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Ms. Susan Edgerton

Ms. Susan Edgerton, Vietnam Veterans of America, Senior Health Care Consultant

Chairman Michaud and Distinguished Members of the House Subcommittee on Health, on behalf of our officers, Board of Directors and members, thank you for providing the opportunity for Vietnam Veterans of America (VVA) to present testimony regarding the Department of Veterans Affairs’ (VA) Readjustment Counseling Services (RCS), or Vet Center program.  This Committee is distinguishing itself for the attention it has focused on the important issue of post-deployment mental health and VVA wants to thank you for your continuing efforts.

VVA has always strongly supported the community-based Vet Center program because of its cost effectiveness, staff commitment, and solid leadership, but especially because of the high quality of its services, including individual and group counseling, marital and family counseling, bereavement counseling, employment counseling, military sexual trauma (MST) counseling, substance abuse assessments, medical referrals, assistance in applying for VA benefits, outreach, and community education.  It is a truly unique resource within the system.  Vet Centers, which operate as a non-medical setting, independent from the Veterans Health Administration main facilities, offer veterans and their families a haven in which to gather in an atmosphere of trust that relieves them from the stigma and societal perceived shame often associated with care-seeking for mental illness elsewhere.  

Because of our core belief in the value of the Vet Center services, VVA was very pleased to learn that in 2007 the VA plans to open new Vet Center facilities in Grand Junction, CO; Orlando, FL; Cape Cod, MA; Iron Mountain, MI; Berlin, NH; and Watertown, NY, (with others located in Montgomery, AL; Fayetteville, AR; Modesto, CA; Fort Myers and Gainesville, FL; Macon, GA; Manhattan, KS; Baton Rouge, LA; Saginaw, MI; Las Cruces, NM; Binghamton, Middletown, and Nassau County, NY; Toledo, OH; Du Bois, PA; Killeen, TX; and Everett, WA scheduled for opening in 2008).  While we are grateful that new centers will offer access to veterans, it is not just the new centers that require staff.  VVA has called on the VA to increase staff at existing centers for the past three years.

Vet centers are asked to do a great deal for our veterans and yet, ideally, they would do even more.  VVA would like to see more family services, including bereavement counseling, counseling for military sexual trauma available at every vet center, and a strong interface between the Department’s recently announced suicide prevention efforts at the VA medical centers.  Recent legislation has also called on federal community mental health centers to aid in the identification and treatment of post-traumatic stress and other post-deployment mental health issues.  We hope that vet centers are integral in sharing their expertise with these community providers and become the hub for strong national networks devoted to this type of care. 

As you know, Mr. Chairman, vet centers are just one venue the Department of Veterans Affairs system employs to address post-deployment mental health issues.  Without a host of accessible health care options to which it can refer veterans, vet centers alone cannot be effective. So while this hearing is assessing the vet center program, it is important to acknowledge that vet centers cannot be successful without VA’s other treatment programs for substance abuse, mental illness, homelessness and post-traumatic stress disorder. 

Accessibility to post-deployment mental health programs within VA may diplomatically be referred to as “uneven”.  Unfortunately, stories of suicides among service members returning from Iraq and Afghanistan with severe and acute mental illness are likely to continue to make the system’s accessibility problems all too visible.  We understand that VA has conducted a study of the prevalence of suicide among recent veterans and hope that the results are available to guide policymaking in the near future.  We are pleased that VA plans to also roll out a national 24-hour hotline and hire suicide prevention counselors at each VA medical center to assist suicidal veterans as recommended by its own Inspector General, but once the crisis passes, VA must have services available to ensure that such veterans receive the care they need. As a point of entry into the system for many veterans, vet centers should also have a strong role in suicide prevention.  In order to be most effective, vet centers require trained personnel and non-traditional hours of operation.  Ideally, each vet center would be able to provide round-the-clock crisis intervention services.

Access to mental health care remains problematic even for veterans currently enrolled.  As thousands of troops who have been or are now deployed in operations in Iraq and Afghanistan return home in need of post-deployment mental health services—chiefly, treatment for Post-traumatic Stress Disorder (PTSD), anxiety, depression, and substance abuse—most experts agree access problems will only worsen.  One study found that about 17% of troops from Iraq were returning with post-deployment mental health issues that required treatment.[1]  A new study has found significantly higher rates of post-deployment mental health and psychosocial conditions (31%), particularly among the youngest veterans.[2] Anecdotally, VVA is aware of veterans of earlier combat eras who have increased demand for services because of the effects of aging and exacerbations of existing conditions caused by exposure to the ongoing deployments in Iraq and Afghanistan.

VA estimates it will treat more than a quarter of a million veterans (263,000) of Operation Enduring Freedom and Operation Iraqi Freedom in FY 2008—54,000 more than will have been treated in FY 2007. This may be an underestimate, just as the VA figures have underestimated the demand for services by recent returnees the past three years. These veterans are seen for a wide variety of problems and concerns, but more than one-third use some sort of post-deployment mental health services.  Experts recognize that the number of those veterans seeking services may grow as veterans readjust to civilian life and they or their loved ones recognize symptoms or signs of PTSD, substance abuse, anxiety or depression that have commonly been associated with combat exposure or long-term deployment. 

In FY 2006, the readjustment counseling service estimates it offered 1,170,439 visits to the 228,612 veterans it treated.  In FY 2005, it offered 1,046,624 visits to 132,853 veterans.  As you might assume, the workload increase is attributable to the almost 5-fold increase in OIF/OEF veterans, but these numbers tell a more subtle story.  While veterans who use the vet centers almost doubled (+72%), visits only increased by about 12%.  Visits per veteran dropped from 8.2 in FY 2004 to 7.9 in FY 2005 to 5.1 in FY 2006.  These statistics show a system under duress in which many veterans who had previously been using the system are not getting the same level of services they once did and new users are probably not getting what they need.   

Staffing patterns have also evolved somewhat in the vet centers with a greater part of the workforce comprised of peer support or outreach counselors—in FY 04 such counselors made up 10.6 of the workforce while in FY 06 they comprised 18.2%.  Perhaps it is not surprising there has been such an increase in workload— peer counselors primarily assigned to outreach are doing their jobs!  Mental health professional staff has comprised about 60% of the workforce, but there are now more social workers and fewer psychologists than in years past.  VVA is concerned that these mental health professionals have the right veteran-specific experience in dealing with the issues they will address—trauma exposure, sexual trauma, or substance abuse.  To that end, we recommend that Congress fund “PTSD scholarships” to fund the education of peer counselors who are prepared to pursue advanced degrees in clinical psychology.  This would create a new stream of vet center counselors who have both shared the experiences of their comrades and received adequate professional training to address their issues.

Vet Center funding also tells us a story.  The FY 2007 budget request for VA estimated that its obligations for readjustment counseling centers would be $106 million.  A $20 million supplement targeted at the vet centers seems generous, but actually represents only a 19% increase in funding to address the large increases in workload the centers have faced annually during the OIF/OEF deployment (for example, there was a 72% increase in FY 2006).  

The story is also incomplete without discussing unmet need.  Notwithstanding the swells within the ranks of the vet centers, recent studies have also shown that four out of five veterans who may need post-deployment mental health care are not properly referred for an evaluation and that many veterans of operations in Iraq and Afghanistan who are using VA facilities have failed to seek care for identified mental and psychosocial conditions.[3]  A June 2006 study conducted by the Institute of Medicine recommended that all veterans deployed to a war zone receive a face-to-face screening for PTSD from an experienced health professional, yet to date this has not taken place for servicemembers returning from current deployments.[4]

Indeed, if these veterans were seeking care in accordance with their demonstrated need, they would overwhelm VA’s current capacity.   In recent years, VA’s internal champions—the Committee on Care of Seriously Chronically Mentally Ill Veterans and the Special Committee on Post-Traumatic Stress Disorder, for example—have expressed doubts about VA’s mental health care capacity to serve these veterans of ongoing deployments.  Last March, the Under Secretary for Health Policy Coordination told a Presidential commission that mental health services were not available everywhere, and that waiting times often rendered some services “virtually inaccessible.”

New vet centers will certainly help in dispersing needed expertise and accessibility to services throughout the system.  However, as Chairman Michaud well remembers, in the fall of 2006, the Democratic staff of the House Committee on Veterans Affairs surveyed 64 Vet Centers.  The subsequent report entitled “Review of Capacity of Department of Veterans Affairs Readjustment Counseling Services Vet Centers” noted that “the Vet Centers have seen a significant increase in outreach and readjustment counseling services to OIF/OEF veterans”.  The report also stated that “…from October 2005 through June 2006, the number of returning veterans from Iraq and Afghanistan who have turned to the Vet Centers for PTSD services and readjustment concerns has doubled.  Without an increase in counseling staffing this increase in workload has affected access to quality care.  Some Vet Centers have started to limit access.” 

Other survey findings noted that “…one in four Vet Centers has taken or will take some action to manage their increasing workload, including limiting services and establishing waiting lists” and “thirty percent of the Vet Centers explicitly commented that they need more staff.”  So while additional RCS facilities and the additional funding Congress provided through its supplemental appropriation for the VA will certainly help, VVA remains concerned that Vet Center services may still not be uniformly available throughout the system. Obviously, VVA is also concerned that services needed by Vietnam veterans and other earlier conflicts, who also have valid needs, may be curtailed or delayed so long as to not be useful and therefore effectively denied.

VVA is therefore compelled to ask the following questions –

Because of the ebbs and flows in its funding, VA has often been reluctant to invest funding in new staff (an ongoing commitment) in times it has additional resources.  Does the RCS have plans to hire more professional staff for the remainder of FY 2007, given that it has received an additional $20 million in the Supplemental Appropriation for the purpose of hiring more staff?  And does the RCS have plans to hire more professional staff in FY 2008, given that the VA will get a $6+ billion increase over FY 2007?

If the RCS is not planning to spend the entire $20 million on adding staff to keep up with the demand for the continually rising demand for services from veterans and their families, what is the RCS plan for how these recently provided funds will be effectively spent?

Does the RCS have plans to hire more peer counselors in FY 2007?  And does the RCS have plans to hire more peer counselors in FY 2008 than it currently has on board?

What are the plans to use the $20 million for substance abuse and the $100 million to enhance other mental health services that address post-deployment mental health issues?

VVA hopes that the Committee will require detailed plans from VA that ensure these questions are answered and Congress’s goals for the system are implemented.

Finally, Mr. Chairman, we could not leave any debate related to post-deployment health without urging you and the Committee to support efforts to reinvigorate the National Vietnam Veterans Longitudinal Study.  This study is not just important to the veterans of the Vietnam era, but would provide important findings about the long-term consequences of post-traumatic stress disorder and other stressors related to deployment to generations of future veterans.  As you know, VA has found ways to thwart this study, which is already required by law, for several years, but the Senate Appropriations Committee has addressed it in the report language accompanying the Military Construction bill.  We hope that you will urge your counterparts on the House Committee on Appropriations to accept and even strengthen this language. 

Mr. Chairman, this concludes my statement.  I will be happy to answer any questions you may have.

[1] Charles W. Hoge, MD, et al.  “Combat Duty in Iraq and Afghanistan, Mental Health Problems and Barriers to Care”, The New England Journal of Medicine, Vol. 351, No. 1:13-22, July 1, 2004.

[2] Karen H. Seal, MD, MPH, et al.  “Bringing the War Back Home: Mental Health Disorders Among 103,788 US Veterans Returning from Iraq and Afghanistan Seen at Department of Veterans Affairs Facilities,” Archives of Internal Medicine, Vol. 167, No. 5, March 12, 2007.

[3] Government Accountability Office.  “Post-Traumatic Stress Disorder: DOD Needs to Identify the Factors Its Providers Use to Make Mental Health Evaluation Referrals for Servicemembers,” GAO-06-397, May 11, 2006.

[4] Subcommittee on Posttraumatic Stress Disorder of the Committee of the Committee on Gulf War and Health, Physiologic, Psychologic, and Psychosocial Effects of Deployment Related Stress.  “Posttraumatic Stress Disorder: Diagnosis and Assessment,” Institute of Medicine of the National Academy of Sciences, June 16, 2006.