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Legislative Hearing on H.R. 3843, H.R. 4041, H.R. 5428, H.R. 5516, H.R. 5543, H.R. 5641, H.R. 5996, H.R. 6123, et al

Legislative Hearing on H.R. 3843, H.R. 4041, H.R. 5428, H.R. 5516, H.R. 5543, H.R. 5641, H.R. 5996, H.R. 6123, H.R. 6127, H.R. 6220, and Draft Legislation.

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LEGISLATIVE HEARING ON H.R. 3843, H.R. 4041, H.R. 5428, H.R. 5516, H.R. 5543, H.R. 5641, H.R. 5996, H.R. 6123, H.R. 6127, H.R. 6220, AND DRAFT LEGISLATION










SEPTEMBER 29, 2010

SERIAL No. 111-101

Printed for the use of the Committee on Veterans' Affairs




For sale by the Superintendent of Documents,  U.S. Government Printing Office
Internet:  Phone: toll free (866) 512-1800; DC area (202) 512-1800
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BOB FILNER, California, Chairman


VIC SNYDER, Arkansas
JOHN J. HALL, New York
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
GLENN C. NYE, Virginia

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




Malcom A. Shorter, Staff Director

MICHAEL H. MICHAUD, Maine, Chairman

VIC SNYDER, Arkansas
GLENN C. NYE, Virginia
HENRY E. BROWN, JR., South Carolina, Ranking

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 29, 2010

Legislative Hearing on H.R. 3843, H.R. 4041, H.R. 5428, H.R. 5516, H.R. 5543, H.R. 5641, H.R. 5996, H.R. 6123, H.R. 6127, H.R. 6220, and Draft Legislation


Chairman Michael H. Michaud
    Prepared statement of Chairman Michaud
Hon. Henry E. Brown, Jr., Ranking Republican Member
    Prepared statement of Congressman Brown


U.S. Department of Veterans Affairs, Robert L. Jesse, M.D., Ph.D., Principal Deputy Under Secretary for Health, Veterans Health Administration
    Prepared statement of Dr. Jesse

American Legion, Jacob B. Gadd, Deputy Director, Veterans Affairs and Rehabilitation Commission
    Prepared statement of Mr. Gadd
Barrow, Hon. John, a Representative in Congress from the State of Georgia
    Prepared statement of Congressman Barrow
Disabled American Veterans, Adrian M. Atizado, Assistant National Legislative Director
    Prepared statement of Mr. Atizado
Paralyzed Veterans of America, Carl Blake, National Legislative Director
    Prepared statement of Mr. Blake
Pingree, Hon. Chellie, a Representative in Congress from the State of Maine
    Prepared statement of Congresswoman Pingree
Sestak, Hon. Joe, a Representative in Congress from the State of Pennsylvania
    Prepared statement of Congressman Sestak
Stearns, Hon. Cliff, a Representative in Congress from the State of Florida
    Prepared statement of Congressman Stearns
Walz, Hon. Timothy J., a Representative in Congress from the State of Minnesota
    Prepared statement of Congressman Walz
Wounded Warrior Project, Ralph Ibson, Senior Fellow for Policy
    Prepared statement of Mr. Ibson


American Federation of Government Employees, AFL-CIO, and AFGE National Veterans Affairs Council, statement
Buyer, Hon. Steve, Ranking Republican Member, Full Committee on Veterans' Affairs, and a Representative in Congress from the State of Indiana, statement
Filner, Hon. Bob, Chairman, Full Committee on Veterans' Affairs, and a Representative in Congress from the State of California, statement
Independence Through Enhancement of Medicare and Medicaid Coalition, letter
National Coalition for Homeless Veterans, statement
National Association for the Advancement of Orthotics and Prosthetics, Thomas Guth, C.P., President, letter
National Nurses United, statement
Veterans of Foreign Wars of the United States, Michael O'Rourke, Assistant Director, National Veterans Service, statement
Vietnam Veterans of America, Richard F. Weidman, Executive Director for Policy and Government Affairs, statement


Post-Hearing Questions and Responses for the Record:

Hon. Michael H. Michaud, Chairman, Subcommittee on Health, Committee on Veterans' Affairs to Jacob B. Gadd, Deputy Director, Veterans Affairs and Rehabilitation Commission, America Legion, letter dated October 4, 2010, and response letter dated November 15, 2010

Hon. Michael H. Michaud, Chairman, Subcommittee on Health, Committee on Veterans' Affairs to Carl Blake, National Legislative Director, Paralyzed Veterans of America, letter dated October 4, 2010, and response letter dated November 15, 2010

Hon. Michael H. Michaud, Chairman, Subcommittee on Health, Committee on Veterans' Affairs to Adrian M. Atizado, Assistant National Legislative Director, Disabled American Veterans, letter dated October 4, 2010, and Mr. Atizado's responses

Hon. Michael H. Michaud, Chairman, Subcommittee on Health, Committee on Veterans' Affairs to Ralph Ibson, Senior Fellow for Policy, Wounded Warrior Project, letter dated October 4, 2010, and Mr. Ibson's responses

Hon. Michael H. Michaud, Chairman, Subcommittee on Health, Committee on Veterans' Affairs to Hon. Eric K. Shinseki, Secretary, U.S. Department of Veterans Affairs, letter dated October 4, 2010, and VA responses

Hon. Cliff Stearns, Republican Member, Subcommittee on Health, Committee on Veterans' Affairs, to Hon. Eric K. Shinseki, Secretary, U.S. Department of Veterans Affairs, letter dated November 16, 2010, and VA responses

LEGISLATIVE HEARING ON H.R. 3843, H.R. 4041, H.R. 5428, H.R. 5516, H.R. 5543, H.R. 5641, H.R. 5996, H.R. 6123, H.R. 6127, H.R. 6220, AND DRAFT LEGISLATION

Wednesday, September 29, 2010
U. S. House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, DC.

The Subcommittee met, pursuant to notice, at 10:00 a.m., in Room 334, Cannon House Office Building, Hon.  Michael Michaud [Chairman of the Subcommittee] presiding.

Present:  Representatives Michaud, Perriello, Brown of South Carolina, and Stearns.


Mr. MICHAUD.  I would like to call the hearing to order, and thank everyone for coming 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 provide their views and discussion on legislation that has been introduced within the Subcommittee's jurisdiction.

This is an important part of the legislative process that will encourage a frank discussion of ideas.  We have 12 important bills before us today. 

We have been hearing that votes might be called between 11:00 and 12:00, so I would ask unanimous consent that my full remarks be submitted for the record so we can try to speed up the hearing process.  Hearing no objection, so ordered.

Mr. MICHAUD.  So I now would recognize Mr. Brown, our distinguished Ranking Member, for any opening statement that he may have.

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


Mr. BROWN OF SOUTH CAROLINA.  Thank you, Mr. Chairman.

I, too, would like to submit my opening statement for the record.  And I would like unanimous consent to also offer Ranking Member of the full Committee, Steve Buyer's statement for the record.

Mr. MICHAUD.  Without objection, so ordered.

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

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

Mr. MICHAUD.  We will now go to our first panel.  And I would recognize Mr. Sestak, to introduce his bill to the Committee.

And I want to thank you very much, first of all for your service to our great Nation and also for your willingness to come today.



Mr. SESTAK.  Thank you, Mr. Chairman and Ranking Member Brown.

First I would like to acknowledge the great work that this Subcommittee has done in the recent Congress.  It is providing unprecedented ways and means to care for our veterans, those who have gone into harm's way on our behalf.

However, with these additional resources, the VA has a responsibility to Congress, the American public, and most especially our veterans to see that it operates the highest possible standards of care.

In support of that goal, I am here to discuss my bill, H.R. 3843, the "Transparency for America's Heroes Act."

This legislation directs the Secretary of Veterans Affairs to make available on the VA Web site redacted records and documents, but not personal identifying information, created by the VA as part of a medical quality assurance program.

It would also require the Secretary to ensure that such records created during the 2-year period prior to the enactment of this Act are also made available in a similar manner.

I authored this bill because I have grown increasingly troubled by reports that give rise to concern of a lingering lack of consistent care and accountability within the VA. 

I must be very clear that I hold in highest regard the thousands of dedicated professionals of the VA, many who have spent their entire careers in the service of our veterans.  However, for the past 24 months, there have been too many revelations of substandard care for our vets. 

Congress, and the American public, have been belatedly informed of prostate cancer victims who received insufficient treatment, the possible exposure of more than 1,800 veterans to serious diseases including hepatitis and human immunodeficiency virus (HIV) while undergoing routine dental procedures, deficiency in thoracic care. 

And last September, we learned only after a Freedom of Information Act (FOIA) request was filed that some elderly veterans were being subjected to substandard, potentially neglectful care in the Philadelphia Community Living Center at Philadelphia VA Medical Center.

The nursing home, according to the Long-Term Care Institute's report, “Failed to provide a sanitary and safe environment for the residents.  And there was a significant failure to promote and protect the residents' rights to autonomy and to be treated with respect and dignity.”

Some of the examples cited shock the conscious.  For example, one patient with an open foot wound was left unattended for so long that live maggots were found falling out of the wound.  Additionally, the floor was found to be covered with dried blood and feeding tubes.

Another diabetic patient complained of chronic failure on the staff's part to administer his insulin shots on schedule.

After hearing these reports, it came to my attention that there were two other recent inspections, one by the Office of Inspector General (OIG) of the VA and one by the Joint Commission on Accreditation of Healthcare Organizations, both of which concluded the facility met quality standards based on the metrics used.

However, it took this separate external investigation of the Long-Term Care Institute, using a different set of inspection criteria to find the maggots, to identify the serious problems at the facility under its older leadership.

What concerns me is the two VA conducted reviews failed to discover these deficiencies and that a Freedom of Information Act request was required to bring this latest revelation, this known latest revelation of poor care to light.

In fact, the report should not have even been released after the FOIA petition was filed under the current law because the third-party inspection was conducted on the VA's quality assurance authority.  And in this case, the report was inadvertently leaked by a VA official who did not follow the normal protocol.

This leads me to believe that there may be numerous of other cases of deficient care, which will never see the light of day because of the inspections in question like the one conducted by the Long-Term Care Institute that were conducted under the VA quality assurance authority.

Under current law, records and documents created by the VA as part of a designated quality assurance program are confidential and privileged and as a result cannot be disclosed to any person or entity except when specifically authorized by statute.

And, yet, in Pennsylvania, similar facilities' reports for citizens of America that are not veterans are placed on Web sites.

The standard rationale for this practice is according to the VA to, “Create a proactive culture of quality improvement allowing for early identification and resolution of quality issues.”  Obviously that was not done.

The VA also states that, “Elimination of protected document status for quality management activity documents would possibly have a chilling effect on the level of objectivity reflected within these improvement activities.”

As a former Admiral who led men and women into battle, I disagree with this assessment.  I am convinced there is a need for a cultural and procedural sea change in the way the VA medical system operates and that the best way to ensure quality care in the VA is through a stringent, transparent oversight.

I certainly learned in the Navy to expect what you inspect and to know what you have found.  This entails vigilance on the part of both Congress and the general public.  If there are other instances of inadequate VA care, they should be revealed immediately along with a confirmation that appropriate corrective actions have been taken like they were not in this case.

My bill, as I conclude, would accomplish this without releasing sensitive information, which could be used to identify patients and health care professionals.  After all, even my personal service record can be given out in public, redacted obviously.

If we fail to ensure this kind of accountability, the goals of the current Administration, the hard work of the recent Congress to finally provide our veterans the care and resources they have been denied for so long will be compromised.  At issue is the very credibility and accountability of one of our Nation's most important health care providers and that of the government itself.

I am reminded of the long-term consequences for us, the Executive Branch, to treat veterans and their families in responsible kind of ways we have tried to do after a failure for too long, particularly after Vietnam.

As our troops continue to return from Iraq and Afghanistan, we can and must do better.  Thank you, Mr. Chairman.

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

Mr. MICHAUD.  Thank you very much, Mr. Sestak, for that description of your piece of legislation.

Are there any questions of the Subcommittee for Mr. Sestak?

Hearing none, thank you very much.

Mr. SESTAK.  Thank you, Mr. Chairman.

Thank you, Mr. Brown?

Mr. MICHAUD.  I would like to recognize Mr. Walz, who is also a Member of the Veterans' Affairs Committee who serves his country with distinction, to introduce his legislation.

Mr. Walz?


Mr. WALZ.  Well, thank you, Chairman Michaud and Ranking Member Brown, for this opportunity to be here. 

I also want to thank you and tell you what a privilege it is to serve with you on the full Committee.  The two of you put veterans first and foremost in everything you do.  And for that, I am incredibly grateful.

I am here today to testify on a bipartisan bill introduced by myself, Mr. Bilirakis, Mr. Miller, and Mr. Pascrell, H.R. 6123, the "Veterans Traumatic Brain Injury and Rehabilitative Services Improvement Act."

First and foremost, the care that our soldiers are getting at our VA hospitals is top quality.  I think all of us in this room have recognized the incredible efforts that have been made, especially dealing with traumatic brain injury (TBI).  But one of the things that I think we see missing is a cohesive, holistic approach to this care.

And this bill does a couple of things that are critically important for these veterans to achieve the quality of life we want to have them achieve.

We are doing a great job of the VA doing on the health professional side of things, but it would cover other VA support services that contribute to the maximum quality of life, things like helping with reemployment, helping with other things as far as adaptive types of things, and then doing a second thing that is not clarified in the current provisions, and this makes it a little broader.  We are asking them to not simply improve lost functioning but to maintain that improvement once it is gained. 

Some of the brain-based research and the things we are seeing show that we can continue to get improvement or at least hold those achievements that we have gotten for these veterans.  And I want to make sure that that gets there.

The ambiguities in the law make the TBI treatment very narrow.  It is incredibly good quality of care on the physical side of things.  We are not encompassing the whole range of things that we could do.  So we need to make sure that there is a comprehensive approach.  That is what this bill ensures.  It provides comprehensive care instead of just physical care.

And I want to be very clear with our VA folks who are here, and we get great input from them on this.  This is not creating any new programs.  It is integrating existing programs for the quality of life improvement of the veterans.  It is just a better way of defining how we care for these TBI patients.  It is a better way of making sure that it is veteran and family centered in how that care goes across the spectrum of things.

This bill has the full support of the Wounded Warrior Project, the Disabled American Veterans, the Blinded Veterans, and the Enlisted Association of the National Guard.

And I want to take special time to thank Ralph Ibson and Christine Hill at the Wounded Warrior Project for bringing this.  These are folks that are out there every day with our heroes.  They are out there trying to understand what it is going to take to bring them back to a quality of life that get as close to approximation as we can to a normal existence for these folks.  And that is what we want to try and do.

So I am appreciative of the work that has been done on this.  I want to be very clear.  I am appreciative of the incredible care that is given to these wounded warriors through the VA.  I think we can define with this bill a little broader on what the VA can go ahead and deliver in terms of comprehensive, holistic care to these veterans. 

And I think at the end of the day, the American people want to see us do everything possible to take these wounded warriors back home, to give them all the care possible, and to improve their quality of life to allow them to function both in the workplace, in social settings, and beyond just physical functioning.

So with that, I would be happy to take any question and, again, thank both of you for the work you are doing.

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

Mr. MICHAUD.  Thank you very much, Mr. Walz, and also thank you very much for your hard work and dedication on the Veterans' Affairs Committee.  We value your opinion and appreciate all the hard work that you have been doing.  So, thank you.

Mr. WALZ.  Thank you, Mr. Chairman.

Mr. MICHAUD.  Are there any questions? 

Seeing none, thank you very much.

Mr. WALZ.  Thank you.

Mr. MICHAUD.  Mr. Barrow, I also want to thank you for coming today to bring forward H.R. 4041 and I look forward to hearing your testimony.  Mr. Barrow?


Mr. BARROW.  Well, thank you, Mr. Chairman.  It is an honor to be with you and thank you for allowing me to testify today.

I want to thank you and my South Carolina neighbor, Mr. Brown, for the tremendous leadership you all are showing in closing the gap that has existed for too long now between the promises that have been made to our veterans and the resources we have committed toward meeting those needs and fulfilling those promises.

The most consistent and frustrating feedback that I get from people I represent is from veterans having problems with the VA.  I suspect it is the same for some of you in your districts as well.

The initial disability determination can take too long.  Communication with the VA can be weak.  Once they are in the system, it is hard to navigate.  Facilities can be too far away.

Well, I can see how major programs in the VA could benefit from a major overhaul and I realize that is not going to happen any time soon.  For better or for worse, the system works well enough for enough folks that the demand for a major overhaul will be a long time coming.  But I do not think any of us really believes that the current system works as well as it could or should.

The problem with today's VA is its complexity.  The medical needs of returning veterans are more complex than they have ever been.  We design very intricate treatments and benefits and services to meet those needs.  Unfortunately, it has become so complex that you need specialized training just to wade through the bureaucracy of it all.

My purpose in coming today is to promote a bill I have introduced, H.R. 4041, which will give veterans the tools they need to navigate this maze.

We all agree that every wounded warrior should have an individualized plan for recovery coordinated by a professional who is trained to successfully navigate the VA system of services and benefits.

The Dole-Shalala Commission calls these professionals Federal Recovery Coordinators (FRCs) and made them a major component of their comprehensive recommendations to improve the VA.  The Federal Recovery Coordinator Program has been authorized by Congress since 2008, but today there are only 20 Federal Recovery Coordinators spread across the entire country coordinating the care of only around 500 wounded veterans.

My bill will increase the number of Federal Recovery Coordinators, formalize their training, and establish guidelines and best practices for successful care coordination.

As envisioned and designed by the Dole-Shalala Commission, a Federal Recovery Coordinator would be a nurse or a social worker with a Master's Degree who has excellent communication, leadership, and resource navigation skills.  Today's wounded warrior might have a unique combination of traumatic physical injury, post-traumatic stress disorder (PTSD), substance abuse, or marital problems, trouble finding a job, or trouble reintegrating back into the community.  A recovery coordinator acts as an air traffic controller to guide veterans to the proper treatment and benefit options.

I have submitted for the record personal testimonies from a few returnees that I represent whose Federal Recovery Coordinators have been a Godsend.  I commend them to you. 

Despite its obvious benefits and successes, the program is in its infancy and needs some help in order to be all that it can be.  My bill will help in three specific ways.

First and foremost, the bill authorizes formal training for 45 new Federal Recovery Coordinators in the next 3 years.  It is obvious that we have too many veterans who desperately need these services and we do not have nearly enough coordinators to meet the demand.

Second, my bill authorizes the development of specialized case management software to complement the work of trained care coordinators.

Third, my bill authorizes the development of uniform best practices for recovery coordination.  The coordinators out there today are blazing valuable new trails, but they work out of sight of each other.  We need to develop and promote what works best so that all of our wounded veterans will get the best chance at getting what they need.

Our goal here has to be helping the veterans who need it and to do it as fast and effectively as we possibly can.  I have seen the Federal Recovery Coordinator Program in action and I am convinced this really is the best way forward.

I appreciate the opportunity to testify before you.  I appreciate the Committee's willingness to take a deeper look at this legislation.  And I will be happy to answer any questions.

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

Mr. MICHAUD.  Thank you very much, Mr. Barrow, for your description of the legislation you presented today.  I really appreciate your advocacy on behalf of our veterans as well.

Are there any questions for Mr. Barrow?

Thank you very much, Mr. Barrow.  I appreciate your coming.

Mr. BARROW.  Thank you, Mr. Chairman.

Mr. MICHAUD.  I would like to recognize Mr. Stearns who also sits on the Veterans' Affairs Committee.  I really appreciate your efforts in helping us deal with veterans' issues.  And Mr. Stearns has two bills before us today, H.R. 5516 and H.R. 5996.

So, Mr. Stearns?


Mr. STEARNS.  Good morning and thank you, Mr. Chairman.

And thank you, Ranking Member, Mr. Brown of South Carolina.

As you mentioned, I have two bills before the Committee today, H.R. 5516,the "Access to Appropriate Immunization for Veterans," and H.R. 5996, a bill to help veterans with chronic obstructive pulmonary disease, COPD.

The first bill is a bipartisan bill that I am proud to have introduced as a co-founder of the COPD Caucus.  COPD is the fourth leading cause, of death in the United States.  It is predicted to be the third leading cause of death by the year 2020 beating both diabetes and stroke.  And 126,000 Americans die each year from this disease.  That is about one death every 4 minutes.

My bill, Mr. Chairman, would increase the VA's ability to diagnose, treat, and manage COPD.  COPD is a chronic condition that does not have a cure.  Early detection and treatment is important to slow or arrest the progression of the disease. 

It is estimated that more than 12 million people are diagnosed with COPD and, yet, this number is believed to be small as COPD is often under-diagnosed.  The Centers for Disease Control and Prevention, CDC, estimates that over 24 million Americans have symptoms of COPD.

Despite all this, there is a lack of awareness by patients and doctors about this disease.  It is a progressive disease.  Early detection is extremely important.  Because there is no cure, early treatment is vital.  Because the COPD rate is three times higher in the veterans' population, Mr. Chairman, than the civilian population, how can the VA not be providing this type of specialized care?  COPD is the fourth most common diagnoses among hospitalized veterans ages 65 to 74.

H.R. 5996 would have the VA develop treatment protocols and related tools for the diagnosis, treatment, and management of chronic obstructive pulmonary disease.  It would also have the VA establish a pilot smoking cessation program targeted towards individuals who have COPD.

While there are many ways that someone can develop this type of disease, the most common is from smoking.  However, it should be noted that COPD has underlying genetic risk factors and healthy nonsmokers can also develop COPD.

I think it is important to note that this is not giving VA any new authority.  VA already has the authority to do what I am asking for.  But for whatever reason, they have not aggressively moved to develop these treatment protocols for the fourth leading cause of death in the United States.  My bill would have the VA begin to develop these treatments for our veterans.

This bill has the support of the U.S. COPD Coalition, the COPD Foundation, the American Thoracic Society, the American Association for Respiratory Care, and the Alpha-1 Foundation and the Alpha-1 Association.

And I would like to submit, Mr. Chairman, by unanimous consent the letters of support for the record.

Mr. MICHAUD.  Is there any objection?  Hearing none, so ordered.

Mr. STEARNS.  The other bill is the "Access to Appropriate Immunizations for Veterans Act of 2010," H.R. 5516.  The VA already has the authority to provide vaccines to veterans to immunize them against preventable diseases.

However, the VA has only established performance measures for two vaccines.  For these two vaccines against the flu and pneumonia, the vaccination rate increased from 27 percent to almost 80 percent and hospitalization rates dropped in half.

My bill would extend all the Centers for Disease Control and Prevention's recommended vaccines to the performance measures. 

It is important to note that the vaccines are not just for children.  In fact, just last week, the New York Times ran an article on how important it is for adults to receive vaccines and booster shots.

I would like to read a part of this article quickly.  “Adult immunizations are not just an important way to prevent the spread of the disease, immunizations are also a phenomenally cost-effective way to preserve health.  When you compare the cost of getting sick with these diseases to the cost of a simple vaccine, it is a modest investment, said Dr. Robert Hopkins, a professor of internal medicine and pediatrics at the University of Arkansas for Medical Centers.”

According to the CDC, each year, approximately 70,000 adult Americans die from vaccine preventable diseases.  Influenza alone is responsible for over one million ambulatory care visits, 200,000 hospitalizations, and 30,000 deaths. 

Only seven percent of Americans over the age of 60 have received the vaccine to protect them from shingles, a painful nerve infection. 

Just 11 percent of young women have received the vaccine against HPV (human papillomavirus), the virus that causes 70 percent of cervical cancers.

Many of our veterans who are in a high-risk category of contracting vaccine preventable diseases, including those with HIV, hepatitis C, and substance abuse disorder, are enrolled in the VA health care system and could simply benefit from receiving these vaccines.

I want the VA to provide superior quality care to our veterans.  Adding vaccinations to the performance measure is a simple common-sense idea that will increase the level of care available and save money by stopping preventable diseases.

The bill would also require the VA to report back to Congress on their progress of supporting vaccinations within the veterans' populations.

And I would like in conclusion to enter the New York Times article into the record and the CDC's recommended vaccination schedule for adults by unanimous consent.

Mr. MICHAUD.  Is there any objection?

Hearing none, so ordered.

Mr. STEARNS.  And thank you, Mr. Chairman, for allowing me to testify.

[The prepared statement and attachments of Congressman Stearns appears in the Appendix.]

Mr. MICHAUD.  Thank you very much, Mr. Stearns, for your testimony on both bills.

Are there any questions from the Committee?

Hearing none, thank you very much.

I would like to call up the second panel.  And while they are coming up, I will introduce them.  We have Jacob Gadd from the American Legion; Carl Blake from the Paralyzed Veterans of America (PVA); Adrian Atizado from the Disabled American Veterans (DAV); and Ralph Ibson from the Wounded Warrior Project (WWP).

We also heard from Mr. Filner and Ms. Pingree.  They will be here a little bit later to present their testimony on the bills that they have introduced.

We will start with Mr. Gadd from the American Legion.



Mr. GADD.  Mr. Chairman and Members of the Subcommittee, thank you for this opportunity today for the American Legion to present our views on today's pending legislation. 

As this legislation covers many different pieces of legislation, I will highlight a few of the bills and draft legislation beginning with H.R. 4041, to authorize certain improvements in the Federal Recovery Coordinator Program.

In 2007, the American Legion approved Resolution 29, Improvements to Implement a Seamless Transition, where we recommended a single recovery coordinator to ensure efficient rehabilitation and transition from military to civilian life and eliminate the delays and gaps in treatment and services.

The program was designed and created an individualized care coordination plan for severely injured servicemembers in order to ensure a warm handoff for severely wounded servicemembers transitioning between the U.S. Department of Defense and VA.

With close to two million servicemembers having deployed in Operation Iraqi Freedom/Operation Enduring Freedom ((OIF/OEF), and now New Dawn, VA has only reported to date that less than 1,000 servicemembers have been assisted through this program.

The American Legion, therefore, recommends expanding the program areas of the FRC Program to include program eligibility, increasing the FRC staff to one individual coordinator per State, and improving communication at the national, State, and local levels.

First, the American Legion believes that coordination of care, especially those who are severely wounded, is essential to ensure they receive the education and benefits that they need and have earned.

However, the American Legion believes efforts to improve care coordination must be directed at not only the severely wounded but any veteran transitioning and to ensure they do not fall through the cracks.

Second, VA reported in 2010 that five new FRCs are in the process of being hired, which brings the total number to 25 across the country.

The American Legion recommends having an FRC within each State to ensure all active-duty Reserve and Guard units receive the same education, outreach, and benefits assistance.

Third, in some cases, the American Legion has had difficulty contacting the FRCs through phone, e-mail, or mailing address.  In addition, the program should increase its outreach through use of a dedicated Web page to update current contact information.

Finally, in regards to development of a computerized tracking program, the American Legion applauds VA's new application, the care management and tracking and reporting application, CMTRA.  This tracking tool allows VA to coordinate care amongst a wide variety of providers such as the OEF/OIF care management team.

However, the American Legion recommends that consolidation of a new software tool be compatible with the CMTRA tool to prevent redundancy or to have any veterans that may fall through the cracks.

Next, H.R. 5641, VA's authorized under title 38, Code of Federal Regulations to provide a comprehensive array of medically necessary in-home services.  VA defines a medical foster home as a noninstitutional long-term care setting for veterans. 

The Medical Foster (MF) Program is owned or rented by the medical foster home caregiver.  Each VA medical center facility appoints an MF coordinator and ensures quality assurance, inspections, maintaining of files and patients.

The American Legion would like to take additional time to contact some veterans within this program to see their safety and get feedback from them on this program.

Draft legislation to amend title 38 to ensure that the Secretary provides veterans with information concerning service-connected disabilities, several Department service officers for the American Legion have identified that the Veterans Health Administration (VHA) providers are not assisting veterans with questions a provider interprets as claims related.

The American Legion is working with Central Office to understand the reasons for this disconnect between VHA and the Veterans Benefits Administration (VBA) and we intend to recommend a Fast Letter or new VHA directive be sent to the field to clarify this policy on VA treating physicians in the case where medical evidence on the veteran's behalf is there and the provider from VHA is not helping with the VBA side on the claims process.

As always, the American Legion thanks this Committee for the opportunity to testify and represent the positions of over 2.4 million veteran members.  Thank you.

[The prepared statement of Mr. Gadd appears in the Appendix.]

Mr. MICHAUD.  Thank you very much.

Mr. Blake?


Mr. BLAKE.  Chairman Michaud, Members of the Subcommittee, on behalf of Paralyzed Veterans of America, I would like to thank you for the opportunity to be here to testify today.

Since you have my full written statement for the record, I will limit my comments to just a select few bills.

PVA cautiously supports H.R. 3843, the "Transparency for America's Heroes Act."  Transparency is critical for the public to be able to see and understand what its government is doing. 

Requiring VA to publish redacted medical quality assurance records on the VA's Web site will provide users of the VA a better understanding of the successes or failures of the VA and the quality of care delivered to veterans.

This may encourage greater efforts on the part of VA employee staff and leadership to ensure that the best care is provided to veterans while ensuring openness.

However, PVA's concern stems from the need for privacy with these health care records.  And the comments of Congressman Sestak notwithstanding, it is important that sufficient safeguards be put in place to prevent the unintended release of personal health information that may be detrimental to a VA patient.

PVA supports H.R. 5428, to better educate injured and amputee veterans on their rights and the requirement that VA staff who work at prosthetics and orthotics clinics or who work as patient advocates for veterans understand these rights as well.

This bill would ensure that VA prosthetics clinics around the country prominently display the Injured and Amputee Veterans' Bill of Rights and that VA employees fully understand it.

This reaffirms the idea that a veteran in need of an assistive device or prosthetic gets the highest quality item available and in a timely manner.

As expressed in previous testimony on this topic, PVA is concerned, however, that this legislation's language seems to ignore veterans who may be in need of special equipment who suffer from a specific diseases and not just a physical injury.

PVA supports H.R. 5543, to repeal the prohibition on collective bargaining with respect to compensation for VA employees which may improve the collective bargaining rights and procedures for certain health care professionals in the VA.

AS PVA testified in March of this year, these changes would be a positive step in addressing the recruitment and retention challenges the VA faces to hire key health care professionals, particularly registered nurses, physicians, physician assistants, and other selected specialists.

PVA generally supports H.R. 5641, the "Heroes at Home Act."  However, it is essential that proper protections are put in place to ensure that it is the desire of the veteran to be transferred to a non-VA nursing home and only in the case that the foster home meets VA standards at the time of transfer.

PVA generally supports H.R. 6127.  However, we do have some concerns with the issues surrounding this bill.  While we see no real argument with granting these men and women who experienced the exposures outlined by this bill, Access to the VA Healthcare System, we question why this is the only group singled out for enrollment. 

Given the long-standing discussions about Operation Iraqi Freedom, veterans being exposed to burn pits or servicemembers exposed to other hazardous materials in any number of settings, we believe proper consideration needs to be given to a broader spectrum of veterans and servicemembers.

PVA generally supports the provisions of the discussion draft on improvements to VA homeless programs.  Too many veterans continue to live on the streets due to drug, mental health, financial, and employment challenges.

Expansion of grant programs for improvements to facilities and increased outreach to more homeless veterans may help them receive services and rehabilitation and achieve the Secretary's goal to end veterans' homelessness.

But as PVA testified last October, we do have some concerns about the long-term effects of the legislation.  By adjusting the payments for geographic areas, we believe it is aimed at providing greater funding to higher cost localities.  This may actually reduce the total number of homeless veterans that can be served if future increases in overall program funding are insufficient.

While the argument could be made that reductions in funding for low cost areas may offset increases to high cost areas, the funding levels provided for homeless programs are seldom sufficient anyway to provide for all the veterans who may need to take advantage of these critical services.

PVA would recommend a very cautious approach on this legislation to ensure that the most vulnerable veterans are not inadvertently hurt in efforts to provide greater funds for some of them.

PVA would like to thank the Subcommittee once again for the opportunity to testify and I would be happy to answer any questions that you might have.  Thank you.

[The prepared statement of Mr. Blake appears in the Appendix.]

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

Mr. Atizado?


Mr. ATIZADO.  Mr. Chairman, Members of the Subcommittee, thank you for inviting DAV to testify at this important hearing of the Subcommittee on Health.

DAV is an organization of 1.2 million service-disabled veterans and devote our energies to rebuilding the lives of disabled veterans and their families.

For the sake of brevity, I will only present a number of bills and would refer the Subcommittee to our written testimony.

DAV is pleased to support H.R. 5516 based on our National Resolution No. 36.  Our Resolution calls for VA to maintain a comprehensive high-quality health care system specifically including preventative health services.  Preventative health services are an important component of the maintenance of general health, especially in elderly and disabled populations.

This bill could contribute to significant cost avoidance by reducing the spread of infectious diseases and by obviating the need for health interventions in acute illnesses.

DAV applauds the intent of H.R. 5641, the "Heroes at Home Act," which would allow VA to contract with certified medical foster homes and pay for care of veterans already eligible for VA paid nursing home care.

DAV is pleased with VA's innovation by offering medical foster homes as part of its long-term care program.  Notably patient participation while voluntary into this program reports and yields exceedingly high veteran satisfaction.

Under this program, the cost to VA is less than $60 a day.  Understandably, VA perceives this program as a cost-effective alternative to nursing home placement and it is gaining popularity in the VA based on its expansion of this program.

However, because this program operates under VA's community residential care authority, veterans in medical foster home programs have to pay for their care from about $50 to as much as $130 a day even veterans who are otherwise entitled to nursing home care fully paid for by VA whether it is under the law or by VA's policy.

As part of The Independent Budget, DAV is greatly concerned that veterans living in medical foster homes are required to use personal funds as payment.  These would include VA disability compensation.  In addition, veterans who do not have the resources to pay a medical foster home caregiver may not avail themselves of such a critical benefit.

DAV urges the Subcommittee to favorably consider this bill and that it be moved expeditiously.

H.R. 6123 would sharpen rehabilitative requirements within the VA to ensure that veterans with TBI under VA care are afforded the opportunity for maximal rehabilitation, which will hopefully lead to independence and a higher quality of life.

DAV appreciates the bill's intent to fix an existing gap in current law affecting the treatment of brain injured veterans.  And this legislation is fully consistent with our National Resolution and, therefore, endorse this bill and urge enactment by Congress.

DAV also supports H.R. 6127, which would provide access for certain veterans to VA health care under the Department's special treatment authority under Priority Group 6. 

Much like my colleague, Mr. Blake, from PVA, we do ask for the Subcommittee's consideration to afford the same eligibility of other veterans who were exposed to toxic and environmental hazards, specifically those veterans who were exposed to open air burn pits in Iraq and Afghanistan.

You know, tests on these burn pits, Mr. Chairman, in the war zones have revealed that the fires have released dioxins, benzene, volatile organic compounds including substances which cause cancer.

Finally, DAV supports the draft legislation to make improvements to VA's programs for homeless veterans.  As the Subcommittee is aware, there is a great need for specific emphasis on the needs of homeless women veterans, women veterans, and homeless veterans with children.  Homeless veterans suffering from serious mental illness is also a vulnerable population.

Section 2 would provide comprehensive services to the vulnerable population of homeless veterans with special needs.  And we note that Section 3 of this bill is identical to Section 3 of H.R. 4810, which the House has unanimously passed in March of this year.

DAV believes this section would provide organizations serving homeless veterans the flexibility to look at their program design to provide the full range of supportive services in the most economical manner.

Mr. Chairman, this concludes my statement.  I would be happy to answer any questions you or other Members of the Subcommittee may have.  Thank you.

[The prepared statement of Mr. Atizado appears in the Appendix.]

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

Mr. Ibson?


Mr. IBSON.  Mr. Chairman, Mr. Brown, thank you for inviting Wounded Warrior Project to testify this morning.

And let me preface my remarks by explaining that Wounded Warrior Project's public policy is informed fully by our daily contacts and work with wounded warriors and their family members across the country.

Several of the bills under consideration today address issues of profound concern to those warriors and their families.  And of those, H.R. 6123, Mr. Walz's bill, is of exceptional importance and addresses deep concerns that we have heard from many, many families.

As Mr. Walz indicated, VA facilities have many, many dedicated, committed rehabilitation staff, yet the services provided are often limited in duration and in scope. 

Just yesterday as part of a several day workshop, an empowerment summit focused on and serving combat veterans with PTSD, I had the occasion to speak to a veteran from Maine, a combat veteran who explained that he also had TBI, and had not really made much use of his, eligibility for VA care. He went to the Togas VA Medical Center and was advised that they would provide him therapy for residuals of his TBI, but limited to12 sessions.  And the explanation was, "we do not provide maintenance therapy." 

Well, as this gentleman pointed out to me and as research clearly indicates, there is profound cause for concern with that approach where gains that have been made, cognitive and otherwise, can be lost and that veteran's conditions simply regresses.

For young veterans with severe TBI, and there are many, many of them, reintegration into their communities and pursuing goals such as meaningful work and independent living may be as important as their medical recovery.  But many have difficulty with community integration, and social isolation can be a persistent issue.  Yet, individuals with severe TBI who receive individualized services to foster independence and social interaction are able to participate meaningfully in community settings.

These patients often need more than medical rehab to achieve maximum independence and they encounter difficulties at many VA facilities, which either perceive they lack the authority, or simply are unwilling to provide, nonmedical supports that are provided in other VA programs.  These include supported employment or life skills coaching.

As Mr. Walz indicated, his bill is a simple one.  It would eliminate and close gaps, eliminate barriers in the system, and we think lead to enhanced recovery and fuller rehabilitation for veterans with many levels of TBI.  And we strongly support it.

Let me touch on a few other bills that raise issues for wounded warriors. 

H.R. 5428 would direct VA to disseminate, display, and educate Department employees on an Injured and Amputee Veterans' Bill of Rights relating to VA prosthetics and orthotics.

While there have been substantial improvements in VA prosthetics care over the years, the bill does address important concerns that warriors have voiced with us.

We are not confident, however, that enacting this measure would solve the problems that it highlights.  To direct VA to disseminate the list of so-called rights does not make those expectations enforceable, nor does the bill require VA to take actions that would convert those expectations into reality.

Nevertheless we would be pleased to work with the Subcommittee and Committee to explore ways to bolster the bill.

H.R. 4041 would direct VA to fund training of recovery coordinators through a school of nursing and medicine.  We concur with earlier expressed views that there is a need to enlarge the program to make greater numbers of FRCs available, particularly to warriors who did not get an FRC because the program was created in 2007.  Many of those with severe injuries predating that date have not had that kind of help and still need it.

We are not persuaded, though, that VA needs the authority that H.R. 4041 would establish nor that its methodology is necessarily an optimal one in terms of avenues for training future FRCs.

We concur with earlier expressed views that H.R. 6127 is consistent with earlier legislation that established health care eligibility related to toxic exposures.  But we do question the incident-specific focus of the bill and believe that there would be merit in taking a more systematic approach given the range of toxic exposures that OIF/OEF veterans have experienced.

And, lastly, we would comment on H.R. 3843 discussed earlier.  We certainly share a concern for ensuring the quality of care afforded veterans in VA health care facilities.  At the same time, a vibrant medical quality assurance program is an important element in fostering a culture of quality improvement. 

And while transparency is certainly important in sustaining confidence in the quality of VA health care, confidentiality has long been deemed a  critical element in ensuring the integrity of an effective medical quality assurance program.

While we take no position in terms of how best to balance those competing tensions, transparency against confidentiality and a strong quality assurance program, this is an area where we would caution the Committee to proceed in a very carefully and in a measured way.

Thank you, Mr. Chairman.

[The prepared statement of Mr. Ibson appears in the Appendix.]

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

And I want to thank the other three panelists as well for your testimony on all the bills we have before us today.

Any questions, Mr. Brown?


Mr. MICHAUD.  Thank you.

As we move forward looking at these bills, later we will probably submit additional questions in writing to each of you.  So, if you could respond in a timely manner, I would appreciate it.

If there are no questions, I would like to thank the second panel.

I would like to now recognize Congresswoman Pingree who has H.R. 6220.  She is my colleague from Maine.  I appreciate her willingness to come today and her advocacy on veterans' issues.  She definitely has been a true advocate for veterans.

I know you have been tied up in the Rules Committee, so I want to thank you for taking the time to come over to present testimony to the Subcommittee on H.R. 6220.


Ms. PINGREE.  Thank you very much, Chairman Michaud. 

I apologize for being late this morning, but it is a busy morning.  I guess we are trying to cram everything into as little time as possible.

And I want to thank you on your great work on behalf of veterans in the State of Maine.  It is a pleasure to serve as your junior member in the State of Maine.

Chairman Michaud and Ranking Member Brown, thank you for having me here today.  I am happy to be here in front of the Veterans' Affairs Subcommittee on Health to talk about the bill I recently introduced, the "Inform All Veterans Act," H.R. 6220.

This bill will ensure that veterans are given complete information about service-connected benefits at all VA medical centers.  All too often a veteran will visit a VA medical center, ask how to file a claim for service-connection, and are either not given correct information on how to pursue their claim or, worse, they leave the medical center thinking their claim is underway when it is not.

This is a symptom of the Veterans Health Administration, Veterans Benefits Administration not communicating well with each other, operating effectively, or operating in silos.  Interagency communication is a necessity, especially when we are talking about basic earned services.

Under this bill, the VHA would be required to ask during the check-in process if a veteran would like information about the disability claims process.  If the answer is yes, then straightforward, easy to understand literature is shared, which will outline how to contact VBA to start the disability claims process.

I believe Congress has a responsibility to take care of our