As this Subcommittee’s hearings have ably documented, the FRC program suffers from acknowledged interdepartmental gaps.

As both your hearings and the General Accountability Office have documented, individual Service departments are not uniformly referring severely and catastrophically wounded warriors to the FRCP for assignment, or are doing so at much too late a point in the transition process.  It is difficult to reconcile service-department practices that defer referral of a severely wounded warrior until that individual has retired with DoD policy or with the DoD-VA understanding under which the FRC program was established.  The DoD policy makes it clear that “all category 3 service members shall be enrolled in the FRCP [Federal Recovery Coordination Program] and shall be assigned an FRC [Federal Recovery Coordinator] and an RT [recovery team].”[2]  The policy instructs further that the FRC is to coordinate with the recovery care coordinator and recovery team to ensure the needs of the service member and his or her family are identified and addressed.  

But rather than advancing seamless transition, individual Service department practices that defer referral for a possible FRC assignment until a severely wounded warrior has retired tend to frustrate realization of the goals the program was developed to achieve.  By way of illustration, many severely and catastrophically wounded warriors may be eligible for assistance not only from military treatment facilities and the TRICARE program, but from the Veterans Health Administration, the Veterans Benefits Administration, the Social Security Administration, and Medicare.  (As GAO recognized, “FRCs are intended to be care coordinators whose planning, coordination, monitoring and problem-resolution activities encompass both health services and benefits provided through DoD, VA, other federal agencies, states, and the private sector.”[3])  It is critical that a Federal coordinator have the depth of experience, training, and authority to navigate these multiple care/benefits systems.  In contrast to those demanding requirements for an FRC, neither warrior transition unit staff nor recovery care coordinators (RCCs) – who are to assist servicemembers whose injuries are not deemed likely to result in a need for medical separation[4] -- have the training, let alone the authority, to help coordinate care and other needs outside the military system.  Resolving this referral problem is vitally important--  failing to make a referral for an FRC until severely wounded servicemembers retire can mean delay in their recovery, rehabilitation and re-integration.   These are the very kinds of problems that sparked the call for a seamless transition. 

The referral issue seems a manifestation of the fact that instead of being operated as a joint, integrated VA-DoD effort, the FRC program tends to be seen -- and marginalized -- as a “VA program.”  Given the program’s importance to severely wounded warriors, it is critical that both departments fully support it.  Experience under the program strongly suggests that that goal will remain elusive until there is truly shared responsibility for the program.  In our view, enactment of H.R. 3016 would achieve that important objective by providing a sound framework for joint operation of the program under principles to ensure early referrals and efficient, effective recovery, transition and reintegration of severely wounded warriors.  We strongly support enactment of this bill.

H.R. 3279

WWP is also pleased to lend our strong support to H.R. 3279.  This bill would clarify that a veteran who has a serious illness incurred or aggravated in service on or after 9/11, and who is deemed to need personal care services, is an “eligible veteran” for purposes of the comprehensive caregiver-assistance program established under Public Law 111-163.  The rationale for providing support services to caregivers of our wounded apply equally to family members caring for a young veteran suffering from a serious illness incurred in service.  Current law governing caregiver-assistance certainly makes it clear that there is not a hard “eligibility-line” between a traumatic injury and other medical conditions.  That is clear since the law states that the defining term, “serious injury,” includes a mental disorder.  Yet while it would cover some veterans with mental health conditions, VA’s interim final rule otherwise reads the statute as covering only “injury” not illness.  But there may be little distinction between the caregiving needs of a young warrior who is profoundly disabled as a result of serious illness in service and one who is injured.  In each instance, a parent or spouse may have permanently left the workforce to care at home for the veteran’s daily needs, leaving that veteran vulnerable to the risk of VA institutionalization if the stresses of caregiving overwhelm that family member.  Surely the needs Congress sought to address through the caregiver-assistance law relate to the emotional, psychological, physical, and financial impact of caregiving, not to the underlying etiology of a veteran’s condition.  Clarifying the law, as proposed in H.R. 3279, would provide needed support for deserving caregivers while averting risks of unwanted institutionalization.

H.R. 3723

H.R. 3723 would change current law – which authorizes VA to provide fee-basis treatment to certain veterans for whom it cannot provide timely, geographically-accessible care in its facilities – to require it to contract for care under those circumstances for all enrolled veterans pursuant to a specified framework.  It is helpful to review this measure in light of section 1, namely its proposed findings that (1) VA’s health care system fails to provide veterans easily accessible treatment; (2) veterans can be provided care more efficiently closer to where they live and with more flexibility in choosing their own doctors; and (3) replacing VA’s fee-basis care system with the model proposed under the bill can yield better care at little to no increased cost.

We concur that the VA health care system does not consistently provide veterans easily accessible treatment.  Of course there are many factors associated with access to care, to include funding and staffing, as well as eligibility-limits on fee-basis care set in current law.  Under section 1703 of title 38, U.S. Code, VA’s authority to provide care or treatment under contract is limited to specified circumstances (such as to provide ongoing needed care in follow-up to an episode of hospitalization[5]) and to specified categories of veterans (such as veterans needing treatment for a service-connected condition or veterans with service-connected  disabilities rated 50% or more[6]).  In short, existing law generally limits VA’s use of this tool to ensuring continuity of care and to accommodate veterans that Congress has identified as having high priority for access to care. 

In this connection, our most recent experience, particularly as it relates to mental health care, is that fee-basis care is seldom an option for warriors with service-incurred mental health conditions despite VA facilities’ too-frequent inability to provide timely care or even the kind of care some need.  This troubling situation exists despite very clear direction to VA facility directors regarding mental health services:

“[These services] must be made accessible when clinically needed to patients receiving health care from VHA.  They may be provided by appropriate facility staff, by telemental health, by referral to other VA facilities, or by sharing agreements, contracts or non-VA fee-basis care to the extent the veteran is eligible.”[7]  (Emphasis added.)

At a time that VA facilities are ignoring or circumventing a directive that calls for utilizing fee-basis care under the limited circumstances authorized in law, it is difficult to embrace the notion implicit in H.R. 3723 that it would be timely to expand eligibility for fee-care to all enrolled veterans.  But, in our view, there also is a real question as to how best to craft a legislative response to a situation where -- VA’s own directive that action “must” be taken -- is construed by some as simply a guideline.  Under these circumstances, one cannot necessarily assume that amending a statutory provision governing fee-basis care to read “shall” rather than “may,” as the bill proposes, would ensure the desired change.  On the other hand, the establishment of such a broad mandate could certainly create serious fiscal-management challenges for VA with unintended results.   We submit that these uncertainties alone raise real concerns, and suggest that the Subcommittee consider the unintended consequences of such a far-reaching bill. 

Finally, we would acknowledge that H.R. 3723 raises a fair question as to whether VA’s fee-basis model can be improved or even redesigned.  In that regard, there is certainly merit to establishing requirements that any health care provider would have to meet in contracting with VA to treat veterans.  But it is not clear that the requirements proposed in H.R. 3723 represent an optimal contracting framework.  For example, the measure calls for a contractor to have “care coordinators to help veterans make, confirm and keep medical appointments.”   But it does not specifically require the contractor to coordinate care with VA clinicians, and as such would not necessarily assure real care-coordination or continuity of care for the veteran.  In addition, the bill’s requirement that a contractor have the ability to process claims from others in the provider’s network suggests that such a contract would likely not, as a practical matter, be open to most individual providers or small group practices.  As such, it is not clear that the bill would, in fact, “allow veterans more flexibility in choosing their own doctors”, as section 1(b)(3) suggests.  In sum, while H.R. 3723 raises questions that merit discussion, we cannot support its enactment.

H.R. 1460

H.R. 1460 would, in essence, direct VA to enroll any veteran who served in a combat zone in the VA health care system, subject to an option not to enroll.  The bill appears aimed at facilitating a combat veteran’s access to care.  As discussed above, however, it has not been our experience that warriors have encountered difficulty in enrolling or are unaware of their eligibility for VA health care.  Rather, we hear of warriors encountering problems after enrollment, particularly in getting timely, effective mental health care.  VA has reported historically high percentages of OEF/OIF veterans’ enrolling and being “seen” at VA health care facilities.  But surveys of both warriors and VA mental health staff strongly suggest that at least some of those facilities may not be adequately staffed to provide timely care or even the right kind of care, and that in meeting VA’s goal of enrolling as many veterans as possible have been less successful in providing the timely, effective care they should expect.  In short, while we have no objection to H.R. 1460, we do not see this bill as solving the more serious access-to-treatment problems some returning warriors are facing.

H.R. 3337

H.R. 3337 would require VA to establish a registry for individuals who may have been exposed to toxic chemicals and fumes from “open burn pits” in Iraq or Afghanistan, and require an independent scientific organization to assess that effort, and make recommendations on (1) collection and maintenance of such information, and (2) on how best to meet the medical needs of those exposed with respect to the likely result of such exposure. 

WWP shares the concern underlying this bill regarding unexplained respiratory and other illnesses among OEF/OIF veterans, and the possible role of environmental exposures in Iraq and Afghanistan.  H.R. 3337 focuses specifically on the potential vulnerability of those who were based or stationed at a location where an open burn pit was used.  We note, however, the recent Institute of Medicine suggestions that “service in Iraq or Afghanistan – that is, a broader consideration of air pollution than exposure only to burn pit emissions -- might be associated with long-term health effects….”[8]  While we have no objection to this legislation, IOM’s findings and recent research[9] suggesting other environmental factors in southwest Asia may also be implicated in increased risk of illness raise a question whether the proposed registry would ultimately be a sufficiently helpful tracking mechanism.

Finally, WWP has no position on the two remaining bills under consideration, H.R. 4079 (addressing requirements for VA’s grant program to assist homeless veterans) and H.R. 3245 (to direct VA and DoD to provide Vet Centers with access to DoD electronic records systems in order to obtain service-discharge records (DD-214 forms).  We would note, however, that warriors with whom we work have not reported any problems obtaining DD-214s or establishing eligibility for Vet Center services.

We would be pleased to answer any questions.

Ralph Ibson is the National Policy Director of Wounded Warrior Project, a national veterans’ service organization dedicated to empowering those wounded in Iraq and Afghanistan.  In that capacity, he heads up research and policy development for WWP’s Washington, DC Office of Policy and Government. 

Prior to joining WWP in December 2008, Ibson served as Vice President for Government Affairs at Mental Health America (previously, the National Mental Health Association (NMHA)), where he led federal relations in support of MHA programs and mission, including advocacy in Congress that culminated in enactment of mental health parity legislation.  Prior to joining NMHA in 2000, Ralph served for ten years on the staff of the Committee on Veterans Affairs in the U.S. House of Representatives where he helped develop major veterans’ health legislation including the Veterans Health Care Eligibility Reform Act and the Veterans Millenium Health Care and Benefits Act.  During that period, he served as Staff Director of the Subcommittee on Health.  Before working in Congress, Mr. Ibson was a Deputy Assistant General Counsel at the Department of Veterans Affairs.  Mr. Ibson holds a JD degree from the University of Pennsylvania Law School and a bachelor's degree in political science from Tufts University.  He is a veteran of service in the U.S. Army.

Mr Ibson and Wounded Warrior Project have not received any federal grants or contracts, during this year or in the last two fiscal years, from any agency or program relevant to the subject of the April 16, 2011 hearing. 



[1] Public Law 110-181, sec. 1611.

[2] Department of Defense Instruction (DODI) Number 1300.24, “Recovery Coordination Program (RCP),” Enclosure 4, sec. 2.d. (December 1, 2009).

[3]  General Accountability Office, “DoD and VA Health Care: Federal Recovery Coordination Program Continues to Expand but Faces Significant Challenges,” GAO-11-250, (Mar 23, 2011) 2. accessed at http://www.gao.gov/products/GAO-11-250

[4] DoDI 1300.24, Enclosure 4, sec. 2.a.

[5]38 U.S.C. sec. 1703(a)(2)(B)

[6] 38 U.S.C. secs. 1703(a)(1)(A); (2)(A)

[7] Department of Veterans Affairs, VHA Handbook 1160.01 (September 11, 2008), sec. 3.a.(1)

[8]Long-Term Health Consequences of Exposure to Burn Pits in Iraq and Afghanistan, Institute of Medicine (Oct. 2011), 114.

http://www.iom.edu/Reports/2011/Long-Term-Health-Consequences-of-Exposure-to-Burn-Pits-in-Iraq-and-Afghanistan.aspx

[9] See “Harsh Environment in Southwest Asia, Not Just Burn Pits, Cause Health Problems in Troops,” U.S. Medicine, vol. 48, no. 3 (March 2012), 33.