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Legislative Hearing on H.R. 2790, H.R. 3458, H.R. 3819, H.R. 4053, H.R. 4107, H.R. 4146, H.R. 4204, and H.R. 4231.

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LEGISLATIVE HEARING ON H.R. 2790, H.R. 3458, H.R. 3819, H.R. 4053, H.R. 4107, H.R. 4146, H.R. 4204, AND H.R. 4231










JANUARY 17, 2008

SERIAL No. 110-63

Printed for the use of the Committee on Veterans' Affairs




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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

MICHAEL H. MICHAUD, Maine, Chairman

VIC SNYDER, Arkansas
PHIL HARE, Illinois
MICHAEL F. DOYLE, Pennsylvania
JEFF MILLER, Florida, Ranking
HENRY E. BROWN, JR., South Carolina

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.



January 17, 2008

Legislative Hearing on H.R. 2790, H.R. 3458, H.R. 3819, H.R. 4053, H.R. 4107, H.R. 4146, H.R. 4204, and H.R. 4231


Chairman Michael Michaud
        Prepared statement of Chairman Michaud
Hon. Jeff Miller, Ranking Republican Member
    Prepared statement of Congressman Miller
Hon. Jerry Moran
Hon. Ginny Brown-Waite


U.S. Department of Veterans Affairs, Gerald M. Cross, M.D., FAAFP, Principal Deputy Under Secretary for Health, Veterans Health Administration
        Prepared statement of Dr. Cross

American Legion, Joseph L. Wilson, Deputy Director, Veterans Affairs and Rehabilitation Division
        Prepared statement of Mr. Wilson
Boswell, Hon. Leonard L., a Representative in Congress from the State of Iowa
        Prepared statement of Congressman Boswell
Capito, Hon. Shelley Moore, a Representative in Congress from the State of West Virginia
        Prepared statement of Congresswoman Capito
Disabled American Veterans, Joy J. Ilem, Assistant National Legislative Director
        Prepared statement of Ms. Ilem
Hare, Hon. Phil, a Representative in Congress from the State of Illinois
Herseth Sandlin, Hon. Stephanie, a Representative in Congress from the State of South Dakota
        Prepared statement Congresswoman Herseth Sandlin
Honda, Hon. Michael M., a Representative in Congress from the State of California
Kagen, Hon. Steve, a Representative in Congress from the State of Wisconsin
Space, Hon. Zack, a Representative in Congress from the State of Ohio
Veterans of Foreign Wars of the United States, Christopher Needham, Senior Legislative Associate, National Legislative Service
        Prepared statement of Mr. Needham
Vietnam Veterans of America, Richard F. Weidman, Executive Director for Policy and Government Affairs
        Prepared statement of Mr. Weidman


American Academy of Physician Assistants, statement
Berkley, Hon. Shelley, a Representative in Congress from the State of Nevada, statement
Mental Health America, statement
Paralyzed Veterans of America, statement


Jonathan Archey, Manager, Federal Relations, Ohio Hospital Association, to Hon. Sherrod Brown, United States Senate, and Hon. Zack Space, U.S. House of Representatives, letter dated October 18, 2007, supporting S. 2142/H.R. 3819

Richard M. Dean, CMSgt (Ret.), Chief Executive Officer, Air Force Sergeants Association, to Hon. Zachary Space, U.S. House of Representatives, letter dated November 5, 2007, support H.R. 3819

U.S. Department of Veterans Affairs, News Release, entitled "VA Vet Centers Coming to 39 Communities, Peake Provide Counseling for all Combat Veterans," dated July 9, 2008.

LEGISLATIVE HEARING ON H.R. 2790, H.R. 3458, H.R. 3819, H.R. 4053, H.R. 4107, H.R. 4146, H.R. 4204, AND H.R. 4231

Thursday, January 17, 2008
U. S. House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, DC.

The Subcommittee met, pursuant to notice, at 10:01 a.m., in Room 340, Cannon House Office Building, Hon. Michael Michaud [Chairman of the Subcommittee] presiding.

Present:  Representatives Michaud, Snyder, Hare, Miller, Moran. 

Also Present:  Representative Brown-Waite.


Mr. MICHAUD.  Why don't we get started.  It is my understanding we have votes at 11:30, so we will try to move this along so we can hear everyone.

I would like to thank everyone for coming here today.  Today's legislative hearing is an opportunity for Members of Congress, veterans, the U.S. Department of Veterans Affairs (VA) and other interested parties to discuss recently introduced legislation that comes under this Subcommittee's jurisdiction.

I do not necessarily agree or disagree with the bills before us today, but I believe that it is an important process, that we encourage a frank discussion of new ideas.  We have eight bills before us today.  I look forward to hearing the testimony on these bills. 

And I would turn it over to Mr. Moran if he has an opening statement.

[The statement of Chairman Michaud appears in the Appendix.]


Mr. MORAN.  Mr. Chairman, thank you very much.  I am happy to serve as the acting Ranking Member until Mr. Miller arrives, and I am interested in hearing the testimony from our colleagues on a variety of issues affecting veterans across the country. 

And I am of the opinion that oftentimes we get some of our best ideas in this Committee by listening to colleagues who do not serve with us on the House Veterans' Affairs Committee, and I welcome the two gentlemen that are with us already this morning and look forward to hearing what they have to say.

I thank you, Mr. Chairman.

Mr. MICHAUD.  Thank you very much.

I now would like to recognize Mr. Hare who also serves as a member of this Committee and a very strong advocate for our veterans.

Mr. Hare?



Mr. HARE.  Good morning.  Thank you, Mr. Chairman.  Thank you for holding this hearing today, and I am pleased to provide testimony in support of H.R. 2790, the bill I introduced to elevate the current physician assistant (PA) advisor to the Veterans Affairs Under Secretary of Health to a full-time Director of PA Services in the VA's Central Office.

I would like to thank my colleague, Representative Jerry Moran for his leadership with me on this bill, as well as Chairman Filner, and Representatives Berkley, Corrine Brown, and Doyle for joining us as co-sponsors of the bill.

PAs have long been a critical component in providing care in the Veterans Health Administration (VHA) with nearly 1,600 PAs currently employed, many of whom are reservists, guardsmen, and veterans.  While the PA advisor position has been valuable in establishing guidelines for utilizing PAs, we do see unnecessary restrictions on PA use, and too many problems still exist.

I do not believe that Congress' original intent for a position has been fulfilled.  Confusion still exists about the medical services PAs can provide from facility to facility. 

VA facilities are telling PAs that they cannot and will not hire PAs and, most critically, the PA advisor has been excluded from critical planning and policy development. 

These issues not only hinder the ability of PA advisors and PAs currently employed by the VA, but they also discourage PAs from even entering the VA system.

Without the PA advisor being able to fully perform his or her role in the full-time Director position, the VHA is missing a clear opportunity to improve the quality of healthcare for our veterans.  Quite simply, this is a position that needs to be made permanent and be based on the VA's Central Office.

The lack of establishing the Director position ignores a valuable resource in improving care, prevents improvements in the recruiting and retention of the PA workforce, and disregards utilizing a critical aspect of the VHA workforce.

Considering the fact that nearly 40 percent of all VA PAs are projected to retire in the next five years, the VA is in danger of losing its PA workforce unless some attention is directed towards the recruitment and retention of this critical group.

One of the biggest challenges currently facing future PAs in the VA system is their exclusion from any recruitment and retention efforts or benefits.

The VA designates physicians, nurses as critical occupations and so priority and scholarships and loan repayment programs goes to these critical occupations.  However, the PAs have not been designated as a critical occupation, so no monies are directed their way.

This is despite the fact that the VA has determined PAs and Nurse Practitioners (NPs) to be functionally interchangeable and equal in the work that they perform.  Many of these problems could be addressed by a Director of PA Services.

H.R. 2790 would legitimatize and recognize the role PAs play by creating a permanent Director that would serve as clear a voice in strategic planning, policy, and staffing development initiatives, as well as an advocate for the physician assistants.

The VA's position on my bill is that the status quo is working just fine and that no change is necessary.  I strongly disagree with that position.  The VA prefers a field-based position and thinks that only 75 percent of the individual's time is necessary to devote to PA patient-care issues in the VA.

However, even though the VA opposes this legislation, VHA Under Secretary for Health, Dr. Kussman, said he intended to make the PA advisor a full-time position in the VA's Central Office.

There is no significant cost to elevating and relocating this individual position.  This change is common sense and it promotes quality medical care for our veterans.

This bill is supported by the American Academy of Physician Assistants (AAPA), the Veterans of Foreign Wars, the Disabled American Veterans, Vietnam Veterans of America, the Blinded Veterans of America, and the Veterans' Affairs Physician Assistant Association.

I would like to thank all the Veterans Service Organizations (VSOs) for their support in this legislation and particularly thank the AAPA for their dedication on this issue.

I thank you, Mr. Chairman, for giving me the opportunity to be here this morning to testify on this critical piece of legislation.

Mr. MICHAUD. Thank you very much, Mr. Hare.

And we have had a request from one of the co-sponsors of this legislation to speak who also sits on the Committee.  So if there is no objection, Mr. Moran.

Mr. MORAN.  Mr. Chairman, thank you, and I am pleased to join my colleague, Mr. Hare, as an original co-sponsor of H.R. 2790, and am pleased to support the testimony that he provided this morning.

I suspect that the Department of Veterans Affairs will testify that this legislation is not necessary, but that is certainly not what I am hearing from my Kansas physician assistants, and very much hope that we can see this bill's passage.

I represent one of the most rural congressional districts in the country and I know in healthcare that our physician assistants are some of our most valuable resources in trying to meet the healthcare needs of Kansans who live in those rural communities.

And I know that that can be equally as true in the VA, and I have been an advocate for our Community Based Outpatient Clinics (CBOCs) and our physician assistants who are providing tremendous services to veterans through the outpatient clinics.

I also know that medical institutions like Cleveland Clinic, Mayo Clinic, M.D. Anderson Cancer Clinic at the University of Texas, and others have Directors of PA Services to make sure that they employ the PAs in an integrated way into their healthcare delivery system.  And I believe that the VA can utilize the same technique to provide a stronger voice for our PAs in making healthcare policy.

It makes sense to me to give the PAs a stronger voice and invite their participation among the healthcare professions that have full-time Directors or consultants within the VA already at the Central Office, our social work, nursing, pharmacy, psychology, dentists, and dieticians.  This just makes a lot of sense to allow the physician assistants the same kind of opportunity.

And I thank Mr. Hare for his leadership on this issue, and thank the Committee for allowing me to speak.

Mr. MICHAUD.  Thank you very much, Mr. Moran.

I now would like to ask unanimous consent that Ms. Brown-Waite be invited to sit at the dais for this Subcommittee hearing. 

Ms. BROWN-WAITE.  Thank you, Mr. Chairman.

Mr. MICHAUD.  Hearing no objections.  It is so ordered. 

Mr. MICHAUD.  I would now like to recognize Zach Space who is also another strong advocate for our veterans in this Nation.  I want to thank you for presenting your legislation and look forward to your testimony.

Mr. Space?


Mr. SPACE.  Thank you, Chairman Michaud, Ranking Member Miller, and Members of the Subcommittee, for holding today's hearing and including H.R. 3819, the "Veterans Emergency Care Fairness Act."  I am grateful for the opportunity to discuss this bill.

In March, I received a letter from Terry Carson who is Chief Executive Officer (CEO) of Harrison Community Hospital in Cadiz, Ohio, a small critical care facility in rural Harrison County.  Mr. Carson wrote to me about a problem he was experiencing at his small hospital when providing emergency care for veterans.

In late May, Senator Sherrod Brown of Ohio and I held a joint field hearing on the issues facing rural veterans, and Mr. Carson participated as a witness to share his experiences.

Mr. Carson explained that currently the VA reimburses non-VA hospitals for emergency care provided to veterans up to the point of stabilization.  Once the patient is deemed stable enough to transfer, he or she is moved to a VA hospital.  Oftentimes that is several hundred miles away from hospitals in rural areas of our country.

The problem Mr. Carson brought to my attention is that oftentimes veterans experience a waiting period for a bed in a VA hospital.  During this limbo, the VA is not required to reimburse the private hospital for care.  Meanwhile, people like Mr. Carson feel morally obligated to continue care despite the fact that they cannot count on reimbursement.

And it should be emphasized that many of the small hospitals, not just in southeastern Ohio but throughout the country, are operating on very, very narrow profit margins.  So it is an economic burden as well.

The "Veterans Emergency Care Fairness Act" closes this loophole by requiring the VA to cover the cost of care while a transfer to a VA hospital is pending and if the private hospital can document attempts to transfer the patient.

Senator Brown introduced an identical companion bill on the Senate side and that has already advanced out of the full Committee.  Senator Brown and I believe this legislation is a reasonable solution for the VA, private hospitals, and most importantly our Nation's veterans.

I have received support for this legislation from people all across the country who have found either themselves or a loved one caught in this hospital limbo.  Additionally, the Ohio Hospital Association and the Air Force Sergeants Association have written letters of support which I can submit for the record today.

This bill is a very good example of how our system of representational democracy is supposed to work.  The constituent contacts his member of Congress.  The member listens, and a legislative fix is found.

I am proud to have had a chance to advocate for Mr. Carson, and I hope you will join me in recognizing his efforts and the efforts of those veterans that his hospital cares for by supporting H.R. 3819.

And, again, I thank you for the opportunity.

[The letters from the Ohio Hospital Association and the Air Force Sergeants Association appear in the Appendix.]

Mr. MICHAUD.  Thank you very much, Mr. Space.

And now I would like to recognize Mrs. Herseth Sandlin for her piece of legislation.  I want to also thank her for her long-time support for our veterans' issues and a long-time member of this Committee.


Ms. HERSETH SANDLIN.  Thank you, Mr. Chairman.  Good morning to you and to the Ranking Member and other Members of the Subcommittee.  I want to thank you for having today's hearing and I appreciate the opportunity to be here to discuss with you the "Women Veterans Healthcare Improvement Act."

This bill, H.R. 4107, which I introduced last fall along with Congresswoman Brown-Waite of Florida, will expand and improve Department of Veterans Affairs healthcare services for women veterans, particularly those who have served in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF).

I would like to thank the Disabled American Veterans (DAV) for their support in helping craft this important bill.  And I would also like to thank the Veterans of Foreign Wars of the United States of America (VFW) for their endorsement of the legislation.

As you know, more women are answering the call to serve and more women veterans need access to services that they are entitled to when they return from their deployments or separate from service and return to civilian life.

With increasing numbers of women now serving in uniform, the challenge of providing adequate healthcare for women veterans is more considerable than ever.  In the future, these needs likely will be significantly greater with more women seeking access to care for a more diverse range of medical conditions.

In fact, more than 1.7 million women nationally are military veterans.  More than 177,000 brave women have served our Nation in Iraq and Afghanistan since September of 2001, and nearly 27,000 are currently deployed in these wars.

By August of 2005, 32.9 percent of women veterans who had served in OIF or OEF had received VA healthcare.  By the end of the following year, that number had increased to 37 percent.  And as the VA compiles the final data for 2007, the percent is expected to increase again.

And according to the VA, the prevalence of potential post traumatic stress disorder (PTSD) among new OEF/OIF women veterans treated at the VA from fiscal year 2002 to 2006 has grown dramatically from approximately one percent in 2002 to nearly 19 percent in 2006.

So the trend is clear, but not surprising.  More women are serving in our Armed Forces, including the National Guard and Reserves.  More women are being deployed overseas and more women veterans need access to healthcare services.  So clearly we must do everything we can from a public policy standpoint to meet the new challenge that this trend presents.

The "Women Veterans Healthcare Improvement Act" calls for a study of healthcare for women veterans who served in OIF and OEF, a study of barriers to women veterans seeking healthcare at the VA, enhancement of VA sexual trauma programs, enhancement of PTSD treatment for women, expansion of family counseling programs, establishment of a pilot program for child care services, establishment of a pilot program for counseling services in a retreat setting for women veterans, and the addition of recently separated women veterans to serve on advisory committees.

We must ensure that the VA is positioned to provide adequate attention to women veterans' programs so quality healthcare and specialized services are available equally for both women and men.

I believe this bill will help the VA better meet specialized needs and develop new systems to better provide for the quality healthcare of women veterans, especially those who are returning from combat who were sexually assaulted or who need child care services, especially in order to better access the healthcare services provided by the VA.

So, Mr. Chairman, Ranking Member Miller, again, thank you for inviting me to testify, and I look forward to answering any questions that you or other Members of the Subcommittee may have.

[The statement of Congresswoman Herseth Sandlin appears in the Appendix.]

Mr. MICHAUD.  Thank you very much.

I have also had a request of one of the original co-sponsors to speak on this bill, Ms. Brown-Waite.


Ms. BROWN-WAITE.  Thank you, Mr. Chairman and Mr. Ranking Member Miller.

When I tour the hospitals in my district, whether it is St. Petersburg, Tampa, or Gainesville, one question I always ask when I see women veterans there waiting is, how is the care.  Do you think you are getting the same services.

And particularly in the area of mental health, women have told me, no, they do not believe they are getting the same services.  And we might ask why. 

When a women comes back from the military, very often she has family at home, children, and it is the caregiver in her that she takes care of the children, takes care of the house, might have a job that she goes to. 

And the trauma of having been at war or having been perhaps sexually assaulted does not really come back until later because the female physiology is a whole lot different.

This bill, I think, will go a long way toward making sure that our female veterans are receiving all of the care that they need and the care that is necessary and tailored to them.

You know, the specific healthcare needs of female servicemembers and veterans are sometimes overlooked by the Department of Defense as well as Department of Veterans Affairs.  This bill will go a long way toward making sure that we have evidence-based treatment that women need to get the help to help them recover from whether it is sexual assaults or trauma of the war.

Thank you, Mr. Chairman, and I yield back and certainly commend Ms. Herseth Sandlin for putting together this bill.  And I am sure you hear the same story from women veterans.  And thank you, Mr. Chairman.

Mr. MICHAUD.  Thank you very much.

And the last bill for the first panel is H.R. 3458, introduced by Ms. Moore Capito.

Ms. CAPITO.  Thank you.

Mr. MICHAUD.  Thank you for coming this morning.  Appreciate it.

Ms. CAPITO.  Thank you, Mr. Chairman.

Mr. MICHAUD.  Thank you for your interest in veterans' issues as well.


Ms. CAPITO.  Thank you.  Thank you for giving me the honor of presenting this to the full Committee.  I appreciate that.  I want to thank the Ranking Member as well.

May I submit my full statement for the record, and I am going to speak very briefly because I have to be on the floor.  So if you saw me looking panicked, that was my problem.

My issue is rural veterans.  I represent a State, West Virginia, which I have in my research material shows that over 14 percent of West Virginians are veterans living in my State.

And I am very concerned with the traumatic brain injury (TBI) issues that many veterans in many rural States and across the Nation are dealing with and making sure that they are able to access the kind of care that they need and deserve.  And I think the Chairman shares the same, I know, issue.

My bill basically introduces five pilot projects where the Secretary would pick five States that do not have the traumatic brain injury centers in their States and designates a case manager for the TBI victims in the State that would be able to follow their cases through their treatment.

And it also opens up the possibilities of using local providers, whether it is a CBOC or a local provider, to help that veteran.  I mean, you can imagine having an injury such as this and then to actually see the physician, you might have to travel eight or nine hours by car makes it very difficult to do it on a regular basis and certainly in some cases almost impossible.

So this is what the bill asks for.  It asks for a pilot study of five States.  It asks for a case manager for each State to specifically deal with this issue.  This was brought to light for me from the Office of Rural Health at West Virginia University who deals with rural healthcare in the State of West Virginia quite frequently. 

It also asks for a report back to Congress every year to see how the needs of rural veterans are being met who unfortunately are suffering from the results of traumatic brain injury.

I thank the Chairman.  I thank all the Members of the Committee.  It is an important issue across the country.  And as I was reading through my background material, I guess I did not realize that rural States really provide a relatively larger majority of men and women to our military than some of our metropolitan areas.  And we want to see that they are able to access the care.  Thank you.

[The statement of Congresswoman Moore Capito appears in the Appendix.]

Mr. MICHAUD.  Thank you very much.

Are there questions for any of our first group of panelists?

[No response.]

Mr. MICHAUD.  Okay.  Hearing no questions, we will dismiss the first panel.

I would like to ask the second panel to come forward.  I would like to thank the second panel.  We are looking forward to hearing your testimony.  And we will start off with Mr. Boswell.



Mr. BOSWELL.  Well, thank you, Mr. Chairman, Mr. Miller, and all of you on the panel.  Good to see you and I appreciate the hard work you are doing for veterans.  Thank you so very, very much.

I would just like to make a couple points here.  I know you are very busy, but some say that suicide is an epidemic, which is sweeping through our veteran population.  And for too long, suicide among veterans has been ignored.  I feel that now is the time to act.

We can no longer be afraid to look at the facts and the sad fact is we are missing adequate information on the number of veterans who commit suicide every year.

Probably all of you, all of us could tell or make reference to how a person or someone in our own acquaintance had a mental health problem and it was not dealt with and oftentimes just kind of swept under the rug and looked at as a sign of weakness.  And that time has got to be gone, has got to pass.

I was shocked as I am sure many of you were when I saw a CBS Evening News report focusing on veteran suicide.  They found that in 2005, over 6,200 veterans committed suicide, 120 a week.

The report also found that veterans were twice as likely to commit suicide as nonveterans.  And these are very devastating circumstances.

However, the data collected did not come from the Department of Veterans Affairs, but rather from individual States.  That is why I introduced H.R. 4204, the "Veterans Suicide Study Act," to direct the Secretary of Veterans Affairs to conduct a study on the rate of suicide among our Nation's veterans. 

I believe it is imperative we have the facts on this terrible problem if we are to effectively treat our veterans as they return home.

While I am pleased that the "Joshua Omvig Veterans Suicide Prevention Act" is now law, we need to continue to get all the facts on suicide among our veterans in order to better treat them as they return home.

I implore this Committee and Congress to act swiftly on H.R. 4204 so we can ensure we have the data we need to treat our Nation's heroes.  This is an issue important to veterans and their families in Iowa and across our Nation.

And I would like to thank you, Mr. Chairman, for allowing me this time, and I would be glad to answer any questions you might have.

But a thought comes to me and I know we have talked to several of you about the "Suicide Prevention Act."  But at some point, we want to measure, and how are we going to measure if we do not have some data?  You know, is it effective?  Maybe we need to go in and adjust that as we work with it or whatever we might need to do.

So I feel like we need to have this information and then we can make comparisons as we see whether we have been effective or not.  We have got to take care of our veterans.  And I know every one of you are committed to that as well.  Thank you very much.

[The statement of Congressman Boswell appears in the Appendix.]

Mr. MICHAUD.  Thank you.


Mr. MILLER.  May I make a statement real quick?

Mr. MICHAUD.  Okay.  Mr. Miller?

Mr. MILLER.  Thank you, Mr. Chairman. 

Mr. Boswell, I salute you on bringing this bill, H.R. 4204, the "Veterans Suicide Study Act," forward.  I am probably not going to be able to stay past 10:30 and I just want whoever is here from VA to hear this from me beforehand.

All I hear on this particular piece of legislation H.R. 4204, is why we cannot do it and why it is not the right piece of legislation.  I would like to see VA get with the sponsor. Let us see if we can fix the language and come out with a piece that says “we can” instead of "we cannot."

Mr. Boswell?

Mr. BOSWELL.  Well, I am not stuck on authorship.  I want something to happen.  You can make it a Committee bill for all I care.  I want something to happen.

Mr. MILLER.  This will be the Boswell bill, I am sure, but I want VA to let us get this thing moving forward.

Mr. BOSWELL.  Thank you.

[The prepared statement of Congressman Miller appears in the Appendix.]

Mr. MICHAUD.  Thank you, Mr. Miller.

Mr. Kagen?


 Mr. KAGEN.  Thank you, Mr. Chairman.  I really appreciate the opportunity to provide these few minutes to present H.R. 4231, which is entitled the "Rural Veterans Mental Health Improvement Act."

I will review with you some of the facts you are already aware of.  We have all become aware that mental health conditions affect many of our soldiers.  And as a physician, I can tell you that the brain is still a vital organ in the human body.  We ought to do everything we can to protect it and to heal it.

There are nine million veterans who live in rural regions in America.  And only one out of three of these veterans are receiving the medical benefits that they have already earned.

To say it another way, two-thirds of rural veterans when they come home do not get their medical benefits for reasons that are becoming apparent more and more every day.

Fifteen percent of veterans who have served in Iraq and Afghanistan now suffer from PTSD, post traumatic stress disorder, but barely of those who have already been diagnosed receive the care that they require.

When people come home from overseas and combat, they have higher rates of divorce and this affects not just our families but our communities because when our soldiers are wounded mentally, they are unable to perform at work.  They lose their jobs, lose their incomes, and all of our communities lose their tax base as a result.

It is not a surprise to anyone that an early and accurate diagnosis of any medical condition saves lives and saves human tragedy.  And that is what we must accomplish by serving all of our veterans, especially those who live in rural areas.

What H.R. 4231 seeks to do is to make it easier for affected patients to receive the care they have earned, first by providing an accurate diagnosis from a qualified mental health specialist at a VA medical center or clinic.  Secondly, for those patients who are affected and diagnosed as having a mental condition, they need to receive care as soon as possible and as close to home as possible. 

For those patients who live more than 30 miles away from a VA medical center, H.R. 4231 seeks to create a voucher system where each affected veteran would receive a voucher, receive the care, the expert care they need from qualified specialists close to home.  If it is close to home, they are going to have a higher probability of receiving the care that they need.

We know from our common experience as Congressmen and women that if it is close to where we are, we are much more likely to get there to that event or to that, shall we say, fund-raising opportunity.

The third thing H.R. 4231 seeks to do is to guarantee that the families who are also affected by the post traumatic stress disorder, by drug and alcohol addictions that occur in such affected veterans, that the family gets the counseling and care that they require to help keep them together.

I am proud to say that my wife, Gayle, who was President of the Congressional Spouse Association for the class of 2006, has made a marriage between United Way and the National Military Family Association to create access to a telephone number that will help rural veterans and those in the cities to get the care and the benefits that they have already needed.

But we have to do more.  This Congress can do more.  And H.R. 4231 seeks to do just that.  It is a pilot program.  It is something that we can measure and monitor to guarantee to push our affected veterans into the care that they really require. 

If we fail to do this, if we turn our back on the needs of our veterans now, especially those mental impairments, the wounds that you will never see, we will be failing to do our complete job.

And I thank you again for the time that you have provided to me.  I will submit my written statement to your official records, and I am open to any questions that you may have.

Mr. MICHAUD.  Thank you very much, Mr. Kagen.

Are there any questions from the Committee?

Mr. Hare?

Mr. HARE.  No questions, Mr. Chairman, except to say to my two friends, Mr. Boswell and Mr. Kagen, I think both bills have a tremendous amount of merit.  And I know how hard you have worked on this issue of suicide among veterans.

And, Mr. Boswell, I will tell you that anything I can do to assist you on this I will, and I am proud to be on the bill with you. 

And, Mr. Kagen, let me just say I come from a very rural area too, in west central Illinois with all or parts of 23 counties.  I do not think we ought to be hung up on who they are talking to, if it works for them, and they can stay close to home.  Their families can go with them. 

I have had veterans that have had to travel two and a half hours by van, get out of the van, go in, and literally sit for two, two and a half hours waiting to be seen for something.  And, quite frankly, they just give up and leave.

And I think it is incumbent upon us and this Congress to make sure that any veteran, any place, just because you live in a rural area, you have problems too.  These people have served.  I think we have an obligation to give them the type of care and the access to the care that they deserve.

So I commend you both for your pieces of legislation and hopefully down the road, we will see this become law because to do anything less, I think, really dishonors the service that these people have put in for this Nation. 

So I want to just thank you, Mr. Chairman.

Mr. MICHAUD.  Thank you very much.

I want to thank this panel as well.  And the last member of the panel, Mr. Honda, who is presenting H.R. 4146, thank you very much for joining us today and we look forward to your testimony.


Mr. HONDA.  Thank you, Mr. Chairman, and thank you for this opportunity.  I would like to thank the leadership of this Committee for holding this hearing and inviting me to testify before the Subcommittee.  I really do appreciate the opportunity to share my thoughts on veterans' emergency services and reimbursement.

In the 109th Congress, I introduced legislation which would amend the "Millennium Healthcare Act" and provides that the VA should cover an uninsured veteran's emergency healthcare cost before and after stabilization if no VA hospital bed is available at a geographically accessible VA facility.

It is a problem that I have been facing with our constituents in my district since I have been on the Board of Supervisors. 

As the Subcommittee knows, I reintroduced this bill as H.R. 4146 right before Veterans Day last year.  And the need for this legislation was brought to my attention by again a constituent, Robert Dahlberg, who is a Vietnam-era veteran.  I would like to read a detailed account of what happened to Robert and why he contacted me.  I will be very brief.

“About two years ago, after my helicopter crashed while fire fighting in northern California, I went to register for my veteran's medical benefits.  And as I was signing up at the VA, I asked a lot of questions to understand what my obligations were in order to get the care.

At one point, I heard the words, and then you will need to get yourself once stabilized to a VA hospital, and these words alarmed me.

And after further investigation, that was it.  Even if I had a heart attack and was stabilized at a non-VA hospital, it was my responsibility to get myself to a VA hospital.  The VA requirements to get one's self to a VA hospital after stabilization is at best a joke and could financially devastate veterans of all ages and family status, leaving them destitute with a huge bill from the non-VA hospital.  And to me, this is unconscionable.”

The unintended loophole created by the "Millennium Healthcare Act" can leave veterans in a financial disaster.  The problem, if nothing is done, is likely to grow as veteran ranks swells with servicemen and women returning from the wars in Iraq and Afghanistan.

Mr. Chairman and Committee Members, we, as legislators, must fix this loophole.  We have a responsibility to our veterans to do so.  We owe them a debt of gratitude for their service and it is inexcusable for us to allow this loophole to even exist. 

It is an unnecessary burden for our returning veterans, Mr. Chairman.  This important fix will save many veterans a great deal of grief and we should not stand by idly as more veterans are served absurd inordinate hospital bills because of this situation, especially as VA hospitals reduce the number of beds they have available.

American Veterans (AMVETS) and the American Legion support this bill, along with some Members of this Committee such as Ms. Ginny Brown-Waite and Mr. John Hall.  I appreciate the bipartisan support this bill has received and urge the Committee to fix this problem with the health and financial stake of our veterans in mind.

Again, I thank you, Mr. Chairman, for this opportunity, and be willing to answer any questions.

Mr. MICHAUD.  Thank you very much, Mr. Honda.

Are there any questions?

[No response.]

Mr. MICHAUD.  We are letting you off easy today.  Thank you very much.  We really appreciate your testimony.

And as staff is preparing the table for panel three, there is one more piece of legislation that was introduced by Ms. Berkley.  It is H.R. 4053.  She is not able to be here, but it is my understanding that Mr. Hare will present that legislation.

Mr. HARE.  Thank you, Mr. Chairman.  I will be very brief.  And I thank you and I thank my friend, Mr. Moran, for allowing me to speak on this bill this morning.

Unfortunately, Ms. Berkley could not be here today to talk about her bill.  As a co-sponsor of her legislation, I would just like to say a few words in support of it.

Nationally, one in five veterans returning from Iraq and Afghanistan suffers from post traumatic stress disorder.  Twenty-three percent of members of the Armed Forces on active duty acknowledge a significant problem with alcohol use.  It is vital that our veterans receive the help that they need to deal with these conditions.

Ms. Berkley has introduced legislation which aims to improve the treatment and services provided by the Department of Veterans Affairs to veterans with post traumatic stress disorder and substance abuse disorders by establishing national centers of excellence on PTSD and substance abuse disorders and expanding the assistance of mental health services for families of veterans, among other initiatives.

As a co-sponsor of the "Mental Health Improvements Act," I feel this bill takes a step in the right direction in providing our veterans with the care that they have earned.

I thank you very much, Mr. Chairman, for allowing me to read this into the record on behalf of Ms. Berkley.  And it is my sincere hope that we will get bipartisan support on this vital piece of legislation from the Committee.  Thank you, Mr. Chairman.

[The statement of Congresswoman Berkley appears in the Appendix.]

Mr. MICHAUD.  Thank you very much, Mr. Hare.

Any questions for Mr. Hare?

[No response.]

Mr. MICHAUD.  Thank you.

So I would invite the third panel to come on up.  And as they are coming up, it will be Joe Wilson who represents the American Legion, Joy Ilem who represents the Disabled American Veterans, Christopher Needham, the Veterans of Foreign War, and Richard Weidman who represents the Vietnam Veterans of America (VVA).

I would like to thank all of you for coming here this morning to give your testimony on the piece of the legislation that we just heard.  And we will start with Mr. Wilson and move on down the table.

Mr. Wilson?



 Mr. WILSON.  Good morning, Mr. Chairman and Members of the Subcommittee.  Thank you for this opportunity to present the American Legion's views on legislation being considered by the Subcommittee today.

the American Legion commends the Subcommittee for holding a hearing to discuss these important and timely issues.

In regards to H.R. 2790, although the American Legion has no specific official position on this issue, we believe VA should do everything in its power to improve access to its healthcare benefits to include provide adequate funding to support programs within the VA medical system.

In regards to H.R. 3458, the American Legion favors the intent of this bill to create a pilot program that would train and assign specified VA case managers for veterans diagnosed with TBI or traumatic brain injury and reside in rural areas.

However, we would encourage the implementation of this program to every venue nationwide thereby ensuring across the board quality and adequate healthcare.

In regards to H.R. 3819 and also H.R. 4146, the American Legion supports provisions to allow VA to pay for emergency room care at non-VA facilities.  We believe this would prevent any delays in treating life-threatening injuries or illnesses for veterans not in close proximity to a VA facility.

We also support H.R. 4146 because H.R. 4146 would alleviate the hardship or burden of veterans paying out-of-pocket expenses unfairly incurred, which is also due to unavailable beds at VA facilities.

In regards to H.R. 4053, according to the Diagnostic and Statistical Manual of Mental Disorders IV, post traumatic stress disorder always follows a traumatic event that causes intense fear and/or helplessness in an individual.  Typically the symptoms develop shortly after the event, but may take years.  Psychological care is considered the most effective means of treatment for PTSD.

In addition to treatment for PTSD, other mental health conditions such as acute reaction to stress and abuse of drugs or alcohol require much attention.  Due to the increasing numbers of veterans seeking care at VA medical facilities to include those from the Gulf War era and OEF/OIF, the American Legion supports a bill to further improve treatment and services provided by the VA to our Nation's veterans.

In regards to H.R. 4107, the American Legion supports this bill to include Sections 101 to 103 and Sections 201 to 206.  In addition, we support expansion and improvement of healthcare services to all veterans.

And regarding H.R. 4204, the American Legion receives contact from actual veterans who disclose their need for immediate help due to their thoughts of harming themselves.  As the number of calls to suicide prevention call centers increase, the need for more suicide prevention counselors throughout the VA medical centers is warranted.

the American Legion supports continued studies on suicides among veterans.  In a proactive effort, these findings must be readily communicated to suicide prevention divisions to increase the prevention of potential tragedies.

In regards to H.R. 4231, according to research conducted by the Department of Veterans Affairs, one in five veterans nationwide who enroll to receive VA healthcare reside in rural areas.  The American Legion believes no veteran should not be penalized or forced to travel long distances to access quality healthcare because of where they choose to live.

Furthermore, all care to include pilot programs should include outreach to every rural venue in which veterans reside.  The American Legion favors the intent of this bill to create a pilot program that would accommodate veterans residing in rural areas.

However, we would encourage the inclusion of every Veterans Integrated Service Network (VISN) across the country as well as a more condensed pilot program than the above mentioned.

Again, thank you, Mr. Chairman, for giving the American Legion this opportunity to present its views on such important issues.  We look forward to working with the Committee in continuing the enhancement of access to quality care for all veterans.

[The statement of Mr. Wilson appears in the Appendix.]

Mr. MICHAUD.  Thank you.

Ms. Ilem?


Ms. ILEM.  Thank you, Mr. Chairman and Members of the Subcommittee.  We appreciate being invited to testify at this legislative hearing today.

The first measure under consideration, H.R. 2790, would establish the position of Director of Physician Assistant Services as a full-time position within the VA Central Office.  We believe PAs are a critical component of VA healthcare and urge the Subcommittee's approval of this measure.

H.R. 3458 would require VA to establish a rural pilot program of VA case managed traumatic brain injury care.  The bill would require the pilot program to be conducted in consultation with the VA Office of Rural Health and includes protections to ensure rural veterans with TBI receive sufficient care from competent, trained providers.

This measure is consistent with recommendations of the Independent Budget related to VA care coordination of fee-basis and contract care, rural healthcare services, and TBI.  Therefore, we have no objection to its enactment.

H.R. 3819 would require the VA to reimburse for emergency treatment provided in a non-VA facility until an eligible veteran is transferred to VA.  In accordance with the mandate from our membership, DAV supports this bill to improve reimbursement policies for non-VA emergency healthcare services.

We believe H.R. 4146 is intended to achieve the same purpose as the bill just mentioned.  However, based on our analysis, we recommend the Subcommittee to proaction on this measure and instead favorably report H.R. 3819.

DAV supports H.R. 4053, a bill to establish new and enhanced treatment programs for post traumatic stress disorder and substance abuse disorder with a special regard for the treatment of veterans who suffer from these comorbid conditions.

It would also provide VA new authority to treat OEF/OIF veterans and their families for combat readjustment problems.

We appreciate the emphasis in Section 201 of the bill which includes provisions for peer counseling and outreach, requires VA referral and coordination with the Office of Rural Health, while ensuring that private providers are properly trained and compliant with VA standards.

However, we continue to have concerns about contracting with non-VA providers for specialized PTSD treatment and other combat readjustment issues.

H.R. 4107 is a comprehensive measure aimed at evaluating the unique needs of women veterans including those who served in Operations Iraqi and Enduring Freedom and improving VA's healthcare and mental health services for women veterans.

This legislation is consistent with recommendations from the research experts in women's health, the Independent Budget.  And, therefore, we support this measure and urge the Subcommittee to recommend its enactment.

H.R. 4204 would require VA to conduct a study on the number of veterans' suicides since 1997.  DAV supports this bill, but recommends including other relevant measures in the legislation that could help reduce veterans' suicide as outlined in our written statement.

H.R. 4231 would establish a five-year mental health services pilot program in seven specific VA networks in which veterans would be issued vouchers for private mental health services at VA expense for up to one year.

We have a number of concerns about this measure, specifically that it lacks contract care coordination features that we believe are essential to the protection of veterans' health and the long-term maintenance of veterans' health services.

Additionally, under this measure, a veteran who receives care in the community without connection to VA loses the many safeguards built into the system for their protection including VA's electronic medical record, evidence-based medicine, patient safety programs, and most importantly VA's expertise in combat-related mental health readjustment services.  For these reasons, we cannot support this measure.

As a community, all of us are concerned about rural veterans' access to care including mental health and readjustment services, especially for our newest generation of war veterans.

However, DAV wants to ensure that veterans receiving contract care through VA are treated in accordance with VA's internal standards of care.

VA has developed a national mental health strategic plan to deploy new mental health programs, ramp up existing specialized services for PTSD and substance abuse treatment, and hire new staff.

Additionally, last year, Congress mandated VA, through its Office of Rural Health, to take specific steps to improve rural veterans' access to care including assessing fee-basis programs and developing a plan to improve access and quality, meeting mental health needs, and conducting an extensive rural outreach program to OEF/OIF veterans and their families.

Implementation of VA's mental health strategic plan in conjunction with the mandate to the Office of Rural Health should create greater access to mental health services for all rural veterans.

Prior to final consideration of this bill, we urge the Subcommittee to request the mandated reports from VA's Office of Rural Health to see what progress has been made thus far.  In our opinion, these reports should provide essential information on how to best develop a comprehensive solution and meet rural veterans' mental health and other healthcare needs.

Mr. Chairman, that completes my statement, and we thank you for the opportunity to testify.

[The statement of Ms. Ilem appears in the Appendix.]


Mr. NEEDHAM.  Mr. Chairman and Members of the Subcommittee, the VFW thanks you for the opportunity to testify today.

There is a wide range of healthcare legislation before us and the common theme through most of them is access.  VA provides first-rate, high-quality healthcare to thousands of veterans every day, but barriers to care remain, whether that is for a veteran living in the country far from a VA clinic, from a woman veteran unsure of her entitlement to healthcare, or from a wounded warrior suffering from TBI who is finding that VA is not yet providing the range of treatment he or she needs.

Today's hearing addresses some of those barriers and we are generally supportive of all of the bills.  Because of time considerations, I will limit my remarks to a few of them.  Our full comments can be found in our written statement.

The first two bills concern a number of our members.  H.R. 3819 and 4146 would close the loophole that is costing a number of our veterans thousands of dollars out of their own pocket for emergency care.  This especially affects veterans who live in rural areas far away from VA clinics.

Under current law, VA can pay for emergency treatment for a veteran who goes to a non-VA facility under certain circumstances and must be an enrolled veteran who uses the system and who does not have any other form of insurance.  It is a safety net for those who otherwise would have no emergency care.

The wrinkle occurs in that once the veteran is stabilized, he or she must be transferred to a VA facility.  There have been cases, though, where VA is unable to accept the veteran.  Maybe VA cannot provide the type of care that the veteran needs or maybe there are not any beds available.

Whatever the reason, when VA refuses to accept a patient, they also refuse to pay for the care.  This is wrong and defeats the purpose of that safety net.

We strongly urge the Committee to close this loophole to ensure that veterans are not penalized for VA's inability to adequately care for them.

The VFW urges passage of H.R. 4107, the "Veterans Emergency Care Fairness Act."  This comprehensive bill would authorize a number of important studies on the healthcare needs of women veterans, especially those returning from Iraq and Afghanistan.

The current conflict is one of a true front lin