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Findings of the President's Commission on Care for America's Returning Wounded Warriors.

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SEPTEMBER 19, 2007

SERIAL No. 110-43

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BOB FILNER, California, Chairman


VIC SNYDER, Arkansas
JOHN J. HALL, New York
PHIL HARE, Illinois
MICHAEL F. DOYLE, Pennsylvania
TIMOTHY J. WALZ, Minnesota

STEVE BUYER,  Indiana, Ranking
HENRY E. BROWN, JR., South Carolina
BRIAN P. BILBRAY, California





Malcom A. Shorter, Staff Director

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records of the Committee on Veterans' Affairs are also published in electronic form. The printed hearing record remains the official version. Because electronic submissions are used to prepare both printed and electronic versions of the hearing record, the process of converting between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process is further refined.



September 19, 2007

Findings of the President's Commission on Care for America's Returning Wounded Warriors


Chairman Bob Filner
    Prepared statement of Chairman Filner
Hon. Steve Buyer, Ranking Republican Member
Hon. Harry E. Mitchell, prepared statement of
Hon. Jerry Moran, prepared statement of
Hon. Ginny Brown-Waite, prepared statement of


President's Commission on Care for America's Returning Wounded Warriors: 
    Hon. Donna E. Shalala, Co-Chair (former Secretary of Health and Human Services)
        Prepared statement of Secretary Shalala
    Hon. Bob Dole, Co-Chair (former United States Senator from the State of Kansas)
        Prepared statement of Senator Dole


Disabled American Veterans, Joseph A. Violante, National Legislative Director, statement
Miller, Hon. Jeff, a Representative in Congress from the State of Florida, statement


Post Hearing Questions and Responses for the Record:

Hon. Bob Filner, Chairman, Committee on Veterans' Affairs, to Hon. Donna E. Shalala, Co-Chair, President's Commission on Care for America's Returning Wounded Warriors, and President, University of Miami, and Hon. Bob Dole, President's Commission on Care for America's Returning Wounded Warriors, letter dated October 18, 2007, also transmitting additional questions from Hon. Joe Donnelly


"Serve, Support, Simplify:  Report of the President's Commission on Care for America's Returning Wounded Warriors," July 2007

"Serve, Support, Simplify:  Report of the President's Commission on Care for America's Returning Wounded Warriors," Subcommittee Report and Survey Findings, July 2007


Wednesday, September 19, 2007
U. S. House of Representatives,
Committee on Veterans' Affairs,
Washington, DC.

The Committee met, pursuant to notice, at 10:02 a.m., in Room 334, Cannon House Office Building, Hon. Bob Filner [Chairman of the Committee] presiding.

Present:  Representatives Filner, Snyder, Herseth Sandlin, Mitchell, Hall, Hare, Berkley, Salazar, Rodriguez, Donnelly, McNerney, Space, Walz, Buyer, Moran, Brown of South Carolina, Boozman, Brown-Waite, Turner, Bilbray, Lamborn, Bilirakis, Buchanan.


The CHAIRMAN.  This meeting of the House Committee on Veterans' Affairs is called to order and we have a distinguished panel to address us this morning. 

As we all know, in March the President signed an Executive Order to establish the President’s Commission on Care for America’s Wounded Warriors.  That came in the wake of the Walter Reed scandal and I must say there were a couple of silver linings in that cloud we call Walter Reed.  One was the Commission that was formed and your report, for which we are grateful. The other, of course, was, we were able to add in the various budget bills that went by over $13 billion of resources for veterans’ healthcare for this year over last year, because all of America understood that we are not caring for the veterans who came back from Iraq and Afghanistan the way they thought that we were doing and we should be doing.

The Commission was charged with the task of examining the effectiveness of returning wounded servicemembers’ transition from deployment in support of the Global War on Terror to returning to productive military service or civilian society, and recommend needed improvements.

That report, of course, was recently released and we will be hearing from the Co-Chairs of that Commission Secretary Donna Shalala, and Senator Bob Dole.  I look forward to a frank discussion of your recommendations.

Of course, we are all focused on how to serve our troops when they transition from the Pentagon to the U.S. Department of Veterans Affairs (VA) for their healthcare.  In order for our troops to experience the seamless transition that they deserve, the bureaucratic problems that prevent many from getting the care they need must be fixed.  And while both VA and the U.S. Department of Defense (DoD) have made adjustments and changes over the last few years in an attempt to address these issues, many obstacles, as you point out, still remain.

As Chairman of the Committee on Veterans' Affairs, I am sensitive to the difficulties involved in coordinating the activities of the Department of Defense and the Department of Veterans Affairs.  They have different missions.  But we no longer have the luxury of time and we, as a country, must act.

Right now, while we prepare to discuss this issue, our servicemembers are in harm’s way.  Some of these brave men and women will be killed or seriously wounded.  We have talked about the necessity of providing a seamless transition for a long, long time.  But now we have a test as a Nation and this is a test that, with your help, we will pass.

I want to welcome our two distinguished panelists.  Donna Shalala was appointed by President Bill Clinton as Secretary of the U.S. Department of Health and Human Services (HHS) in 1993 where she served for eight years, becoming the longest serving Secretary of HHS in our Nation’s history.  She directed the welfare reform process, made health insurance available to an estimated three and a half million children, raised child immunization rates to the highest levels in history, led major reforms of the Food and Drug Administration's drug approval process and food safety system, revitalized our National Institutes of Health and directed a major management in policy reform of Medicare.

You have dealt, Secretary Shalala, with large bureaucracies like the VA and DoD before this, and so we welcome your experience in implementing programs that work for people, not against people.

Senator Dole, your story is well-known.  But every time I read it, I am just amazed by your strength and courage.  You were twice decorated for heroism, receiving two Purple Hearts for injuries and the Bronze Star Medal with combat "V" for valor.  You joined the United States Army’s Enlisted Resource Corps to fight in World War II and became a second lieutenant in the 10th Mount Division.  In April of 1945, while engaged in combat in the hills of north Italy, you were hit by German machine gun fire in the upper right back and badly injured, waiting nine hours on the battlefield before being taken to the evacuation hospital before you began your recovery at a U.S. Army hospital in Michigan.  And then, of course, a distinguished career in politics.

So thank you both for your service, not only on this Commission, but I know your commitment to implementing the recommendations.  You are not letting this just become something on people’s shelves.  I asked both of our panelists what they were going to do and they said we are going to get this done.  And so we welcome your energy, your enthusiasm, and the expertise that you brought to this adventure and we look forward to hearing from you.

[The statement of Chairman Filner appears on in the Appendix.]

The CHAIRMAN.  I would yield to the Ranking Member, Mr. Buyer.


Mr. BUYER.  Thank you, Mr. Filner.

Secretary Shalala and Senator Dole, we thank you for your work.  Your report is before us and we appreciate your service to our country.  Our country continues to call upon you, and you always step forward willingly to serve others and that is what separates you from so many.  So on behalf of the country, I extend my appreciation for your contribution.

We are involved in a long war against terrorism.  For this, the Nation’s mothers, fathers and spouses trust their sons and daughters and spouses to the Nation’s armed forces.  They must be confident that they will be cared for should harm come their way.  I believe that systems are still dysfunctional.  The question is, are the bureaucracies, organizationally and culturally, ill-suited to make the bold changes necessary for a seamless transition?

I have my questions, because the bureaucracy will tell us that they are on top of it, that they are fixing it.  The bureaucracy has had six years of ground combat to fix this problem.  We have developed new combat systems in the last six years, perfected new tactics, ushered in new governments.  It is time our servicemembers and veterans have seamless transition.

I personally have been fighting this battle over seamless transition since I arrived in Washington in 1992.  From the year 2004, when I was a Subcommittee Chairman and a full Committee Chairman, I held 19 hearings on the issue of seamless transition.  Legislation mandating the cooperation between the Pentagon and VA, Senator Dole, dates back to perhaps your memory.  1982 is when the mandate came from Congress and the Senate.

So it is time our servicemembers and veterans have the seamless transition.  It is why I was equally enthused when I heard that President Bush hailed your work product and directed that the Administration prepare legislative proposals reflecting your recommendations.  I think I can speak for all of us here that we look forward to seeing these proposals.  We expect to get those proposals soon so we can act to improve the care and the seamless transition that our Nation’s warriors are entitled.

We look forward to your testimony and your candor is always welcomed.

I yield back.

The CHAIRMAN.  Thank you, Mr. Buyer. 

You have as much time as you need and we will start with Secretary Shalala.  Thank you again for your service.



Secretary SHALALA.  Mr. Chairman, Mr. Buyer and sitting Members of the Committee, thank you for giving us the opportunity to testify today, and in particular with Senator Bob Dole, about the recommendations of our Commission—

The CHAIRMAN.  Madam Secretary, can you pull the microphone closer to you—thank you.

Secretary SHALALA.  Thank you for giving me the opportunity to testify today.  It is truly a privilege to serve, to have served on the President’s Commission on Care for America’s Returning Wounded Warriors, especially with Senator Dole whose shrewdness and distinction as a great public servant and whose knowledge of this subject and dedication was really an inspiration to all of us.

We worked hard, but we had an awful lot of fun and I learned a lot from him in the process.  We were joined by a stellar group of Commissioners, each of whom gave their full energy and attention to the critical mission we faced.  One of them, Ed Eckenhoff, who just arrived, of course, is the head of the National Rehabilitation Hospital here in Washington and one of the great experts on rehabilitation in this country and we are delighted to see Commissioner Eckenhoff here with us.

As you know, we had an extremely short time frame to complete our mission, but we were propelled by a sense of urgency that the issues before us required.  Mr. Chairman and Members of the Committee, we know you share this sense of urgency and that is why we are pleased to be with you today to discuss not only our recommendations, but the critical need to implement them. 

We have been truly heartened by the response to our report that we have received from Congress, from the White House and throughout the country.  This country has rallied behind the need to help those who have put their lives on the line in service to our country and we are optimistic that the Congress and the Administration will move quickly to respond to this need by enacting all of our recommendations.

We were reminded again in Saturday’s Washington Post the problems facing our injured service men and women have not gone away.  Congress and the Administration have spent a great deal of time these past few weeks discussing the future of the war in Iraq.  And while this debate is one that our Nation must have, I implore you not to forget about those who have already sacrificed so much—our injured men and women.  They need to be front and center in the Congressional debate and within the Administration.  The story of Staff Sgt. John Daniel Shannon, as told in the Washington Post is a story that we heard throughout our time with the Commission, a story of numerous case managers, none of whom held responsibility for spearheading an integrated care system, a story of lost paperwork and frustration, a story of a disability system that was in desperate need of repair.

It is stories like this that sparked the creation of our Commission and stories like this that should and must drive immediate Congressional and White House action.  This past July, it was the Commission’s honor to present to the President, to Congress and the public, six groundbreaking patient and family-centered recommendations that make sweeping changes in military and veterans’ healthcare and services.  The recommendations include the first major overhaul of the disability system in more than 50 years. 

It includes the creation of recovery plans with recovery coordinators; a new e-Benefits web site; and guaranteeing care for post traumatic stress disorder (PTSD) from the VA for any servicemember deployed to Iraq and Afghanistan.  Our report, Serve, Support and Simplify, is a bold blueprint for action that will enable injured servicemembers to successfully transition, as quickly as possible, back to their military duties or to civilian life.  Our report calls for, and I quote, "fundamental changes in care management and the disability system."  I respectfully request that this report to be submitted for the record, Mr. Chairman.

Specifically, our six recommendations will immediately create comprehensive recovery plans to provide the right care at the right time and in the right place.  We recommend that we completely restructure the disability determination and compensation systems, aggressively prevent and treat post traumatic stress disorder and traumatic brain injury (TBI), significantly strengthen support for families, rapidly transfer patient information between DoD and VA, and strongly support Walter Reed by recruiting and retaining first rate professionals through 2011.

Our six recommendations do not require massive new programs or a flurry of new legislation.  We have identified 34 specific action steps that must be taken to implement the six recommendations.  Only six of the 34 items require legislation, and that is what we will focus on today.  A complete list of the action steps for the six recommendations is included on the last page of my testimony.

Let me summarize the first three actions that require legislation and then my colleague, Senator Dole, will cover the remaining three.

The first is to improve access to care for servicemembers with post traumatic stress disorder.  We call on Congress to authorize the VA to provide lifetime treatment for PTSD for any veteran deployed to Iraq or Afghanistan in need of such services.  This presumptive eligibility for the diagnosis and treatment of PTSD should occur regardless of the length of time that has transpired since the exposure to combat events.

The current conflicts involve intense urban fighting, often against civilian combatants, and many servicemembers witness or experience acts of terrorism.  Five hundred thousand servicemembers have been deployed multiple times.  The longer servicemembers are in the field, they are more likely to experience events which can lead to symptoms of PTSD.  The consequences of PTSD can be devastating.  The VA is a recognized leader in the treatment of combat-related PTSD, with an extensive network of specialized inpatient, outpatient, day hospital, and residential treatment programs.  Therefore, we ask that any veteran of the Iraq or Afghanistan conflicts be able to obtain prompt access to the VA’s extensive resources for diagnosis and treatment.

Next, we ask Congress to strengthen the support for our military families.  In our travels across the country, it has become abundantly clear that we not only need to help the severely injured, we need to help their loved ones as well.  These loved ones are often on the front lines of care and they are in desperate need of support.  Therefore, we call upon Congress to make servicemembers with combat-related injuries eligible for respite care and aide and personal attendant benefits.  These benefits are provided in the current Extended Care Health Option program under TRICARE.

Presently, DoD provides no other benefit for care-giving.  Yet we know that many families are caring for their injured servicemember at home, and many of these servicemembers have complex injuries.  These families, forced into stressful new situations, don’t need more anxiety and confusion.  They need support.  Families are unprepared to provide 24/7 care.  Those that try, wear out quickly.  By providing help for the caregiver, families can better deal with the stress and problems that arise when caring for a loved one with complex injuries in their homes.

We also recommended that Congress amend the Family and Medical Leave Act  (FMLA) to extend unpaid leave from 12 weeks to up to six months for a family member of a servicemember who has a combat-related injury and meets the other FMLA eligibility requirements.  According to initial findings of research conducted by the Commission, approximately two-thirds of injured servicemembers reported that their family members or their close friends stayed with them for an extended time while they were hospitalized; one in five had to give up their job to do so.  That is simply unacceptable.

Getting family members to the bedside of an injured servicemember is not a problem.  The services have developed effective procedures to make this happen, and the private sector has stepped up to provide temporary housing.  Because most injured servicemembers recovery quickly and return to duty, a family member’s stay may be short.  However, for those whose loved one has incurred complex injuries, the stay may last much longer.  Extending the Family and Medical Leave Act for these families will make a tremendous difference in the quality of their lives.  Congress enacted the initial Family and Medical Leave Act in 1993, when I was Secretary of Health and Human Services.  Since then, its provisions have provided over 60 million workers the opportunity to care for their family members when they need it most.  We have tremendous experience and evidence with that Act.  All of these family members have been able to care for a family member without losing their jobs.

We were pleased to see the Senate has already unanimously passed the Support for Injured Servicemembers Act which implements this particular recommendation.  We hope that the House will quickly follow suit.

Mr. Chairman, having served in government for about half of my adult life, I believe that government can work to improve the lives of its citizens.  But sometimes, people of good will want to solve a problem and their idea is to fix a problem by adding a program or a new regulation.  What we have done in this report and the reason why it is short and very focused, is rather than simply coming to you and recommending new legislation on top of existing legislation, we have rethought existing programs. 

And one of the things we have done that is never done on commissions is that we have suggested simplifying the program itself so it is very clear who is responsible for what.  And Senator Dole will be speaking to the disability provision that we have recommended.  So don’t think of this as adding another piece of legislation that adds a program on top of programs.  I spent years, as you well know, trying to sort out Medicare.  Part of the problem with the most complex legislation is that it is almost impossible for an ordinary competent government worker to administer the programs, let alone the people that are supposed to get the services of that legislation to understand them, not because someone tried to create a complex bureaucracy, but because they kept trying to fix problems by adding new legislation which added to the complexity of the administration.

So read this and the word "simplify" as attempting to make clear who is responsible for what and making it much easier for the patient and their families, as well as the people that have to administer the programs, to administer those programs in a way that is very responsive and very efficient for the programs.

I believe our recommendations are doable, whether it is requiring Congressional legislation or implementation by DoD or VA.  We made sure what we were recommending could actually be acted on quickly.  The advantage of having Senator Dole and me up here is that in many ways we are the old warriors.  We know—


Secretary SHALALA.  Me too.  We have a pretty good feel for what the bureaucracy can administer and what can be implemented, because we have been through this.  And I hope that you, I know that you agree with us that our seriously injured servicemembers must not be made to wait.  They deserve a healthcare system that serves, supports and simplifies.

So I would like to thank the Committee again on behalf of the Commission for the opportunity to discuss our recommendations.  And because those of you who know me know I don’t mince words, I leave the Committee and the Administration with three simple words.  Just do it.  Thank you very much.

[The statement of Secretary Shalala, and the Commission reports, appears in the Appendix.]

Secretary SHALALA.  Senator Dole?

Senator DOLE.  Oh, thank you.


Senator DOLE.  Well, first let me thank the Chairman, Steve and others for being here.  I want to thank Congressman Moran, Congressman Salazar, Congresswoman Berkley and others who have already introduced a draft of the legislation which may not be totally accurate, because we drafted it as we were going through.  I know the Administration is working on a draft, and I know there are others on the Committee who have joined this bipartisan effort, which leads me to the second point.

I know which political party my Co-Chair is in and she knows which party I am in.  But frankly, I don’t know the political affiliation of any of the other seven members.  We never discussed politics.  It was totally nonpartisan.  We never discussed costs.  My view was, if we spend billions and billions and billions of dollars of getting young women and men in harm’s way, we will have to spend what it takes to get them back in as normal a life as possible, whatever it takes.  And I think that is where we are coming from.

So it is going to cost a little money.  And Bob, we may use some of that which you have authorized.  So—

The CHAIRMAN.  Are you sure you are not a Democrat?


Senator DOLE.  Pardon?

The CHAIRMAN.  Are you sure you are not a Democrat?

Senator DOLE.  Yeah.  But, you know we—


Senator DOLE.  No.  We went way back to the Commission headed by Omar Bradley in 1956.  Now, most of you weren’t around then, but I was.  And there have been a lot of commissions.  This problem just didn’t happen with Building 18 at Walter Reed Hospital.  It has been out there for years and years and years.  We have 25 million, probably 26 million, veterans now.  As they get older, especially the World War II generation more and more need hospital care and VA care.  One thing we found, and we had visits all over the country, I don’t remember a single complaint—there may have been one—about the acute care the soldiers received from the battlefield until the end of their acute care. 

That is not the problem, as my Co-Chair Secretary Shalala pointed out—it is what happens after that.  It is the bureaucracy which is true in many civilian hospitals, too.  And that is why we are so honored to have Ed Eckenhoff, Chairman of the National Rehabilitation Hospital, on our Commission.  He understands the private sector.  One thing we also underscored in our report is that we want the soldier to get the best possible care.  If it is not available in a DoD or a VA facility, then they are authorized to go the best private facility that they can find.  We can do no less.  And Ed was very helpful, not only in that area, but many others. 

We had a young man named Jose Ramos on the Commission, and he would have been here today but he has a test.  He is back in school.  He lost an arm in Iraq.  Another young man from our Commission, Marc Giammatteo, is attending Harvard, which I won’t hold against him, but—well, my wife attended Harvard.  Marc has a very badly damaged leg.  We had a young woman on the Commission, Tammy Edwards, whose husband had burns on 70 percent of his body.  So we had a good representative Commission.  We had people who really understood the problem.

And I must say, I had a Co-Chairman who must have invented the Energizer Bunny, because all we did was work, work, work and she would tell us what to do and we would all try to do it.  We learned a lot from each other and we really think we have got some common sense ideas.  Some have said, "Why didn’t you go way back and overhaul the whole system?"  Well, our charter was limited to Iraq and Afghanistan and people who may follow.  Now, we hope that war ends quickly.  We don’t want any more injuries.  One is too many.  One death is too many.

But one thing we discovered in trying to get down to the brass tacks was the group, the seriously injured group, those were severe TBI or spinal cord injuries or amputees or whatever.  There are about 3,000.  Now, if we can’t manage the care of that group in the United States of America, with all the VA facilities and all the DoD facilities we have we are in pretty bad shape.  And we can.  We just need to work out some of the wrinkles and that is where we believe our Commission can be helpful.

We can’t dictate anything to this Committee.  I spent 35 and a half years in Congress and I know how the system functions.  And we know it takes time.  We have been pushing the Executive Branch.  I was at the White House last week and I can say very honestly, I am really not surprised, but I am very pleased with the effort they are making on the executive side and they will have their legislation ready in what, another ten days?

Secretary SHALALA.  Ten days.

Senator DOLE.  So the veteran groups can look at it, and certainly Members of this Committee.  We also had some outstanding staff, and I would just introduce our Director, Marie Michnich who is here and Karen Guice who worked with the Veterans Service Organizations (VSOs) and Sue Hosek of RAND Corporation who has had about 30 years experience working with these same problems.  So I think we have some credibility.  At my age, I don’t need this job.  And you know, I told that to the President.  Well, I guess I didn’t see him.  I saw him later.  But I told that to the people at the White House and we told it to Bob Gates.  Donna—excuse me,  Secretary Shalala, she has got a lot to do.  She is busy. 

The University of Miami football team, they got off to kind of a bad start, but they will recover.


Senator DOLE.  So, you know, we wanted to do something that might mean something to somebody.  I talked to a young man from Kansas two days ago.  I was at Fort Sam Houston.  He is a triple amputee.  I think there are about 10 or 11 of those.  His name is Sergeant Matt Lammers and I just was in disbelief of his attitude and his spirit and what an inspiration he is.  He said he can get down with one arm.  He has got two legs gone above the knee and one arm above the elbow missing.  He has two children, one six and a baby about one year old.  And how he can get down on the floor and play with his children and get back in a chair by himself without any assistance.

Now, if that doesn’t inspire us to do what we need to do to make certain that young man and his family and his children are taken care of.  If you would just write him a blank check, it would be all right with us.  But are those young people going to be able to go to college?  Is he going to be able to earn enough money?  He won’t be able to do it with the pension he gets.  So these are some of the things you may want to look at and I know some of the things have been looked at elsewhere.

I have been interested in veteran affairs—I will confess.  I didn’t know much about disabilities until I had one, and then you suddenly become interested.  I served as a service officer of the American Legion and VFW when I was County Attorney a hundred years ago in Russell, Kansas.  And I worked with veterans all my life and all my years in Congress and now I am working with World War II veterans.  They have what they call an Honor Flight where they bring in World War II veterans from your districts, without any cost to them.  They charter them in.  They go out and visit the memorials—spending most of their time at the World War II Memorial.  They have a box lunch and they go back home and this makes their whole life.  There will be a group in from Cleveland this afternoon.  I will be down to say hello.

But the point I make is that we hope we have credibility.  This is not perfect and there are changes you will want to make.  And Secretary Shalala, I can’t think of anybody with more experience in working with Congress than she has had and anybody more effective.  So I just want to touch on three other points.

As Secretary Shalala said, there are six areas where we believe Congress needs to act, and you may think of others.  And what we would like to do, but it may not be possible, is somehow get some of our suggestions into a conference report that you may be holding later this year on the Senate passed bill and your bill because these veterans can’t wait much longer.  And when we talk about the wait they have to get their claim settled and we know that if it doesn’t make it in this year’s bill, it will be next year, and that is a long time.

We think Saturday’s story in the Washington Post would not have been there had Secretary Shalala’s idea been adopted with the care coordinator.  When you get out of the battlefield, and you walk or are carried into Walter Reed, you are assigned a recovery coordinator who stays with you throughout your treatment.  Jose Ramos, who is on our Commission, had so many case workers that he couldn’t remember their names.  And that is what happened to this Sergeant Shannon.

So Secretary Shalala had a great idea.  It is the first recommendation.  And we are not talking about adding thousands or another bureaucracy.  We are talking about 20, 30, 40, 50 people who have followed the seriously injured from day one until the time they leave the hospital or go back home or back to work.  Secretary Shalala has already touched on that.  She outlined three major recommendations.  Let me just touch on the others.

We want to get the DoD out of the disability business and we think they wouldn’t mind doing that themselves.  Veterans tell us that they get better ratings from the Veterans Administration, so we are trying to figure out some way—how do we work this so it is fair and we don’t penalize anybody and still have the DoD with some.  First they would have to get together with the VA and work out what kind of a physical it would be.  And after the physical, when you are determined to be unfit for duty, then you go to the VA and they make your disability rating—not the DoD, but the Veterans Administration.

We have also added what will be called transition payment.  I know from personal experience, when you first get out of the service, whether you are in the hospital or not—it doesn’t make any difference—you are sort of at sea for two or three months.  And so we have these transition payments.  It would be your base pay for three months, or whatever Congress decides, while you are getting home, getting settled, getting your kids in school, getting a job, whatever.

There is another payment.  It will all be in the same check—but something that has never really been considered separately and that is called quality of life.  I think when you get your rating, I am certain if you are an amputee or you lost your sight, it is a consideration.  But if you have lost your sight or if you are Sergeant Lammers who has lost three limbs, your quality of life has gone from a ten to what, one, two or three?  We think that should be compensable and that should be added to any other payment, whatever your rating may be, because you have lost that qualify of life forever.

It has never been specifically identified.  I guess some who examine soldiers would probably say, well, they will include something.  But we want to make certain that happens.  Then, of course, there is the earning loss payment which you would receive based on your disability, what your earnings loss might have been in your lifetime.

So we think, and we know there is another commission working on the disability program.  I think it is fair to say that they have endorsed what we have done with two, is it two exceptions, Karen or Sue?

Ms. GUICE.  They are still working on their recommendations.

Senator DOLE.  In other words, we are pretty much in agreement and their report is due out I think sometime in the next 30 days or 45 days.  But in other words, we don’t want to wait and I know you don’t want to wait.  I think they would tell you now what they are going to do.  So now there are differences in ratings depending on which military service or which regional office determines the rating.  In our national survey of injured servicemembers, fewer than half understood the DoD’s disability evaluation system and only 42 percent of retired or separated servicemembers who had filed a VA claim understood the process.  That is about one of out two that even understood what was happening.

So, as I said, we recommend that DoD do one thing.  They retain the authority to determine the fitness to serve.  Out of the 28,000 wounded, 60, 70 percent are back to duty in 30 days and then there is another 10 or 12 percent that aren’t hospitalized very long.  But there is a group, say around 3,000, 3,200 that are very seriously injured and are going to need very special care for a long time.  We believe that there should be only one physical exam, done by the DoD, and then the VA should resume all responsibility for establishing the disability and the rating.

This new structure, I think, makes it reliable and transparent and accountable.  Under this action item, DoD and VA can focus on what they do best.  The DoD determines fitness and the VA can determine your earnings loss and what your rating should be and the other things that my colleague has mentioned.  The VA can do what they should do and I think it is a much simpler system that better supports the needs of those who transition between active duty and veteran status.

In our fifth action step, we recommend healthcare coverage for servicemembers who are found unfit because of conditions that were acquired in combat, supporting combat or preparing for combat.  That includes about everybody, because once you sign up you are getting ready for combat the next day.  So we think Congress should authorize comprehensive lifetime healthcare coverage and pharmacy benefits for those servicemembers and their families through DoD’s TRICARE program.

Is it fair to say what the White House maybe —

Secretary SHALALA.  Well—

Senator DOLE.  We think the White House is going even further on this.

Secretary SHALALA.  We think the White House is considering going even further to recommend that everyone who is declared unfit for service for health reasons, they will cover the individual and their family’s healthcare forever.  The advantage of that is, obviously, it is easier to get a job if you are disabled, even if you can work 20 hours a week, if you don’t have to worry about working for benefits for your family members.  I think it will help keep families together and will allow people to go to work and not have to worry about getting their healthcare covered.  It is a tremendous step forward.  We have limited jurisdiction and the White House may recommend going further in that regard.

Senator DOLE.  So we have given a short summary here and we know there are questions and other members may want to make statements.  We know everybody on this Committee wants to do what we want to do, and that is to make it work, and particularly for those who are really going to be jammed up the rest of their life.  We want outcomes.  We put in more money, as the Secretary indicated, for education.  To keep people in the program, we raised the benefit 10 percent a year if they stayed.  There is also a stipend to keep them in school.  When these veterans finally leave the hospital and go to school, they are going to be better equipped to move into the mainstream of American life and have a better quality of life and a life of dignity for themselves and their family.

So you all know the figures.  In Vietnam, five out of eight seriously injured survived.  Now it is seven out of eight and we owe a debt to the people on the battlefield, the medics, the doctors, the nurses, therapists and all the people that take care of these men and women who come back.  Many who come back are not injured or wounded.  Their illnesses, the things that happened to them are not their fault.  But they are entitled to the same care.  You don’t have to be shot to receive benefits under our program.  If it is combat-related which, as I said, covers about everybody, and if you are on the way to combat or whatever you are doing and you have an injury that is, that should be covered.

So I just say, Congressman Filner and Congressman Buyer and others we are grateful for this opportunity.  We did tell the other Commissioners that we would continue to try to help get this done. We are going to be around, Secretary Shalala will be around, for a long time.  I will be around for a while at least and we are going to keep working on this.  Hopefully, we are going to have your help.  So thank you very much.

[The statement of Senator Dole appears in the Appendix.]

The CHAIRMAN.  Thank you so much.


The CHAIRMAN.  Your common sense and your sense of urgency come through and provide a standard through which we have to meet.  The Executive Branch will speak for itself.  But we, in Congress here, have to act and act quickly.  And we thank you for giving us that impetus and that charge and the background that you have here.

Secretary Shalala, you have had quite an effect on the Senator.  If you had talked to him, or if he had talked like this —

Secretary SHALALA.  We assure you, though, he did not become a Democrat in the process.

The CHAIRMAN.  If he had learned this ten years ago, you might not have had your last four years in the Cabinet, so—

Senator DOLE.  I think the key, Mr. Chairman, is that I don’t think we had any disagreements—I mean we may have—it doesn’t mean everything was just whatever somebody wanted.  But a lot of our Commission members had the ideas.  On electronic transfer of records, we had this outstanding doctor from the Cleveland Clinic.  He was a tremendous help to us because it is one of the problems out there.  The VA has a great system.  The DoD is trying to catch up.  When you leave Walter Reed, you leave with a stack of paper.  When you leave a VA hospital, you don’t have anything.  They can just punch a button and they can get your record.  And there is a recommendation on information technology (IT), which we think makes a lot of sense and doesn’t cost a big, big bundle of money.

The CHAIRMAN.  Again, thank you so much.  Your charge was the current war, but when I read your recommendations and I think about our Vietnam vets, it seems we could easily substitute Vietnam for what you said and do the same things.  I think we did not treat our returning Vietnam vets with the honor, respect and care that they needed and we are paying a heavy price for it.  And we still can correct some of that, but we also see what we have to do and get it right.  Otherwise, we are going to be left with the kinds of homelessness and suicide rates that we saw —

Senator DOLE.  I don’t want to—this is the last time I will interrupt but—

The CHAIRMAN.  I doubt it.

Senator DOLE.  We are in the Senate.  We never interrupt.  But what we discussed is that it is a new kind of warfare.  There are new kind of injuries.  There is new technology.  There are new opportunities.  We tried to update—and I know the Chairman would have rather gone way back and kind of overhauled the whole system—but we did what our charter said.  We tried to update and make some recommendations that are forward-looking.

Now, some people may resist change.  I assume in the Bradley Commission Report there were some who resisted change.  But we have to bring the benefits and everything else up-to-date and we tried to do that in our report.

The CHAIRMAN.  Did you at all, as we looked at the disability system and recommended a major transition, we do have a problem that exists right now, 600,000 or more backlogged claims.  Some of us want to just cut through that bureaucracy right now, for example, and if a claim has been well documented and had advice of a veteran service officer, for example, to accept in the same way the Internal Revenue Service accepts your tax return and sends you a check for a refund, subject to audit, and just move out those 600,000, you know, as rapidly as we can.  Did you at all think about that or take that up at all?

Secretary SHALALA.  No.  We actually didn’t look at the backlog.  As you know, this country has had considerable experience.  The backlogs in Social Security were cleaned up.  That requires a systems approach.  That was not within our jurisdiction.  We do believe, though, that our recommendations will actually help to make sure we don’t create new backlogs because it will be much more straightforward as to who is responsible for what, what you are going to get and the combination of benefits, including, I should point out, an annuity even if you haven’t spent 20 years in the military.  All those found medically unfit to serve and leave before 20 years, will get an annuity. 

I got an annuity after 14 years in the Federal service.  If you are injured, you ought to be able to take that annuity with you from the DoD.  So that is added to the pieces and that is pretty straightforward.  I think that the combination of transition and some of these different ways of simplifying the system will help eliminate the backlog.  So we didn’t speak to it directly, but we just need a more modernized, straightforward system that is easier for everybody to understand.

Senator DOLE.  Another thing is, I remember way back when I was at the retirement board and I had some pretty serious injuries.  I couldn’t use my hands and I couldn’t walk at the time.  But I got a disability based on the fact that I was a captain.  If I were a colonel, I would have gotten a lot more money, even with lesser disabilities.  That didn’t make any sense to me then, and it doesn’t make any sense to me now.  So we think we have devised a system where you get this annuity payment, but then you also get a rating, whether you are a colonel or a private first class.  We think we ought to make certain that you are being compensated for the disability.

And your rank—if you have been in the service 10 or 20 years, and many people dedicate their life to the service and we want to reward that, you will get the payment that the Secretary just pointed out, this so-called annuity whatever you have been in the service six years or have been in the service 25 years.

The CHAIRMAN.  You all mentioned, on the basis of a medical discharge, that TRICARE should be given for life.  This Committee has been concerned about the practice of using a personality disorder discharge which we think is almost a purposeful misdiagnosis of a preexisting condition, and therefore, would not obligate our government from compensating these servicemembers in the future.  We think that is a big mistake and I don’t know if you took that up in your report or not.  But I mean we think we might have to put a temporary stop to these diagnoses because they are doing great disservice to these young men and women who are serving so faithfully.  Did you look at that issue at all?

Senator DOLE.  I think the Secretary is looking for the—we have the facts on it.  I think the number discharged for personality disorder since 2000 has been about 6,000.  I think there are some misleading figures out there; am I correct, or did you find that?

Secretary SHALALA.  Right.  I think—that is right.  Eighty percent were never in combat.

Senator DOLE.  We did check on that because you had raised the question when you testified.

Secretary SHALALA.  On page 47 of our supplemental report, it is 6,000.  And if I remember correctly, most of them were not in combat specifically.  That obviously could use some study.  But one of the things that we recommend is that the standard of care for PTSD, and a lot of the appeals are about that, must be widely disseminated.  We need more research on that subject.  But everyone who comes for care ought to be treated and everybody ought to be eligible to be treated, no matter when they served in combat.

And I wish I could say that the private sector had great centers of excellence.  The experts in the world are in our military and in our VA, in particular.  And while there are some private sector rehab hospitals that have some capabilities, most of this is in-house.  We need to disseminate the standard of care.  There are a number of centers and we need to make that available to everyone.

The CHAIRMAN.  And thank you, Senator Dole, for praising the whole system of care, not only in the VA, but on the battlefield today.  The Secretary, the VA and I and Congressman Boozman just returned from Iraq and Afghanistan and what we did was, we followed that trail of the wounded warrior from when they are wounded, to their medical evacuation, to a forward base hospital, to a regional hospital, to Landstuhl, Germany, and we followed that for very specific individuals and the incredible professionalism, expertise, dedication, morale.  I mean, and these kids, I mean they are 19, 20, 21, who are doing all of this and we were just amazed at their professionalism and leading to this, you know, this incredible survival rate once you, if you survive a battlefield injury.  So thank you for praising them, because they are a tremendous, tremendous asset to this Nation.

Senator DOLE.  I think in our report there is a segment that tracks a veteran from injury through medical treatment.

Secretary SHALALA.  We did.

Senator DOLE. We have a little chart in there.

Secretary SHALALA.  We did.  And the University of Miami actually trains those trauma teams.  The soldiers and military personnel fly in from different parts of the country.  We turn them into a team before they go off to Iraq and Afghanistan.  And the medicine today is unbelievable.  The disability system is based on a 30-year-old medical system.  That is the whole point here.  If you saw the schedules on orthopedics in the disability system that we have in VA, it is unbelievable.  It doesn’t reflect modern medicine.  This has to be brought up to date.  It is just unacceptable the way it is currently set.  And in this case, we know what to do.

Senator DOLE.  The one place we need help, and Steve may have pointed this out in his hearings, is in the mental health field.  There are not enough professionals available in the private sector or in VA and military hospitals.  I don’t know where they are going to come from, but—

The CHAIRMAN.  Thank you.  Thank you again.  And that team work, by the way, was so vital, as we watched it in Iraq and Afghanistan.

Mr. Buyer, you are recognized for five minutes.

Mr. BUYER.  Thank you.

You know, it is great to see your enthusiasm.  As you know, that can move mountains.  And so not only is it your credibility, but your enthusiasm that has got me excited.  And Mr. Dole, they kind of poked you here a little bit when you talked about spending as much money as necessary.  I think you espoused exactly how you felt all the years that I have known you on these issues.  When I came here in 1992, we had a VA system that was depicted in the movie "Born on the Fourth of the July."   And as a country we didn’t do well. 

And Ms. Shalala, Dr. Ken Kaiser, your good friend who was then the Under Secretary of Health during the Clinton Administration, had his ideas of moving to outpatient care and we embraced that.  And we have invested well—when you look at 1995 as a benchmark, we have invested probably in excess of $300 billion. 

So I embrace exactly what you said, Senator Dole, and—

Senator DOLE.  Thank you.

Mr. BUYER.  —a couple of things I wanted to touch on and I thank you, Secretary Shalala, for your comments.  You made yourself narrow and then you went deep and that is why you have got a good product.  We have the Disability Commission that was out there, so you were respectful of them.  Yet you touched on a few areas.  So we are with great anticipation waiting on their testimony to us.

I have some questions regarding the TRICARE for Life.  I created the TRICARE for Life for the military retirees when I was Chairman of the Personnel Subcommittee in our Armed Services Committee.  So when you say, Senator Dole, that you would like to get DoD out of the disability business, there are a couple of things that I need to ask.  In order to get DoD out of this business, we still have the medical retirees, or as your recommendation, to even do away with medical retirees.  That is one question.

The other is, if we are going to say that TRICARE for Life is available to those who are found unfit because of conditions acquired in combat, supporting combat or preparing for combat, then DoD pays for the TRICARE for Life.  So they are not going to be totally out of that.  We are not going to be able to stovepipe that.  So there are still going to be payors.  And so I will be a good listener when the disability commission comes over and I will embrace your recommendations.

My question to you is about implementation.  So if we are going to take the TRICARE for Life program and we are now going to implement that, the eligibility, are we going to restrict that eligibility to a core constituency, meaning those, as you defined here, and what is the effective date?

Senator DOLE.  Why don’t you go first?

Secretary SHALALA.  The effective date is going to be determined by Congress and there will be legislation that will be coming up.  I think—

Mr. BUYER.  Do you have a recommendation?

Mr. SHALALA.  —we are talking about, that will be part of, back to 2001.  And you will see legislation.  That, obviously, is something that can be discussed with Congress in terms of setting that, as well as who is to be covered.  We are simply talking about DoD making only the fit/unfit decision and if one is not fit for health reasons and you get a medical discharge, then you ought to have the opportunity—and then you go over and get your disability out of VA.  You ought to have the opportunity to have your healthcare covered.

The addition here is to cover your family as well, to encourage you to go on and get education, as well as to get ready to go to work, if you can.  If you can’t, obviously, there are all sorts of services that would be available for you.

Mr. BUYER.  All right.  With regard to the issue on VA contract care, if DoD, what you are trying to do is move these to be patient-centric, thank you very much.  I wanted to jump up and hug you when I heard you talk about patient-centric.

Secretary SHALALA.  Oh, that would be fun.


The CHAIRMAN.  Trust me, it is not.


Mr. BUYER.  Well, I am hetero, Mr. Filner.

Senator DOLE.  Steve, could I ask—

Mr. BUYER.  I am not sure.


Mr. BUYER.  Sure, Senator Dole.

Senator DOLE.  You raised a point that I don’t have an answer to on medical retirees. 

Sue, would you, or Karen, address that?  Let’s say you have served 25 years and you—

Secretary SHALALA.  This is Sue Hosek from the Rand Corporation.

Senator DOLE.  RAND Corporation.  She has had 30 years working with these issues.

How do you treat the medical retiree—I should know, but I don’t.

Ms. HOSEK.  If you are declared unfit, you get your discharge for medical reasons.  And obviously, if you have served 20 years, you are still going to get your retirement.  What our proposal does is to provide essentially a partial retirement benefit in the form of an annuity payment for those who don’t reach the 20 years.  Right now they walk away with nothing.  A