Mr. Chairman, Ranking Member, and members of the subcommittee, on behalf of Iraq and Afghanistan Veterans of America’s one hundred and ninety thousand members and supporters, I would like to thank you for allowing us testify before your subcommittee on “Healing the of Physical Injuries of War.”

“Veterans need to know that their country will continue to take care of their service-related injuries. A servicemember's body pays a heavy toll from the high physical demands of deployments. It's more than just paying disability claims, it's a back or knee that starts to cause problems for a middle-aged man because he spent four years humping with a pack and patrolling with 60 lbs of gear.” – IAVA Veteran

My name is Tom Tarantino and I am a Legislative Associate with IAVA.  I proudly served 10 years in the Army beginning my career as an enlisted Reservist, and leaving service as an Active Duty Cavalry Officer.  During these ten years, my single most important duty was to take care of other soldiers.  In the military they teach us to have each other’s backs.  And although my uniform is now a suit and tie, I am proud to work with this Congress to continue to have the backs of America’s servicemembers and veterans.

Over the past few years this Committee has helped secure impressive improvements to the VA health care system. For the first time in over twenty years, the VA now has a timely and fully funded budget that will end the practice of rationing health care services. The VA is developing a virtual lifetime service record that will seamlessly transition a veteran’s health record from DOD to the VA, ensuring a higher quality of care. Female veterans can now receive postnatal care for their newborn babies, and family caregivers of severely wounded veterans will have the training and assistance they need to support their loved ones. Thank you for all the work this Committee has done and will continue to do in the months and years to come.

Specifically, we look forward to the work this Committee will do to continue to improve VA health care. The VA is the largest health care provider in the nation, and overall, it provides much higher quality of care than the nation’s private sector hospitals. The pressing problem with the VA health care system is not the quality of care, but a lack of access to the system.  In order to continue to improve on both the quality of care and access to the system, IAVA fully supports all of the recommendations contained in this year’s Independent Budget that address issues related to specialized services, access to care, invisible wounds, prosthetics, long term-care, finance and administration. IAVA would like to focus our testimony on just few of those key issues as they relate to Iraq and Afghanistan veterans seeking treatment for combat injuries, especially Traumatic Brain Injury.

We asked our members what they thought of the treatment they were receiving at the VA and we received a wide range of opinions, both complimentary and critical. However, several common themes appeared: 1) Long waits for quality appointments 2) Rude administrative staff 3) Growing distrust of VA health care 4) Long drives to VA facilities. We received only a few complaints about the actual quality of care at the VA.

1. Rethink and adapt the VA’s rehabilitation practices for wounds of the wars in Iraq and Afghanistan

Traumatic Brain Injury (TBI) is the signature wound of the wars in Iraq and Afghanistan. To properly treat these returning combat veterans with mild to severe TBI, the VA must completely rethink and adapt their medical rehabilitation practices just as the DOD has had to adapt to fight an unconventional war against insurgents.

“I suffered a TBI in Iraq and now have PTSD.  Due to my symptoms, I lost my job, my family, my self-respect and for a time, my freedom!  I have had to swallow my pride and accept Government assistance.  I would rather work but the jobs I might be able to hold for a short time pay so little I would not be able to visit and take care of my sons.  At times I feel like a complete failure.” – IAVA Veteran

As our friends over at Wounded Warrior Project (WWP) have stated, any successful rehabilitation of a veteran suffering from TBI “must be veteran-centered.” This means ensuring that all TBI patients are given a thoughtful individualized rehabilitation plan that is thorough and honest about what the VA can and cannot provide.  Any rehabilitation plan must include the veteran’s family as a core component to rehabilitation.

“After my wife straightened out the VA doctors and fired a few, I finally got a doctor that truly listens and does what needs to be done to make sure I have what I need. She spends time talking with me and my wife. Some of the doctors have a problem talking with my wife, but I have a TBI and I don't understand things well and she explains them to me and makes sure I do as I am suppose to. She is my caregiver and my best friend. She advocates for me and does whatever she has to, to make the doctor understand me, and vice versa.” – IAVA Veteran

IAVA is concerned that the VA has limited or denied access to some veterans seeking recovery services for Traumatic Brain Injury.  Current statute requires that the VA provide services to “restore” function to wounded veterans.[1] Full recovery should always be the desired outcome for a rehabilitation plan.  However, sustaining current functions or preventing future harm should also warrant access to VA services. I have no doubt that the members of this committee agree that the VA’s role isn’t just to help those who might get better, but it also to help those who might get worse. IAVA recommends adjusting these statutes to embrace the realities of injuries like TBI. Veterans should be able to focus more on recovery then fighting with the VA.

“I have a possible traumatic brain injury or it could be PTSD but whatever it is, there is no way I could sit there and try and read through 10 pages of legal speak. Believe me I tried. Even if I read through all of it, I have no idea what I am reading cause I can't focus on anything.” – IAVA Veteran

2. I have to wait how long to see a VA doctor?

Among IAVA members seeking services at the VA, the single most common complaint is how long it takes to schedule an appointment.

“I did visit the VA, but will not again. Sorry to say, but the process to get an appointment is impossible. I had to get an appointment to get an appointment. What I mean is this - It took 3 weeks to get an appointment to see a nurse who assessed my injury, then she made an appointment to for me to see a doctor about my injury for 3 weeks later. By the time I was able to see a doctor, it was over 6 weeks. I lost 2 days of work. It seems like the process is set up to discourage patient care.” – IAVA Veteran

When veterans began returning home from Iraq and Afghanistan, the VA was caught unprepared, with a serious shortage of staff and an exceedingly inadequate budget. Wait times varied regionally, but for some patients, lasted six months or more. The problems weren’t limited to primary care along; the backlog was especially severe for veterans seeking mental health treatment. In recent years, wait times for primary and specialty care at the VA have improved, but approximately 8 percent of patients—or more than 450,000 veterans—are still waiting more than 30 days for their desired appointments, according to the VA.[2] Moreover, the VA’s Inspector General suggests that wait may be even longer than the VA admits.   And there are still some veterans who have  “to wait on the phone for 2+ hours to speak with someone to set an appointment with [a] primary care physician that ends up being 4-6 weeks away from the date of my call.” Even when veterans are able to schedule an appointment, many times they still have to sit around the hospital for hours once they arrive because the VA “booked 20 patients during a 2 hour window.”

For veterans, long wait times mean that they may have to suffer for months until their next appointment or opt for not receiving the care they need at all.

“Ortho is a nightmare. I had to schedule a cortisone shot 2 1/2 months in advance, even though my shoulder was in pain now.” – IAVA Veteran

Just as the VA is working to address the VA disability backlog, the VA must continue attacking the issue of long appointment wait times. As recommended in the Independent Budget, the solution involves improved tracking, a completely revamped scheduling IT system and an increase in the number of medical providers in critical areas.  To this end, IAVA supports the following recommendations from the Independent Budget:

• The Veterans Health Administration should make external comparisons to measure its performance in providing timely access to care.
• The VHA should fully implement complementary aspects of the Institute for Healthcare Improvement’s Advanced Clinic Access principles and measures for primary and specialty care to maximize productivity of clinical care resources by identifying additional high-volume clinics that could benefit.
• VA should consider implementing complementary recommendations contained in the Booz Allen Hamilton report Patient Scheduling and Waiting Times Measurement Improvement Study.
• The VHA should certify the validity and quality of waiting time data from its 50 high-volume clinics to measure the performance of networks and facilities.
• The VHA should complete implementation of the eight recommendations for corrective action identified in the July 8, 2005 report by the VA Office of Inspector General.
• VA must ensure that schedulers receive adequate annual training on scheduling policies and practices in accordance with the OIG’s recommendations.

III. How far is too far to drive?

Some veterans have to drive for an “entire day to get to their local VA facility” and IAVA is concerned that the VA has yet to develop a consistent and humane policy for answering an age old question, “How far is too far to make a veteran drive to the VA?” About 3 million veterans, or 37.8 percent of veterans enrolled in the VA system, reside in rural areas,[3] and as of 2003, “more than 25 percent of veterans enrolled in VA health care—over 1.7 million-- live over 60 minutes driving time from a VA hospital.”[4]

“I have an obvious service related injury that I receive a prescription for (Celebrex for a knee that was injured by IED)… rather than give me a referral to a local orthopedist in town, they wanted me to drive 5.5 hours to Tucson, which I could not do because of a busy work schedule.  The whole process is very slow and cumbersome.” – IAVA Veteran

IAVA acknowledges that the VA can’t always be a short drive from every veteran. However, we believe that the VA should issue clear guidelines for when a veteran lives too far from a local VA facility. These veterans should be given the choice to continue using the VA or access more convenient local medical care.

“My main concern with the VA health care system is distance. We only have an outpatient clinic here and if I need anything more than a flu shot, I have to drive 125 miles to the nearest VA hospital.” –IAVA Veteran

IAVA also believes that the VA should assist veterans who need to drive to their appointment or need a ride. IAVA recommends that that the VA should 1) Promote, oversee, and evaluate a pilot program that provides a network of drivers for veterans struggling to ?nd transportation to the nearest VA hospital and 2) Provide a lodging stipend and mileage reimbursement for veterans forced to travel long distances for VA medical care, comparable to the stipend paid to VA employees when they travel.

“For anything dental or surgical I have to travel 2 hours and often times for appointments that don't last 30 minutes. Additionally, because I don't qualify for travel pay, I often have to ask social workers for gas cards. The SWs appear to be annoyed by me whenever I ask for their assistance in obtaining gas cards.” – IAVA Veteran

IV. “I hear the VA is a nightmare.”

Some of our members openly fear the VA.  Recent media reports about HIV and Hepatitis exposure have only served to fuel that fire. A veteran returning home from Afghanistan who reads about his or her battle buddies being exposed to infectious diseases while being treated at the local VA will likely think twice before seeking the care s/he needs.

“As a Navy Hospital Corpsman who has worked in a VA hospital I am nervous about care provided by the VA.” – IAVA Veteran

Whether or not these fears are warranted is a topic for another hearing, but the end result is still the same, VA health care has a public relations problem. Until the VA adequately addresses this issue many combat veterans will be weary to seek treatment. IAVA believes that the VA must address this issue head on by owning the mistake, doing everything in their power to take care of those affected and then redoubling efforts to make sure proper medical procedures are followed at other facilities.

What we don’t want to see are stories like the saga of Judy Yarzebinski. After being treated at a local VA she was notified that she had been exposed to dirty equipment. Sadly she tested positive for hepatitis C and due to other medical issues cannot be treated for it. Judy will now have to live with fevers, headaches, fatigue, loss of appetite, nausea, vomiting, and diarrhea for the rest of her life. To make matters worse the VA now denies having caused the exposure in the first place. Public battles such as this are exactly what make weary veterans reluctant to seek out VA care.

IAVA believes that in order for the VA to conduct effective outreach, it must centralize its efforts between VHA, VBA, and NCA and aggressively re-brand itself as one Department of Veterans Affairs.  The average veteran (and the average American for that matter) does not understand the difference between the VHA and the VBA.  When I wait an entire semester for my GI Bill check to come, I’m upset with the VA, not the VBA.  When I wait 2 months for a medical appointment, I’m upset with the VA, not the VHA.  If the VA wants to effectively improve communications, it must speak to the veteran population clearly, and re-brand itself to the American people.

The Department of Veterans Affairs must develop a relationship with servicemembers while they are still in the service.  Like many successful college alumni associations that greet students at orientation and put on student programs throughout their time in college, the VA must shed its passive persona and start recruiting veterans and their families more aggressively into VA programs. Once a veteran leaves the military, the VA should create a regular means of communicating with veterans about events, benefits, programs and opportunities. IAVA is encouraged by the development of the Veterans Relationship Manager.  Leveraging modern technology to develop a single means of communication between all sectors of the VA and a veteran is a step in the right direction. If a veteran received half as many letters and emails from the VA, as college grads do from their alumni association, we would be getting somewhere.

To assist in building this relationship IAVA recommends automatically enrolling all troops leaving active-duty service, whether from the active or reserve component, in VA health care.

“Getting a VA card AND being vested (and what vested means) is a great way to prepare, even for those who work and have their own insurance, in case of lay off or other emergency.” – IAVA Veteran

In addition to providing a more seamless transition for separating combat veterans, automatic enrollment will cement the relationship between the VA and veterans.

Overall the VA continues to provide good care to our nation’s veterans.  However, we must continue to strive for better.  In the military, they teach us to never stop improving our fighting position and be forever vigilant.  It is this proactive ethos that continues to lead to victory on the battlefield.  If we are to honor the service and sacrifice of America’s warriors, we must instill this spirit in all of the services that we develop to care for them.  No one program or piece of technology will solve these problems, but together we can ensure that the citizens of this country have a system of care that honors the freedoms that we enjoy and care for those who have sacrificed blood and limb on our behalf.

[1] “such professional, counseling, and guidance services and treatment programs as are necessary to restore, to the maximum extent possible, the physical, mental, and psychological functioning of an ill or disabled person.” 38 U.S.C. 1701(8).  

[2] VA Performance and Accountability Report, FY 2009, p. II- 145.

[3] U.S. Department of Veterans Affairs, “About Rural Veterans: Common Challenges Faced by Rural Veterans,” January 6, 2010: http://www.ruralhealth.va.gov/RURALHEALTH/ About_Rural_Veterans.asp

[4] GAO-03-756T, “Department of Veterans Affairs: Key Management Challenges in Health and Disability Programs,” May 8, 2003, p. 6: http://www.gao.gov/new. items/d03756t.pdf.