[Senate Hearing 110-374]
[From the U.S. Government Publishing Office]
S. Hrg. 110-374
HEARING ON VA AND DOD COLLABORATION: REPORT OF THE PRESIDENT'S
COMMISSION ON CARE FOR AMERICA'S RETURNING WOUNDED WARRIORS; REPORT OF
THE VETERANS DISABILITY BENEFITS COMMISSION; AND OTHER RELATED REPORTS
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
OCTOBER 17, 2007
__________
Printed for the use of the Committee on Veterans' Affairs
Available via the World Wide Web: http://www.access.gpo.gov/congress/
senate
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COMMITTEE ON VETERANS' AFFAIRS
Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West Richard M. Burr, North Carolina,
Virginia Ranking Member
Patty Murray, Washington Arlen Specter, Pennsylvania
Barack Obama, Illinois Larry E. Craig, Idaho,
Bernard Sanders, (I) Vermont Johnny Isakson, Georgia
Sherrod Brown, Ohio Lindsey O. Graham, South Carolina
Jim Webb, Virginia Kay Bailey Hutchison, Texas
Jon Tester, Montana John Ensign, Nevada
William E. Brew, Staff Director
Lupe Wissel, Republican Staff Director
C O N T E N T S
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October 17, 2007
SENATORS
Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........ 1
Prepared statement........................................... 3
Burr, Hon. Richard M., Ranking Member, U.S. Senator from North
Carolina....................................................... 5
Craig, Hon. Larry E., U.S. Senator from Idaho.................... 8
Murray, Hon. Patty, U.S. Senator from Washington................. 9
Tester, Hon. Jon, U.S. Senator from Montana...................... 10
Prepared statement........................................... 11
Brown, Hon. Sherrod, U.S. Senator from Ohio...................... 11
Hutchison, Hon. Kay Bailey, U.S. Senator from Texas.............. 12
Isakson, Hon. Johnny, U.S. Senator from Georgia.................. 13
Webb, Hon. Jim, U.S. Senator from Virginia....................... 39
WITNESSES
Shalala, Hon. Donna E., Co-Chair, President's Commission on Care
for America's Returning Wounded Warriors....................... 14
Prepared statement........................................... 18
Dole, Hon. Bob, Co-Chair, President's Commission on Care for
America's Returning Wounded Warriors........................... 21
Prepared statement........................................... 26
Response to written questions submitted by Hon. Daniel K.
Akaka...................................................... 29
Scott, LTG James Terry, U.S. Army (Ret.), Chairman, Veterans
Disability Benefits Commission................................. 43
Prepared statement........................................... 48
Response to written questions submitted by Hon. Daniel K.
Akaka...................................................... 66
Dunne, RADM Patrick W., U.S. Navy (Ret.), Assistant Secretary for
Policy and Planning, U.S. Department of Veterans Affairs....... 68
Prepared statement........................................... 70
Response to written questions submitted by Hon. Daniel K.
Akaka...................................................... 74
West, Togo D., Jr., Co-Chair, Independent Review Group........... 74
Prepared statement........................................... 76
Attachment................................................. 78
Del Negro, Ariana, wife of 1LT Charles Gatlin.................... 91
Prepared statement........................................... 92
Duffy, Col. Peter J., U.S. Army Reserve (Ret.), Deputy Director
of Legislative Affairs, National Guard Association of the
United States.................................................. 98
Prepared statement........................................... 101
Response to written questions submitted by Hon. Daniel K.
Akaka...................................................... 102
Manar, Gerald T., Deputy Director, National Veterans Service,
Veterans of Foreign Wars of the United States, on behalf of the
members of the Independent Budget.............................. 105
Prepared statement........................................... 107
Response to written questions submitted by Hon. Daniel K.
Akaka...................................................... 112
Beck, Meredith, National Policy Director, Wounded Warrior Project
(WWP).......................................................... 112
Prepared statement........................................... 115
Strobridge, Col. Steven P., U.S. Air Force (Ret.), Director,
Government Relations, Military Officers Association of America. 117
Prepared statement........................................... 118
Response to written questions submitted by Hon. Daniel K.
Akaka...................................................... 124
APPENDIX
Obama, Hon. Barack, U.S. Senator from Illinois; prepared
statement...................................................... 133
HEARING ON VA AND DOD COLLABORATION: REPORT OF THE PRESIDENT'S
COMMISSION ON CARE FOR AMERICA'S RETURNING WOUNDED WARRIORS; REPORT OF
THE VETERANS DISABILITY BENEFITS COMMISSION; AND OTHER RELATED REPORTS
----------
WEDNESDAY, OCTOBER 17, 2007
U.S. Senate,
Committee on Veterans' Affairs,
Washington, D.C.
The Committee met, pursuant to notice, at 9:30 a.m., in
room 562, Dirksen Senate Office Building, Hon. Daniel K. Akaka,
Chairman of the Committee, presiding.
Present: Senators Akaka, Murray, Brown, Tester, Webb, Burr,
Craig, Isakson, and Hutchison.
OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, U.S.
SENATOR FROM HAWAII
Chairman Akaka. The oversight hearing on DOD-VA
Collaboration and Cooperation will come to order.
With a big smile, I want to say aloha and welcome. Welcome
to all of you to the Committee's hearing on issues relating to
the findings of the President's Commission on Care for
America's Returning Wounded Warriors, known as the Dole-Shalala
Commission for its two distinguished Co-Chairs, the Veterans
Disability Benefits Commission, and other groups that have
recently examined matters regarding coordination and
collaboration between the Departments of Defense and Veterans
Affairs in the care and treatment of veterans from Operations
Enduring Freedom and Iraqi Freedom.
Today's hearing is the latest in a series of hearings we
have held this year that focus on the issue of coordination and
collaboration between the two departments. Since our first
hearing last January on this subject, the problems that gained
public attention involving Walter Reed Army Medical Center
brought more energy to this issue. Our committee and the Armed
Services Committee have worked together toward achieving the
goal of wounded warriors receiving optimal care and
experiencing a truly seamless transition from DOD to VA, but
there is much more that needs to be done.
The problems at Walter Reed led to the creation of the
Dole-Shalala Commission, the Task Force on Returning Global War
on Terror Heroes, and DOD's Independent Review Group, each of
which we will hear from today. We will also hear from the
Veterans Disability Benefits Commission, which had been in
existence for some time when the stories about Walter Reed
first broke. I note that the Commission earlier this month
issued a comprehensive report on the overall Disability
Compensation System. The Committee will hold a subsequent
hearing to take testimony on that report.
General Scott, the Chair of the Commission, has been
invited here today to provide the views of the Commission on
the recommendations of the Dole-Shalala Commission and to
discuss areas of overlap between the Disability Benefits
Commission and other entities which were created in response to
the stories about Walter Reed.
It is important to recall that the problems identified at
Walter Reed were not about the quality of health care provided
by DOD, but more about a process that created confusion and
inequities in the delivery of disability benefits to wounded
warriors. The stories about Walter Reed also highlighted
existing problems in the organization of medical holdover
detachments and in the hand-off between the military services
and VA for wounded or seriously injured or ill servicemembers.
The good news is that since this spring, much hard work has
been done by DOD, VA, and the military services in seeking to
resolve these problems. However, lately DOD and VA may have
been recognizing the significant problems of adapting the
departments to the stresses of the current conflicts, I am
satisfied that real work is now underway.
I am particularly impressed by the work of the Joint VA and
DOD Senior Oversight Committee, co-chaired by VA's Deputy
Secretary Gordon Mansfield, and DOD's Deputy Secretary Gordon
England, that meets every Tuesday to work on a wide range of
ongoing transition issues. This, as you know, is an
unprecedented level of attention to the issue of DOD-VA
cooperation and collaboration.
Today's hearing gives us an important opportunity to review
the recommendations of the Dole-Shalala Commission, the
Disability Benefits Commission, and other reports that impact
the interaction between DOD and VA, especially in those areas
which still need improvement and where there is overlap or
potential disagreement. I hope to gain a better understanding
of the relationship among all the various recommendations with
a particular focus on how the recommendations may relate to
legislation developed by the White House and the response to
the Dole-Shalala Commission. Senator Burr and I, along with the
Chairman and Ranking Member of the Armed Services Committee,
were briefed on this draft legislation earlier this month and I
have many questions and concerns about it.
I thank Senator Dole and Secretary Shalala and our other
distinguished witnesses for joining us today. Their testimony
will allow us to better understand the many recommendations and
help identify areas where Congressional action is required.
At our first hearing in January, I spoke about the stress
that a new veteran with a life-altering wound or injury endures
when faced with the challenge of applying for benefits and
transitioning from one health care system to another while
still in the process of recovery and rehabilitation. With the
input of the many recommendations that we will hear about
today, I believe that we can continue to make progress toward
achieving the goal of a truly smooth and seamless transition.
I have a longer statement that I will place in the record,
which is available at the press table.
[The prepared statement of Chairman Akaka follows:]
Prepared Statement of Hon. Daniel K. Akaka, Chairman,
U.S. Senator from Hawaii
Aloha and welcome to the Committee's hearing on issues relating to
the findings of the President's Commission on Care for America's
Returning Wounded Warriors, known as the Dole-Shalala Commission for
its two distinguished co-chairs; the Veterans' Disability Benefits
Commission; and other groups that have recently examined matters
regarding coordination and collaboration between the Departments of
Defense and Veterans Affairs in the care and treatment of veterans from
Operations Enduring Freedom and Iraqi Freedom.
Today's hearing is the latest in a series of hearings we have held
this year that focus on the issue of coordination and collaboration
between the two Departments. That series began with this Committee's
first hearing of the 110th Congress on January 23. Later, when stories
broke about conditions at the Walter Reed Army Medical Center, this
issue became more energized, and, since that time, our Committee has
worked in close collaboration with the Senate Armed Services Committee
to find appropriate legislative solutions for the many problems that
have been identified. On March 2, 2007, Chairman Levin and I visited
Walter Reed to gain a first-hand understanding of the problems. Our
visit highlighted matters involving overlapping jurisdiction and a real
need for our Committees to work closely together.
On April 12, the two Committees held an unprecedented joint hearing
to review and explore issues and problems relating to how those
returning from combat in Iraq and Afghanistan were receiving care and
services. That hearing set the foundation for the development of the
Senate's proposed Wounded Warrior legislation which is currently in
conference with the House as part of the 2008 National Defense
Authorization bill.
I could not be more pleased with the cooperative manner in which
the staffs of the two Committees worked to develop this extremely
important and comprehensive legislative package that addresses health
care, benefits, and transition issues involving both DOD and VA. In
crafting this legislation, the staffs met on a regular basis, received
briefings from Army and VA leadership, visited Walter Reed to meet with
Army and VA representatives, and were briefed on the findings of groups
created by the Administration to look into the Walter Reed problems.
It is important to remember that the problems identified at Walter
Reed were not about the quality of health care provided by DOD, but
about an overall process that created confusion and inequities in the
delivery of disability benefits to wounded warriors. The stories about
Walter Reed also highlighted existing problems in the organization of
medical hold/medical holdover detachments and in the hand-off between
the military services and VA of wounded or seriously injured or ill
servicemembers.
The good news is that, since this spring, much hard work has been
done by DOD, VA, and the military services in seeking ways to resolve
the problems which were identified. However late DOD and VA may have
been in recognizing the significant problems of adapting their
Departments to the stresses of the current conflicts, I am satisfied
that real work is now underway. I am particularly impressed by the work
of the joint VA and DOD Senior Oversight Committee, co-chaired by VA's
Deputy Secretary Gordon Mansfield and DOD's Deputy Secretary Gordon
England, that meets weekly to work on a wide range of ongoing
transition issues. This is an unprecedented level of attention to the
issue of DOD-VA cooperation and collaboration.
Nevertheless, it is clear that much hard work lies ahead and that
the problems faced by individual veterans and their families continue
to demand attention and solutions. Today's hearing gives our Committee
the opportunity to continue our work in this area.
The problems highlighted by the situation at Walter Reed led to the
creation of a number of entities--the Dole-Shalala Commission, which
was established by the President on March 6, 2007, and presented its
report on July 30, 2007; the Task Force on Returning Global War on
Terror Heroes, also established by the President on March 6, 2007,
which issued its report on April 19, 2007; and DOD's Independent Review
Group, established by Secretary Gates on February 23, 2007, and which
completed its report on April 19, 2007. The Committee will be hearing
from each of these groups today.
The Committee will also be hearing today from the Veterans'
Disability Benefits Commission (VDBC), which was established by
Congress in 2004, and which, on October 3, issued its report. The VDBC
report provides an in-depth analysis of the benefits and services
available to veterans, servicemembers, their survivors, and their
families to compensate and provide assistance for the effects of
disabilities and deaths attributable to military service. The VDBC was
invited today to present its views on the recommendations of the Dole-
Shalala Commission and the other entities which were created in
response to the stories about Walter Reed and to discuss areas of
overlap between its recommendations and those of the other groups. The
Committee will have other hearings, beginning early next year, on the
VDBC's overall report and recommendations.
Among the issues that the Committee will focus on today are those
relating to the existing DOD and VA systems for providing compensation
and other benefits to servicemembers injured during their service. This
is a key area of overlap between the Dole-Shalala Commission and the
VDBC.
The Dole-Shalala Commission, on the basis of its work over a
relatively short period of time--their first public meeting was in mid-
April and they issued their report in late July--recommended a complete
restructuring of the DOD and VA disability systems, as one element of
its report that includes six recommendations focused primarily on
collaboration between DOD and VA and on the needs of newly injured
servicemembers. It is not clear from the Commission's report what
outside expertise the Commission relied on to reach this conclusion.
The only suggestion we have received thus far on how this comprehensive
revision might be carried out came in the form of draft legislation on
which Senator Burr and I, along with our counterparts on the Armed
Services Committee, were briefed last week. This draft legislation,
apparently developed by the White House, would have the Congress cede
the responsibility for the proposed comprehensive retooling of VA's
compensation system to the Secretary of Veterans Affairs and require
the Secretary to accomplish this monumental task over a very few
months.
The VDBC, in contrast, took a more systematic approach, carried out
over a period of two and a half years, that focused exclusively on the
complex and often inefficient service-connected disability structure.
The VDBC conducted 26 public meetings, carried out extensive research,
and received significant input from outside entities, including the CNA
Corporation and the Institute of Medicine.
As part of its effort, the VDBC articulated eight principles that
it believes should guide the development and delivery of future
benefits for veterans and their families. It structured its analysis by
developing 31 research questions. The Commission's staff drafted 11
white papers that analyzed 16 of those questions and presented options
to the Commission for their deliberation. Attorneys conducted legal
analyses of several of these issues and gave the Commission a
historical context for much of the legislation that sets forth the
benefits available to disabled veterans, their families, and survivors.
On the basis of its analysis and considerations, the VDBC made 113
recommendations designed to improve VA's disability compensation
program for the 21st century. These recommendations collectively
address the appropriateness and purpose of benefits, the benefit levels
and payment rates, and the processes and procedures used to determine
eligibility for benefits.
Many significant recommendations made by the VDBC are not
contemplated in the Dole-Shalala report and warrant further review
before any action is taken on the Dole-Shalala recommendation related
to the overall disability benefits system and on how the Dole-Shalala
recommendation may relate to the legislation developed by the White
House that I mentioned earlier.
With respect to that draft White House legislation, I have many
questions and concerns about it, but wish to make two general points
about it. First, whatever legislation is finally submitted by the White
House will not have my support as a replacement for the Wounded Warrior
legislation that is now pending in the NDAA conference. Our Committee
and the Armed Services Committee, and our counterparts in the House,
have worked diligently on the Wounded Warriors legislation and I see no
basis to scrap that effort this late in the Session. The second point I
wish to make about the draft legislation is this: As Chairman of the
Veterans' Affairs Committee, I will unequivocally oppose any proposal
that would abdicate the role and responsibility of the Congress for
dealing with the VA compensation system by giving that task to the VA
Secretary. On that point, it is worth noting that there is no confirmed
Secretary of Veterans Affairs at present. It is inconceivable to me
that there would be any significant support for giving such a
monumental task to VA, especially when there is no leadership in place.
There are a number of other recommendations from the Dole-Shalala
Commission that I hope to learn more about today, including those
relating to care coordination, treatment for PTSD, providing support
for family members who have to take time off from their jobs to be with
their wounded family members, and recommendations relating to VA's
vocational rehabilitation program.
With regard to coordination of care, I am pleased by the Dole-
Shalala Commission's recommendation that each seriously injured
servicemember be provided with a ``Recovery Coordinator'' to serve as
the patient and family's primary point of contact throughout their
treatment and to ensure that the servicemember is getting the care he
or she needs. This is a concept the Committee has already embraced in
our health care omnibus legislation, S. 1233, which is currently
pending passage by the full Senate. It is clear that the need exists
for care coordinators to assist patients in navigating through the two
systems. However, I believe that if every servicemember is to be
provided with a Recovery Coordinator, we must also ensure that their
efforts are managed efficiently. Basic questions such as which agencies
will hire and train them must be answered.
We must also uncover what the real impediments are to accessing
treatment for Post Traumatic Stress Disorder that prompted the Dole-
Shalala Commission to recommend improvements in this area. Is it
identifying servicemembers with more severe symptoms, and getting them
in the door, or is it that when they do present themselves at a DOD or
VA facility, they are not being given proper care? The Dole-Shalala
Commission says that Congress should enable VA to provide aggressive
PTSD care, but it is my belief that VA already has the authority to
provide the care, and that our role in Congress is to ensure that VA
has the resources to do the job.
In addition, the Dole-Shalala Commission recommended that the
Family Medical Leave Act should be amended to allow up to 6 months'
leave for a family member of a servicemember who has a combat-related
injury. Though the Commission's recommendation as formulated does not
fall within the jurisdiction of our Committee, other proposals
addressing the need to support the families of those who are recovering
from combat injuries have been made that do, so we will be looking at
the ramifications of these approaches.
And finally, I find the President's Commission's recommendations
relating to VA's Vocational Rehabilitation and Employment Program
confusing, especially the proposal to offer individuals a monetary
incentive to complete a program of rehabilitation and the subsequent
effect that completion would have on an individual's level of service-
connected compensation. Since the Committee has an oversight hearing of
this program scheduled for later this month, I do not intend to pursue
these issues at today's hearing in great depth. I will have some
questions on these recommendations for the record and perhaps later on
in connection with the oversight hearing at the end of the month.
In closing, I note that, at the Committee's first hearing in
January, I spoke about the stress that a new veteran with a life
altering wound or injury endures when faced with the challenge of
applying for benefits and transitioning from one health care system to
another, while still in the process of recovery and rehabilitation.
With the input of the many recommendations that we will hear about
today, I believe that we can continue to make progress toward achieving
the goal of a truly smooth and seamless transition.
Chairman Akaka. In the interest of time and to allow others
to speak, I will stop here and turn to the Committee's Ranking
Member, Senator Richard Burr, for his opening remarks.
STATEMENT OF HON. RICHARD M. BURR, RANKING MEMBER,
U.S. SENATOR FROM NORTH CAROLINA
Senator Burr. Aloha, Mr. Chairman. I didn't know it would
be quite as challenging linguistically on this Committee as it
is to serve with Senator Akaka, but he has challenged me to
learn more than just what we need to do as it relates to
changes in the disability system. Mr. Chairman, thank you.
I welcome all of our distinguished panelists and I
appreciate you being here this morning. You have all spent many
hours with one thought in mind, and that is improving the lives
of those who served our country in the Armed Forces. You have
given us policy suggestions that I believe can help shape how
we care for our servicemen and women for decades to come. For
your commitment to them and for your advocacy on their behalf,
I am here this morning to say thank you to each and every one
of you.
Let me begin by making two very broad points. First, we are
here today to review recommendations on how best to deliver
health care, disability compensation, and rehabilitative
benefits to those who have been injured in military service to
our country. As we look at our strengths and our inefficiencies
in getting the job done right, we have to keep in mind that the
opportunities for today's professional warrior are
fundamentally different than in earlier generations. Today,
all-volunteer forces know that injury, even serious injury,
need not be an impediment to continuing on with a productive
and fulfilling life.
I am amazed when I hear over and over how some soldiers
with very serious injuries are able to return to their units,
or how they plan to resume fully active lives, go to school and
get a job. Modern technology and modern attitudes about
disabilities not only give them that hope, they appropriately
give them that expectation.
Our job, then, is to give these brave men and women the
tools they need and to remove the stumbling blocks that are in
their way. In fact, they demand that from their government.
Today's soldier chooses a military career and their
expectation is the same as it would be for any professional
working in any organization in America. If one is hurt on the
job, one expects quick, effective, and relatively hassle-free
physical, vocational restoration and supportive services from
the employer.
My second point is about our system of benefits and
services for our veterans, servicemembers, and their families.
Rather than use my words, I will read the Dole-Shalala
Commission report where they said the Commission learned that,
on the whole, we are a generous and giving Nation when it comes
to providing for our servicemembers and veterans. Benefits
include health care for veterans through the VA, for retirees
through the Military Health System, and through civilian
providers through TRICARE. In addition, we pay retirement and
disability benefits and provide for education, adaptive
equipment, employment hiring preferences, and more.
The total cost of these benefits was well over $127 billion
in 2006. So as of last year, we had a budget of over $127
billion to assist veterans and servicemembers, more than double
what it was just a decade ago.
I highlight this information to suggest that the challenges
facing many veterans today have as much to do with confusing
bureaucratic programs operated by many different offices of the
government as they do with the lack of benefit programs or the
lack of resources. I will never shy away from providing our
military men and women and our veterans with the resources they
need, but I expect and these citizens expect that these
resources will be used effectively to deliver needed benefits
and services.
There is a saying that goes, if you aren't part of the
solution, then you must be part of the problem. So let us
commit to talking today about meeting the challenges ahead of
us. Secretary Shalala and Senator Dole, when you briefed us 2
weeks ago, I was pleased to hear that officials and staff at
the Department of Veterans Affairs and the Department of
Defense were beginning to implement 90 percent of your
Commission's recommendations.
Mr. Chairman, I am committed to you, and I look forward to
working with you, to conduct oversight of the Departments of
Veterans Affairs and Defense to ensure that the best of these
recommendations to improve veterans' care are implemented
without delay.
Senator Dole and Secretary Shalala, you also said in our
recent briefing that 10 percent of your Commission's
recommendations require legislative action. You called this the
hard part. Of course, I am speaking about the recommendations
to reform the Disability Compensation System. As you know, the
Veterans Disability Benefits Commission has also spent the
better part of 3 years looking at the hard part. I expect
everyone calls it the hard part for a very good reason, and I
think this Committee will soon find that out. I am fully aware
that reforming the disability system will require a large up-
front cost, but if done properly, it would also be an
investment.
Chairman Akaka, once again, I pledge to you as the
Committee works to better the lives and well-being of those
wounded in defense of the country, knowing that the character
of men and women of our Armed Forces is an investment that
comes with little risk and great reward.
One final thought before I conclude my statement. Almost
every Member of Congress has had the opportunity to visit
soldiers, Marines, sailors, and airmen who are fighting in the
war on terror. In my own conversations with them, I can't help
but be inspired by their love of country, their commitment to
duty, their extraordinary optimism in the face of adversity. We
have all referred to men and women who served with Senator Dole
in the Second World War as ``The Greatest Generation,'' and my
encounters with today's heroes remind me that greatness--when
we talk about risking one's life for the freedom of others--is
of every generation. Greatness belongs to the few whose deeds
merit that title.
To all who have served in combat, to the families who have
sacrificed so that their loved ones could serve the rest of us,
and to all who have been injured or who have died for our
freedoms, you have my enduring respect and gratitude. No matter
when you served or on what continent you fought, you have made
the most supreme sacrifice. For that, and I know I speak for
everyone in this room, we are eternally grateful.
Again, I thank our distinguished guests this morning for
their willingness to share their knowledge with this Committee
and I think I speak for the Chairman when I say that we are
anxious to go forward and to begin this process.
Thank you, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Burr. Using
what we call ``the early bird system,'' I am going to call next
on Senator Craig, and he will be followed by Senator Murray.
Senator Burr. Mr. Chairman, could I ask my colleagues to
indulge me for one additional minute? We have been joined by a
very special person and I just want to highlight that for our
audience today. Sarah Wade, would you stand up for a second? I
just want you to meet a very special person.
Sarah Wade is the wife of Retired Army Sergeant Edward
``Ted'' Wade. Following Ted's serious injury in Iraq on
February 4, 2004, Sarah suspended her studies at the University
of North Carolina at Chapel Hill to serve as an advocate for
her husband and has recently become a public policy intern for
the Wounded Warrior Project, a nonprofit organization dedicated
to assisting military personnel injured in Iraq and
Afghanistan.
She was born and raised in Washington, D.C. Sarah currently
resides in Chapel Hill, North Carolina, a constituent of mine
and the wife of a very brave U.S. soldier. Thank you for being
here, Sarah.
[Applause.]
Chairman Akaka. Thank you, Senator Burr.
Senator Craig?
STATEMENT OF HON. LARRY E. CRAIG,
U.S. SENATOR FROM IDAHO
Senator Craig. Mr. Chairman, Richard, I will be brief, but
I do want to welcome both Secretary Shalala and Senator Dole
before this Committee and to reminisce only briefly. If Bob
hadn't said, Larry, there is work to be done on the Veterans
Affairs Committee a good number of years ago, and you ought to
go do it, I might not be here. And that work has continued.
Thank you, Bob, for appointing me to this Committee a good
number of years ago, and we have continued to work according to
your wishes.
I want to thank all of the panelists and the Commissions
who are before us today. The work you do is critically
important to veterans, to soldiers who will become veterans
soon across this Nation, and we thank you for it.
Earlier this year, Mr. Chairman, I asked a Member of the
staff here on the Veterans Affairs Committee to submit
testimony before Secretary Shalala and Senator Dole's
Commission regarding the DOD-VA collaboration, especially as it
relates to the overlapping health benefits systems. I have been
very involved over the past few years in examining ways that
DOD and VA can work together closely.
We early on began to use the word ``seamless,'' but it
became pretty obvious to me that it was a word, it was not a
reality, not in the way we want it to be. And I would hope, Mr.
Chairman, Richard, that as we work through this, seamless
becomes a system and simply not a phrase, because that is
exactly what is doable today if we can cause DOD and VA to come
together in a way that recognizes what we want to achieve for
America's veterans.
I have used testimony from General Omar Bradley's
Commission in 1956. I know Senator Dole has referred to it on
occasion. I would hope that 51 years after today, that this
Committee has not convened in a way that it is referring to the
Dole-Shalala Commission as goals that should have been achieved
but were not accomplished.
I know government is a daunting system and sometimes very,
very difficult to change, Mr. Chairman. We can and we must
change it. And for the sake of America's veterans, I hope we
can.
So to meet that challenge, Mr. Chairman and Senator Burr, I
accept your challenge to do just that, to look back a few years
from now and say that we have accomplished what we set out to
do. It is now a seamless system. When one transfers from active
to veteran, it is simply the push of a button and the movement
of a system. We have watched the failure too long. We have
watched the bureaucracy be too daunting. It shouldn't require
the wife of a soldier to become an advocate simply to work
their way through a system that is impossible or nearly
impossible to penetrate.
We are moving in those directions. Now our challenge from
the Commissions is to revisit it and revisit it on an annual
basis, to challenge it, to oversee it, and to force it to
change. Thank you for being with us.
Chairman Akaka. Thank you very much, Senator Craig.
Now we will hear from Senator Murray.
STATEMENT OF HON. PATTY MURRAY,
U.S. SENATOR FROM WASHINGTON
Senator Murray. Thank you very much, Chairman Akaka,
Ranking Member Burr, for holding this really important hearing.
Secretary Shalala, Senator Dole, welcome to our Committee.
Thank you for the work you have done and for being here today
to present the recommendations of your Commission as well as
the other three reports that we are going to hear about today
about how we can improve the care for our servicemembers and
veterans as they transition from the military to the VA.
It has been 8 months now since the Washington Post exposed
the scandalous conditions that all of us read and were shocked
by, mice running in walls and moldy walls and holes in ceilings
and the bureaucratic maze that our men and women who fought so
bravely for us faced when they got home. Obviously, no one
should have to endure those kinds of conditions, but most of
all, the men and women who fought so courageously for all of
us.
I think it is important to remember that it wasn't just
Walter Reed. I think, as you well know, it was many of our
facilities that were facing very bad conditions. This was
symptomatic of the entire system, and it wasn't just
infrastructure. It was a long time waiting to see a doctor. It
was bureaucratic ineptitude. It was VA claims backlogs that
were taking months and years that were really harming our men
and women's ability to be able to take care of their families
when they come home.
I think all of us know that, without hesitation, these men
and women take on the task that this Nation has given them.
They answer the call to serve in Iraq or Afghanistan or
wherever we send them. They have left their loved ones for
years. They have put their careers on hold. They put their
lives on the line, and the least we can do is make sure when
they come home, they get prompt, respective, comprehensive
support for the work that they have done.
I have said, Mr. Chairman, many times that no matter how
divided this country may be over this current war in Iraq, this
country is extremely united behind making sure that the men and
women who have fought for us get the care that they deserve. We
have taken that and used it this year, and the first time in
the Iraq supplemental war bill, putting in funding for
veterans, $1.8 billion in emergency funding, for the first time
counting the care of veterans as part of the cost of war, which
I think is extremely important to do. Of course, this year's VA
military construction bill increased funding $3.6 billion over
the President's request as a recognition of the costs that we
are responsible for.
But I do think this environment that the country is in
today, where we are all so supportive of these men and women,
gives us a chance today to do these fundamental reforms to the
VA and DOD that are so badly needed, and we need to really
strike while the iron is hot.
The Senate has already done that. We passed the Dignified
Treatment of Wounded Warriors Act, which deals with the
seamless transition process. That bill is now being worked out
with the House and hopefully will be enacted soon so we can
begin to provide some real solutions. I am interested today in
how the Commission report ties in with that and how we can make
sure we are doing that correctly together.
But I am especially pleased that we are now actually
looking at all of this and we are seeing studies and commission
reports and recommendations by a number of different groups who
are going to be in front of us today and I look forward to
hearing from all of our witnesses and having a chance for us to
really do the best with the best information we have.
Senator Dole, Secretary Shalala, I am especially looking
forward to your thoughts on the administration's proposed
legislation to carry out your recommendations and I am very
glad to see the President come to the table on this issue and
to work with us, I hope, as part of moving forward the
Dignified Treatment of Wounded Warriors Act, as well.
So, Mr. Chairman, this is a very important hearing. The
country is waiting. They want to know what we are doing and how
we are moving forward and it is incumbent upon all of us to act
well, so thank you very much.
Chairman Akaka. Thank you very much, Senator Murray.
Senator Tester?
STATEMENT OF HON. JON TESTER,
U.S. SENATOR FROM MONTANA
Senator Tester. Thank you, Mr. Chairman and Ranking Member
Burr. I really, really appreciate the fact that you are having
this hearing. I think it is long overdue to really take a look
at what families and veterans have gone through to navigate
through the bureaucracy of the DOD and the VA.
I also want to thank everybody who is on these panels here
today. It truly is an all-star cast of expert witnesses and I
want to tell you I appreciate Senator Dole, Secretary Shalala
coming today and I look forward to your testimony, as I am sure
we all do.
I would ask, Mr. Chairman, that my entire statement be put
in the record, but I do want to talk about a few things.
Over the last 10 months, I have held ten listening sessions
with veterans throughout the State of Montana. The last one was
last weekend in Mile City, Montana. At these listening
sessions, I have heard about good things that have happened
with the VA and I have heard about some things that have been,
quite honestly, unacceptable with the VA.
As we go forth in what we are doing here in this Committee,
I think it is critically important that we take all the
necessary steps. I have heard just this morning issues or words
like complex, impenetrable, bureaucratic, ineptitude. I think
we all know that there is room for improvement and I think that
the people who fought for this country and put their lives on
the line and protected us in times of war and even not deserve
it and we owe it to them.
Just yesterday, a fellow by the name of Dan Gallagher from
Missoula, head of the VFW in Missoula--in fact, he is here in
the audience today--stepped into my office and said it is just
a matter of course that when people first apply for benefits,
they get turned down, right out of the chute. It is just the
way things are done. That is a bad way to do business and we
cannot accept that kind of work ethic, quite honestly. It is
almost like the VA is working against the veterans instead of
working for the veterans. So, we need to make sure that good
health care and good benefits that happen for some of our
veterans, occur for all of our veterans.
With that, I very much look forward to your testimony,
Senator Dole, Secretary Shalala. And thank you, Mr. Chairman
and Ranking Member Burr.
[The prepared statement of Senator Tester follows:]
Prepared Statement of Hon. Jon Tester, U.S. Senator from Montana
Thank you, Mr. Chairman. I am glad that we are having this
hearing--it is long overdue for us to take a look at what families are
going through when it comes to navigating the DOD and VA bureaucracies.
We've all heard the stories about the current system being
complicated for injured servicemembers to navigate and stretched beyond
the capabilities of the doctors and claims processors.
I met yesterday with the head of the American Legion Post in
Missoula--Dan Gallagher. Dan has spent his entire adult life helping
Montana veterans get the care and the benefits that they're entitled
to.
He brought me a letter and in it, he said this:
``Our veterans and our returning warriors have a right to the care
their service has earned them. We cannot let the yellow ribbons to,
once again, become red tape.''
My friend, Dan Gallagher, has it exactly right. But that is exactly
what is happening to a number of vets. Not just the catastrophically
injured vets that we've all read so much about at Walter Reed and other
places, but all throughout the DOD and the VA.
I want to thank the witnesses for being here, because I think they
all share a real desire for change in the system. We've got to simplify
where we can, and make this process a lot less painful for veterans and
their families.
Above all, I think this is going to require a lot more resources.
And it will require a real attitude change within the bureaucracies.
Folks are there to help servicemembers and families, not tell them what
can't be done.
With that, Mr. Chairman, let me stop and let the witnesses have
their say.
Chairman Akaka. Without objection, your statement will be
included in the record.
Senator Brown?
STATEMENT OF HON. SHERROD BROWN,
U.S. SENATOR FROM OHIO
Senator Brown. Thank you very much, Mr. Chairman, Ranking
Member Burr. Senator Dole, thank you for your service to our
country, both in wartime and in the Senate, and fellow
Clevelander Madam Secretary, nice to see you today. Thank you
for your service.
Everyone always says the right thing about veterans at
hearings like this and as elected officials and at all the
right veterans' halls and all the right celebrations and all
the patriotic gatherings. Yet this institution has made some
terrible mistakes and some terrible choices when it comes to
veterans' health care, I think. We have always had plenty of
money for war. We have always had plenty of money for tax cuts,
for especially the top one or two or 5 percent in this country.
Yet the sacrifice in this war that we are in now has hardly
been spread evenly in the population and so many of the people
that have gained the most have sacrificed the least. There has
not been enough money for body armor, not enough money for
MRAP, not enough resources, as Senator Murray's comments point
out, not enough resources for VA health care. We have a lot of
work to do.
By passing the Veterans' Organizations Independent Budget,
the military construction bill that Senator Murray played such
a major role in, it is very much an important first step.
Coordination, as several have said, including Senator Craig,
coordination and making it really seamless, more than just a
word of DOD and VA, is so very, very important. Extending, as
the Commission recommends, extending family and medical leave,
establishing a caseworker that will work with families of
soldiers to coordinate care and services is so very important.
A timely and accurate disability rating is so very important.
Particularly, we need to improve the diagnosis and
treatment of PTSD and all that we have seen coming from this
war, and I know that Senator Dole's feelings and Secretary
Shalala's feelings are so strong about that. I have spent, as
so many of us have, much of the last 4 years meeting with
soldiers, welcoming the troops home, encouraging them to get
the treatment they need when they resist for good reason:
because they want to integrate themselves back into their
workplace; their families; their communities. It is so very
important that this transition be done right and this
Commission's recommendations will help there.
One last point. Ohio has one of the lowest average payments
for disability compensation--well below the national average.
We are a large State with a huge veteran population and we need
to do better. That is partly an issue we can help fix within
the VA. It is partly an Ohio issue. We need to work together to
do all of that.
I am so appreciative of the service of not just Senator
Dole and Secretary Shalala, but our other panelists, too; and I
thank the Chairman.
Chairman Akaka. Thank you very much, Senator Brown. Now we
will hear from Senator Hutchison.
STATEMENT OF HON. KAY BAILEY HUTCHISON,
U.S. SENATOR FROM TEXAS
Senator Hutchison. Thank you, Mr. Chairman. First, I want
to say to Secretary Shalala and Bob Dole, there has not been a
better, more committed advocate for veterans in this Nation in
our history than you, Bob Dole, and thank you so much for
continuing from your great service in World War II to helping
those who have followed you. Thank you. And Madam Secretary,
you had another full-time job. You didn't need to take this on,
but you did and we all so appreciate it, that you would once
again suit up for your service outside of your regular duties,
which we all know are huge. So thank you both very much.
Let me say a couple of things. I am the Ranking Member on
the Veterans Affairs and Military Construction Appropriations
Subcommittee, so I have been dealing with the issues of
funding, of course, for veterans, but also trying to make sure
that we have the seamless transition. Now, you did in your
report address this issue, suggesting that we have the rapid
transfer of patient information between DOD and VA. But I do
want to say that this is something where the VA is really
leading.
We have the state-of-the-art electronic medical records in
the VA system. It was never brought home better than after
Katrina in New Orleans when the whole Veterans' Hospital had to
be vacated and not one record was lost--not one. So our
veterans in New Orleans got superb treatment wherever they
were, wherever they evacuated, and that is a testament to the
system. Of the 155 VA hospitals, every one is set with the
electronic records, so we know there is a system that works.
However, as has been said here, it is the transition to
DOD, and the anecdotal information that we get is phenomenal.
In Houston, for instance, I was called because our veterans who
were injured and therefore retired with disabilities were
waiting months and even almost a year for their disability
benefits. So we immediately went to the VA and they tasked
people to go down to try to fix that hiatus because we just
didn't have enough people processing.
I know that because the VA system is so good, if we put our
minds to it and we take your direction, which you also saw, and
bring DOD up to the same standards so that people can have a
seamless transition, that everyone will be ahead. It is
inexcusable for someone injured in Iraq or Afghanistan to go on
medical disability and not get their benefits for three to nine
or 10 months. It is just inexcusable. So that is the issue that
I think we have to address immediately and I really think it is
in DOD and matching those up.
So thank you for your service. Thank you for being here to
report to us, and we will follow up, I assure you, on your
recommendations. Thank you.
Chairman Akaka. Thank you very much, Senator Hutchison.
Now we will hear from Senator Isakson.
STATEMENT OF HON. JOHNNY ISAKSON,
U.S. SENATOR FROM GEORGIA
Senator Isakson. Well, thank you very much, Chairman Akaka.
I appreciate you and the Ranking Member doing this. Senator
Dole, it is a pleasure to see you again. Secretary Shalala,
thank you for your service to the country.
My remarks will be limited to the seamless transition
issue. I want to commend you on your recommendations and the
focus on that and point out what I have in a couple of previous
hearings that we have had.
General Schoomaker did a great job in Augusta with the
Augusta VA, called the Uptown VA Hospital, and the DOD
facility, Eisenhower Medical Center, created a seamless
transition of treatment and rehabilitation for wounded warriors
coming back that is really second to none. In fact, I told the
story previously, and I will tell it one more time at the risk
of being repetitive because I think it is so important.
I met a Sergeant Harris when I was at the Augusta VA. She
had gone to Iraq and on the second day of her deployment had a
Traumatic Brain Injury from an exploding IED. She came back to
the States. DOD treated her. They could not correct it, so she
was severed from the military and went to the VA hospital. They
corrected the Traumatic Brain Injury and reenlisted her in the
military and she was on active duty at the Augusta Eisenhower
Medical Facility, which shows when you have a good seamless
transition and continuous care it is of immeasurable benefit to
our wounded warriors.
So I commend you on your recommendations on that, your
recommendations on electronic records and evaluations. All are
critically important to seeing to it our veterans get the very
best and the timeliness of care, and I thank you again for both
of your service to the country.
Chairman Akaka. Thank you very much, Senator Isakson. I am
pleased to welcome our first panel. We are fortunate to have
two highly distinguished public servants testifying before the
Committee today.
I am honored to welcome the Co-Chairs of the President's
Commission on Care for America's Returning Wounded Warriors,
former Senator Bob Dole of Kansas and Donna Shalala, Secretary
of Health and Human Services during the Clinton administration.
Senator Dole and Secretary Shalala were called by the
President to lead an evaluation of the care and services
provided to America's wounded servicemembers when they return
home from battle. They are here today to share their findings
and recommendations with the Committee.
Senator Dole and Secretary Shalala, we are pleased to have
you here today and look forward to your testimony. Your full
statements will appear in the record of the hearing and you may
begin with your statement, Secretary Shalala.
STATEMENT OF HON. DONNA E. SHALALA, CO-CHAIR, PRESIDENT'S
COMMISSION ON CARE FOR AMERICA'S, RETURNING WOUNDED WARRIORS
Ms. Shalala. Thank you very much, Chairman Akaka, Ranking
Member Burr, distinguished Members of this Committee. Before I
begin, let me introduce one member of the Commission who has
joined us, Ed Eckenhoff, who runs the National Rehabilitation
Hospital, a private rehabilitation hospital here in Washington,
D.C., one of the leading experts on rehabilitation in this
country; and Marie Michnich, who was our Executive Director,
who is at the Institute of Medicine of the National Academy of
Sciences; and Dr. Sue Hosek from the RAND Corporation, one of
the leading experts in military health, who was our Research
Director; and Dr. Karen Geiss from the Medical College of
Wisconsin, who was the Deputy Executive Director of our
Commission. We had a very short period of time so we literally
grabbed talented people from all over this country to come join
us to do our work.
It was a privilege to serve on the President's Commission
with Senator Dole. We never had a disagreement. He is fun to
work with, but more importantly, he knows this system and cares
deeply about what happens to these young men and women who come
back from conflict.
Of our nine Commissioners, four were severely injured in
current or past conflicts and one was the wife of a soldier
from Iraq. This was not a Commission of the usual suspects. It
was a Commission that had a very high percentage of young
people who had current information and current experiences and
included people who had not been on commissions before but took
a fresh look at these issues.
We presented six groundbreaking patient- and family-
centered recommendations, and one of the important things about
our recommendations is they were not bureaucracy-centered. They
were patient-centered and family-centered. We tried to look at
the issues from the point of view of the people that were
directly affected, as opposed to the people that provided just
the services.
Our report, which is called ``Serve, Support, and
Simplify,'' we believe is not only short, but it is a blueprint
for and certainly a very clearly outline for the kinds of
changes we believe must take place.
Let me also emphasize, as General Scott will, that our
recommendations stand on the report of others. We built upon
other recommendations. We looked carefully at the Bradley
Commission and all the previous commissions as well as more
recent commissions.
Our six recommendations do not require massive new programs
or a flurry of new legislation. We identified with the six
recommendations 34 specific action steps that must be taken to
implement the six recommendations. Only six of the 34 require
Congressional action, and that is what I want to focus on
today. I want to talk about those six that require action by
Congress and then Senator Dole will discuss how the
recommendations will work together to create a new system.
The first action step calls for Congress to simplify the
DOD and VA disability systems. I realize in this town the word
``simplify'' is not often used, but I think that our point here
is it ought not to take an expert to understand the system. Any
injured soldier or member of their family ought to be able to
understand what is going to happen to them and what benefits
are available to them and how the disability system works.
Right now, DOD and VA assess each servicemember's
disability for completely different reasons. DOD needs to
determine if they can continue to do their job despite their
medical condition. If they can't, then they must discharge the
servicemember. The degree of disability, the length of time
spent in service depends on the amount of military compensation
and benefits.
DOD generally only rates a condition that prevents the
servicemember from doing their job. The VA determines how
disabled a veteran is based on every medical condition that
occurred was made worse while in the military service. The
degree of disability is part of how the VA determines what
benefits, services, and the amount of compensation the veteran
will get.
Over the years, this evaluation system has become really
convoluted as we tried to fix problems and that is the point we
are making today. People of good will in this Congress and in
the agencies, every time they had a problem they added a new
regulation, a new requirement, a new piece of legislation, and
that is why the system is so convoluted and so complex today.
We recommend simplifying the system. DOD retains their
authority to determine fitness to serve. If a servicemember
whose health conditions make them unfit for duty, they would be
separated from the military with a lifetime annuity payment
based on their rank and years of military service. They don't
have to wait 20 years. If they get severely injured, they have
been in for 11 years, they can't any longer serve in the
military. They would leave the military with an annuity payment
based on their rank and that 11 years of service.
This recommendation brings DOD in line with other employers
of choice. That is the way the employment system works where
you have an annuity system in this country, and it is a very
important step in maintaining a volunteer Army, from our point
of view.
We also believe that only one physical exam should be
performed rather than the two required now--one by each
department--and that that physical should be performed by DOD.
The VA then would assume all responsibility for establishing
the disability rating based on that physical and for providing
all disability compensation.
So you split the two responsibilities based on their
expertise and the appropriate role for each department, but it
is the VA that makes the disability determination. It is a much
simpler system. It supports those that are transitioning
between active duty and veteran status and it puts the DOD in
the right frame. They provide the necessary military strength
and expertise to keep our Nation safe and secure. They can
determine their own fitness standard for serving.
Now, obviously, there are some soldiers that the DOD will
find a job for even though they have an injury--an amputation,
for example--and that is really for them to work out with those
soldiers. They have an interest in doing that. They would like
to keep people employed. But if the decision is that that
soldier, sailor, or Marine should go over to the VA system,
they would leave with an annuity. They would go to the VA
system and get their disability rating, the disability payment,
and some other things that we recommend.
The second action step out of the six is that we recommend
health coverage for servicemembers who are found unfit because
of conditions that were acquired in combat, supporting combat,
or preparing for combat. We believe that Congress should
authorize comprehensive lifetime health care coverage and
pharmacy benefits for those servicemembers and their families
through DOD's TRICARE program, and the important phrase here is
``and their families.''
Many of these young people can take a job, but finding a
job that has benefits that will cover their families is
probably a real challenge. This will change their lives if this
benefit is available. We really believe it will help them to
find employment because they will have a lot more choices.
Our third action step is to ask Congress to clarify the
objectives for the VA disability payment system by revising the
three types of payments which are currently provided to many
veterans. The primary objective should be to return the
disabled veteran to normal activities insofar as possible and
as quickly as possible by focusing on education, training, and
employment. We recommend changing the existing disability
compensation payments for injured servicemembers to include
three components: Transition support, earnings loss, and
quality of life.
Transition payments are, of course, temporary payments to
help with expenses as disabled veterans integrate into civilian
life. Veterans should receive either 3 months of base pay if
they are returning to their communities and not participating
in further rehabilitation, or an amount to cover living
expenses while they are participating in education or work
training programs. We also believe that the time for
participating in these training programs should be expanded to
72 months for those who may need to attend part-time. Most of
the students in this country are not going to school full-time.
They are going to school part-time, and our veterans, our
investments in these veterans ought to reflect what is
happening in the larger society.
Second, earnings loss payments. We should make up for any
lower earning capacity remaining after transition and after
training. That is what we mean by modernizing the system.
Earnings loss payments should be credited to Social Security
earnings and would end when the veteran retires and claims
Social Security benefits. Now, the President has a slightly
different recommendation in this area.
In addition, we believe that quality of life payments
should be provided to disabled veterans, and these payments are
based on a more modern concept of disability, and that is our
point about the current disability system. It is very old
fashioned. No one except this government is paying disability
payments this way any longer. Everybody has quality of life
payments as part of the payment scheme. We need to take into
account an injury's impact on an individual's total quality of
life, independent of the ability to work. And if you look at
the private sector payments, they combine these two when
someone has a disability.
We also call for the disability status of veterans to be
reevaluated periodically, and we see this as a positive
provision that would ensure that all disabled veterans are seen
by a health professional at least every few years. What we
don't want is for the payment to go out of date for an
individual veteran.
By simplifying and modernizing the DOD and VA disability
systems, we will make the systems less confusing, we will
eliminate payment inequities, and we will provide a foundation
with appropriate incentives for injured veterans.
Our fourth action step asks you to authorize the VA to
provide lifetime treatment for PTSD for any veteran deployed to
Iraq or Afghanistan that needs such services. This presumptive
eligibility for the diagnosis and treatment of PTSD should
occur regardless of the length of time that has transpired
since the exposure to combat events.
One of the things that we learned from talking to young
veterans is that when they get out, they want to get out, and
many of them are asked but they don't answer because they want
to go home. They have got to be able to come back and get
evaluated. We are involved in very intense urban fighting,
often against civilian combatants, and many servicemembers
witness or experience acts of terrorism. Many of these
servicemembers have deployed multiple times. We need to make
sure that those services are available forever for these
servicemembers.
Next, we ask Congress to strengthen support for military
families. The fact that a wife has to give up whatever she is
doing, whether it is school or a job, and other family
members--we met husbands, we met mothers that were giving up
their positions. We have asked that they be provided benefits,
as well, as caregiving benefits. We have asked for more
intensity in the family support systems that are made
available. We have asked that the Family and Medical Leave Act,
which Congress has been supportive of, goes from 12 weeks to up
to 6 months for a family member of a servicemember who has come
back with a related injury and meets the eligibility
requirements.
The military does a very good job of getting family members
to the bedside of an injured servicemember. That is not the
problem. It is once they get there and the kinds of services
that we provide for them and what we say to them about their
lifetime responsibilities in attendant care. That is our
responsibility as a Nation. They will do it if they must, but
it seems to us fundamentally unfair that we are not providing
more support to these family members, and we have made a series
of recommendations.
Mr. Chairman, I believe the government can work to improve
the lives of its citizens. I also believe that when we fix
problems, we often add to their complexity. I, of course, had
to manage the Medicare program, which is an example of that
kind of complexity. Here, we have a chance to think clearly
about the system and to simplify it, make it more
straightforward, make it fairer, and invest resources where
they will really make a difference.
Thank you very much, and I will yield to my colleague,
Senator Dole.
[The prepared statement of Ms. Shalala follows:]
Prepared Statement of Donna E. Shalala, Co-Chair, President's
Commission on Care for America's Returning Wounded Warriors
Good morning Chairman Akaka and distinguished Members of the
Committee. Thank you for the opportunity to testify today, along with
my fellow Co-Chair, Senator Bob Dole, about the recommendations our
Commission presented to the President, Congress and the public in late
July.
It was a true privilege to serve on the President's Commission on
Care for America's Returning Wounded Warriors, especially with Senator
Dole, whose knowledge of and experience with veterans' issues was
invaluable during our short Commission tenure. We were joined by a
remarkable group of commissioners, with their own unique experiences
and expertise. Of our nine commissioners, four were severely injured in
current or past conflicts and one was the wife of a soldier from Iraq
who was severely burned.
The Commission presented six groundbreaking patient and family
centered recommendations that make sweeping changes in military and
veterans' health care and services. At the heart of these
recommendations is our belief in a system of care and benefits that
enables injured or ill service men and women to maximize their
successful transition, as quickly as possible, back to their military
duties or civilian life. Our report--Serve, Support, Simplify--is a
bold blueprint for such a system. I respectfully request that this
report be submitted for the record.
Let me take a moment here to emphasize that our efforts built upon
the recommendations and reports of others--most of them here today. We
are united in our call for change. We were not duplicative of these
recommendations, but added to them in significant ways.
Our six recommendations do not require massive new programs or a
flurry of new legislation. We identify 34 specific action steps that
must be taken to implement the six recommendations. Only six of these
34 items require legislation, and that's what I will focus on today.
I will summarize the actions that require legislation, and, then,
Senator Dole will discuss how all of our recommendations would work
together to create the best system of care to return our wounded
warriors to optimal health and productivity.
Our first action step calls for Congress to simplify the DOD and VA
disability systems. Right now, these Departments assess each
servicemember's disability for different reasons. DOD needs to
determine if servicemembers can continue to do their job despite their
medical condition. If they can't, then the DOD must discharge the
servicemembers. The degree of disability and the length of time spent
in service determine the amount of military compensation and benefits.
DOD generally only rates the condition that prevents the servicemembers
from doing their job. VA determines how disabled a veteran is based on
every medical condition that occurred or was made worse while in
military service. The degree of disability is part of how the VA
determines what benefits, services, and amount of compensation the
veteran will get. Veterans can ask the VA to rate additional
disabilities at any time.
Over the years, the disability evaluation system has become
convoluted as we tried to fix problems. What we created is a system
that is confusing and takes too long. In our national survey of injured
servicemembers, less than half understood the DOD's disability
evaluation process. And, only 42 percent of retired or separated
servicemembers who had filed a VA claim understood the VA process. The
system is dysfunctional and we need to fix it.
We recommend that DOD retain authority to determine fitness to
serve. Servicemembers whose health conditions make them unfit for duty
would be separated from the military with a lifetime annuity payment
based on their rank and years of military service. This recommendation
brings the DOD in line with other employers of choice--an important
step in maintaining an all volunteer professional military force.
We believe that only one physical exam should be performed, rather
than the two required now--one by each Department--and it should be
performed by the DOD. The VA should assume all responsibility for
establishing the disability rating based on that physical and for
providing all disability compensation.
It is a much simpler system that better supports the needs of those
transitioning between active duty and veteran status. It modernizes the
system and allows the two Departments to focus on their unique and
separate missions. DOD must provide the necessary military strength and
expertise to keep our Nation safe and secure. DOD should determine
fitness standards and provide for the health and readiness of the
military workforce. As an employer, DOD must also provide retirement
benefits. The VA's mission is to care for our Nation's veterans by
providing appropriate benefits and services.
In our second action step, we recommend health care coverage for
servicemembers who are found unfit because of conditions that were
acquired in combat, supporting combat, or preparing for combat.
Congress should authorize comprehensive lifetime health care coverage
and pharmacy benefits for those servicemembers and their families
through DOD's TRICARE program.
We believe this action item would help these individuals find
employment that best fits their needs and talents instead of making a
career choice based on whether family health care coverage is provided.
In our third action step, we would like Congress to clarify the
objectives for the VA disability payment system by revising the three
types of payments currently provided to many veterans. The primary
objective should be to return disabled veterans to normal activities,
insofar as possible, and as quickly as possible, by focusing on
education, training, and employment. We recommend changing the existing
disability compensation payments for injured servicemembers to include
three components: transition support, earnings loss, and quality of
life.
``Transition Payments'' are temporary payments to help with
expenses as disabled veterans integrate into civilian life. Veterans
should receive either 3 months of base pay, if they are returning to
their communities and not participating in further rehabilitation; or
an amount to cover living expenses while they are participating in
education or work training programs. We also believe that the time
allowed for participating in these training programs should be expanded
to 72 months for those who might need to attend part-time.
``Earnings Loss Payments'' make up for any lower earning capacity
remaining after transition and after training. Initial evaluation of
the remaining work-related disability should occur when training ends.
Earnings loss payments should be credited as Social Security earnings
and would end when the veteran retires and claims Social Security
benefits.
In addition, we believe that ``Quality of Life Payments'' should be
provided to disabled veterans. These payments are based on a more
modern concept of disability that takes into account an injury's impact
on an individual's total quality of life--independent of the ability to
work.
We also call for the disability status of veterans to be
reevaluated every 3 years and compensation adjusted, as necessary. We
see this as a positive provision that would ensure all disabled
veterans are seen by a health professional at least every few years.
By simplifying and modernizing the DOD and VA disability systems,
Congress will make the systems less confusing, eliminate payment
inequalities, and provide a foundation with appropriate incentives for
injured veterans to return to productive life.
Our fourth action step calls on Congress to authorize the VA to
provide lifetime treatment for PTSD for any veteran deployed to Iraq or
Afghanistan in need of such services. This ``presumptive eligibility''
for the diagnosis and treatment of PTSD should occur regardless of the
length of time that has transpired since the exposure to combat events.
The current conflicts involve intense urban fighting, often against
civilian combatants, and many servicemembers witness or experience acts
of terrorism. Five hundred thousand servicemembers have been deployed
multiple times. The longer servicemembers are in the field, the more
likely they are to experience events--which can lead to symptoms of
PTSD. The consequences of PTSD can be devastating. The VA is a
recognized leader in the treatment of combat-related PTSD, with an
extensive network of specialized inpatient, outpatient, day hospital,
and residential treatment programs. Therefore, we ask that any veteran
of the Iraq or Afghanistan conflicts be able to obtain prompt access to
the VA for diagnosis and treatment.
Next, we ask Congress to strengthen support for our military
families.
In our travels across the country, it become abundantly clear that
we not only needed to help the severely injured, we needed to help
their loved ones too. These loved ones are often on the front lines of
care and they are in desperate need of support. Therefore, we call upon
Congress to make servicemembers with combat related injuries eligible
for respite care and aide and personal attendant benefits. These
benefits are provided in the current Extended Care Health Option
program under TRICARE. Presently, DOD provides no other benefit for
care-giving. Yet we know that many families are caring for their
injured servicemember at home--and many of these servicemembers have
complex injuries. These families, forced into stressful new situations,
don't need more anxiety and confusion, they need support. Families are
unprepared to provide 24/7 care. Those that try, wear out quickly. By
providing help for the caregiver, families can better deal with the
stress and problems that arise when caring for a loved one with complex
injuries at home.
We also recommend that Congress amend the Family and Medical Leave
Act (FMLA) to extend unpaid leave from 12 weeks to up to 6 months for a
family member of a servicemember who has a combat-related injury and
meets other FMLA eligibility requirements. According to initial
findings of research conducted by the Commission, approximately two-
thirds of injured servicemembers reported that their family members or
close friends stayed with them for an extended time while they were
hospitalized; one in five gave up a job to do so.
Getting family members to the bedside of an injured servicemember
is not the problem. The services have developed effective procedures to
make this happen, and the private sector has stepped up to provide
temporary housing. Because most injured servicemembers recover quickly
and return to duty, the family member's stay may be short. However, for
those whose loved one has incurred complex injuries, the stay may last
much longer. Extending the Family and Medical Leave Act for these
families will make a tremendous difference in the quality of their
lives. Congress enacted the initial Family and Medical Leave Act in
1993, when I was Secretary of Health and Human Services. Since then,
its provisions have provided over 60 million workers the opportunity to
care for their family members when they need it most--without putting
their jobs on the line.
We are pleased to see that many Members of Congress have embraced
this proposal and we hope to see it enacted soon.
Mr. Chairman, I believe that government can work to improve the
lives of its citizens. But sometimes, we fix problems by adding more
complexity that in turn creates problems. What we've done with the
Commission's recommendations is strip some of that away to simplify the
system, to go back to basic principles and to make necessary programs
more patient and family centered.
We have been truly heartened by the response our report has
received in the White House, the halls of Congress and throughout the
country. The Nation has rallied behind the need to help those who have
put their lives on the line in service to our country. We have met with
the White House and the Departments of Veterans Affairs and Defense and
are pleased to report that they are moving forward on implementing
those recommendations requiring administrative action. We are
optimistic that Congress will do the same for those recommendations
that require legislation.
On behalf of the Commission, I want to thank the Committee again
for the opportunity to discuss our recommendations. I look forward to
joining Senator Dole in answering your questions.
STATEMENT OF HON. BOB DOLE, CO-CHAIR, PRESIDENT'S COMMISSION ON
CARE FOR AMERICA'S RETURNING WOUNDED WARRIORS
Senator Dole. Mr. Chairman, thank you very much, and my
colleagues, thank you very much. I want to tell you, Senator
Isakson, I talked to Doug Bernard yesterday about what is
happening in Augusta and it really appears to be a great
program. I think what you need are more participants. You have
got the facilities. I am not sure there is anything we can do
about that, but I am going to meet with the Executive Director
tomorrow.
And I want to thank Senator Brown because my Great
Grandfather comes from Montpelier, Ohio, so I have got a little
Ohio strain in my system somewhere.
And Mr. Chairman, Senator Inouye and I were both in Italy
in World War II and we were wounded a week apart and a hill
apart and we ended up in the same hospital--in Percy Jones
General Hospital in Michigan--with former Senator Phil Hart,
whom the Hart Building is named after. Phil Hart was a
remarkable guy and he wasn't so badly injured, so he used to
run errands for us and do all these things. He is married to
Jane Briggs, and, at that time, the Briggs family owned the
Detroit Tigers. So, we were able to go to baseball games--had
free tickets and all that. Now they have renamed that facility
the Hart-Dole-Inouye Building. Not that that gets us anywhere,
but if we are ever there, I assume we can get in. [Laughter.]
So, that is a little history. What I am trying to point out
here: it is a different generation. And let me say right up
front, because you are going to hear from maybe some of the
veterans' groups who have some problems--and we suggest that is
a good thing to have a discussion--some are pushing back a
little because of the changes we are making. There is always a
fear that somebody may lose something or that somebody may gain
from our recommendations.
And I will confess, we believe we are talking about a
different generation. If you can see these young men and
women--we met with some yesterday at the White House--their
attitude, and you have got Ted Wade and his wife in the
audience, and what they want to do with their future. So, we
front-loaded these recommendations with more money for
education, more money for family services, recognizing for the
first time that quality of life should be compensable. If you
lose your sight or lose a limb, you have gone from a ten to,
what, a five, four, three. I don't know. But we recognize that
may be considered now by some, and we are going to directly
address the issue, as Secretary Shalala has already pointed
out.
So, if these young men and women who are making sacrifices
today, and as Senator Murray said, we can have different views
on what is happening in Iraq, but we ought to have the same
view on how we treat those who return. And one thing we never
discussed in our Commission was politics. I knew the
Secretary's affiliation and she knew mine. I don't think we
ever knew the others, and we didn't really care. And we never
talked about cost. Cost is never an object. Whatever you think
of the war, President Bush, or whatever, the President gave
three words, said, ``whatever it takes,'' and that was sort of
our charge.
I must say, I have been around a long time. I have been
around the White House a long time, as I said yesterday, not as
long as I wanted to be around the White House----
[Laughter.]
Senator Dole [continuing]. But, I was around a long time--
many administrations. But the White House staff is really
working hard on our recommendations and recommendations from
the Disability Commission in hopes that Congress will take some
action this year, if possible. There is a conference report
floating around that if the Veterans Committee would sign off,
some of these provisions might be included in that conference
report. What is the number, S. 1606? It is the defense
authorization bill. But in any event, that is a technical
matter that you can take care of.
But as Secretary Shalala pointed out, what we didn't want
to do is load you up with 350 recommendations. Secretary Gates
told us when we met with him a couple of months or 3 months
ago, he had 351 recommendations on his desk at that time--just
DOD recommendations. So, we felt the best way to approach this
is to try to simplify it, as the Secretary said, and reduce the
number of recommendations and have some action steps and put
the pressure on the administration to do about 90 percent of
these things without legislation.
So we come to Congress with a fairly limited list of things
to do, and there is some push-back. It may be that this
generation of young men and women, who I believe are now the
greatest generation--I think we passed the baton to this
generation--if they would do a little better than we did, that
is OK. These are grandsons and sons of Vietnam veterans and
World War II veterans, and if their son or grandson does a
little better, has better educational opportunities, better
family opportunities, that is good. That shows we are making
progress. It shows we recognize the sacrifices that these young
men and women make.
So there shouldn't be any dollar costs, and we never talked
about dollars. We didn't have anybody to ask, what is all this
going to cost? I assume somebody here will think of that. We
guessed maybe a billion dollars the first year and maybe more
the second and third years. But again, we just wanted to do it
right.
One thing that I want to stress before I forget it, we also
believe that if you can't find the best care at a VA facility
or a DOD facility, you ought to be able to go to a private
facility. If you live in Idaho or Kansas or Montana or
wherever, you may not have a facility close by, but if there is
a facility close to some disabled veteran where they can
provide--whether it is PTI or PTSD or whatever it might be--
excellent treatment, that ought to be available. You shouldn't
have to drive 400 or 500 miles and spend the night and do all
those things in order to get excellent treatment. And I say
that because Ed Eckenhoff here, who was on our Commission and
who has a serious disability, is the Director of the National
Rehabilitation Center and he has treated--how many?
Mr. Eckenhoff. Last fiscal year, 46.
Senator Dole. But how many Iraqi-Afghan veterans have you
treated?
Mr. Eckenhoff. 46.
Senator Dole. Oh, 46. So they get excellent care, and you
can look at some of the recoveries that are remarkable, because
I am not downgrading the VA or the DOD, but I was saying in
some cases, the private sector opportunity ought to be
available.
One thing we found, because I think the Washington Post
story was a wake-up call for all of us, regardless of our party
or whatever, veterans or non-veterans, it pointed out that we
had a problem. It was primarily a facilities problem, but it
became a patient problem if you were an outpatient and had to
stay in a place like that. Building 18 is not part of the
Walter Reed campus, but it is part of Walter Reed and it never
should have happened. So the President appoints a commission.
Congress has hearings. A lot of good things have happened, but
we still haven't passed anything that is going to make a real
difference.
I don't want to take a lot of time, and you have already
put my statement in the record, but I want to recite just three
cases to give you an example of what can happen.
First is a soldier injured when his Bradley Fighting
Vehicle rolled over on an improvised explosive device and he
was airlifted to Baghdad and received the first of over 40
operations. He was then taken to Landstuhl Regional Medical
Center for additional medical care. And then he ended up at
Brooke Army Medical Center's burn center, which is the best in
the world. It is a great place and I am certain many of you
have visited there. In addition to his burn injury, he also had
Traumatic Brain Injury and his wife joined him and left their
son with his grandmother in Kansas.
Over the next 2 years--some of the things that Senator
Murray has pointed out--the family had to deal with many issues
including military pay and a permanent change of station move,
while maintaining their personal support, much needed to help
their soldier get better. Then, when the soldier finally came
home, he was severely limited in what he could do. The wife
became his full-time caregiver. Now, obviously she doesn't
object to that, but it shouldn't be necessary. She should be
able to pursue her job, her school, her education. So, there
are some provisions for care: we provide for respite care and
additional benefits to make certain that a spouse--it could be
a husband or a wife--can move on with their life and still be
there.
The second story is about a Marine corpsman who was hit by
a rocket when his base in Iraq was attacked and he woke up a
few days later in Bethesda Naval Medical Center, and after
several operations and amputation of his left arm, he was
transferred to Walter Reed for therapy and eventually retired.
The third story is about an officer whose convoy is
ambushed by insurgents and rocket-propelled grenades and one
grenade exploded in the leg well of the vehicle and severely
injured his right leg. The second exploded at the rear of the
vehicle, causing shrapnel wounds of his neck, shoulders, arms,
and back, and he was evacuated and finally reached Landstuhl.
After his two-and-a-half years at Walter Reed, they were able
to salvage his leg and he is on the temporary disability
retired list.
Now, the reason I cite these three stories, they have
several things in common. The medical care and compassion that
these individuals received in the theater was exceptional. You
go back and look at World War II. For every one killed, there
was maybe one survivor. For every one killed today, I think the
number of survivors is 14 or 16. It is way up there. We have
made a lot of progress from the battlefield, and you want to
give a lot of credit to these medics who are out there on the
battlefield rescuing these young men and women.
So, the survival rate is very high because of improved
technology, improved care, improved transportation. It took me
8 weeks to get from Italy to Miami, Florida--my first stop--and
now you can be wounded in Baghdad on a Tuesday and be in bed at
Walter Reed on a Friday. That is just how it has improved. It
meant life for many people who would have otherwise not made
it.
But, here are some of the things that happened. Each of
these individuals encountered problems with difficult and
inflexible systems. They had complex injuries and required
lengthy rehabilitation. They each had case manager after case
manager. We had a young man on our Commission, Jose Ramos, who
lost an arm in Iraq. He had so many case workers, he couldn't
remember their names. Now, you wonder why they don't keep their
appointments and don't see the doctor and don't get out on
time. Jose is just a great guy, and I want to thank the
initiator of the provision of the Recovery Care Coordinator,
which Secretary Shalala initiated, where this one care
coordinator will follow that patient from the time they walk
into Walter Reed Hospital, or wherever it may be--and about 26
percent of people go to Walter Reed, that is their first stop--
and they will follow them all the way through until they go
back to the unit, go home, or go to the VA.
To me, that is a big, big improvement as far as moving the
process along--giving that person not only the responsibility,
but the authority to be there on the take-off and be certain
that they are part of the team. And, I think that it is not
expensive. We are talking about 50 to 100 Recovery
Coordinators. It is not a big, big bureaucracy. And they are
going to be trained by the Public Health Service and the DOD
and the VA, and to the credit of the administration, that
program is already underway. They have already started the
training. I don't know when the first ones are going to be
available, but very soon. I thank Secretary Shalala for that.
In addition, they had trouble scheduling outpatient visits
and follow-up care was difficult. The amount of paperwork, as
somebody mentioned, was enormous. The VA does have the best IT
system of anyplace, any hospital, but DOD is a little behind.
We had a very fine man on our Commission, Dr. Martin Harris
from the Cleveland Clinic, and that is what he does. He is an
expert. And he is working now with the DOD and the VA, and we
think we can make their systems compatible without spending a
lot of big money and do it very quickly.
We are also going to have a Web site where you just punch a
button and you can find out all the services that may be
available for a particular veteran. When is that going to be
available? They are testing it right now. I have to check with
the experts--we call them the three wise ladies--behind me
here.
In any event, the rest of my statement is in the record. We
know that Congress may not agree with everything we
recommended. We both have been around government a long time
and members of our Commission are certainly aware of that. We
would like to think it is a perfect product, but we know that
is not the case. And, certainly we want the VSOs, the Veteran
Service Organizations, to weigh in. But we want to make certain
that everybody understands that we are talking about a new
generation of young men and young women who are making
sacrifices. It is a different time, different opportunities,
different injuries, different technologies, and we think,
maybe, some different compensation. They may get a few more
dollars than maybe somebody in Vietnam. But our charge was only
Iraq and Afghanistan. We only had 4 months. We didn't have time
to go back and look at the other 25 million veterans and say,
well, we ought to do this, this, and this.
I am just very honored. We have a great staff and we had a
lot of help from the DOD and the VA. I think they really try. I
have been going to Walter Reed as a patient for, I don't know,
30 years or more. I think it is a great place and they have
great doctors. One thing we were concerned about, since they
are going to close, is: during the transition the quality of
care would drop off and some poor guy coming here from Iraq
with a bad injury would not get first-rate treatment.
So, our sixth recommendation is--and I am certain everybody
agrees with--that you keep Walter Reed up and running as a
first-class A-1 hospital until somebody finally turns off the
lights. So, up until that final day when the move is made, they
are available to take care of anybody with any kind of an
injury that they deal with at Walter Reed. We also say that if
they need--you know, a lot of these doctors don't want to stay
on a ship that is going to sink in about 4 years--so, we want
to provide some incentives, some additional pay, to keep those
doctors--whether they are Army doctors or contract doctors or
nurses or therapists--keep them there during this transition.
But, I know most everybody here and I know that you are
concerned about veterans. We all are. It is not a partisan
issue. Some veterans have problems. I started working with
veterans when I was a young county attorney in Russell County,
Kansas, as a service officer for the VFW and the American
Legion, and later, the Disabled American Veterans. And so, we
have had problems. We have always had problems. That is why
they had the Bradley Commission. That is why we have had about
ten commissions since then. It is always a work-in-progress.
Obviously, we think we can fix it. It probably won't be
perfect, but we need your help. Nothing is going to happen
unless Congress steps up to the plate and says, you know, this
is a pretty good idea, or maybe we ought to change it, or maybe
it is not a good idea. But, I really believe you are going to
like most of it, and it is because of the hard work and
dedication of the staff members.
We had two amputees on the Commission. Ed is disabled. I
have a slight disability, and then we had the wife of this
young sergeant who was burned over 70 percent of his body. So
we had a representative Commission, as Secretary Shalala said,
and I think we are going to continue working. We are
volunteers. We will be happy to come back. We will be happy to
sit down with staff. I know Karen and Sue and Marie will be
happy to sit down with staff and go into details. We want to
thank you for giving us this opportunity.
[The prepared statement of Senator Dole follows:]
Prepared Statement of Bob Dole, Co-Chair President's Commission on Care
for America's Returning Wounded Warriors before the United States
Senate
Good morning Mr. Chairman and Members of the Committee. It is a
pleasure to appear before you today, along with my fellow Co-Chair
Donna Shalala.
We look forward to working with you, and the other individuals here
today, to support this Nation's goal of assuring that our service men
and woman receive the benefits and services they deserve.
It has been an honor to serve on this Commission, especially with
Secretary Shalala. I have said it before and I will say it here today,
she's been a ``Triple A'' co-chair. She has boundless energy and kept
us going as we tackled this important challenge. It has been a great
experience to work with her and our fellow commissioners.
Our recommendations were guided by the Commission chaired by
General Omar Bradley in 1956, which said: ``Our philosophy of veterans'
benefits must be modernized and the whole structure of traditional
veterans' programs brought up to date.''
Problems accompany change--wars change, people change, techniques
change, injuries change, and we need to keep our military and veterans
health care system up-to-date. I find it remarkable that 50 years later
we are finding so much of what General Bradley had recommended is still
relevant today.
Secretary Shalala has outlined the action steps to be taken by
Congress. I will now tell you how our recommendations--all of them--
work to create a system that serves, supports, and simplifies.
First, let me review our recommendations:
1. Immediately Create Comprehensive Recovery Plans to Provide the
Right Care and Support at the Right Time in the Right Place
2. Completely Restructure the Disability Determination and
Compensation Systems
3. Aggressively Prevent and Treat Post Traumatic Stress Disorder
and Traumatic Brain Injury
4. Significantly Strengthen Support for Families
5. Rapidly Transfer Patient Information Between DOD and VA
6. Strongly Support Walter Reed by Recruiting and Retaining First
Rate Professionals Through 2011.
Now let me tell you how they would work using the experiences of
three wounded warriors.
The first is a soldier who was injured when his Bradley Fighting
Vehicle rolled over an improvised explosive device. He was airlifted to
Baghdad where he received the first of over 40 operations. He was then
taken to Landstuhl Regional Medical Center for additional medical care
and stabilization, after which he was taken to Brook Army Medical
Center's burn center. In addition to his burn injuries, he also had a
Traumatic Brain Injury. His wife joined him at Landstuhl and traveled
with him to Brook, leaving their son with his grandmother in Kansas.
Over the next 2 years, this family had to deal with many issues
including military pay and a permanent change of station move, while
maintaining the personal support needed to help their soldier get
better. When the soldier finally came home, severely limited in what he
could do, the wife became his full time caregiver.
My second story is about a Marine corpsman who was hit by a rocket
when his base in Iraq was attacked. He lost consciousness and woke up a
few days later at Bethesda Naval Medical Center after several
operations and amputation of his left arm. He was transferred to Walter
Reed for occupational and physical therapy and eventually medically
retired.
My third story is about an officer whose convoy was ambushed by
insurgents using small arms fire and rocket-propelled grenades. One RPG
exploded in the leg well of his vehicle, severely injuring his right
leg. The second RPG exploded at the rear of his vehicle causing
shrapnel wounds to his neck, shoulders, arms, and back. He was
evacuated to Al Assad, then Balad, and finally Landstuhl with
operations on his leg at each stop. He was ultimately evacuated Walter
Reed. After 2\1/2\ years of rehabilitation and additional operations to
salvage his leg, he is on the temporary disability retired list.
These stories have several things in common. The medical care and
compassion that these individuals received in theater was exceptional.
Today's military trauma care saves lives that would have been
impossible in previous wars. The military medical evacuation system
that removes injured servicemembers from the field of battle to a
military treatment facility in the U.S. within 36 hours after the
injury is nothing short of remarkable.
However, each of these individuals encountered problems with
difficult and inflexible systems. They each had complex injuries and
required lengthy rehabilitation.
They each had case manager after case manager. One told us he had
over 10 and could never remember what they were managing, never mind
their names. Communication between the providers of care and services
and the servicemember were spotty at best and, often, didn't happen at
all.
Scheduling outpatient visits for necessary follow up and care was
difficult. The amount of paperwork was enormous, never ending, and
redundant. Patients and their families had no single point of contact.
Processing for a medical discharge took months and delayed patient and
family decisions. At Walter Reed, outpatients exceeded the facility's
capacity to house them, creating the problems of Building 18.
Had our recommendations been in place, each of these individuals
would have had a recovery coordinator assigned at the time they arrived
at a stateside military hospital. The recovery coordinator would have
developed a recovery plan along with the patient's medical team and
other personnel designed to return the patient to optimal functioning.
The recovery plan would make the best treatment and services
available--including those in the VA or the private sector. The plan
would not stop after the patient's discharge from the hospital, but
continue to guide recovery through outpatient care, rehabilitation, and
any necessary retraining or education. The recovery coordinator would
serve as a single point of contact for the patient and family.
We recommended that the recovery coordinator be part of an elite
unit of the Public Health Service. We did so because we thought it best
to place these individuals outside of either the DOD or VA. Part of
this reasoning was because we were concerned that VA or DOD employees
would not be allow to effectively reach out to the other Department,
marshalling needed services, with any degree of authority.
We also recommended that Walter Reed be supported until it closes.
Perhaps some of the difficulties with outpatient clinic appointments
and medical hold and holdover at Walter Reed would not have been so
problematic if our recommendation had been in effect.
Fortunately, only one of the individuals I mentioned had a
Traumatic Brain Injury and none have developed Post Traumatic Stress
Disorder. We recommended that the DOD and VA aggressively prevent and
treat TBI and Post Traumatic Stress Disorder.
New ways of protecting our servicemembers from these devastating
conditions would be developed and implemented. Military leaders, VA and
DOD medical providers, family members and caregivers would have access
to educational programs to better understand these problems and how to
help.
Health care providers in both the DOD and the VA would be using the
most contemporary clinical practice guidelines to assess and evaluate
servicemembers and veterans for these conditions.
More mental health professionals would be available in the DOD and
VA. Anyone concerned he or she might have PTSD could go to the VA, an
internationally recognized expert in combat related PTSD, to get care.
Families, such as the one in my first story, also need support and
help. With our recommendations, the grandmother, who took a leave of
absence from her job to stay with her grandson, would be able to take
an additional 3 months under an enhanced provision within the Family
Medical Leave Act.
The wounded warrior's wife would be able to get respite care or aid
and attendant care through the ECHO program within TRICARE. As the
primary caregiver for her wounded husband, she needs assistance,
assistance that currently does not exist in the DOD.
She would also get training and counseling to help care for her
husband.
All three injured individuals had to deal with mountains of
paperwork--paperwork that was frequently lost or unavailable at
critical process decision points. In this day of electronic everything,
it is frustrating to fill out form after form, repeating the same
information over and over again.
But the problem with information technology should not be solved by
starting over--that will just delay things. Instead, we have
recommended that DOD and VA be held to a scorecard for documenting the
progress of information sharing. While we all want interoperability of
medical records, we don't have to wait for this goal to become reality.
Much can be made visible now.
We have also recommended the development of a web portal that will
provide tailored information to each servicemember and veteran specific
to their situation. We understand that this effort is currently
underway and we are ready to try the product.
We have also recommended a complete reform of the current
disability evaluation and compensation system as Secretary Shalala has
just told you.
Under this recommendation, each of our wounded warriors would be
evaluated as to whether they could perform any military duty by the
DOD. If not, each would be medically discharged with an annuity based
on rank and time in service. They each would get TRICARE for themselves
and their family.
The single medical exam performed by the DOD to determine fitness
to serve would also serve as the exam used by the VA to determine the
disability rating using an updated rating schedule. The disability
rating determines what VA benefits and services the veteran could
receive, and the VA's disability compensation.
Each would get to select one of two transition payments to take
effect upon discharge. They could elect to get 3 months of basic pay,
or enroll in an educational or training program with an enhanced
stipend for up to 72 months.
At the end of the 3 months or after completing the educational
program, each would get a quality of life payment based on their
specific injuries. They would also get an additional payment to make up
for any earnings loss.
We realize that adopting a new system requires a leap of faith for
many. We are therefore, recommending that two studies be done in the
short term. We need to determine the right amount of transition pay. We
also need to determine what a quality of life payment would look like.
Once these are completed, and we should not take forever, reforming the
current disability evaluation and compensation system should move
forward.
For those of you familiar with the Commission's members, you will
recognize the individuals in the stories. One is Chris Edwards, whose
wife, Tammy Edwards, served as a Commissioner. The other stories belong
to Jose Ramos and Marc Giammatteo, two of our other Commissioners. I
want to personally thank all the Commissioners for their dedication and
hard work.
I have one last story. This soldier was hit by machine gun fire
when he tried to assist a wounded comrade. It took 9 hours to evacuate
him from the battlefield and 24 hours to further evacuate him to a
field hospital. It took almost 2 months after his injury to evacuate
him to a stateside Army Hospital. He underwent 9 operations, survived a
blood clot and, over a period of 3 years learned to adapt to his
disability through rehabilitation, with his mother at his side. His
community chipped in to pay his hospital bills and one private sector
surgeon performed 7 additional operations at no charge.
Of course, this last guy is me. I only bring my story up to show
the differences between now and then. We should always try to improve
on what has gone before. This may mean that some of the more recent
wounded warriors get benefits that I don't and that's OK.
I really believe that these are really bold recommendations and
doable, but it requires a sense of urgency and strong leadership.
We stand ready to assist you in any way as we work together to
create a system that serves our bravest men and women who have made the
ultimate sacrifice for our Nation.
Thank you.
______
Responses to Written Questions Submitted by Hon. Daniel K. Akaka to
Senator Bob Dole and Secretary Donna Shalala
Comprehensive Recovery Plans
Question 1. The idea of a coordinated recovery plan is one I
embrace fully. The Committee-reported bill on traumatic brain injury
includes this concept. However, I am trying to understand more fully
the Commission's recommendation for a single recovery coordinator. The
final report of the Commission urged the development of a corps of
recovery coordinators within the Public Health Service. At the hearing,
you talked about a much larger role for VA in this process, with VA
taking the lead in all respects. When did this change and was the
Commission involved in this change?
Response. In our recommendations regarding the Recovery Plan and
Coordinator, we recommended placing the Coordinators within an elite
unit of the Public Health Services. Since our report was issued, we
understand that the VA has requested that the Coordinators be placed
within the VA and trained by a cadre of personnel from the PHS, VA and
DOD. The Commission was not involved in this change.
Question 2. Should VA assume the responsibility for the Recovery
Care Coordinators, does this mean that VA will be responsible for
coordinating the care of seriously injured servicemembers upon their
arrival at a military hospital? As I understand it, some of these
servicemembers will either return to active duty and not be enrolled in
the VA system for years or spend months or years in the DOD medical
system going through recovery and rehabilitation. My question is, do
you believe this care coordination role is one VA should be performing
prior to a servicemember's separation from the military?
Response. We thought long and hard before placing the Coordinators
outside of the two Departments. We were concerned that placing the
individuals wholly within either the VA or the DOD would make it
unlikely that the Coordinators would be able to function as we
envisioned. The Coordinators must be able to operate across the two
Departments and the private sector to access the best care and services
for an injured servicemember. Their work should commence as soon as
possible after the injury and continue throughout the recovery period,
which can indeed be quite long. We were concerned that if the
Coordinators resided within the VA, the services would not allow them
full access to DOD/service resources or the ability to bring them to
bear for the injured servicemember (and vice versa). We were also
concerned that belonging to either department might constrain the use
of private sources of care.
Impact on VA Claims Process
Question 3. Your report recommends that VA update the entire
disability rating schedule to reflect current injuries and modern
concepts of the impact of disability on quality of life. Given that a
comprehensive overhaul of the rating schedule has not been done in over
50 years, I agree that such an endeavor is long overdue. However, at a
time when VA already faces a sizable claims backlog, imposing a new
rating schedule would require an expansive commitment to re-training
staff to use the new schedule. Did your study consider the impact such
a enormous undertaking would have on the already overburdened claims
process?
Response. Most of the current backlog is from veterans already
receiving disability compensation and applying for an increase. Under
our system, with the 3-year automatic review, the workload would be
more predictable and more easily managed. Failing to update, and
appropriately maintain, the current disability rating system is a
disservice to our injured servicemembers. PTSD and TBI are not
adequately addressed in the current VASRD. Quality of life is reflected
in some of the ratings, but not others. The schedule does not reflect
significant advances in medical technology for amputation and other
conditions. Yes, current raters would need to be trained in a new
system--a system that will ultimately benefit veterans. The added
resources needed to make the transition would be modest in comparison
to the budget for veterans' disability programs.
Expert Consultation
Question 4. As you noted in your Op-Ed in Tuesday's Washington
Post, the VA disability system is confusing. The Veterans' Disability
Benefits Commission had the support of Mr. Robert Epley, who has served
in various capacities at VA, including former Director of the
Compensation and Pension Service. Can you please tell me who from VA
was available to assist the Commission by providing expert advice?
Response. Dr. Gail Wilensky, one of our Commissioners, was the co-
chair of the 2003 President's Task Force to Improve Health Care
Delivery for Our Nation's Veterans. This 2-year effort focused
considerable attention on improving the seamless transition to veteran
status. As one of the nation's leading health economists and policy
experts, Dr. Wilensky also has expertise in disability systems. The
three Commissioners who were in the system and became advocates for
other servicemembers--Tammy Edwards, Marc Giammatteo, and Jose Ramos--
gave us a most important servicemember's perspective. Our
recommendations covered both the DOD and VA disability (and retirement)
systems and our staff included senior staff from both systems. In
addition, we consulted with the Veterans' Disability Benefits
Commission senior staff, Admiral Cooper and his senior staff, GAO's
veterans' disability analysts, several of the experts who served on the
Institute of Medicine panels, and officials in the Office of the
Undersecretary of Defense for Personnel and Readiness and the military
services. Our research director, Susan Hosek, had significant expertise
from her 35 years as a RAND researcher, including 6 years as director
of RAND's preeminent defense manpower research group. She was also a
member of the President's Task Force to Improve Health Care Delivery
for Our Nation's Veterans.
Survey
Question 5. Over 40 percent of those who responded to the survey
were active duty servicemembers and thus not yet eligible for VA
disability compensation. These servicemembers would likely not have had
the sort of contact with VA to be able to make a knowledgeable response
to survey questions regarding the VA compensation system.
How were their responses weighted in comparison to
recently separated or medically retired veterans who had actual
experience with VA?
Do you know how many survey respondents had actually
sought VA disability compensation?
I understand that the response rate to the telephone
survey was less than thirty percent and that, for some subsets of the
survey, the response rate was in the single digits. How does such a low
response rate affect the validity of the survey?
Response. As of the end of May 2007, 10,185 servicemembers met the
criteria for our survey: (1) medically evacuated from theater to the
U.S. for deployment-related injuries or illnesses or (2) subsequently
diagnosed with PTSD and (3) separated/retired for no more than 2 years.
The last criteria was necessary because of DOD survey regulations but
data on the flow of casualties out of theater indicated that this
criterion eliminated very few. Of these, only 1,715 had separated or
retired from military service. We included all of these individuals in
the sample for the survey and they accounted for 29 percent of the
sample and 26 percent of the responses. We developed weights so that we
could present findings that were representative of the population we
sampled. The survey's questions about VA disability evaluation were
asked only to the separated/retired group. We also separately tabulated
the results for the other questions since we knew that this group--most
of whom were injured relatively early--may have had different
experiences.
Among survey respondents who had separated or retired, 89 percent
had filed a VA disability claim and almost all the others planned to do
so. Of those who had filed, 58 percent had completed the process by the
time of the survey.
The overall response rate was 30 percent and there was almost no
difference across sub-groups (e.g., military service, component, age,
rank, sex, category of injury). There were two reasons for non-
response: inability to locate the respondent during the 2-week period
the survey was in the field and refusal by those we were able to
locate. We located 50 percent of the sample and completed interviews
with 60 percent of them. Only 15 percent refused the survey outright.
Our response rates were at least comparable to rates on similar DOD
surveys of military personnel, even though these surveys are in the
field for months, not weeks, and involve more follow-up. The response
rates were well above what we anticipated based on experience with this
population.
Different Eras vs. Different Systems
Question 6. Should the disability system be changed in the manner
in which you recommended, how do we reconcile veterans from different
eras receiving different benefits? Do we run the risk of disadvantaging
older veterans from World War II, Korea and Vietnam?
Response. As with all transitions, some individuals may be more
comfortable with their current status and not wish to change. This
should be allowed. For those that wish to come under the new system,
they should be allowed an election period. Going forward, all medically
discharged servicemembers would come under the new system. Ultimately,
the decision rests with Congress.
Disability Appeals
Question 7. Should VA be given responsibility for making the sole
disability determination for servicemembers being medically retired
from the military, what process did you envision for servicemembers to
appeal a VA disability decision with which they disagree?
Response. Under our recommendations, the DOD determines fitness to
serve and, when a member is found medically unfit and no longer
``employable'' in any military capacity, provides a retirement annuity.
Prior to discharge, the servicemember could appeal the finding of unfit
and petition for retention, as they do now. The discharged
servicemember, now technically a veteran, would get his or her
disability rating from the VA. The current system of disability rating
appeal within the VA can still be used to adjudicate any challenge.
Question 8. What do you believe would be the impact on VA's
resources if it took on the responsibility for handling these claims
that are now managed by DOD?
Response. While we were not able to actually quantify the exact
impact, we believe that there is a net efficiency in having only one
physical exam (by DOD) and one disability evaluation determination (by
VA). As our survey shows, all servicemembers who are medically
discharged from military service currently file a VA disability claim
and the number of new VA claims will not change under the new system.
Since DOD will conduct a physical exam that meets VA requirements for
disability evaluation, there will be many fewer physical exams
performed by the VA.
VA Information Technology
Question 9. I could not agree more with the Commission's assessment
that VA and DOD need to move quickly to get clinical and benefit data
to users. I note your action plan established a 12-month time line for
VA and DOD to make this happen. This is certainly a noble goal but, as
I am sure you know, DOD and VA have been working toward sharing health
information for the past decade without great success and VA internally
has been working a similar process for benefits information for well
over a decade.
How does the Commission envision the Departments meeting such a
short time line for comprehensive data sharing?
Response. Commissioner Martin Harris, CIO for the Cleveland Clinic
and an expert in health information systems, worked closely with our
staff experts to evaluate the two departments' plans for information
interoperability and progress in implementing those plans. Given
progress to date, the Departments agreed with Dr. Harris' conclusion
that they most information can be made available in the short term
(viewable), thus the year time line. The departments should be held
accountable for data-exchange outcomes, not process. We have provided a
scorecard to use in this regard. We fully understand the frustration
with the slow progress in achieving interoperability. We were
encouraged with the recent electronic availability of the DD214.
Unemployment Compensation for Ex-Servicemembers
Question 10. With respect to your Commission's suggestion for
``transition payments'' during the first 3 months following discharge
from active duty. How do those payments relate to the benefits
available through the Unemployment Compensation for Ex-Servicemembers
(UCX) program?
Response. The UCX is a state based and run unemployment
compensation program. It provides income for ex-servicemembers after
active duty while they search for a job. Because this is a state run
program, eligibility and benefits vary. Our recommendation was for
those servicemembers found unfit and medically retired. They would
receive a standard 3 months of full pay while transitioning between
active duty and work. This would supplement UCX for those who meet the
state requirements.
Chairman Akaka. Thank you very much, Senator Dole. Without
objection, your statement will be included in the record.
Senator Dole. I don't know what it says. I forgot to read
it. [Laughter.]
Chairman Akaka. Thank you both for your statements and we
do have questions here.
One of the Commission's recommendations is that Congress
enable all veterans who need PTSD care to receive it from VA.
We have worked very hard this year to ensure a solid level of
resources so that VA could continue to improve their efforts in
PTSD. But, I am unaware of any existing impediment in law or
otherwise which now bars veterans from getting care for PTSD.
My question to you is, what exactly is the basis for this
recommendation?
Ms. Shalala. Well, I think we want to make sure that there
is a presumption that anyone can walk in forever, whether or
not they have gotten care before, and we want to make it clear
that there ought not to be a time constraint, because we know
that PTSD can show up a year later or 2 years later.
And one of the points that Senator Dole keeps making is
that this is a different generation. Many of them want to go
home immediately. They are asked the question, is there
something we should know? Are you feeling, you know, any
symptoms after coming back? They all answer no, and then a year
later or 6 months later or 2 years later, it shows up. So, I
think that making it very clear that they have access to
services, lifetime services, is extremely important.
Chairman Akaka. Thank you.
Senator Dole. Could I ask Sue to make a point on that?
Chairman Akaka. Please state your name, also.
Senator Dole. Sue Hosek with the RAND Corporation.
Ms. Hosek. Yes. Currently, veterans get 2 years'
eligibility at the VA after they leave the service, but after
that time--and PTSD symptoms can appear after that time--they
first have to go through the process of being declared
eligible, and our concern was that some of these people need to
be seen immediately and not wait for the disability evaluation
to occur.
Chairman Akaka. Thank you. Thank you very much. You know
that----
Ms. Shalala. It ought to be clearly a walk-in service so
that people can be seen right away.
Senator Burr. Well, we have a polytrauma center in Richmond
which does a good job with PTSD and TBI.
Ms. Shalala. Which we visited.
Chairman Akaka. I do appreciate that your Commission was
tasked with focusing on improving the care and benefits for
those returning from the wars in Iraq and Afghanistan. My
question to both of you gets to the crux of the challenge we
face as we work to effect meaningful disability reform. Do you
believe there should be a separate disability process for
servicemembers who are wounded, injured, or become ill in a
combat zone versus those who suffer disabilities elsewhere?
Senator Dole. No. Our view is once you are in uniform, you
don't have to be shot at to be injured, or while in the line of
duty. If it is somebody who is derelict in his duties and, you
know, drugs or something like that are involved, then there is
a question. But, I think I have gotten it right--it is across-
the-board.
And ``combat-related'' is not a narrow definition. Maybe
General Scott can elaborate on that when he comes up here. But,
as soon as you sign up in the Army, you are getting ready for
combat. You may never get there, but you are training for it,
so it is a pretty broad term.
Chairman Akaka. What is your opinion--this has to do with
quality of life--what is your opinion of the recommendation
made by the Veterans Disability Benefits Commission that until
a systematic methodology is developed for evaluating and
compensating for the impact of disability on quality of life,
that there should be an immediate interim 25 percent increase
to compensation rates?
Senator Dole. My view is that we are going to--this is
going to be done very quickly. There is going to be a
commission determining what a quality of life payment would be
for, say, an amputee or someone who lost sight, somebody with
severe burns; and that commission is going to report back to
Congress. Congress has to have a say, and should have a say.
And that is not going to be very far off. So, I think by the
time we start one system, getting ready for the other system, I
am not certain--if it is going to take 4 or 5 years, I would
say maybe it is a good idea. But this ought to be done in 6
months.
Ms. Shalala. Quality of life payments are well established
in the private sector. An internal study ought to set some
standards for us, and I agree with Senator Dole to keep the
pressure on, getting the facts and getting this set up.
Senator Dole. You know, this is going to be a significant
amount added to somebody's loss of earnings. We have got two
new benefits here. The transition payment, which Secretary
Shalala discussed--there is going to be a commission to look at
that, whether it ought to be 3 months of base pay, whether it
will be something else.
And then we have got this quality of life payment, which is
based on, I assume, the kind of injury. But we are talking
about things that maybe you won't be able to do. You know,
people have a social life. Maybe you won't be able to dance, or
maybe you can't play the piano like before. Maybe there are
things you can't do that really affect your quality of life. We
think it is time it is recognized and paid for.
Chairman Akaka. Thank you. Senator Burr?
Senator Burr. Thank you, Mr. Chairman.
Let me just point to the fact that I think this is a great
team. Both of you bring unusual experience and expertise and
you have a passion that blends very well. I sat here listening
to the Chairman and your comments. It reminded me of the words
of Thomas Jefferson when he said, ``I am not an advocate of
frequent changes in laws and constitutions, but laws and
institutions must advance to keep pace with the progress of the
human mind.''
Really, the heart of what you have talked about recognizes
the fact that we have got generations in this system. And are
we the ones that are going to recommend--do you put the focus
on the current and the future ones and begin to distinguish the
challenges that our troops are faced with coming out of the
conflicts today, and the types of wounds that they have got and
the uniqueness of that, in comparison to everybody else in the
system. And isn't it time that we begin to recognize that there
are two systems, because there are two sets of injuries.
Senator Dole. Now that is--go ahead.
Senator Burr. No. I want to go to the fact that some of the
veterans' organizations have expressed concern with creating a
new disability system even though it only applies
prospectively, and I----
Senator Dole. If you like what you are in, you can stay
there.
Senator Burr. That is right. What are the challenges that
you two see associated with a swift implementation of the
recommendations to this new disability system?
Senator Dole. For you to persuade these people who are
opposed to it to get on board. There are not many. I mean, I
think there are some legitimate concerns that I think you can
all address. But just to say that, ``Well, we don't want any
change, we like this 600 pages of band-aids we have been
putting on over the years''--but again, I want to make the
generational divide. Somebody has to stand up and say it is a
different kind of warfare; it is a different generation. We
have got to look ahead, as General Bradley did in 1956, and
say, well, it is about time after, what, 51 years or whatever
it is. Maybe we ought to move ahead.
What you need to do, really, is to get a group of these
young men and women, the Wades, for example, and others, to
tell you how they feel about it, because they are different
than our generation. I never thought I got enough money, of
course. I am an average American veteran. You never think you
get quite enough. But we think we have addressed some of those
concerns and we want to work with the veterans' groups.
Have you got anything to add there?
Ms. Shalala. You know, the problem with change is that
everybody thinks you are doing it because you are trying to
save money. You start out with this kind of attitude that if
you take on a system, particularly a complex system, you are
trying to reduce the budget. In this case, that is not what we
are trying to do at all.
Are there managerial challenges to creating this
transition? Not really. I have implemented very complex
changes--welfare reform, for example; major changes in the
Medicare system; Social Security Disability went through a
major change. It is possible at a managerial level to implement
a transition, because you are only dealing with new people
coming in. Anyone that has the current system and loves it can
keep it--anyone who has already been evaluated. What you are
doing is introducing a new system, and if it is only focused on
the new people, it is relatively easy to put in place.
And, as I have indicated, there is private sector
experience here. You are not inventing something that hasn't
been tried in the private sector. In the case of family
support, we are simply saying, add more resources. Be more
sensitive to women and to heads of households. Don't think of
the family members as people who have to coordinate care. Give
them the option of going on with their professional lives, in
many cases, and having the kind of support system and quality
support system they think their loved one deserves and needs.
So, some of it is an investment in resources, but most of
it is things that we know how to do. We certainly have to work
with the definitions. But the numbers will be relatively small
in the transition.
Senator Burr. Secretary Shalala, did any of the Commission
members worry about whether the VA could handle two disability
systems?
Senator Dole. I don't think so, and we had VA people
detailed to us. Top-level people worked with our three wise
ladies and I don't think----
Senator Burr. So, we can be fairly confident that the
Commission came to a consensus that this was not a problem. We
can handle two systems.
Let me ask one last thing. My time has run out, but the
White House made a proposal yesterday--they publicly made their
proposal. There were differences. There were changes from that
of your recommendation. Could you highlight those changes? I
know you alluded to one of them dealing with the Social
Security earnings.
Ms. Shalala. Right. They spend more money. They eliminate--
they allow you to keep your Social Security at the same time,
for example, was one change that they recommended. I am not
sure that I have all of them----
Senator Dole. They expand TRICARE, too.
Ms. Shalala. They expand TRICARE more dramatically than we
did. Whatever they did, they added as opposed to restricted our
recommendations, and while we discussed that at some point--
yes, the main thing was the earnings loss component, that that
earnings loss component should disappear when the veteran
begins to receive Social Security. The administration has
altered that proposal and not made the loss of earnings subject
to the FICA tax and they don't stop that earnings--that income
when the person gets on Social Security. So they make it for a
lifetime.
Senator Dole. That is one big objection one or two of the
VSOs had, so that has been resolved.
Senator Burr. Well, my hope, and I believe I can speak for
the entire Committee, is that we know if we can find consensus
between the VSOs and the administration and both of the
Commissions that are recommending, we can get legislation as
quickly as what you said, Senator Dole.
Ms. Shalala. And, I think we want to be very clear about
the veterans' groups who we have all worked with. I haven't
worked as extensively as Senator Dole. We would not have the
kind of substantial system we have in this country without
their advocacy. I fully understand that they should question
every proposal rigorously, because they are absolutely in the
right place in terms of who they represent.
We are simply saying, look, we think that we can make it
even better for future generations. We can simplify it. We all
ought to be able to understand this. This system took me--I
spent a lifetime understanding health care systems and complex
organizations. It took me a while to kind of get my arms around
and try to understand it. We ought not to have government
programs that require expertise to understand.
Senator Burr. Thank you both.
Chairman Akaka. Thank you very much, Senator Burr.
Senator Murray?
Senator Murray. Thank you, Mr. Chairman.
Thank you both for really taking the time to look at this
through the patients' eyes and the veterans' eyes rather than
through the bureaucratic lens that too often, I think, gets
focused on the system. I really appreciate the work that you
and the Commission did on this.
I heard Senator Tester say earlier, too often, it is like
the veteran is fighting the system rather than the system
working for you, and just listening to it, it sounds like you
are trying to change that mindset of the VA, which is really
important.
One of my concerns is we do not have a Secretary of the VA
currently. We haven't received a recommendation from the
administration or anyone sent over here for that position. Are
you concerned that the implementation of this, which is going
to put a lot of pressure on the VA to do, it is going to take
somebody at the top to really keep that culture that you are
talking about, are you concerned that we don't have a head of
the VA right now and are you working with the administration to
get someone?
Ms. Shalala. I am not.
Senator Dole. I think we were asked that question
yesterday, which is a good question. Right now, Deputy
Secretary Gordon Mansfield meets every week with Gordon England
of DOD and they have these weekly meetings and they are really
moving ahead with these recommendations. In fact, they have
been given a mandate by the White House to move ahead. But
obviously, the sooner we have somebody on board who is really
going to push this program----
Senator Murray. And who comes with the right mindset, too.
Senator Dole. I think that is going to be very soon.
Senator Murray. Okay.
Senator Dole. It will be up to, of course, your
confirmation, but I think you will have a nominee----
Senator Murray. Well, I would assume, though, that you
would want the nominee to have that culture and mindset that
you are speaking about, as well, so----
Senator Dole. We hope the nominee is asked before he is
nominated or she is nominated that they have looked at this and
they have looked at the other commission and they can support
it vigorously.
Senator Murray. Some of the critics are concerned that a
lot of your recommendations are Executive Branch implemented,
not Legislative Branch implemented. Are you concerned about
that at all?
Ms. Shalala. Well, I think that reflects a certain
shrewdness on our part to try to make sure----
Senator Murray. Oh, you trust us less than them?
Ms. Shalala. No. No, not that. But we wanted to move
immediately. We actually divided up what required legislation
and what didn't require legislation.
Senator Murray. Is there a time line for the
administration----
Ms. Shalala. We expect, I think, almost everything to be
done within a year. We did not give them a lifetime for
implementation, and each of us is checking on--for instance,
Dr. Harris is right on top of the IT recommendations. Senator
Dole has been over on a regular basis to ask questions. Our
staffs have been over to see how the implementation is going.
So, we did not walk away from this and we did divide up the
recommendations so that--I am a big believer in identifying the
short-term things that you can do internally and then the
longer-term things that require legislation----
Senator Dole. Right. We could probably provide a list to
the Committee of what the administration----
Senator Murray. Has done already?
Ms. Shalala. And an update on all of that.
Senator Murray. I think that would be helpful.
Ms. Shalala. But we actually thought about it, to make sure
that things were getting done.
Senator Murray. OK. Well, specifically, I wanted to ask
you, one of the biggest differences between your report and the
report produced by the Veterans Disability Benefits Commission
is the way in which you do compensate combat-injured versus
non-combat-injured veterans. The way I hear you, your approach
creates benefits specifically for combat and combat-related
injuries and the Veterans Disability Benefits Commission
compensates veterans based on the severity of their disability,
not on the circumstances or the location. I am a little bit
confused about what you consider to be combat injury. Is
everything--if you are training for combat and you are here--is
that considered combat injury?
Ms. Shalala. Our definition of combat-related is very broad
and it only applies to two provisions under our disability
plan. The first is: that those found unfit due to combat-
related injury or illness would receive a lifetime TRICARE
coverage; and the second is, that these individuals would
receive quality-of-life payments from the VA for life, as well.
That definition includes those training for combat----
Senator Murray. So, if you are training here, that would
be----
Ms. Shalala. If you are training for combat its part of our
definition. So it is very broad.
Senator Murray. What if you----
Senator Dole. We tried line of duty; we tried combat-
related. We want to make it broad. And we were told by DOD,
well, once you sign up for whatever it is, whatever service,
you are, in effect, training for combat someday. So----
Senator Murray. Okay, so it includes training. What about
in-theater non-combat----
Ms. Shalala. Yes.
Senator Murray. Your vehicle rolls over----
Ms. Shalala. Yes.
Senator Murray [continuing]. Is that considered combat?
Ms. Shalala. Absolutely. Absolutely. And you could look at
the two systems we recommended. We were focused on these
Afghanistan and Iraqi wars, trying to set up a system. But
again, we believe we have one plan and we used as broad a
definition as we could. But, that is, in part, for Congress to
decide.
Senator Murray. OK. One other quick question. You have
recommended a single medical exam, which I think makes a whole
lot of sense. But, I am worried that that means, perhaps, the
government could arbitrarily cut off a veteran without giving
him a chance to appeal. Can you tell me how a veteran would
deal with an appeal? Do they have the opportunity to disagree
with the disability rating?
Ms. Shalala. They would always have an appeal. We asked DOD
to do the exam based on standards that they and the VA agree
to. So there is a single exam----
Senator Murray. And once they leave DOD, they have that
exam----
Ms. Shalala. They have that exam. They take it over to VA--
--
Senator Murray. Do they have a chance then----
Ms. Shalala [continuing]. And VA then looks at the whole
person.
Senator Murray. OK. Do they have a chance then to appeal
that?
Ms. Shalala. There is always an appeal process. I don't
know of a program without an appeal process.
Senator Dole. In fact, we make certain that the DOD
examiner understands that one can have disabilities and still
be fit for duty. But, we want that examiner to hand over to the
VA everything that may be wrong with that individual, so they
can make an appropriate rating.
Ms. Shalala. And that is why the two agencies define what
is covered in the physicals. So, the whole thing goes over to
VA and then the disability determination is done over there.
Senator Murray. Okay.
Senator Dole. I think there is a feeling, Senator Murray,
that the VA is a little more generous, too, with the ratings,
so from the standpoint of the veteran, I think that is a plus.
Ms. Shalala. And the advantage is there, because DOD is
only making a fit/unfit [determination], though they are making
a comprehensive exam. But you don't leave the DOD without your
annuity in hand----
Senator Murray. Okay.
Ms. Shalala. Even if you have only had 5 years or 3 years,
based on your rank, you leave with an annuity that you have
forever, no matter what happens over at the----
Senator Murray. And just so I understand, too, you have
this one-time decision that you can stay with the current
system or transition to this. Is there any provision for
somebody who decides down the road a couple of years that that
doesn't work for them, or do you just say--I mean--it is going
to be a very confusing time for people to have to make that
decision.
Ms. Shalala. It is soldiers and sailors and Marines from
October 1 of 2001 on, and what you are asking is if they have
already had their rating, if they decide later they want to
come into the new system whether they could. We didn't
stipulate----
Senator Dole. We left it open.
Ms. Shalala. We left that question open and that obviously
is something that Congress----
Senator Murray. I believe in the administration's draft
legislation they are saying----
Ms. Shalala. The administration said, ``no.'' We left that
open.
Senator Murray. You didn't----
Ms. Shalala. Our recommendation was to leave it----
Senator Murray [continuing]. Are you----
Ms. Shalala [continuing]. We left it open for Congress to
make that decision.
Senator Murray [continuing]. Are you concerned, then, with
a massive----
Ms. Shalala. No.
Senator Murray [continuing]. With a big change----
Ms. Shalala. I am not concerned with big numbers if you go
from 2001 on. I think most people will probably stick with
their current system if they have already gone through the
evaluation process, and----
Senator Dole. We have a young man on the Commission, Jose
Ramos, who is in the current system and I think it is working
for him. If he wanted to change----
Ms. Shalala. He could.
Senator Dole. He could do that, right?
Senator Murray. He has a one-time chance to make that
decision under the administration's legislation.
Ms. Shalala. Yes, under the administration's legislation.
Under ours, we left that open, which means the Congress just
makes a judgment about that. And, when you are in a transition
period, you may make a different decision, just for the
transition period of maybe a certain number of years, as
opposed to long-term.
Senator Murray. Thank you, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Murray.
Senator Webb?
STATEMENT FROM HON. JIM WEBB,
U.S. SENATOR FROM VIRGINIA
Senator Webb. Thank you, Mr. Chairman, and Senator Dole and
Secretary Shalala. I did watch your testimony from my office. I
have a couple of questions from the testimony, and I want you
to know that I am not walking in here cold right now. Further,
I didn't move down to this seat to get away from Senator
Tester. It is the only seat that has a microphone.
With respect to PTSD, I, as many know, worked on the
Veterans Committee on the House side for four years as a
committee counsel and when we were doing a lot of pioneering of
that program and I would support what you are doing on that
because PTSD sort of oscillates through your life. There are
relatively few, in the experiences that we had, who would be
leaving the military and be diagnosed with PTSD, and yet down
the road, in my experience, it sort of popped up in about an 8-
year cycle and then about a 20-year cycle with people who had
served in Vietnam, so I would fully support that.
I would like to make a point just from having watched the
testimony and having worked in this area off and on all of my
adult life. It is one I hope we don't lose as we start
analogizing to the civilian employment structure, and that is
that a volunteer force is not per se a career force. This is
not a direct analogy to civilian employment. There are a lot of
people who enlist in the military for reasons other than normal
employment opportunity--because they love their country or they
have got a family tradition, people who don't really intend to
stay for a career.
It is for that reason that I have very strong feelings
about readjustment assistance in addition to the types of
things that we have been talking about here. I know, Senator
Dole, you mentioned many times in your testimony about the need
to focus on education, the fact that cost shouldn't be an issue
when we look at that. You mentioned these people since 9/11, we
keep calling them the new greatest generation.
I introduced a bill--this is not directly under the purview
of your recommendations, but it is important when we are
talking about how we are going to help people transition into
the future. I introduced a bill to give the people who have
served since 9/11 the same G.I. educational benefits as the
people who came back from World War II received. It is not true
today, and I think that it is a great oversight in the
veterans' law that we have not done that.
I was wondering, Senator Dole, if you could mention to us
how important the educational piece was for you in terms of
putting together your life after having served.
Senator Dole. Well, there were 16 million of us in World
War II and I think 8.5 million took advantage of the G.I. Bill.
The G.I. Bill was signed down in the Mayflower Hotel, in room
320, and one of the big principals happened to be the National
Commander of the American Legion, who happened to be a Kansan
at that point. In any event, it made a big difference--not only
the education piece, but the other benefits that were in the
G.I. Bill; and it barely passed the Congress, as you probably
remember, no more than four or five votes. It wasn't something
that just sort of swept through the Congress. There was a lot
of debate about it, and I don't know what the objections could
have been.
I think it is the single most important piece of
legislation when it comes to education, in how it changed
America, than anything I can think of. Because, if you get a
college education, then you want your children to get a college
education, and a lot of us didn't have any money. Our parents
didn't have any money. And suddenly, we had this opportunity.
They even gave me a left-handed typewriter, a recording machine
that I could take to class because I wasn't able to write then
with my left hand. I had the best notes in class. I was very
popular around test time every year. And they ought to take the
same care of the veterans today.
Senator Webb. Well, the program they have today is
basically a peacetime program. The individual sort of has to
pay in $100 a month for the first year. They all pretty much
have to, even though it is supposedly voluntary. We have been
doing analysis. It doesn't even take care of, say, 20 percent
of what the costs would be at one of the better institutions,
where after World War II, people got everything.
We had the VA testifying in front of us when I mentioned
this and they said that to do the World War II G.I. Bill today
would be too complicated because you had to look at different
tuition payments and different schools, and I just have a hard
time believing that. We put, I think, 7.8 million people
through regular college after World War II and they did it with
a stubby pencil on the back of a memo pad, they were able to
figure it out. So I can't----
Senator Dole. I am reminded that the vocational
rehabilitation program provides, I think--one of our Commission
members is a Harvard student, and, of course, it costs quite a
bit to go to Harvard. I have never known why, but----
[Laughter.]
Senator Dole [continuing]. So, there is money there----
Senator Webb. I benefited from that program after Vietnam.
I was in vocational rehabilitation when I went to law school. I
think we can--I hope we can--get your support for this for all
people. For instance, on something like PTSD, there are a lot
of these things that aren't manifesting themselves immediately
that would come under the rubric of the type of issues that you
are talking about today, and the No. 1 thing that I can think
of in terms of trying to help people readjust back into
civilian life is a good education.
Ms. Shalala. And Senator Dole came out with a great idea,
and that is for every year people stay in, we increase the
stipend, which actually incentivizes people to stay in for
longer than a year in the program. I think that is very
important.
Senator Dole. Ten percent a year. We give them a 10-percent
increase.
Ms. Shalala. You look at the drop-out rate in the education
programs that you are currently funding and it looks like an
inner-city high school.
Senator Webb. People can't keep up. They can't go to
community college on the Montgomery G.I. Bill.
Ms. Shalala. And I had a young man who contacted me because
he wanted to go to the University of Miami. When he called, he
was in Miami, though he called up to Tampa. They offered him
enough money to go to a community college, but he wanted a
specialized kind of course. Now, we have made an effort to
accommodate him and get him fit together with our programs,
because I was hardly going to turn him away.
Those kinds of investments will make a huge difference in
the long run for us, and we just have to fit it with modern
systems. There is lots of aid available in the States and from
the Federal Government, but it is the wrap money to make sure
it is possible for them to go full-time. So, that is why we
want to extend the time for those that go part-time, but we
also have to know what we are doing and it should not be to
keep people down at a certain income level.
But the incentive system, I think is terrific, because it
encourages--you get more resources as you stay in school.
Senator Webb. Thank you very much. Mr. Chairman, if I may
say one other thing, years ago when I worked on the veterans'
programs, Senator Dole had an incredible reputation. I am not
saying anything people don't already know, but wherever he was
traveling, he was known to go to the VA hospitals in that area
and not allow media to go with him, just to go in and talk to
veterans. Again, I am not saying anything people don't know,
but we couldn't have a better person and a greater national
treasure doing this job. Thank you.
Chairman Akaka. Thank you very much, Senator Webb.
Senator Tester?
Senator Tester. Thank you, Mr. Chairman, and I want to
apologize to the panel for having to go to a Banking markup
meeting. There are some things that I want to visit and I will
be as brief as possible.
Montana, as you both know, is a very rural State. You both
know we have a high percentage of folks in the military. We
have a high percentage of veterans. I think out of 930,000
people, we have about 110,000 veterans. It is extremely rural.
And I think, Senator Dole, in your comments, you talked about
disabled veterans in rural areas being able to access private
care in the areas of TBI and PTSD. Do you see that being
applicable in other areas? I am talking about specialty care,
routine care, anything like that--do you see any benefits of
allowing that to happen in rural or frontier areas?
Ms. Shalala. I do certainly. I visited some of the
conversions and actually helped fund some of the conversions of
hospitals to rehabilitation centers in Montana. You have some
very interesting ways of using existing facilities, and there
is no question in my mind that for certain kinds of
rehabilitation that you would have some facilities. We would
have to do a treatment plan and make sure that it fits with
whatever the treatment plan is, so that people go home and use
existing facilities and take advantage of doctors in rural
areas or in the small towns. But, I certainly have spent enough
time in Montana looking at the health care system to know that
if you had a treatment plan, a way of getting accountability to
make sure that you are measuring progress, we certainly should
take advantage of what is available.
Senator Dole. There is a Sergeant Edmondson that I think
maybe Senator Burr is familiar with in New Bern, North
Carolina, who has a bad TBI. He was able to negotiate to go to
the Rehabilitation Institute of Chicago for treatment, where he
made remarkable progress. Now, I know we don't have any cities
like that in Kansas or Montana, or facilities like that. Then
again, Ed Eckenhoff on our Commission has had 46 Iraq-Afghan
veterans in the rehabilitation center here. So, the answer is,
we live out in the country and we have got to make it easy for
these people from the standpoint of their cost; and some are in
wheelchairs, so it is hard to travel. We would like to have
them get there and back in the same day, if possible.
Ms. Shalala. We have a lot of experience in telemedicine.
Senator Murray has been interested in it a long time, and
taking advantage of that. Medicine has changed, so the key is
the treatment plan, the accountability, and our ability to
tailor it to what works for an individual.
Senator Tester. Thank you. Thank you for your answers. I
couldn't agree more, although I will tell you from a
telemedicine standpoint, when it comes to PTSD or TBI, I have
some concerns about that.
Ms. Shalala. In fact, you need a place with expertise in
those areas. I also want to make it clear that most of the
expertise in this country in TBI and PTSD is in the veterans
hospitals and in the military. The research that is going on,
the clinical research that is going on, while there are some
private sector centers, there's nothing like what is going on
in the military and in veterans hospitals in this country.
Senator Tester. Well, I certainly appreciate that. I can
tell you that my opinion has changed dramatically over the
last--since the first of January--in that, I think that in
rural areas there is a real need that is not being met because
of distance; and so, thank you for your answers and thank you
for your testimony, too.
Chairman Akaka. Thank you very much, Senator Tester.
Before going to panel two, let me ask the Members if anyone
has any questions for a second round.
[No response.]
Chairman Akaka. Thank you very much. I want to thank our
first panel very, very much. Your testimony, your comments,
your advice and recommendations have been very helpful.
Senator Dole. Thank you.
Chairman Akaka. Thank you.
I now welcome our second panel. Lieutenant General Terry
Scott joins us today as Chairman of the Veterans Disability
Benefits Commission. Under General Scott's leadership, the
Veterans Disability Benefits Commission recently completed an
extensive 2-year review of the benefits and services provided
to disabled veterans by the Departments of Defense and Veterans
Affairs.
Patrick Dunne is Assistant Secretary for Veterans Affairs
for Policy and Planning. He appears before this Committee today
representing the Task Force on Returning Global War on Terror
Heroes, an interdepartmental panel assembled to address
administrative barriers to the care of wounded servicemembers.
Former VA Secretary Togo West joins us today as Co-Chair of
the Department of Defense's Independent Review Group on
Rehabilitative Care and Administrative Processes at Walter Reed
Army Medical Center and National Naval Medical Center.
Secretary West served as Secretary of the Army and Secretary of
Veterans Affairs during the Clinton Administration. He will
present the Independent Review Group's perspective on how DOD
can improve the care of wounded servicemembers.
I thank all of you for joining us today and look forward to
your testimony. Your full statements will appear in the record
of the hearing, and in the interest of time, please try to
limit your direct statement to 5 minutes.
So at this time, I would like to call on General Scott for
your statement.
STATEMENT OF LIEUTENANT GENERAL JAMES TERRY SCOTT, U.S. ARMY
(RET.), CHAIRMAN, VETERANS DISABILITY BENEFITS COMMISSION
General Scott. Chairman Akaka, Ranking Member Burr, Members
of the Committee, it is a great pleasure to appear before you
again today representing the Veterans Disability Benefits
Commission. I had the opportunity to testify before you in the
joint session with the Armed Services Committee last April and
it is a real pleasure to be back.
I would like to introduce some of the Commissioners who
were able to be present here today, Commissioner Brown,
Commissioner Carroll, Commissioner Cassiday, Commissioner
Grady, Commissioner Jordan, Commissioner McGinn, Commissioner
Surratt, and Commissioner Wynn. This lady and gentlemen devoted
a lot of time to the two-and-a-half years that the Commission
was meeting, and we met once a month in Washington until the
last couple of months and we met twice a month from then on.
Also, I would like to recognize the efforts of the Executive
Director, Mr. Ray Wilburn, who has done a tremendous job of
keeping things moving when the Commissioners were not present.
Sir, you asked today that I focus directly on areas of
overlap between the recommendations of our Commission and those
of the President's Commission on Care for America's Wounded
Warriors, the Dole-Shalala Commission, and the Task Force on
Returning Global War on Terror Heroes (also known as the
Nicholson Task Force), and the DOD Independent Review Group
(known as the Marsh-West Group).
You also asked for our views on how to improve the VA and
DOD collaboration and cooperation, and how could we resolve the
longstanding issue of creating a VA-DOD Electronic Health
Record. So, per your request, sir, that is what I am going to
address here today.
First, let me say that there is a tremendous amount of
consistency in the findings and recommendations of these four
reports. I prepared for the record, and passed to your staff, a
matrix that listed the four commissions and the subject areas
that they covered. I commend that to the staff and to the
Members if they have the time to read it, because it lays out
in detail how each of the four commissions addressed each of
the important issues.
It is, of course, well known that the scope of these four
commissions was quite different, and this resulted in some
variations in some areas of the recommendation. For instance,
our commission was not chartered to address the issues at
Walter Reed, per se, and we did not.
All of us want to see improvements in benefits and services
for the injured and disabled servicemembers and veterans. I
might make a couple of points here. We found nine areas with
considerable overlap among the reports and some areas with some
limited overlap or some differences, or perhaps it was
differences of interpretation.
The Veterans Disability Benefits Commission believes that
all disabilities and injuries should be compensated based on
the severity of the disability, and I believe that was covered
in the question and answer portion of the last session, so I
will go on from that.
Our Commission also believed that VA disability
compensation should not end and be replaced with Social
Security at retirement age, and we provided some hypotheticals
as to what effect that would have on the severely-disabled
veterans. So, I will be glad to respond to questions on that
later, but that may be a moot issue since, apparently, the
legislation will not have that in it.
I will talk briefly, sir, about the VA and DOD disability
process. All four reports address the problems with the process
used when servicemembers are determined to be fit or unfit for
military duty. We conducted a detailed analysis of those
separated or retired as unfit for duty during the 7-year period
from 2002 to 2006 and compared their ratings with ratings
subsequently completed by the VA. We found that the combined
ratings by the VA were higher, on average, than the ratings by
the services. When comparing the ratings for individual
diagnosis, VA ratings were statistically significantly higher
than those of the services.
We concluded that there should be a realignment of the
process, and that is essentially the same conclusion reached by
the Dole-Shalala Commission, the Independent Review Group, and
the Nicholson Task Force. We also believe that the services
should determine if the servicemember is fit or unfit, and VA
should be responsible for assigning disability ratings. The
Dole-Shalala Commission made the same recommendation.
In redesigning the VA disability process and specifying the
benefits available for those servicemembers, we should
recognize that the overwhelming proportion of servicemembers
medically discharged as unfit do not meet the several
definitions of severely disabled.
Our Commission did not specify which department should
conduct this single examination. In fact, we believe that in
some locations, it might be best determined by the capabilities
of the two departments at that local level.
All four study groups recommended developing a case
management system for severely injured servicemembers and their
families to ensure that the right care and support at the right
time and in the right place. A single case manager should have
overall responsibility. The other commissions agreed.
Family support is addressed by all of the study groups
except the Nicholson Task Force. The families of the severely
injured are assisting in the care and rehabilitation of these
wounded warriors. Our Commission recommended that VA be
authorized to provide similar services to those provided by DOD
to families of the severely injured. We also recommended
extending the CHAMP VA medical care to caregivers of 100
percent disabled veterans, and providing a caregiver allowance.
We recommended eliminating any TRICARE co-pays and deductibles
for the severely disabled because we do not believe the injured
should have to pay in any way for their injuries.
Regarding Post Traumatic Stress Disorder and Traumatic
Brain Injury.--All four reports recommend improvements in
awareness; research; treatment; staffing; and diagnosis
examination of Post Traumatic Stress Disorder and Traumatic
Brain Injury. Our Commission focused more on compensating and
rating these conditions, and we recommend a holistic approach
to PTSD be established that couples compensation, treatment,
and vocational assessment. We also believe that reevaluation
should occur every 2 to 3 years to gauge treatment
effectiveness and encourage wellness. Regarding Traumatic Brain
Injury, we recommend including medical criteria for this
diagnosis as a priority in the revision of the VA schedule for
rating disabilities.
Regarding ancillary benefits.--Our Commission recommended
increases to several benefits that have not kept pace with the
cost of living, extending eligibility in some cases to burn
victims, and expanding the auto and housing allowances. We also
recommended eliminating the premiums for Traumatic
Servicemembers Group Life Insurance, as we do not believe that
the servicemember should have to insure themselves for
traumatic injuries. Perhaps most importantly, our Commission
recommends establishing a pre-stabilization allowance similar
in theory to that recommended by the Dole-Shalala Commission.
Regarding quality of life.--As was mentioned in the Q and A
before, both our Commission and the Dole-Shalala Commission
recommend a compensation payment for the impact of disability
on quality of life. Current compensation payments do not
provide payment above that required to offset earnings loss.
Therefore, there is currently no compensation for the impact of
disability on quality of life for most veterans. While
permanent quality of life measures are developed and
implemented, we recommend that compensation payments should be
increased up to 25 percent with priority to the more severely
disabled, and we provide some hypotheticals that show how that
might be.
In other words, the 100 percent disabled person might get a
25 percent boost for quality of life, whereas the 10 percent
disabled might get a very much smaller boost in payments for
quality of life. So, it would be scaled based on the severity
of the disability--it is an ``up to 25 percent,'' not a flat 25
percent across the board, as has been quoted in some of the
media.
Vocational rehabilitation.--All but the Independent Review
Group addressed vocational rehabilitation. Both the Dole-
Shalala Commission and our Commission found that the
effectiveness of the program is not currently assessed and that
graduates are not followed except for a very brief time period.
Both Commissions recommend either an incentive bonus of up to
25 percent--that would be the Dole-Shalala--or exploring
incentives as a way to encourage completion of vocational
rehabilitation. The Nicholson Task Force focused on using
existing programs and opportunities in that regard.
Concurrent receipt.--Regarding concurrent receipt of
military retirement and VA disability, our Commission found
that these two are different programs with entirely different
missions. DOD retirement recognizes years of service and VA
disability payments compensate for impairment in earnings and
should compensate for impact on quality of life. Over time,
Congress should eliminate the ban on concurrent receipt for all
military retirees and for all servicemembers who are separated
from the military due to service-connected disabilities.
Priority should be given to those veterans who separate or
retire with less than 20 years of service, with a disability
rating of greater than 50 percent, or a disability as a result
of combat.
Payment offsets should also be eliminated for survivors of
those who die in service or retirees who die of service-
connected causes so that these survivors can receive both the
VA Dependency and Indemnity Compensation, known as DIC, and DOD
survivors' benefit, known as SBP.
The Dole-Shalala Commission also recommends that DOD
compensate for years of service, while VA compensates for
disability.
Hazards exposures and presumptions.--Our Commission and the
Nicholson Task Force both addressed hazards and exposures, but
in different ways. Our Commission recommended a new presumption
process as proposed by the Institute of Medicine. The new
process includes enhanced registries of servicemembers and
veterans based on exposure, deployment, and disease histories.
And sir, I commend, particularly to the staff but also to the
Members, this report done by the IOM. This subcommittee was
chaired by Dr. Jonathan Simmet from Johns Hopkins, and I think
that he provided all of us with some truly innovative ideas
about how to address the issue of presumptions of disability.
Improving VA and DOD collaboration.--In addition to
assessing the areas of overlap among the four reports, you
asked my views on how to improve collaboration and cooperation
between VA and DOD. We found many encouraging signs and also
areas which need improvement. The Joint Executive Council has
demonstrated how both departments can benefit from coordinated
planning and increased cooperation. The results are evident in
specific initiatives, including the integration of the North
Chicago VA Medical Center and the Naval Health Clinic-Great
Lakes. This coordinated treatment of severely injured in
dedicated polytrauma centers is also very effective. However,
we believe the JEC planning effort can be significantly
improved by including specific milestones and designating
responsible officials for each.
Successfully transitioning servicemembers to civilian life
is crucial and ensuring that servicemembers understand the
benefits and services that are available to them is essential.
The Transition Assistance Program and the Disabled Transition
Assistance Program briefing should be mandatory and adequately
funded.
After leaving service, many veterans find it difficult to
prove that injuries and diseases that occur later in life are
the result of military service. We believe that all separating
servicemembers should receive a separation examination to
establish a baseline for medical conditions.
There is one way of expediting disability benefits in
effect now. It is called a Benefits Delivery at Discharge
process. It is available at 140 military facilities and these
claims are processed at two VA locations. We believe that this
Benefits Delivery at Discharge should be available to virtually
all separating members, including Guard and Reserve.
One cause for delay in claims processing, even in the BDD
process, is the availability of the discharge document. Our
Commission recommends that DOD immediately provide VA with an
authenticated electronic document so that processing can begin
right away.
Lastly, sir, on IT compatibility.--All the reports address
the absolute necessity for the VA and the DOD to have
compatible information systems, but also to recognize that this
will not solve all problems. Much has been said about the goal
of seamless transition, which is not a current reality. Not all
of DOD's medical and personnel records are electronic, and
those that are electronic are not yet fully compatible between
the services, much less between VA and DOD. There has been an
agreement to create a joint Inpatient Electronic Record that
would be instantly accessible. We do believe that development
and implementation of this information system should be
expedited and that a detailed management plan should be
developed with a lead agent designated and with specific
milestones and plan completion dates.
In conclusion, VA and DOD have much to gain by greater
coordination. Servicemembers and veterans have even more to
gain by the two departments working together. A lot of valuable
work has been done. However, a great deal of work remains, and
the only way the goal of a reasonably seamless transition will
ever be realized is if the two departments are required to
develop realistic challenging goals with specific milestones.
Congress should review these plans and oversee progress.
Congress also has a responsibility to ensure that sufficient
funding is provided to accomplish the goals and objectives
contained in these IT plans.
Sir, that ends my oral statement and I will gladly answer
any questions after the other presentations.
[The prepared statement of General Scott follows:]
Prepared Statement of James Terry Scott, LTG, USA (Ret), Chairman,
Veterans' Disability Benefits Commission
Chairman Akaka, Ranking Member Burr, and Members of the Committee:
It is my pleasure to appear before you today representing the Veterans'
Disability Benefits Commission.
You asked that I focus directly today on areas of overlap between
the recommendations of our Commission and those of the President's
Commission on Care for America's Returning Wounded Warriors (the Dole-
Shalala Commission), the Task Force on Returning Global War on Terror
Heroes (the Nicholson Task Force), and the DOD Independent Review Group
(the Marsh/West Group.) You also asked for views on how to improve VA
and DOD collaboration and cooperation and to resolve the long standing
issue of creating a VA/DOD electronic health record.
First, let me say that there is a tremendous amount of consistency
among the findings and recommendations of the four reports. The scope
of the four efforts was quite different and this resulted in variations
in some areas. But we all want to see improvements in benefits and
services for injured and disabled servicemembers and veterans. Our
Commission generally agrees with the advice provided by the Independent
Review Group and the Task Force and more recently by the Dole-Shalala
Commission, but we differ with two of the Dole-Shalala suggestions. We
believe that all disabilities and injuries should be compensated based
on severity of disability and not be limited to combat or combat-
related injuries. Nor does our Commission believe that VA disability
compensation should end and be replaced with Social Security at
retirement age.
For our own purposes, we prepared a matrix comparing the findings
and recommendations of the four reports which I am pleased to share
with the Committee. I caution that the matrix is not intended to be
exhaustive nor a verbatim listing of all findings and recommendations.
Rather it is a broad overview that I found useful.
The matrix contains a description of each study group's focus and a
brief summary of findings and recommendations and a summary of topics
that overlap. The major topics with considerable overlap are: VA/DOD
Disability Process; Case Management; Family Support; IT Compatibility;
PTSD; TBI; Ancillary Benefits; Quality of Life; and Vocational
Rehabilitation. Other topics with limited overlap include: Concurrent
Receipt; Hazards and Exposures; Combat/Combat Related, Social Security,
and Walter Reed. Our Commission addressed all of these topics except
Walter Reed, which was not within the scope of our charge.
va/dod disability process
All four reports addressed the problems with the process used when
servicemembers are determined to be fit or unfit for military duty. Our
Commission conducted a detailed analysis of those separated or retired
as unfit for duty during the 7-year period from 2000 through 2006 and
compared their ratings with ratings subsequently completed by VA. We
found that the combined ratings by VA were higher, on average, than
ratings by the Services. For example, individuals rated zero percent by
the Services were rated an average of 30 percent by VA and those rated
30 percent by the Services were rated an average of 56 percent by VA.
Among individuals rated by the Services as zero, 10, or 20 percent, VA
rated them 30 percent or higher 61 percent of the time. This was
largely because VA rated 2.4 to 3.3 more conditions than the Services.
When comparing the ratings for individual diagnoses, VA ratings were
statistically significantly higher than the Services for 10 of 13
frequent diagnoses analyzed.
We concluded that there should be a realignment of the process and
this is essentially the same conclusion reached by the Dole-Shalala
Commission, the Independent Review Group, and the Nicholson Task Force.
We also believe that the Services should determine if the servicemember
is fit or unfit and VA should be responsible for assigning disability
ratings to all conditions found as part of a single, comprehensive
examination. The Dole-Shalala Commission made the same recommendation.
In redesigning the VA/DOD disability process and specifying the
benefits available for these servicemembers, it may be appropriate to
focus specifically on the severely disabled. However, we should also
recognize that the overwhelming proportion of servicemembers medically
discharged as unfit do not meet the several definitions of severely
disabled. During the 7-year period 2000 through 2006, there were 83,008
servicemembers medically discharged as unfit. DOD rated 81 percent of
these as 0 through 20 percent disabled and provided separation pay.
Only 5,060 (6.1 percent) were rated by DOD as 50 percent through 100
percent and, of these, only 1,478 (1.8 percent) were rated 100 percent.
The process and the benefits should be appropriate for all
servicemembers found unfit, not just the severely disabled.
Our Commission did not specify which department should conduct the
single examination; in fact we believe that this should be determined
more by the capabilities of the two departments at the local level. Our
Commission extensively reviewed the examination process used by VA with
the advice of the Institute of Medicine and made recommendations
relating to the use of templates, training and certification of
examiners, and quality assurance. Completion of a thorough and
comprehensive examination is essential for accurate ratings and these
recommendations should be addressed no matter which department conducts
the examinations.
case management
All four study groups recommended developing a case management
system for severely injured servicemembers and their families to ensure
the right care and support at the right time and in the right place. A
single case manager should have overall responsibility. The Dole-
Shalala Commission also recommended comprehensive recovery plans.
Improving case management is a key topic upon which there is strong
agreement.
family support
Family support is addressed by all of the study groups except the
Nicholson Task Force. The families of the severely injured are
assisting in the care and rehabilitation of these wounded warriors.
Some are sacrificing jobs, careers, homes, and health insurance, and
facing a tremendous impact on their own health in order to support
their injured family members. Our Commission recommended that VA be
authorized to provide similar services as currently provided by DOD to
families of the severely injured. We also recommended extending ChampVA
medical care to caregivers (currently this benefit is provided only to
dependents of 100 percent disabled veterans, not caregivers) and
providing a caregiver allowance. We also recommended eliminating any
TRICARE copays and deductibles for the severely disabled because we do
not believe the injured should have to pay in any way for their
injuries. We feel that our recommendations would more fully meet the
needs of the families and caregivers of all severely disabled. The
Dole-Shalala Commission would limit TRICARE coverage to only families
of those unfit due to combat-related injuries.
ptsd and tbi
All four reports recommend improvements in awareness, research,
treatment, staffing, and diagnosis/examination of Post Traumatic Stress
Disorder (PTSD) and Traumatic Brain Injury (TBI). Our Commission
focused more on compensating and rating these conditions and recommend
that a ``holistic'' approach to PTSD be established that couples
compensation, treatment, and vocational assessment. We also believe
that re-evaluation should occur every 2 to 3 years to gauge treatment
effectiveness and encourage wellness. Regarding TBI, we recommend
including medical criteria for this diagnosis as a priority in the
revision to the VA Schedule for Rating Disabilities.
ancillary benefits
Our Commission recommended increases to several benefits that have
not kept pace with cost of living, extending eligibility in some
instances to burn victims, and expanding auto and housing allowances.
We also recommended eliminating the premiums for Traumatic
Servicemembers' Group Life Insurance (TSGLI) as we do not believe
servicemembers should have to insure themselves for Traumatic Injuries.
Perhaps most importantly, our Commission recommends establishing a pre-
stabilization allowance of up to 50 percent of current compensation for
up to 5 years to address the real out-of-pocket expenses for the
severely disabled. The Dole-Shalala Commission recommended a transition
pay of 3 months' base pay or longer-term payments if participating in
rehabilitation, education, or training. This is conceptually similar to
our Pre-stabilization recommendation.
quality of life
Both our Commission and the Dole-Shalala Commission recommend a
compensation payment for the impact of disability on quality of life.
We believe the level of compensation should be based on the severity of
disability and should make up for average impairments of earnings
capacity and the impact of disability on functionality and quality of
life. It should not be based on whether it occurred during combat or
combat training; or the geographic location of injury, or whether the
disability occurred during wartime or a time of peace. Current
compensation payments do not provide payment above that required to
offset earnings loss. Therefore, there is currently no compensation for
the impact of disability on quality of life for most veterans. While
permanent quality of life measures are developed and implemented, we
recommend that compensation payments should be increased up to 25
percent with priority to the more seriously disabled.
vocational rehabilitation
All but the Independent Review Group addressed vocational
rehabilitation. Both the Dole-Shalala Commission and our Commission
found that the effectiveness of the program is not currently assessed
and graduates are not followed except for a very brief time period.
Both commissions recommend either an incentive bonus of up to 25
percent (Dole-Shalala) or exploring incentives as a way to encourage
completion. The Nicholson Task Force focused on using existing programs
and opportunities.
concurrent receipt
Regarding concurrent receipt of military retirement and VA
disability payments, our Commission found these to be two different
programs with entirely different missions. DOD retirement recognizes
years of service and VA disability payments compensate for impairment
in earnings and should compensate for impact on quality of life.
Over time, Congress should eliminate the ban on concurrent receipt
for all military retirees and for all servicemembers who are separated
from the military due to service-connected disabilities. Priority
should be given to veterans who separate or retire with less than 20
years of service and a service-connected disability rating of 50
percent or greater or disability as a result of combat. Payment offset
should also be eliminated for survivors of those who die in service or
retirees who die of service-related causes so that the survivors can
receive both VA Dependency and Indemnity Compensation (known as DIC)
and DOD Survivors Benefit Plan (known as SBP.)
The Dole-Shalala Commission also recommends that DOD compensate for
years of service while VA compensates for disability.
hazards and exposures
Our Commission and the Nicholson Task Force both addressed hazards
and exposures but in different ways. The Nicholson Task Force
recommended creating a center of excellence and a registry for embedded
shrapnel or fragments from blast injuries. Our Commission recommended a
new presumption process as proposed by the Institute of Medicine. The
new process includes enhanced registries of servicemembers and veterans
based on exposure, deployment, and disease histories.
improving va and dod collaboration
In addition to assessing areas of overlap among the four reports,
you asked my views on how to improve collaboration and cooperation
between VA and DOD. Our Commission made several recommendations that we
believe would enhance benefits and services for servicemembers and
veterans, both while they are transitioning from the military to
civilian status and for many years in the future. We found many
encouraging signs and also areas which need improvement.
The Joint Executive Council (JEC) established by statute has
demonstrated how both departments can benefit from coordinated planning
and increased cooperation. We applaud the results that are evident in
specific initiatives. These include the integration of the North
Chicago VA Medical Center and the Naval Health Clinic Great Lakes
(named last week for astronaut James Lovell), in the coordinated
treatment of severely injured in dedicated poly trauma centers, and in
shared rehabilitation units. These are all indications of how joint
efforts can benefit both departments and improve service to veterans
and servicemembers. However, we believe that the JEC planning effort
can be significantly improved by including specific milestones and
designating responsible officials for each. We also suggest that
transition coordination and effectiveness could be improved by
including the Department of Labor and the Social Security
Administration in some capacity in the JEC since these organizations
have major transition roles.
Successfully transitioning servicemembers to civilian life is
crucial and ensuring that servicemembers understand the benefits and
services that are available to them is essential. Information is
disseminated through the Transition Assistance Program (TAP) and the
Disabled Transition Assistance Program (DTAP.) We believe that the TAP
briefings should be mandatory for all separating servicemembers,
especially the Guard and Reserves and those in medical hold status.
Currently, these briefings are not mandatory in all Services. In
addition, we found that funding for these briefings has been static for
the last decade and we recommend that adequate funding be provided. All
servicemembers should be knowledgeable about benefits prior to leaving
the service.
After leaving service, many veterans find it difficult to prove
that injuries and diseases that occur later in life are the result of
military service. The veteran, with the assistance of VA, has to
produce evidence that the condition originated in service. This is made
more difficult because not all separating servicemembers receive
separation examinations; only those who intend to file a claim for VA
disability benefits. We believe that all separating servicemembers
should receive a separation examination to establish a baseline for
medical conditions. An entrance examination is required to enter active
duty and a separation examination should be required to leave active
duty.
Application for disability benefits is expedited through the
Benefits Delivery at Discharge (BDD) process which is currently
available at some 140 military facilities and these claims are
processed at two VA locations. Two problems exist with the BDD process:
(1) it is not available unless the individual has an established date
of discharge and is within 180 days of that date; and (2) it is not
available at all locations. Those on medical hold or on the temporary
disability retired list are often precluded from participating in BDD
and Guard and Reserves often separate at locations where BDD is not
available. We believe that BDD should be available to virtually all
separating servicemembers, including Guard and Reserves.
One cause for delay in claims processing even in the BDD process is
availability of the DD-214 discharge document. Our Commission
recommends that DOD immediately provide VA with an authenticated
electronic document so that processing can begin right away.
it compatibility
All of the reports address the absolute necessity for VA and DOD to
have compatible information systems. All recognize the importance of
this capability but also recognize that this will not solve all
problems.
Much has been said over the past several years about ``seamless
transition.'' This is an admirable goal but it is not a current
reality. Not all of DOD's medical and personnel records are electronic
and those that are electronic are not yet fully compatible between the
Services, much less between VA and DOD. The AHLTA and VistA systems are
not compatible. AHLTA may provide a more modern platform than VistA,
but significant functions in the older VA system are not available to
DOD users. For example, inpatient discharge summaries and digital
images are not yet available in AHLTA. Therefore, DOD cannot easily
transfer these types of information to VA upon a servicemember's
discharge or transfer for medical care without paper copies first being
scanned. In January 2007, VA and DOD announced an agreement to create a
joint inpatient electronic record that would be instantly accessible to
clinicians in both departments. As far as we know, the departments have
not committed to a completion date although the Nicholson Task Force
identified January 31, 2008 as the date for completion of an analysis
of alternatives.
Veterans Benefits Administration continues to use paper claims
folders and has no long-term plan to convert them to electronic
records. Both VA and DOD will have to continue to use paper records
well into the future. Plans need to be made to convert existing paper
records and finally be able to exclusively use electronic records at
some time in the future.
Our Commission believes that development and implementation of
compatible information systems should be expedited. We also agree with
the Government Accountability Office that a detailed project management
plan should be developed with a lead agent designated and with specific
milestones and planned completion dates. We understand why the
departments are reluctant to establish planned completion dates since
they will be expected to achieve those goals. However, we believe that
planned completion dates for specific actions are absolutely essential
in order to estimate resource requirements and to monitor progress.
Compatible electronic systems will greatly enhance the ability of
both departments to share information and work together. This critical
interface will also improve claims processing and avoid some of the
unfortunate cases that ``slip through the cracks'' during the
transition from VA to DOD.
In conclusion, VA and DOD have much to gain by greater coordination
and collaboration but servicemembers and veterans have even more to
gain by the two departments working better together. A lot of valuable
work has been done by VA and DOD and they should be commended for the
progress made. However, a great deal of work remains and the only way
that the goal of a reasonably seamless transition will ever be realized
is if the two departments are required to develop realistic, yet
challenging, goals with specific milestones. Joint ventures, sharing
agreements, and integrations should be the norm rather than the
exception. Congress should review the plan and oversee progress.
Congress also has the responsibility to ensure that sufficient funding
is provided to accomplish the goals and objectives contained in the
plan.
Veterans' Disability Benefits Commission
Table 1.--Commission/Task Force Comparisons: Primary Topics and Areas of Overlap
----------------------------------------------------------------------------------------------------------------
Veterans'
Disability Independent Review
Study Group Topic Benefits Group GWOT Task Force PCCWW
Commission
----------------------------------------------------------------------------------------------------------------
VA/DOD Disability Process....... Realign disability DOD should Joint process Restructure
evaluation overhaul the DES whereby VA/DOD disability &
process--Services system by cooperate in compensation
determine fitness implementing a assigning a systems--DOD/VA
for duty, VA single physical disability should create a
rates disability. exam (as evaluation, single,
described by GAO determining comprehensive
2004). The fitness for standardized
services should retention, level medical exam that
consistently be of disability DOD administers,
determining retirement & VA DOD maintains
fitness for duty compensation. authority over
& VA provides fitness & pays
disability for years of
rating. DOD service while VA
should also establishes
expand the rating,
Disability compensation &
Advisory Council, benefits.
Conduct quality
assurance reviews
on previous 0-20
percent & EPTS
cases, Evaluate
loss of function
due to burns
similar to
amputation.
Case Management................. Intensive case Create tri-Service System of case & Comprehensive
management with policy & co-management. Recovery Plans &
an identifiable guidelines for Coordinators with
lead agent. case management HHS as lead.
services &
training, Assign
single primary
care physician &
case manager.
Family Support.................. Authorize VA to Provide family None.............. Strengthen support
provide family education on for families
services, Extend benefits, Survey through TRICARE
health care & families on their Respite Care &
allowance to needs, Assign Aid and Attendant
caregivers, family advocates. Benefit,*
Eliminate SBP-DIC Caregiver
offset, Eliminate training, Extend
TRICARE co-pays & FMLA for 6
deductibles for months, All
severely injured combat-related
families. injured families
should have full
TRICARE coverage.
IT Compatibility................ Expedite Streamline Enhance VA Rapidly transfer
development & transition by computerized patient
implementation of rapidly Patient Record information,
compatible developing a System & Create a
information standard electronic MyeBenefits Web
systems with a automated system enrollment, VA site.
detailed plan, interface for a needs to develop
milestones, & bilateral a patient
lead agency, Use exchange of tracking
IT to improve clinical and application
claims cycle time. administrative compatible with
info between DOD DOD, Create a TBI
& VA (Described database, Improve
in 2003 PTF). VA's access to
military health
records & create
an interface with
DOD, Create OIF/
OEF identifiers
and markers for
polytrauma,
Improve IT
interoperability
between VA & HHS
Indian Health
Services.
PTSD............................ Holistic approach Functional/ Provide Outreach & VA should care for
that couples cognitive Education to all OIF/OEF vets
treatment, measures & Community Health with PTSD & (with
rehabilitation, screenings upon Centers on VA DOD) improve
compensation & re- entry & post- benefits & prevention,
evaluation for deployment, services (to diagnosis &
wellness, Revise comprehensive & reach vets with treatment, reduce
Rating Schedule universal PTSD). PTSD stigma. DOD
for PTSD, clinical practice should address
Baseline level of & coding its mental health
benefits, PTSD guidelines for shortage,
exam process, blast injuries Disseminate
Examiner & rater and TBI with PTSD clinical practice
training & overlay to guidelines to all
certification, include recording providers.
research on of exposures to
Military Sexual blast in patient
Trauma. record. VA/DOD
create center of
excellence for
TBI and PTSD
treatment,
research &
training.
TBI............................. Update the Rating Functional/ Screen all GWOT DOD/VA should
Schedule for TBI. cognitive veterans for TBI. prevent,
measures & diagnose, & treat
screenings upon TBI, Partner with
entry & post- the private
deployment, sector on TBI
comprehensive & care, Disseminate
universal clinical practice
clinical practice guidelines to all
& coding providers.
guidelines for
blast injuries
and TBI with PTSD
overlay to
include recording
of exposures to
blast in patient
record. VA/DOD
create center of
excellence for
TBI and PTSD
treatment,
research &
training.
Ancillary Benefits.............. Adjust & extend DOD should partner Expedite Adapted Transition (3
A&A, Extend auto with VA to Housing and months of base
& housing provide Special Home pay or long-term)
allowances to treatment, Adaptation payments,
veterans with education & Grants, Expand Earnings-loss
severe burns, research in HUD National payments, All
Eliminate TSGLI prosthesis care, Housing Locator, unfit combat-
premiums, Improve production & Enhance capacity related injured
SDVI & VMLI, amputee therapy, to provide Dental should receive
Increase benefits Allow VA patients care through VA & full TRICARE
to original to use Military private sector. coverage.
intention, Adjust and private
automatically for prosthetist.
inflation,
Provide a
Stabilization
Allowance,
Research
additional
ancillary
benefits.
Quality of Life................. Compensate for 3 Survey patients on None.............. Determine
consequences: their needs. appropriate QOL
work disability, payments.
loss of
functionality &
QOL, VA develop
measures for QOL
loss, but in the
meantime create
up to 25 percent
QOL payment,
Research health-
related QOL &
need for
additional
ancillary
benefits,
Increase SMC to
address impact on
QOL.
Vocational Rehabilitation & Test VR&E None.............. Extend VR&E VR&E effectiveness
Employment (VR&E). incentives, evaluation is not well
Review & revise determination established and
12-year time time limit, should offer
limit, Expand Expand completion
VR&E to all eligibility for incentives of up
medically SBA Patriot to a 25 percent
separating Express Loans, bonus.
servicemembers, & Increase Career
allow all service Fairs & integrate
disabled veterans Hire Vets First
access to VR&E Campaign, Provide
counseling, VR&E Credentialing,
should screen all Certification,
IU applicants, Financial Aid
increase VR&E Education
staffing, Assistance, &
tracking, & Employment
resources. rights, Develop
Wounded Warrior
Intern & Wounded
Veterans
Readjustment Work
Experience
Programs.
Concurrent Receipt.............. Eliminate the ban. None.............. None.............. Create a DOD
Annuity payment
based on rank &
years of service.
Hazards & Exposures............. Create a new None.............. Create an embedded None.
structure for Fragment
Presumption based Surveillance
on casual Center and
relationship Registry.
using four
categories.
Combat/Combat-Related........... Benefits based on None.............. None.............. Benefits and
severity of process
disability, not specifically for
on circumstances combat/combat-
or location. related injuries
only.
Social Security/Disability Compensation for .................. .................. Compensation for
Compensation for Earnings. earnings loss Earnings Ends
continues for when retirement
life. Social Security
begins.
Walter Reed National Military None.............. Accelerate BRAC None.............. Recruit & retain
Medical Center (WRNMMC). construction first-rate
projects for professionals for
WRNMMC & new WRAMC through
complex at 2011 with
Belvoir, New resources and
command and incentives to
control structure hire civilian
for WRNMMC, Apply health care
regulatory relief professionals &
to A-76 process, admin staff.
Survey patients &
families, Staff &
train Med
Hold(over)
personnel,
reevaluate
efficiency wedge,
Assign a senior
facility engineer
to oversee non-
medical
maintenance,
Modernize
facility
assessment tools
& prioritize
repairs.
----------------------------------------------------------------------------------------------------------------
* This refers to the Aid and Attendant benefit under TRICARE's Extended Care Health Option, and not VA's Aid and
Attendance benefit.
Table 2.--Other Veterans' Commissions & Task Forces: Purposes, Findings and Recommendations
----------------------------------------------------------------------------------------------------------------
Report Findings &
Entity Chairperson Charged by Purpose Date Recommendations
----------------------------------------------------------------------------------------------------------------
IRG on Rehabilitative Care & Former VA Secretary of Review continuum 4/11/07 Problems
Admin @ Walter Reed & Secretary Togo Defense. of care, resulted from a
National Naval (Bethesda). West & Former leadership & failure of
Army Secretary oversight leadership,
& Congressman issues loss of
John Marsh. resulting in resources &
deficiencies spending
reported at authority under
Walter Reed BRAC,
Scope: Walter contracting
Reed patients & out, nursing
families. and other staff
shortages,
challenges of
signature
injuries, &
failure of the
Medical
Holdover
system. Other
reports have
recommended
changes to the
MEB/PEB process
over the last
10 years, but
none have been
implemented,
which the IRG
endorsed as
well as a
combined DOD/VA
evaluation
system.
Task Force on Returning Global R. James Executive Order Improve the 4/19/07 There were 25
War on Terror (GWOT) Heroes. Nicholson, of the delivery of recommendations
Secretary of President. Federal . Action areas
Veterans services and included health
Affairs. benefits to care, case
GWOT management,
servicemembers continuity of
& veterans. care, TBI
Scope: All GWOT screening, VA
servicemembers Liaisons at
& veterans. military
facilities,
small business
loans,
education,
career
training,
employment
rights,
financial aid,
housing
locator,
electronic
tracking
between
systems,
dental, rural
health, VA/DOD
joint
disability
process &
exams, VR&E
extension, &
home
adaptation.
Recommendations
can be
accomplished
within existing
authority &
resources.
Outreach should
cover TAP/DTAP
attendance, job
fairs, vets
preference, & a
GWOT
newsletter,
comprehensive
database of
Federal
services &
benefits.
President's Commission on Care Former Senator Executive Order Recommend 7/25/07 There were 6
for America's Returning Bob Dole & of the Improvements recommendations
Wounded Warriors (PCCWW). Former HHS President. for transition, : (1)
Secretary Donna high-quality Immediately
Shalala. services for creating a
returning comprehensive
wounded troops, recovery plan
access to with a lead
benefits & Recovery
services. Coordinator;
Scope: Wounded (2) Completely
OIF/OEF restructure the
servicemembers, disability
veterans, systems so DOD
families. determines
fitness and VA
disability
benefits; (3)
Aggressively
prevent & treat
PTSD & TBI; (4)
Significantly
strengthen
support for
families with
amendments to
TRICARE & FMLA;
(5) Rapidly
transfer
patient info, &
develop a
Federal
benefits Web
site, and; (6)
Strongly
support Walter
Reed by
recruiting &
retaining 1st-
rate
professionals
through 2011.
Veterans' Disability Benefits LTG James Terry PL 108-136...... Appropriateness 10/3/07 113
Commission. Scott (USA, of Benefit, recommendations
Ret.). level of that focused
Benefit, on:
Determination compensation
Standards. for quality of
Scope: All life & a 25
disabled percent
servicemembers, allowance until
veterans, VA develops
families. measures; line
of duty;
earnings
disparity for
service
connected
veterans with
mental
disorders &
young entry; VA
Rating Schedule
revisions,
especially for
PTSD, TBI, &
IU; A holistic
approach for
PTSD that
couples
compensation,
treatment,
rehabilitation,
& re-
evaluation;
caregiver
health care &
an allowance;
presumption
standards for
exposures; DOD
disability
evaluations and
separation
exams with
Services
determining
fitness for
duty & VA
adjudicating a
rating;
concurrent
receipt and
survivor
concurrent
receipt; IT
interoperabilit
y; & joint
ventures,
sharing
agreements, &
integration.
----------------------------------------------------------------------------------------------------------------
* Final report.
Table 3.--Total Recommendations
------------------------------------------------------------------------
Veterans'
Disability Independent
Benefits Review Group GWOT Task Force PCCWW
Commission
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113 20 25 6
------------------------------------------------------------------------
* 23 action items.
Executive Summary
The Veterans' Disability Benefits Commission was established by
Public Law 108-136, the National Defense Authorization Act of 2004.
Between May 2005 and October 2007, the Commission conducted an in-depth
analysis of the benefits and services available to veterans,
servicemembers, their survivors, and their families to compensate and
provide assistance for the effects of disabilities and deaths
attributable to military service. The Department of Veterans Affairs
(VA) expended $40.5 billion on the wide array of these benefits and
services in fiscal year 2006. The Commission addressed the
appropriateness and purpose of benefits, benefit levels and payment
rates, and the processes and procedures used to determine eligibility.
The Commission reviewed past studies on these subjects, the legislative
history of the benefit programs, and related issues that have been
debated repeatedly over many decades.
Congress created the Commission out of concern for a variety of
issues pertinent to disabled veterans, disabled servicemembers, their
survivors, and their families. Those matters included care for severely
injured servicemembers, treatment and compensation for Post Traumatic
Stress Disorder (PTSD), the concurrent receipt of military retired pay
and disability compensation, the timeliness of processing disabled
veterans' claims for benefits, and the size of the backlog of those
claims. Another area of concern was the program known as Individual
Unemployability, which allows veterans with severe service-connected
disabilities to receive benefits at the highest possible rate if their
disabilities prevent them from working. The Commission gave these
issues special attention.
The Commission received extensive analytical support from the CNA
Corporation (CNAC), a well-known research and consulting organization.
CNAC performed an in-depth economic analysis of the average impairment
of earning capacity resulting from service-connected disabilities. In
addition, to assess the impact of disabilities and deaths on quality of
life, CNAC conducted surveys of disabled veterans and survivors. To
gain insight into claims processing issues, CNAC surveyed raters from
VA and representatives of veterans' service organizations who assist
veterans in filing claims. CNAC also completed a literature review and
a comparative analysis of disability programs similar to those provided
by VA.
The Commission received expert medical advice from the Institute of
Medicine (IOM) of the National Academies. Required by statute to
consult with IOM, the Commission asked the institute to conduct a
thorough analysis of the VA Schedule for Rating Disabilities (hereafter
the Rating Schedule) and a study of the processes used to decide
whether one may presume that a disability is connected to military
service. In addition, the Commission examined two studies that IOM
conducted for VA about the diagnosis of PTSD and compensation to
veterans for that disorder. Unfortunately, a third IOM study--of the
treatment of PTSD--was not completed in time to be considered by the
Commission. Additionally, the Commission conducted eight field visits
and held numerous public sessions.
guiding principles
The Commission wrestled with philosophical and moral questions
about how a Nation cares for disabled veterans and their survivors and
how it expresses its gratitude for their sacrifices. The Commission
agreed that the United States has a solemn obligation, expressed so
eloquently by President Lincoln, ``. . . to care for him who shall have
borne the battle, and for his widow, and his orphan . . .''\1\
---------------------------------------------------------------------------
\1\ Lincoln, Abraham, Second Inaugural Address, March 4, 1865,
http://www.ourdocuments.gov/doc.php?flash=true&doc=38.
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In going about its work, the Commission has been mindful of the
1956 Bradley Commission principles, which have provided a valuable and
historic baseline. This Commission's report addresses what has changed
and what has endured over those five decades and throughout our
Nation's wars and conflicts since the Bradley report. Many of the
changes--social, technological, cultural, medical, and economic--that
have taken place during that time span are significant and must be
carefully considered as our Nation renews its compact with our disabled
veterans and their families. This long-term context, a history of both
significant change and key elements of constancy from the 1950's to the
21st century, provides the solid basis for this Commission's
principles, conclusions, and recommendations.
This Commission identified eight principles that it believes should
guide the development and delivery of future benefits for veterans and
their families:
1. Benefits should recognize the often enormous sacrifices of
military service as a continuing cost of war, and commend military
service as the highest obligation of citizenship.
2. The goal of disability benefits should be rehabilitation and
reintegration into civilian life to the maximum extent possible and
preservation of the veterans' dignity.
3. Benefits should be uniformly based on severity of service-
connected disability without regard to the circumstances of the
disability (wartime v. peacetime, combat v. training, or geographical
location.)
4. Benefits and services should be provided that collectively
compensate for the consequence of service-connected disability on the
average impairment of earnings capacity, the ability to engage in usual
life activities, and quality of life.
5. Benefits and standards for determining benefits should be
updated or adapted frequently based on changes in the economic and
social impact of disability and impairment, advances in medical
knowledge and technology, and the evolving nature of warfare and
military service.
6. Benefits should include access to a full range of health care
provided at no cost to service-disabled veterans. Priority for care
must be based on service connection and degree of disability.
7. Funding and resources to adequately meet the needs of service-
disabled veterans and their families must be fully provided while being
aware of the burden on current and future generations.
8. Benefits to our Nation's service-disabled veterans must be
delivered in a consistent, fair, equitable, and timely manner.
With these principles clearly in mind, the Nation must set the firm
foundation upon which to shape and evolve a system of appropriate--and
generous--benefits for the disabled veterans of tomorrow.
The Commission believes that just as citizens have a duty to serve
in the military, the Federal Government has a duty to preserve the
well-being and dignity of disabled veterans by facilitating their
rehabilitation and reintegration into civilian life. The Commission
believes that compensation should be based on the nature and severity
of disability, not whether the disability occurred during wartime,
combat, training, or overseas. It is virtually impossible to accurately
determine a disease's origin or to differentiate the value of sacrifice
among veterans whose disabilities are of similar type and severity.
Setting different rates of compensation for the same degree of severity
would be both impractical and inequitable.
Disabled veterans require a range of services and benefits,
including compensation, health care, specially adapted housing and
vehicles, insurance, and other services tailored to their special
needs. Compensation must help service-disabled veterans achieve parity
in earnings with nonservice-disabled veterans. Compensation must also
address the impact of disability on quality of life. Money alone is a
poor substitute for the consequences of the injuries and disabilities
faced by veterans, but it is essential to ease the burdens they
experience.
It is the duty of Congress and VA to ensure that the benefits and
services for disabled veterans and survivors are adequate and meet
their intended outcomes. IOM concluded that the VA Rating Schedule has
not been adequately revised since 1945. This situation should not be
allowed to continue. Systematic updates to the Rating Schedule and
assessments of the appropriateness of the level of benefits should be
made on a frequent basis.
Excellent health care should be provided in a timely manner at no
cost to veterans with service-connected disabilities (i.e., service-
disabled veterans) and, in the case of severely injured veterans, to
their families and caregivers.
The funding and resources necessary to fully support programs for
service-disabled veterans must be sufficient while ensuring that the
burden on the Nation is reasonable. Care and benefits for service-
disabled veterans are a cost of maintaining a military force during
peacetime and of fighting wars. Benefits and services must be provided
promptly and equitably.
results of the commission's analysis
The analyses conducted by the Commission with the assistance of IOM
and CNAC provide a consistent and complementary picture of many aspects
of veterans' disability compensation.
ensure horizontal and vertical equity
For veterans to receive proper compensation for their service-
connected disabilities, the VA Rating Schedule must be designed so that
ratings result in horizontal and vertical equity in terms of
compensation for average impairments of earning capacity. Horizontal
equity means that persons with the same ratings percentage should have
experienced the same loss of earning capacity. Vertical equity means
that loss of earning capacity should increase in proportion to an
increase in the degree of disability. A comparison of the earnings of
disabled veterans with those of veterans who lacked service-connected
disabilities revealed that the average amount of earnings lost by
disabled veterans generally increased as disability ratings increased.
In addition, mortality rates rose with degree of disability. Thus,
vertical equity is achieved. The average earnings loss was similar
across different types of disabilities except for PTSD and other mental
disorders, indicating that horizontal equity also is generally being
achieved at the level of body systems.
ensure parity with nondisabled veterans
Overall, disabled veterans who first apply to VA for compensation
at age 55 (the average age) receive amounts of money that are nearly
equal to their average loss of earnings as a consequence of their
disabilities among the broad spectrum of physical disabilities.
The earnings of a representative sample of nondisabled veterans
were compared with the sum of earnings plus compensation of disabled
veterans to determine the extent to which disability compensation helps
disabled veterans achieve parity with their nondisabled counterparts.
Among veterans whose primary disabilities are physical, those who are
granted Individual Unemployability are substantially below parity;
those who are rated 100 percent disabled and who enter the system at a
younger age (45 years or less) are slightly below parity; and those who
enter at age 65 or older are above parity. For those whose primary
disabilities are mental, the sum of earnings plus VA compensation is
generally below parity at average age of entry, substantially below
parity for severely disabled individuals who enter the system at a
younger age, and above parity for those who enter at age 65 or older.
Also, among veterans whose primary disabilities are mental, those rated
10 percent disabled are slightly below parity. Thus, parity is
generally present with respect to earnings loss except among
individuals whose primary disabilities are mental, among the younger
severely disabled, and among those granted Individual Unemployability.
compensate for loss of quality of life
Parity in average loss of earnings means that disability
compensation does not compensate veterans for the adverse impact of
their disabilities on quality of life.
Current law requires only that the VA Rating Schedule compensate
service-disabled veterans for average impairment of earning capacity.
However, the Commission concluded early in its deliberations that VA
disability compensation should recompense veterans not only for average
impairments of earning capacity, but also for their inability to
participate in usual life activities and for the impact of their
disabilities on quality of life. IOM reached the same conclusion;
moreover, it made extensive recommendations on steps to develop and
implement a methodology to evaluate the impact of disabilities on
veterans' quality of life and to provide appropriate compensation.
The Commission concluded that the VA Rating Schedule should be
revised to include compensation for the impact of service-connected
disabilities on quality of life. For some veterans, quality of life is
addressed in a limited fashion by special monthly compensation for loss
of limbs or loss of use of limbs. Some ancillary benefits attempt to
ameliorate the impact of disability. However, the Commission urges
Congress to consider increases in some special monthly compensation
awards to address the profound impact of certain disabilities on
quality of life and to assess whether other ancillary benefits might be
appropriate. While a recommended systematic methodology is developed
for evaluating and compensating for the impact of disability on quality
of life, the Commission believes that an immediate interim increase of
up to 25 percent of compensation should be enacted.
A survey of a representative sample of disabled veterans and
survivors was conducted to assess their quality of life and other
issues. The survey found that among veterans whose primary disability
is physical, their physical health is inferior to that of the general
population for all levels of disability, and their physical health
generally worsens as their level of disability increases. Physical
disabilities did not lead to decreased mental health. For veterans
whose primary disability is mental, not only were their mental health
scores much lower than those of the general population, but their
physical health scores were well below population norms for all levels
of mental disability. Those veterans with PTSD had the lowest physical
health scores.
The survey also sought to address two specific issues through
indirect questions. There are concerns that service-disabled veterans
tend not to follow medical treatments because they fear it might impact
their disability benefits. This premise was not substantiated.
Likewise, when questioned whether VA benefits created a disincentive to
work, only 12 percent of respondents indicated they might work or work
more if not for compensation benefits; thus, this is not a major issue.
update the rating schedule
The Rating Schedule consists of slightly more than 700 diagnostic
codes organized under 14 body systems, such as the musculoskeletal
system, organs of special sense, and mental disorders. For each code,
the schedule provides criteria for assigning a percentage rating. The
criteria are primarily based on loss or loss of function of a body part
or system, as verified by medical evidence; however, the criteria for
mental disorders are based on the individual's ``social and industrial
inadaptability,'' meaning the overall ability to function in the
workplace and everyday life.
IOM concluded that it has been 62 years since the VA Rating
Schedule was adequately revised and made a series of recommendations
for immediately updating the Rating Schedule and requiring that it be
revised on a systematic and frequent basis. The Commission generally
agrees with these recommendations; however, the Commission does not
agree that the revision should begin with those body systems that have
not been revised for the longest time period. Rather, the Commission
recommends that first priority be given to revising the mental health
and neurological body systems to expeditiously address PTSD, other
mental disorders, and Traumatic Brain Injury. A quick review by VA of
the Rating Schedule could be completed to determine the sequence in
which the other body systems should be addressed, and a timeline should
be developed for completing the revision.
To emphasize the importance and urgency of revising the Rating
Schedule, the Commission urges Congress to require that the entire
schedule be reviewed and updated as needed over the next 5 years.
Congress should monitor progress carefully. Thereafter, the Rating
Schedule should be reviewed and updated on a frequent basis.
individual unemployability
The Individual Unemployability (IU) program enables a veteran rated
60 percent or more but less than 100 percent to receive benefits at the
100 percent rate if he or she is unable to work because of service-
connected disabilities. IU has received considerable attention recently
because the number of veterans granted IU increased by 90 percent. The
Commission found this increase to be explained by the aging of the
cohort of Vietnam veterans.
develop ptsd-specific rating criteria and improve ptsd treatment
Concerning PTSD and other mental disorders, it is very clear that
having one set of criteria for rating all mental disorders has been
ineffective. IOM recommended separate criteria for PTSD. Similarly, the
CNAC survey of VA raters found that raters believe separate criteria
for PTSD would enable them to rate PTSD claims more effectively. In
addition, the earnings analysis described above demonstrates that there
is a disparity in earnings of those with PTSD and other mental
disorders and that the current scheme for rating all mental disorders
in five categories of severity--10, 30, 50, 70, and 100 percent--does
not result in adequate compensation. It is also unclear why 31 percent
of those with PTSD as their primary diagnosis are granted IU,
especially since incapacity to work is part of the current criteria for
granting 100 percent for PTSD and other mental disorders. It would seem
that many of these veterans should be awarded 100 percent ratings
without IU. The Commission agrees with the IOM recommendation that new
Rating Schedule criteria specific to PTSD should be developed and
implemented based on criteria from the Diagnostic and Statistical
Manual of Mental Disorders.
The Commission believes that a new, holistic approach to PTSD
should be considered. This approach should couple PTSD treatment,
compensation, and vocational assessment. The Commission believes that
PTSD is treatable, that it frequently recurs and remits, and that
veterans with PTSD would be better served by a new approach to their
care. There is little interaction between the Veterans Health
Administration, which examines veterans for evaluation of severity of
symptoms and treats veterans with PTSD, and the Veterans Benefits
Administration, which assigns disability ratings and may or may not
require periodic reexamination. It is evident that PTSD reexaminations
have been scheduled with less frequency in recent years due to the
backlog of disability claims. It is also evident that case management
of PTSD patients could be improved through greater interaction between
the therapy received in Vet Centers and treatment in VA medical
centers. IOM concluded that the use of standardized testing and the
frequency of reexaminations should be recommended by clinicians on a
case-by-case basis, but did not suggest how that would be achieved. The
Commission suggests that treatment should be required and its
effectiveness assessed to promote wellness of the veteran.
Reexaminations should be scheduled and conducted every 2 to 3 years.
improve performance of vocational rehabilitation and employment
The Commission believes that the goal of disability benefits, as
expressed in guiding principle 2, is not being met. In spite of the
studies done and recommendations made in recent years, the Vocational
Rehabilitation and Employment (VR&E) program is not accomplishing its
primary goal. The Commission believes that recent studies have provided
the necessary analyses and that VA possesses the necessary expertise to
remedy this failure. Simply put, VA must develop specific plans and
Congress must provide the resources to quickly elevate the performance
of VR&E.
allow concurrent receipt
The Commission carefully reviewed whether disabled veterans should
be permitted to receive both military retirement benefits and VA
disability compensation. The Commission also reviewed whether the
survivors of veterans who die either on active duty or as a result of a
service-connected disability should be allowed to receive both
Department of Defense (DOD) Survivor Benefit Plan (SBP) and VA
Dependency and Indemnity Compensation (DIC). Currently, military
retirees with service-connected disabilities rated 50 percent or higher
are authorized to receive both benefits, which are being phased in over
the next few years. Survivors are not authorized to receive both
benefits. The Commission is persuaded that these programs have unique
intents and purposes: military retirement benefits and SBP are intended
to compensate for years of service, while VA disability compensation
and DIC are intended to compensate for disability or death attributable
to military service. It should be permissible to receive both sets of
benefits concurrently.
In addition, the Commission believes that those separated as
medically unfit with less than 20 years of service should also be able
to receive military retirement and VA compensation without offset.
Currently, those receiving ratings of less than 30 percent from DOD
receive separation pay, which must be paid back through deductions from
VA compensation for the unfitting conditions before VA compensation is
received. Those receiving DOD ratings of 30 percent or higher and a
continuing disability retirement have their DOD payments offset by any
VA compensation. Priority among medical discharges should be given to
those separated or retired with less than 20 years of service and
disability rating greater than 50 percent or disability as a result of
combat.
allow young, severely injured veterans to receive
social security disability insurance
Among the benefits available for disabled veterans, those not able
to work may be eligible for Social Security Disability Insurance
(SSDI). To be eligible for SSDI, an individual must have worked a
minimum number of quarters, be unable to work because of medical
conditions, not have income above a minimum level, and be less than 65
years of age. At 65, SSDI converts to normal Social Security at the
same amount. Some very young servicemembers who are severely injured
may not have sufficient quarters to qualify for SSDI. The Commission
recommends eliminating the minimum quarters requirement for the
severely injured. Only 61 percent of those granted IU by VA and 54
percent of those rated 100 percent by VA are receiving SSDI.
Considering the very low earnings by those rated 100 percent and the
exceptionally low earnings of those granted IU, it is apparent that
either these veterans do not know to apply for SSDI or are being denied
the insurance. Increased outreach should be made and better
coordination between VA and Social Security should result in increased
mutual acceptance of decisions.
realign the va-dod process for rating disabilities
The Commission also assessed the consistency of ratings by DOD and
VA on individuals found unfit for military service by DOD under 10
U.S.C. chapter 61. Some 83,000 servicemembers were found unfit between
2000 and 2006. DOD rated 81 percent of those individuals as less than
30 percent and discharged them with severance pay, including over
13,000 who were found unfit by the Army and given zero percent ratings.
79% of these servicemembers later filed claims with VA and received
substantially higher ratings. The reasons for the higher ratings are
that VA rates about three more conditions than DOD, and at the
individual diagnosis level VA assigns higher ratings than DOD.
The Commission finds that the policies and procedures used by VA
and DOD are not consistent and the resulting dual systems are not in
the best interest of the injured servicemembers nor the Nation.
Existing practices that allow servicemembers to be found unfit for pre-
existing conditions after up to 8 years of active duty and that allow
DOD to rate only the conditions that DOD finds unfitting should be
reexamined. Servicemembers being considered unfit should be given a
single, comprehensive examination and all identified conditions should
be rated and compensated.
The Commission agrees with the President's Commission on the Care
of Returning Wounded Warriors that the DOD and VA disability evaluation
process should be realigned so that the military determines if the
servicemember is unfit for service and awards continuing payment for
years of service and health care coverage for the family while VA pays
disability compensation. However, in accordance with one of our key
guiding principles, the Commission believes that benefits should not be
limited to combat and combat-related injuries. Nor does the Commission
believe that VA disability compensation should end and be replaced with
Social Security at retirement age.
link benefits to cost-of-living increases
In its review, the Commission found that the ancillary and special-
purpose benefits payments and award limits are not automatically
indexed to cost of living. A few of these benefits have not been
increased in many years, and as a result, some no longer meet the
original intent of Congress. The Commission recommends that Congress
raise ancillary and special-purpose benefits to the levels originally
intended and provide for automatic annual adjustments to keep pace with
the cost of living.
simplify and expedite the processing of disability claims and appeals
VA disability benefits and services are not currently provided in a
timely manner. Court decisions, statutory changes, and resource
limitations have all contributed to this unacceptable situation.
Numerous studies over the years have assessed the processing of both
claims and appeals and have made numerous recommendations for change.
Still, veterans seeking disability compensation face a complex process.
The population of veterans is steadily decreasing with the passing of
veterans of World War II and the Korean War. Yet, the aging of the
Vietnam Era veterans means that they are filing original and reopened
claims in large numbers. Technology offers opportunities for
improvement, but it is unlikely to solve all problems. The Commission
believes that increased reliance on best business practices and maximum
use of information technology should be coupled with a simplified and
expedited process for well-documented claims to improve timeliness and
reduce the backlog. The Commission is aware that a significant increase
in claims processing staff has been recently approved but is also aware
that the time required for training and the slow development of job
experience will limit the speed with which results can realistically
occur.
The Commission believes that claimants should be allowed to state
that claim information submitted is complete and waive the normal 60-
day timeframe permitted for further development.
improve transition assistance
A smooth transition from military to civilian status is crucial for
veterans and their families to quickly adjust to civilian life. This
goal, often expressed as ``seamless transition,'' has yet to be fully
realized, although VA and DOD have made significant improvements during
the past few years. The two departments' medical and other systems are
not truly compatible, and both departments will have to rely on paper
records for many years. Perhaps the single most important step that can
be taken to assist veterans, particularly those who are disabled and
their families, and to reduce the lengthy delays plaguing claims
processing would be to achieve electronic compatibility. In addition,
the Commission believes that making VA benefit payments effective the
day after discharge will help ease the financial aspect of transition.
improve support for severely disabled veterans and their caregivers
Severely disabled servicemembers who are about to transition into
civilian life need far more support and assistance than is currently
provided. An effective case management program should be established
with a clearly identified lead agent who has authority and
responsibility to intercede on behalf of disabled individuals. The lead
agent should be an advocate for servicemembers and their families. In
addition, VA should be authorized to provide family assistance similar
to that provided by DOD up until discharge. TRICARE deductibles and
copays are costs incurred by the severely disabled; the Commission
believes that these costs should be waived. In addition, consideration
should be given to expanding health care and providing an allowance for
caregivers of the severely disabled. Currently, health care is only
provided for the dependents of severely disabled veterans but not for
parents and other family members who are caregivers.
implement a new process for determining presumption
Various processes have been used to create presumptions when there
are uncertainties as to whether a disabling condition is caused by
military service. Presumptions are established when there is evidence
that a condition is experienced by a sufficient cohort of veterans and
it is reasonable to presume that all veterans in that cohort who
experience the condition acquired the condition due to military
service. The Commission asked IOM to review the processes used in the
past to establish presumptions and to recommend a framework that would
rely on more scientific principles. IOM conducted an extensive analysis
and recommended a detailed and comprehensive approach that includes the
creation of an advisory committee and a scientific review board,
formalizing the process and making it transparent, improving research,
and tracking military troop locations and environmental exposures.
Perhaps most importantly, the approach includes using a causal effect
standard for decisionmaking rather than a less-precise statistical
association. The Commission endorses the recommendations of the IOM but
expresses concern about the causal effect standard. Consideration
should also be given to combining the advisory committee on
presumptions with the recommended advisory committee on the Rating
Schedule.
conclusion
The Commission made 113 recommendations. All are important and
should receive attention from Congress, DOD, and VA. The Commission
suggests that the following recommendations receive immediate
consideration. Congress should establish an executive oversight group
to ensure timely and effective implementation of the Commission
recommendations.
priority recommendations
Recommendation 4.23--Chapter 4, Section I.5
VA should immediately begin to update the current Rating Schedule,
beginning with those body systems addressing the evaluation and rating
of Post Traumatic Stress Disorder and other mental disorders and of
Traumatic Brain Injury. Then proceed through the other body systems
until the Rating Schedule has been comprehensively revised. The
revision process should be completed within 5 years. VA should create a
system for keeping the Rating Schedule up to date, including a
published schedule for revising each body system.
Recommendation 5.28--Chapter 5, Section III.3
VA should develop and implement new criteria specific to Post
Traumatic Stress Disorder in the VA Schedule for Rating Disabilities.
VA should base those criteria on the Diagnostic and Statistical Manual
of Mental Disorders and should consider a multidimensional framework
for characterizing disability due to Post Traumatic Stress Disorder.
Recommendation 5.30--Chapter 5, Section III.3
VA should establish a holistic approach that couples Post Traumatic
Stress Disorder treatment, compensation, and vocational assessment.
Reevaluation should occur every 2-3 years to gauge treatment
effectiveness and encourage wellness.
Recommendation 6.14--Chapter 6, Section IV.2
Congress should eliminate the ban on concurrent receipt for all
military retirees and for all servicemembers who separated from the
military due to service-connected disabilities. In the future, priority
should be given to veterans who separated or retired from the military
under chapter 61 with
fewer than 20 years service and a service-connected
disability rating greater than 50 percent, or
disability as a result of combat.
Recommendation 7.4--Chapter 7, Section II.3
Eligibility for Individual Unemployability (IU) should be
consistently based on the impact of an individual's service-connected
disabilities, in combination with education, employment history, and
medical effects of an individual's age or potential employability. VA
should implement a periodic and comprehensive evaluation of veterans
eligible for IU. Authorize a gradual reduction in compensation for IU
recipients who are able to return to substantially gainful employment
rather than abruptly terminating disability payments at an arbitrary
level of earning.
Recommendation 7.5--Chapter 7, Section II.3
Recognizing that Individual Unemployability (IU) is an attempt to
accommodate individuals with multiple lesser ratings but who remain
unable to work, the Commission recommends that as the VA Schedule for
Rating Disabilities is revised, every effort should be made to
accommodate such individuals fairly within the basic rating system
without the need for an IU rating.
Recommendation 7.6--Chapter 7, Section III.2
Congress should increase the compensation rates up to 25 percent as
an interim and baseline future benefit for loss of quality of life,
pending development and implementation of a quality-of-life measure in
the Rating Schedule. In particular, the measure should take into
account the quality of life and other non-work-related effects of
severe disabilities on veterans and family members.
Recommendation 7.8--Chapter 7, Section III.2
Congress should consider increasing special monthly compensation,
where appropriate, to address the more profound impact on quality of
life of the disabilities subject to special monthly compensation.
Congress should also review ancillary benefits to determine where
additional benefits could improve disabled veterans' quality of life.
Recommendation 7.12--Chapter 7, Section VI
VA and DOD should realign the disability evaluation process so that
the services determine fitness for duty, and servicemembers who are
found unfit are referred to VA for disability rating. All conditions
that are identified as part of a single, comprehensive medical
examination should be rated and compensated.
Recommendation 7.13--Chapter 7, Section V.3
Congress should enact legislation that brings ancillary and
special-purpose benefits to the levels originally intended, considering
the cost of living, and provides for automatic annual adjustments to
keep pace with the cost of living.
Recommendation 8.2--Chapter 8, Section III.1.B
Congress should eliminate the Survivor Benefit Plan/Dependency and
Indemnity Compensation offset for survivors of retirees and in-service
deaths.
Recommendation 9.1--Chapter 9, Section II.5.A.b
Improve claims cycle time by
establishing a simplified and expedited process for well-
documented claims, using best business practices and maximum feasible
use of information technology; and
implementing an expedited process by which the claimant
can state the claim information is complete and waive the time period
(60 days) allowed for further development.
Congress should mandate and provide appropriate resources to reduce
the VA claims backlog by 50 percent within 2 years.
Recommendation 10.11--Chapter 10, Section VII
VA and DOD should expedite development and implementation of
compatible information systems including a detailed project management
plan that includes specific milestones and lead agency assignment.
Recommendation 11.1--Chapter 11
Congress should establish an executive oversight group to ensure
timely and effective implementation of the Commission's
recommendations. This group should be co-chaired by VA and DOD and
consist of senior representatives from appropriate departments and
agencies. It is further recommended that the Veterans' Affairs
Committees hold hearings and require annual reports to measure and
assess progress.
One commissioner submitted a statement of separate views regarding
four aspects of the report. His statement is in Appendix L.
additional resources:
Electronic access to the complete report of the Veterans'
Disability Benefits Commission is available at: http://
www.vetscommission.org
Also available on the Commission's Web site are:
Bios of the Commissioners
Commission Charter
Commission Charter (renewed, 2-21-2007)
Public Law 108-136 establishing the Commission
Extension of the Commission's Charter in Public Law 109-
163
Legislative History of VA Disability Compensation Program,
Economic Systems Inc., Dec 2004
Appendices to the Legislative History (Dec 2004)
Literature Review of VA Disability Compensation Program,
Economic Systems Inc., Dec 2004
Appendices to the Literature Review (Dec 2004)
Commission's Approved Research Questions, October 14, 2005
Institute of Medicine (IOM) Summary of the PTSD Review
contracted by the Veterans Health Administration, Mar 2006
A History and Analysis of Presumptions of Service
Connection (1921-1993)
An Updated Legal Analysis of Presumptions of Service
Connection (1993-2006)
Center for Naval Analyses (CNA) Literature Review (Final),
May 2006
Appendix to the CNA Literature Review (Final), May 2006
Veterans' Claims Adjudication Commission (VCAC), also
known as the Melidosian Commission Report (1996)
Blue Ribbon Panel on Claims Processing: Proposals to
Improve Disability Claims Processing in the Veterans Benefits
Administration, November 1993
Bradley Commission Report 1956
IOM Report to VA on Post Traumatic Stress Disorder:
Diagnosis and Assessment, 2006
Testimony of Chairman Scott at a Joint Hearing of the
Senate Armed Services & Veterans' Affairs Committees, April 12, 2007
CNA Report: Findings from Raters and VSOs Surveys, May
2007
IOM Report to VA on PTSD Compensation and Military
Service, 2007
A 21st Century System for Evaluating Veterans for
Disability Benefits, IOM Final Report, June 2007
Improving the Presumptive Disability Decision-Making
Process for Veterans, IOM Final Report, and Executive Summary August
2007
CNA Final Report: Final Report for the Veterans'
Disability Benefits Commission: Compensation, Survey Results and
Selected Topics, August 2007
______
Response to Written Questions Submitted by Hon. Daniel K. Akaka to
James Terry Scott, LTG, USA (Ret.), Chairman, Veterans' Disability
Benefits Commission
Before addressing the specific questions asked, I would like to
make it clear that my comments are my own and do not represent the
views of the other members of the Commission. The Commission completed
its work and submitted its report on October 3, 2007.
differences in recommendations
Question. Please compare your Commisson's recommendation to provide
a quality of life payment as part of disability compensation with the
Dole-Shalala commission's recommendation to revamp the entire
disability system?
Response. First, it is important to emphasize the results of the
overall analysis that the Veterans' Disability Benefits Commission
conducted of the entire VA and DOD system for determining compensation
for injuries, diseases, and deaths attributable to military service.
Our Commission addressed the entire system, not just how the system
addresses those found unfit for military duty As a result of our
comprehensive analysis, we made a series of broad recommendations
intended to significantly improve the existing system, including a
realignment of the processes used by DOD and VA when a servicemember is
found by DOD to be unfit for military duty. If implemented, our
recommendations would result in important and major changes.
Our Commission's efforts relied extensively on analysis conducted
for our Commission by the Institute of Medicine (IOM) of the National
Academies and by the CNA Corporation (CNAC). Taken together, their work
provides a picture of a disability system that needs considerable
improvement but one that is generally sound. For example, IOM concluded
that an effective system should ensure vertical and horizontal equity
to compensate disabled veterans for average loss of earnings capacity.
Horizontal equity would ensure that veterans with different types of
disabilities but with similar severity of disabilities would have
similar loss of earnings. Vertical equity would ensure that as rating
severity increases, earnings loss would also increase. CNAC's analysis
concluded that general loss would also increase. CNAC's analysis
concluded that there is general parity overall with average VA
compensation for all made service-disabled veterans about at parity
with earnings loss and that there is not much difference among physical
disorders. They did find significant exceptions with PTSD and other
mental disorders and those who experience severe disabilities at a
young age; these groups receive compensation that does not achieve
parity with earnings loss.
IOM concluded that compensation should be provided for more than
work disability or earnings loss; it would also compensate for loss of
ability to engage in usual life activities and loss of quality of life.
The CNAC analysis provided that current compensation payments generally
provide parity with respect to earnings loss but that there is not
compensation for quality of life. In addition, the CNAC analysis
provided an accurate assessment of the extent to which disability
impacts on quality of life and demonstrated that health declined as
degree of disability increased. CNAC also found that mental disorders
impacted on physical health to an extent unanticipated. Thus, the CNAC
analysis supported the independent conclusions of the IOM concerning
compensation for impact of disability on quality of life. The Dole-
Shalala Commission also recommended that compensation should recognized
effects on quality of life.
Our Commission asked the IOM to address whether some other system
of evaluating disability would be preferable to the use of the VA
Rating Schedule. Specifically, IOM was asked to compare and contrast
the Rating Schedule to the American Medical Association Guides to the
Evaluation of Permanent Impairment. IOM found that the Guides are
designed for use by physicians, measures and rates impairment and, to
some extent, daily functioning, but not disability or quality of life,
and does not provide mental ratings. IOM recommended updating and
improving the Rating Schedule rather than adopting an impairment
schedule developed for other purposes.
Concerning the recommendation by the Dole-Shalala Commission to
``completely restructure'' the disability and compensation system, my
interpretation is that the overall focus of their report is on the
processes currently used to determine whether a servicemember is fit or
unfit for duty and to provide benefits and compensation for those found
unfit. They recommended that the existing processes be restructured so
that DOD determines fitness for duty and, for those unfit, DOD provides
payment for time of service; VA rates the disability and compensates
for disability. Our Commission essentially recommended the same
realignment. The Dole-Shalala Commission recommended specifically that
DO administer a single, comprehensive examination that could be used by
both DOD and VA. Our Commission agreed that a single, comprehensive
examinations be conducted but felt that either DOD or VA could
administer the examination, depending on local capability of the
clinical staffs. However, we extensively reviewed the examination
process with the advice of the Institute of Medicine and made several
recommendations to improve the examinations and ensure consistency and
reliability. These recommendations include greater use of templates,
improved training and certification of examiners, and enhanced quality
control. These recommendations should be implemented no matter which
department conducts the examinations.
dual rating schedule
Question. Based on the Commission's work, do you believe that it is
either necessary or appropriate to have two different disability
ratings schedules, one for veterans of the current conflicts and one
for veterans of earlier eras?
Response. Our Commission believes that there should be a single
process used and the benefits available should be appropriate for all
veterans. The processing steps may vary somewhat in the case of
servicemembers found unfit for duty, but in general, all veterans'
claims should be processed similarly and in a timely manner. Our
Commission also believes that the payment rate of disability
compensation should be based on severity of disability without regard
to the circumstances of the disability. This is Principle 3 of our
Commission's 8 principles. We do not believe that veterans'
compensation should be different if the injury occurs during wartime or
peacetime, during combat or combat-related duties, in the United States
or abroad, or other distinctions. We believe that military service is a
24-hour a day responsibility as demonstrated by the fact that
servicemembers are subject to the Uniformed Code of Military Justice
continuously during active duty. In addition to issues of equity, such
distinctions among circumstances would require subjective judgment on
the part of rating officials and would serve to add further complexity
into an already complex process.
All veterans should be evaluated using the same criteria, namely
the VA Rating Schedule and that no attempt should be made to develop
and apply different criteria or a different Rating Schedule to veterans
who served during different periods of time. It is clear that VA has
not been successful in keeping one rating schedule up to date. Our
Commission recognized that VA had undertaken a project to revise the
rating schedule as a result of a critical 1989 GAS report and had
published a notice of its intent to update the entire schedule in
August 1989. IOM carefully reviewed the revisions to the rating
schedule and found that only 373 of 798 diagnostic codes (47 percent)
had been revised since 1990. A substantial proportion (281, or 35
percent) of the schedule's diagnostic codes had not been revised at all
since 1945 and 18 percent (144 codes) were revised between 1945 and
1989. Our recommendation 4.23 concerning updating the VA rating
schedule said that the revision of the rating schedule should be
completed within 5 years and our report (Prepublication page 80)
indicated that five years is a realistic timetable. Our Commission felt
that it would be important to establish a deadline that cold reasonably
be met, considering VA's lack of progress in the past. We meant that
deadline to be a maximum, not an estimate for how long the revision
should take. In retrospect, we should have expressed this more
carefully as an outside limit. We did not estimate how long a complete
revision should take.
I believe that practical consideration also argue against
attempting to create and maintain two separate processes and benefits.
It is well known and accepted that VA has had an ongoing problem with
timeliness of claims processing and with a continuing and growing
backlog of claims well beyond the volume of pending claims needed to
sustain efficient operations. During the period 2000-2006, VA received
some 1.2 million original claims while DOD separated or retired some
83,000 servicemembers as unfit for military duty. Thus, the number of
unfit separations and retirements were only 6.9 percent of all original
claims.
I am also aware of proposals that would restrict benefits,
particularly TRICARE family health care, to those with very strictly
defined serious disabilities who are separated or retired as unfit.
During the period of 2000 to 2006 reviewed by our Commission, less than
two percent (1,478 of 83,008) of those separated or discharged as unfit
were rated by DOD as 100 percent disabled and only six percent (5,060
of 83,008) were rated 50 percent or higher. Currently, servicemembers
found unfit and rated 30 percent disabled or higher are eligible for
TRICARE. The Dole-Shalala Commission recommended that all those fond
unfit because of combat-related injuries should receive comprehensive
health care for themselves and their families. As discussed previously,
I do not believe a distinction should be made regarding combat-related
injuries, but I agree with providing TRICARE to everyone found unfit.
Chairman Akaka. Thank you very much, General.
Admiral Dunne?
STATEMENT OF REAR ADMIRAL PATRICK W. DUNNE, U.S. NAVY (RET.),
ASSISTANT SECRETARY FOR POLICY AND PLANNING, U.S. DEPARTMENT OF
VETERANS AFFAIRS
Admiral Dunne. Good morning, Mr. Chairman and distinguished
Members of the Committee. Thank you for the opportunity to
discuss the recent activities to serve our Nation's veterans
through improved processes and greater collaboration with DOD.
On April 19, the President's Task Force on Returning Global
War on Terror Heroes issued its 25 recommendations to improve
health care, benefits, employment, education, housing, and
outreach using existing authority and resource levels. This
report was unique in that it also included an ambitious
schedule of action and target dates. Thanks to outstanding
interagency cooperation, 56 of 58 action items have been
completed or initiated.
The results of these initiatives support seamless and world
class health delivery. VA and DOD drafted a joint policy
document on co-management and case management of severely
injured servicemembers. This will enhance individualized
support for the wounded, severely injured, or ill servicemember
and his or her family throughout the recovery process.
To assist OEF/OIF wounded servicemembers and their families
in navigating through the transition process, VA hired 106 new
Transition Patient Advocates. These men and women, often
veterans themselves, work with case managers and clinicians to
ensure that patients and families can focus on recovery.
VA also revised its electronic health care enrollment form
to include a selection option for OEF/OIF to ensure proper
priority of care.
DOD and VA work collaboratively to expand access to
servicemembers' electronic health records by jointly developing
the electronic capability to transfer digital radiographs from
Walter Reed, Bethesda, and Brooke to VA's polytrauma centers.
The capability for electronic transmission of historic health
care data from DOD MTFs to VA medical centers is complete in
the domains of allergies, outpatient medications, laboratory
results, and radiology. Additionally, a contract was recently
awarded for an independent assessment of Inpatient Electronic
Health Records in VA and DOD.
In response to the report on the President's Commission on
Care for America's Returning Wounded Warriors, we are preparing
a statement of objectives to contract for studies of quality of
life and long-term transition benefits.
An MOU was signed by DOD, HHS, and VA to define the role of
the Public Health Service in the Recovery Coordinator Program.
Two members of the Public Health Service Commission Corps are
detailed from HHS to VA and are working with us to establish
the Recovery Coordinator Program.
Rulemaking is underway to revise the ratings schedule
provisions for evaluating disability due to Traumatic Brain
Injury and burns.
Two weeks ago, the Veterans Disability Benefits Commission
issued its report and recommendations. While some of the
recommendations are similar to existing ones, others are new
and we are carefully studying them.
To oversee the implementation of these recommendations, VA
and DOD established the Wounded, Ill, and Injured Senior
Oversight Committee on May 3. This Committee is co-chaired by
the Deputy Secretary of Veterans Affairs and Deputy Secretary
of Defense and meets weekly.
In a collaborative effort with DOD, VA made great strides
in addressing issues surrounding PTSD and TBI across the full
continuum of care. The focus has been to create a
comprehensive, effective, and individual program dedicated to
all aspects of care for our patients and their families. VA and
DOD have partnered to develop clinical practice guidelines for
PTSD, major depressive disorder, acute psychosis, and substance
abuse disorders. Our Senior Oversight Committee also approved a
National Center of Excellence for PTSD and TBI.
VA and DOD are also working closely to redesign and
establish one Disability Evaluation System. A pilot program is
being finalized to ensure no servicemember is disadvantaged by
this new system and that the servicemember receives high-
quality medical care and appropriate compensation and benefits.
The proposed new system will be much more efficient, and I have
provided additional details in my written testimony.
VA now has 153 Benefits Delivery at Discharge sites to
speed up processing of applications for compensation. VA also
processes the claims of OEF/OIF veterans on an expedited basis.
Collaborating with DOD, we have accomplished a great deal,
but there is still much more to do. We at VA are committed to
strengthening our partnership with DOD to ensure our
servicemembers and veterans receive the care and benefits they
have earned.
I will be happy to answer your questions.
[The prepared statement of Admiral Dunne follows:]
Prepared Statement of Hon. Patrick W. Dunne, Rear Admiral, U.S. Navy
(ret) Assistant Secretary for Policy and Planning
Good morning, Mr. Chairman and distinguished Members of the
Committee. Thank you for holding this hearing and providing the
opportunity to discuss the recent activities of the Department of
Veterans Affairs (VA) to improve benefits and services to our Nation's
veterans through improved processes and greater collaboration with the
Department of Defense (DOD).
The level of attention currently focused on our wounded
servicemembers and their families is unprecedented--and rightly so.
Over the past 7 months, I have had the privilege of being engaged in
many activities dedicated to ensuring our returning heroes from
Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF)
receive the best available care and services. I join my colleagues from
VA in striving to provide a lifetime of world-class care and support
for all our veterans and their families.
On March 6, 2007, by Executive Order, the President established the
interagency Task Force on Returning Global War on Terror Heroes. VA
Secretary Nicholson was appointed to Chair the Task Force and I was
proud to support him as the Executive Secretary. On April 19, 2007, the
Task Force issued its report to the President. The Task Force made 25
recommendations to improve the delivery of Federal services and
benefits to returning servicemembers. The Report contained
recommendations in the areas of health care, benefits, employment,
education, housing and outreach that could be achieved with existing
authority and resource levels. The report was unique in that it also
included an ambitious schedule of milestones and actions necessary to
implement its recommendations. We continue to monitor implementation
and I am pleased to inform you that, thanks to outstanding interagency
cooperation, as of August 28, 56 of 58 action items have been completed
or initiated.
The results of actions taken in response to recommendations in the
Task Force Report are having a positive impact on the lives of
servicemembers, veterans, and their families. I would like to highlight
some of the progress achieved.
In response to a Task Force recommendation, the Small Business
Administration launched the Patriot Express Loan Initiative. This
program provides a full range of lending, business counseling, and
procurement programs to separating servicemembers, veterans, spouses,
survivors, and eligible dependents. This program has already approved
more than $23 million in loans since it began in mid-June.
Several initiatives have and will continue to support seamless and
world-class health care delivery. VA and DOD have drafted a joint
policy document on co-management and case management of severely
injured servicemembers. The goal is to provide individualized,
integrated, interagency and intergovernmental support for the wounded,
severely injured or ill servicemember and his/her family throughout the
process of treatment, rehabilitation, and renewal. VA and DOD will work
together to minimize fragmentation of Federal clinical and non-clinical
services, improve the coordination of medical and rehabilitative care,
and ensure access to all needed resources.
To assist OEF/OIF wounded servicemembers and their families in
navigating through the transition process, VA hired 100 new Transition
Patient Advocates (TPA). These men and women, often veterans
themselves, recognize the difficulty in understanding the many
different programs and processes which come into play. VA TPAs work
with case managers and clinicians to ensure that patients and families
can focus on recovery.
VA also revised its electronic health care enrollment form to
include a selection option for OEF/OIF to ensure proper priority of
care.
Many advances are the result of improved records management and
greater sharing and Information Technology (IT) interoperability with
DOD. In response to Task Force recommendations, DOD and VA worked
collaboratively to expand access to servicemembers' electronic health
records by jointly developing the electronic capability to transfer
digital radiographs from Military Treatment Facilities (MTFs) at Walter
Reed, Bethesda, and Brooke to VA Polytrauma Rehabilitation Centers. The
capability for electronic transmission of historical health care data
from DOD MTFs to VA Medical Centers is complete in the domains of
allergies, outpatient medications, laboratory results, and radiology.
Additionally, a contract was recently awarded for an independent
assessment of inpatient electronic health records in the Departments of
Veterans Affairs and Defense. The contract will provide recommendations
for the scope and elements of a joint electronic inpatient medical
record.
In July of this year, the Report of the President's Commission on
Care for America's Returning Wounded Warriors was issued. This
Commission had a greater scope than the Task Force and was not
constrained by existing authority and resources. We are preparing the
statement of objectives to contract for studies of Quality of Life and
long-term transition benefits. An MOU was signed by DOD, HHS and VA to
define the role of the Public Health Service in the Recovery
Coordinator program. Two members of the Public Health Service
commissioned corps are detailed from HHS to VA and are working with VA
and DOD to establish the Recovery Coordinator program. Rulemaking is
underway to revise the Rating Schedule provisions for evaluating
disability due to Traumatic Brain Injury and scars.
Two weeks ago, the Veterans Disability Benefits Commission issued
its report and recommendations. While some of the recommendations are
similar to existing ones, others are new, and we are reviewing them
carefully.
To ensure a seamless continuum of benefits and health care services
to wounded, ill, and injured servicemembers, the Departments of
Veterans Affairs and Defense began an integrative effort, and
established the Wounded, Ill, and Injured Senior Oversight Committee
(SOC) on May 3, 2007. The SOC, composed of senior military and civilian
officials from both Departments, was established for a 12-month time
period, and was tasked to ensure the recommendations of the task forces
and committees were properly reviewed, coordinated, implemented, and
resourced. The Committee is co-chaired by the Deputy Secretary of
Veterans Affairs and Deputy Secretary of Defense, and meets weekly to
streamline processes, mitigate potential conflicts, and expedite the
two Departments' efforts to improve support of injured servicemembers'
recovery, rehabilitation, and reintegration.
Senior Veterans Affairs and Defense officials serve on the SOC.
This includes the Service Secretaries, the Chairman of the Joint Chiefs
of Staff, the Service Chiefs, and VA's Under Secretary for Health,
Under Secretary for Benefits, Assistant Secretary for Policy and
Planning, and Deputy Assistant Secretary for Information and
Technology. The driving principle guiding the SOC's efforts is the
establishment of a seamless continuum that is efficient and effective
in meeting the needs of our wounded, ill, and injured servicemembers/
veterans and their families.
Supporting the SOC decisionmaking process is an Overarching
Integrated Product Team (OIPT), composed of the Under Secretary of
Benefits, Assistant Secretary of Policy and Planning, and other senior
officials from VA and DOD. The OIPT reports to the SOC and coordinates,
integrates, and synchronizes the work of eight Lines of Action and
recommends sourcing solutions for resource needs.
The diagram below depicts the structure supporting the SOC. The
Lines of Action, which have Senior Executive Service Co-Leads from both
Departments, establish plans, set and track milestones, and identify
and enact early, short-term solutions.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
The Lines of Action (LOA) and their goals are:
LoA #1: Redesign the Disability Evaluation System
Goal: To develop a single, supportive, and transparent disability
evaluation system.
LoA #2: Address Traumatic Brain Injury/Psychological
Health
Goal: To provide servicemembers with lifelong standardized and
comprehensive screening, diagnosis, and care for all levels of
Traumatic Brain Injury and Post Traumatic Stress Disorder, in
conjunction with education for patients and family members.
LoA #3: Fix Case Management
Goal: To coordinate health care, rehabilitation, and benefits,
delivery of services and support that will effectively guide and
facilitate servicemembers and their families through necessary
processes.
LoA #4: Expedite Data Sharing
Goal: To ensure appropriate beneficiary and medical information is
visible, accessible, and understandable through secure and
interoperable information management systems.
LoA #5: Facilities
Goal: To provide servicemembers and families with the best possible
facilities for care and recovery.
LoA #6: ``Clean Sheet'' End-to-End Review
Goal: To honor our servicemembers by providing wounded, ill, and
injured personnel and their families the best quality care and a
compassionate, fair, timely, and non-adversarial disability
adjudication process--enabling servicemembers to return to the fullest,
most productive and complete quality of life possible.
LoA #7: Comprehensive Legislation and Public Affairs
Goal: To coordinate the development of comprehensive legislation
that will provide the best possible care and treatment for injured
servicemembers and families. Additionally, to keep the public informed
of significant accomplishments and events.
LoA #8: Personnel, Pay, and Financial Benefits
Goal: To provide compassionate, timely, accurate and standardized
personnel, pay, and financial support practices for Wounded, Injured
and Ill to ensure appropriate data sharing, quality control, and
support benefits.
In a collaborative effort with DOD, VA has made great strides in
addressing issues surrounding Post Traumatic Stress Disorder (PTSD) and
Traumatic Brain Injury (TBI) across the full continuum of care. The
focus of these efforts has been to create and ensure a comprehensive,
effective, and individually focused program dedicated to prevention,
protection, identification, diagnosis, treatment, recovery, and
rehabilitation for our military members, veterans, and families who
deal with these important health conditions.
Since June 2007, a collaborative team of VA and DOD experts known
as the ``Red Cell'' has worked to: (1) create an integrated,
comprehensive Department of Veterans Affairs/Defense program to
identify, treat, document, and follow-up those who experience TBI or
PTSD conditions while either deployed or in garrison; and (2) determine
how to build resilience, both in people and in organizations, to
prevent issues from developing and to reduce their impact if they do
occur.
VA and DOD have partnered to develop clinical practice guidelines
(CPG) for PTSD, Major Depressive Disorder, Acute Psychosis, and
Substance Use Disorders. These guidelines help practitioners determine
the best available and most appropriate care.
Our Senior Oversight Committee also has approved a National Center
of Excellence for PTSD and TBI. It will include liaisons from both VA
and DHHS, as well as an external advisory panel organized under the
Defense Health Board to provide the best advisors across the country to
the military health system. This center will facilitate coordination
and collaboration between VA and the Military Services, promoting and
informing best practice development, research, education and training.
As of the first half of fiscal year 2007, approximately 263,900
returning veterans have sought care from VA medical centers and
clinics. Of these, about 38 percent have received at least a
preliminary diagnosis of a mental health condition, and 18 percent have
received a preliminary diagnosis of PTSD, making it the most common,
but by no means the only mental health condition related to the stress
of deployment. Professionals with special expertise in PTSD are
available in all medical centers to serve veterans with PTSD. Most are
best served in outpatient programs, but for those with more severe
symptoms, VA has inpatient and residential rehabilitation options
across the country.
VA has taken several actions at multiple levels to promote the
recruitment and retention of mental health professionals in the
Veterans Health Administration (VHA). In February 2007, both an
Education Debt Reduction Program and an Employee Incentive Referral
Initiative began. The new mental health Education Debt Reduction
Program currently provides up to $38,000 of education loan repayment
for qualified student debt. The Employee Incentive Referral program
provides a bonus to VA employees who refer mental health providers who
are hired into VA positions. These initiatives have already generated
significant interest.
At the local level, opportunities have been developed for VA
facilities to engage in local advertising and recruitment activities
and to cover interview-related costs, relocation expenses, and provide
limited hiring bonuses for exceptional applicants. VA has also
established opportunities for supporting individual training and
education activities for mental health employees, demonstrating an
investment in staff can also have a positive impact on retention.
Rates of hiring have increased significantly in recent months,
suggesting that the enhanced recruitment efforts are having a positive
impact. Since fiscal year 2005, VA has authorized 4,367 new Mental
Health Enhancement positions. As of August 31, 2007, 81 percent of
these positions have been filled.
In terms of treating TBI, VA offers comprehensive primary and
specialty health care to our veterans, and is an acknowledged national
leader in providing specialty care in the treatment and rehabilitation
of TBI and polytrauma. Since 1992, VA has maintained four specialized
TBI Centers. In 2005, VA established the Polytrauma System of Care,
leveraging and enhancing the existing Brain Injury Polytrauma expertise
existing at these TBI centers to meet the needs of seriously injured
veterans and active duty servicemembers from operations in Iraq,
Afghanistan, and elsewhere. The Secretary of Veterans Affairs recently
announced the decision to locate a fifth Polytrauma Center in San
Antonio TX.
The Departments of Veterans Affairs and Defense are also working
closely to redesign and establish one Disability Evaluation System
(DES) for use by servicemembers. A pilot program is being explored via
tabletop exercise to ensure that no servicemember is disadvantaged by
this new system, and that the servicemember receives the high quality
medical care and appropriate compensation and benefits for the
residuals of his or her disabilities incurred or aggravated by military
service. An operational pilot program should be completed in the second
quarter of 2008. If it is as successful as we plan, this pilot program
will be expanded beyond the Washington Capital Region to become the DES
system, worldwide.
The proposed new system will be much more efficient. It will
produce more consistent outcomes and, with VA and DOD working together
as a team, the new system will be a seamless, single process for users.
We envision it cutting in half the time it takes for a servicemember to
go through the DES, from the time the member is referred to a Medical
Evaluation Board (MEB) to the time the member is discharged from active
military service and receives his or her first payment from VA.
An important improvement in this proposed system is that the
servicemember will only be required to have one medical examination or
series of medical examinations, depending on the severity of the
potentially disqualifying conditions to meet the requirements of both
DOD and VA. Currently, a service-specific medical examination is
required for the purpose of determining a servicemember's ability to
continue on active military service based on the residual unfitting
disability and the servicemember's, rank, rating, or military
occupational skills, and a VA medical examination is also required for
the purpose of evaluating the residual of the disability under VA's
Schedule for Rating Disability and assigning a percentage evaluation to
the disability. Under the current system, if servicemembers are found
unfit and are separated or retired, they must complete the second VA
exam to determine whether the claimed medical conditions are service-
connected and represent impediments to full employment capability.
Under the proposed new DES system, the one-medical-examination
process collects information required by both Departments. Under this
system, when the servicemember transitions to civilian life, VA will
already have the information needed to immediately start paying the
veteran the appropriate amount of compensation for the residuals of his
or her disability incurred or aggravated by military service.
Over the last 5 years, the Veterans Benefits Administration (VBA)
service coordinators conducted more than 38,000 briefings attended by
more than 1.5 million active duty and reserve personnel and their
family members. Additionally, through the Benefits Delivery at
Discharge program, servicemembers at 153 military bases in the United
States, Germany, and Korea are assisted in filing for disability
benefits prior to separation. This fosters continuity of care between
the military and VA systems and speeds up VA's processing of their
application for compensation. Claims decisions can be completed prior
to separation, and veterans can begin receiving VA compensation
payments, without delay, upon separation from the military. VBA also
processes the claims of OEF/OIF veterans who apply for VA disability
compensation or pension on an expedited basis.
Thank you for providing me this opportunity to share with you
recent activities in the Department of Veterans Affairs. I will be
happy to answer any questions you may have.
______
Response to written questions submitted by Rear Admiral Patrick W.
Dunne, U.S. Navy (Ret.), Assistant Secretary for Policy and Planniing,
U.S. Department of Veterans Affairs
Question 1. According to recent testimony by Mr. Dominguez, DOD's
Principal Under Secretary of Defense for Personnel and Readiness, DOD
and VA are working closely to redesign and establish one disability
evaluation system for use by servicemembers. I understand that this
redesign was done without the benefit of knowing the recommendations of
the Veterans Disability Benefits Commission. How is the redesign being
carried out, what information was considered, and what are the expected
outcomes? Does the redesign of the Disability Evaluation System include
improved processes for all separating servicemembers or just those
separating as a result of being found unfit or continued service?
Response. The Department of Veterans Affairs (VA)/Department of
Defense (DOD) Disability Evaluation System (DES) pilot program will
begin on November 26, 2007. The intent of the DES pilot is to evaluate
a stream-lined process designed to improve the timeliness and
effectiveness of the DES program. This pilot program integrates VA and
DOD processes thereby maximizing resources, eliminating duplication,
and improving case management practices. The pilot will operate within
the parameters of titles 10 and 38, United States Code and will be used
for personnel who are separating through the medical evaluation board
(MEB)/physical evaluation board (PEB) process.
VA and DOD designed a program that would remove current burdens on
servicemembers by simplifying the process and producing a single
disability rating. A key feature of the DES pilot is the use of one
comprehensive medical examination, using VA-based protocols, that is
administered by DOD. This single medical exam will meet the needs of
the PEB in determining a servicemember's fitness for duty and the needs
of VA for determining a total service-connected disability rating.
To ensure a seamless transition of our wounded, ill, or injured
servicemembers from DOD care, benefits, and services to the VA system,
the DES pilot will test enhanced case management methods; identify
opportunities to improve the flow of information; and identify
additional resources, which may be necessary to facilitate successful
transitions for servicemembers and families.
Chairman Akaka. Thank you very much, Secretary Dunne.
Secretary West?
STATEMENT OF TOGO D. WEST, JR., CO-CHAIR, INDEPENDENT REVIEW
GROUP, REPORT ON REHABILITATIVE CARE AND ADMINISTRATIVE
PROCESSES AT WALTER REED ARMY MEDICAL CENTER AND NATIONAL NAVAL
MEDICAL CENTER
Mr. West. Mr. Chairman, Ranking Member Senator Burr of my
home State of North Carolina, Senator Murray, and Members of
the Committee, thank you for including the Independent Review
Group in your hearing today. I am aware--we are aware--that you
are focusing on disability issues, but you asked us to speak to
questions of overlap or cooperation between DOD and the
Department of Veterans Affairs that are touched on by our
report and that would assist in providing the best of care to
returning servicemembers and veterans.
I will do that quickly. You have my statement. I won't take
the time to go through it. I want to make two points about two
issues that we touch on that certainly have to do with
cooperation between DOD and VA.
First of all, let me say this issue of how the two
departments, the two largest in terms of personnel in our
government, can cooperate to support servicemembers and
veterans is not a new one, of course. We were talking about it
when I was the Secretary of Veterans Affairs, also when I was
Secretary of the Army, and that is now turning out to be a
while back. Indeed, it was before me.
Something that was said here today, I think, is well worth
saying. Let me speak specifically to the issue of electronic
records. VA has certainly outdistanced the Department of
Defense on that score. The fact is that the transition to an
essentially paperless health records system is in many ways a
marvel. DOD is not there, and although I have heard some
encouraging statements both today and in past weeks, it is not
clear to me how quickly they will get there.
As General Scott pointed out--and I know you noticed his
comment, it is not just that DOD as a whole is not where VA is
in getting its medical records online, as it were; it is that
the individual services are not there. They can't even talk
with each other within the Department of Defense. Indeed, the
Army has three systems that can't talk to each other.
And so, when we talk about the objective of getting some
kind of useful collaboration between the two departments on
something that is as essential as the ability to put health
care records in an electronic means and make them available so
that they can go where a servicemember or former servicemember
or veteran needs them to go within the two systems, we are
talking about something that is not yet upon us, and I am
concerned we will have difficulty getting to. I understand that
the DOD part of it is a concern of another committee, but it is
the concern of the entire Senate, as well.
The Secretary of Defense and his people have made it clear
that they understand our recommendations and the
recommendations of the other commissions. But, I say to you,
that is an area that is going to take a lot of pressure.
Perhaps I will leave it at that and you can ask me questions
about it later.
Secondly, we had some strong language in the Independent
Review Group's report, as everyone else has had, concerning the
disability review process. We said then, and in our testimony
several subsequent times, that it makes no sense not to have
one system. It is no surprise, as I say in my comments, that a
department of government, several departments of government,
can offer good rationales for having the complicated systems
they have. Three levels of review--for example, in the Army
before you get a decision, before you even get to VA, if you
are a servicemember who is eventually discharged and needs to
continue in the VA system. Their reasons are good: that the
local commanders can make a better decision as to who is fit to
return, yet you need a level further after that to decide, and
so on.
But, the servicemembers and their families--as you have
heard from Senator Dole and Secretary Shalala, for example--to
servicemembers and their families, it looks like an
incomprehensible nightmare. We, as a government, should be able
to resolve that.
I am encouraged by what we are hearing in terms of moving
forward with a plan to proceed. Indeed, the members of the
Independent Review Group are meeting tomorrow with Assistant
Secretary Cassell to talk further about DOD's efforts to
resolve its internal process. But that again is an area that
will require continued oversight and urging, because we have
talked about and considered improving the disability review
process, as it involves both DOD and VA for a number of years
there, as well. It is not a new issue this year.
Finally, the Independent Review Group was the first body
called into action when the national scandal known as the
Walter Reed situation broke. Shortly after Secretary Gates took
over, he asked our group, which I have to say, in contrast to
what Senator Dole and Secretary Shalala were able to say about
their group, ours was the normal suspects--a couple of formers:
former Secretaries of the Army; some former military doctors
too; one a former Surgeon General of the Air Force; and the
other former Congressman Schwartz, who is also a doctor who
served as a military doctor; but also a former Navy nurse, Rear
Admiral Kathy Martin, who was a Deputy Surgeon General; and a
former Commander of Bethesda National Naval Medical Center; as
well as a former command sergeant, and two other private
citizens.
I mention that to say that our focus as we met and did our
deliberations, despite what the formal letters of reference may
have said in terms of what we were called on to do, were to
essentially find out what happened, find out why it happened,
and find out what needed to be done to fix both that problem
and its implications in other active duty facilities, as well.
We were not asked to look at VA, and indeed in an early draft
of our terms of reference there is a specific line that told us
to stay away from looking at the Department of Veterans
Affairs. At the suggestion of several of us, including me, that
was taken out. We understood what our area was, but, of course
it would make sense for us to look at the overlap at the place
of transition.
And so, our report heavily focuses on DOD and the many
things that need to be done there. But, I have to conclude by
saying with respect to that effort, that we found that where
DOD and VA have been making efforts to cooperate and to
collaborate, and there have been a number of them, the
Department of Veterans Affairs has been better able to move
ahead. You haven't asked me for a comparison and I am not
really offering one, but I am pointing out that the difficult
challenge continues to lie in pushing that large department,
which has so many different actors who have to participate, to
bring their activities to the point where they can work
together and mesh together with VA.
So, I thank you for this hearing. I thank you for including
us in it. I know you have had hearings like this before--I have
heard them referred to--and so have others. But wherever the
Senate or House of Representatives gathers in a Committee or in
full session to consider these problems of our servicemembers
and our veterans, there on that day is another opportunity for
the improvement of what we can do for them. Thank you.
[The prepared statement of Mr. West follows:]
Prepared Statement of Hon. Togo D. West, Jr., Co-Chair,
Independent Review Group
The report by the Independent Review Group is replete with findings
and recommendations covering a wide range of issues and circumstances
which have come to our attention. They converge around four core
concerns. Let me pose them as questions.
Firstly, who are we--as a country, as an Army, as a health care
center--here at Walter Reed? Unfortunately, if one considers reports we
have heard from servicemembers and their families about the lapses in
support to them during their rehabilitation phase of care, we would
conclude that we may be answering that question in ways that are not
attractive to us as an Army or as a Nation. We say so much about
ourselves by the attitudes we display toward those who look to the
Nation for support during the most vulnerable times of their lives. We
have included a number of findings and recommendations involving the
assignment and training of caseworkers, increases in the numbers of
caseworkers and adjustment of the caseworker to patient ratio,
assignments of primary care physicians, and attention to the nursing
shortages.
Secondly, who and what are we to become? The Base Realignment and
Consolidation (BRAC) process and the A-76 process have caused
incalculable dislocation in Walter Reed operations and threaten the
future of both installations.
Thirdly, how are our servicemembers doing? At every turn, the IRG
has encountered servicemembers, their families, health care
professionals, and thoughtful observers who point out how challenging
the traumas associated with TBI (Traumatic Brain Injury), and PTSD
(Post Traumatic Stress Disorder) have become; and how challenging they
have been in terms of both DOD and Department of Veterans Affairs
diagnosis, evaluation, and treatment. We believe there is a need for
greater and better coordinated research in this area. We have made a
detailed recommendation with respect to a center of excellence and
increased attention to cooperative efforts by both the Department of
Defense and the Department of Veterans Affairs.
Fourth, how long? The IRG has operated with what is, for me, a rare
sense of unity and consensus in our effort. If there is one issue, on
which we are even more unified than all others, it is that the horrors
that are inflicted on our wounded servicemembers and their families in
the name of the physical disability review process, known in the
Department of Defense as the MEB/PEB process, simply must be stopped.
It is no surprise to you on the Committee, or to us on the IRG,
that each part of the governmental process can make sound arguments to
defend and explain why three, and in the case of the Army four,
separate Board proceedings--with associated paperwork demands on the
wounded servicemember and family, accompanied by delays and economic
dislocation for assisting family members, and characterized prominently
by inexplicable differences in standards and results--are justified.
We, however, are a Nation which values the every day good sense of the
common man or woman--that is why we call it common sense. And common
sense says that from our servicemembers' and families' point of view
this must seem a wildly, incomprehensible way to settle for
servicemembers and families the question of whether the member must
leave the service and, if so, under what conditions. We recommend one
combined physical disability review process for both DOD and VA. (See
Attachment for specific areas that require collaboration between the
DOD and VA.)
Virtually every finding and recommendation we make, then can be
traced to these four concerns: (1) leadership and attitude; (2) the
transition from Walter Reed Army Medical Center to Walter Reed National
Medical Center; (3) the extraordinary use of IED (improvised explosive
devices) in the current wars and their impacts on the brains and
psyches of our servicemembers; and (4) the long-standing and seemingly
intractable problem of reforming the disability review process.
It is important to note that at the conclusion of the IRG
investigation, Army officials said the service has resolved, or is in
the process of resolving, 24 of the 26 findings listed in the report.
To be sure, it was the degradation in facilities that first caught
the eye of media reporters. Important as that is, however, we believe
that there is far more to be dealt with here than applying paint to
rooms or even in crawling around basements to deal finally with
electrical problems. We had experts of every sort assigned to us, and
talented and experienced health professionals as part of the
Independent Review Group itself.
None of these concerns, however, is our bottom line: not BRAC, not
facilities, not even the search for failures, breakdowns, or culprits.
Rather our bottom line is this:
(1) We are the United States of America.
(2) These are our sons and daughters, brothers and sisters, uncles
and aunts, even a grandparent or two who lie and sit wounded.
(3) Their families are our families, we are their neighbors, and
we, their fellow citizens and residents.
(4) Their anguish is our anguish.
(5) We can and must do better.
______
Attachment
Finding:
There are inconsistencies within the Department of Defense and the
Department of Veterans Affairs regulatory systems which deal with the
functional loss of limb due to Traumatic Injury and burn. Currently,
the disability system does not adequately compensate for the functional
and physiological loss of limb in burn patients.
Discussion:
The Code of Federal Regulations, Title 38, Part IV (Veterans
Affairs Schedule for Ratings and Disabilities) does not address
specific disability ratings for burn injuries. It does thoroughly cover
amputations. It also addresses many skin injuries such as scarring,
disfigurement and dermatitis. There exists a gap for addressing issues
specific to burn injuries. Burned skin needs extra protection from the
sun and elements; it does not sweat normally and needs extra
precautions (for example: ultraviolet protective clothing and salves)
for warm/hot environments. Because there are not specific disability
ratings for burn patients, they do not qualify for home or vehicle
modification as an amputee patient would.
Recommendations:
1. The Secretary of Defense should request the Secretary of
Veterans Affairs to update the Code of Federal Regulations, Title 38,
Part IV to account for the unique disabilities and needs of traumatic
amputees and burn victims, focused on a loss of function and post-
service needs. This would require an expedited process for publishing
the change.
2. The Secretary of Defense should review the Physical Evaluation
Board determinations of all burn cases, dating back to 2001, within 1
year after the update to United States Code 38.
Finding:
When an amputee leaves the Department of Defense medical system,
the follow-on care, the amputee receives, may not be as technologically
advanced outside the military medical system.
Discussion:
The Department of Defense, from clinical necessity, has been on the
cutting edge of prosthetic replacement for traumatic amputation. The
Department of Veterans Affairs has largely been focused on patients who
lost a limb (or limbs) through disease or accident instead of combat.
In addition, many amputees in the Veterans Affairs system are much
older than those who have suffered an amputation due to combat.
The Sun-Times News Group recently reported, MAJ (RET) Tammy
Duckworth, currently the Director of the Illinois Department of
Veterans Affairs, testified before the U.S. Senate Committee for
Veterans Affairs on March 27, 2007 and stated, ``The U.S. Department of
Veterans Affairs is absolutely not ready to treat amputee patients at
the high tech levels set at Walter Reed. Much of the technology is
expensive and most of the Veterans Affairs personnel are not trained on
equipment that has been on the market for several years, let alone the
state-of-the-art innovations that occur almost monthly in this field. I
recommend that the VA expand its existing SHARE program that allows
patients to access private prosthetic practitioners. There is simply
not enough time for U.S. Department of Veterans Affairs to catch up in
the field in time to adequately serve the new amputees from Operations
Iraqi and Enduring Freedom during these critical first 2 years
following amputation. Perhaps after the end of current wars in Iraq and
Afghanistan, the VA will have time to advance its prosthetics
program.'' Travel for prosthetic care also includes Department of
Defense beneficiaries follow up post amputation patients often requires
travel to medical centers with competent prosthetics departments. Often
a patient does not live in a geographic area where TRICARE Prime is
offered. The TRICARE Prime travel benefit covers per diem and travel if
a patient is referred to care more than 100 miles away from their home.
TRICARE Standard does not offer a travel benefit.
Recommendations:
1. The Secretary of Defense should pursue partnerships with the
Secretary of Veterans Affairs to provide treatment; promote education
and research in prosthesis care, production, and amputee therapy.
2. The Secretary of Defense should pursue a partnership with the
Secretary of Veterans Affairs to expand the Department of Veterans
Affairs' existing program to allow patients to access the military
health system and private prosthetic practitioners.
3. Review TRICARE regulations (CFR 199.17) and update specifically
to change them so that the geographic home of the patient does not
limit access to benefits for prosthetic care and treatment.
Finding:
There are serious difficulties in administering the Physical
Disability Evaluation System due to a significant variance in policy
and guidelines within the military health system.
Discussion:
There is much disparity among the Services in the application of
the Physical Disability Evaluation System that stems from ambiguous
interpretation and implementation of a Byzantine and complex disability
process. It is almost as if a peacetime, draft-era program is being
applied to an all-volunteer force engaged in war.
The Governing Statute, implementing publications and regulatory
guidelines: Code of Federal Regulation: Title 10, USC chapter 61,
provides the Secretaries of the Military Departments with the authority
to retire or separate members for physical disability. Code of Fed reg
Title 38, provides the authority for the VA. DOD Directive 1332.18,
Separation or Retirement for Physical Disability; DOD Instruction
1332.38, Physical Disability Evaluation; DOD Instruction 1332.39,
Application of Veterans Affairs Schedule for Rating Disabilities, and
applicable service specific regulations or instructions set forth the
polices and procedures implementing the statute. For each respective
service, the governing service specific guidelines include: Department
of the Air Force, AFI 36-3212, Physical Evaluation for Retention,
Retirement, and Separation; Department of the Army, AR 635-40, Physical
Evaluation for Retention, Retirement, or Separation; Department of the
Navy, SECNAV Instruction 1850.4E and Department of the Navy Disability
Evaluation Manual. A Government Accounting Office (GAO) Report (2006),
acknowledged the differences among the services and recommended
improved oversight of the physical disability evaluation system, to
which the Department of Defense agreed and indicated an intent to
implement.
``The Government Accountability Office noted that eligibility
criteria for disability programs need to be brought into line with the
current state of science, medicine, technology and labor market
conditions.''
During the course of its review, the Independent Review Group
identified no less than five Government Accountability Office reports
and one Presidential Task Force report that noted deficiencies and made
recommendations to improve the physical disability evaluation system.
These reports include:
November 2004 Government Accountability Office Report: VA
and DOD Health Care: Efforts to coordinate a single physical exam
process for servicemembers leaving the military
September 2005 Veterans Affairs and Department of Defense
Health Care: VA has policies and outreach efforts to smooth transition
from DOD Health Care, but sharing of Health Information remains
limited.
June 2006 Government Accountability Office Report: VA and
DOD Health Care: Efforts to provide seamless transition of care for OEF
and OIF servicemembers and veteran's.
March 2006 Military Disability System: Improved oversight
needed to ensure consistent and timely outcomes for reserve and active
duty servicemembers.
March 2007 Government Accountability Office Report: DOD
and VA Health Care: Challenges encountered by injured servicemembers
during their recovery process.
2003 President's Task Force to Improve Health Care
Delivery for Our Nation's Veterans.
Despite the comprehensive findings and recommendations in these
reports, the Group found little evidence of action on the
recommendations.
Recommendations:
1. The Secretary of Defense should provide recommendations to
Congress to amend Title 10 United States Code, Chapter 61, and Title 38
United States Code, to allow the ``fitness for duty'' determination to
be adjudicated by the Department of Defense and the disability rating
be adjudicated by the Department of Veterans Affairs.
2. Following the changes to the United States Code, the Secretary
of Defense, should quickly promulgate regulatory guidelines and policy
to the Service Secretaries.
Finding:
The current Medical Evaluation Board/Physical Evaluation Board
process is extremely cumbersome, inconsistent, and confusing to
providers, patients, and families.
Discussion:
The physical disability evaluation system is the means by which
servicemembers are retired or separated due to physical disability in
accordance with the aforementioned references. The Department of
Defense Directive (DODD) 1332.18, Section 3.2 outlines four elements of
the physical evaluation disability system: the physical evaluation;
appellate review; counseling; and final disposition. According to the
Department of Defense regulations, the physical evaluation process
consists of the Medical Evaluation Board and the Physical Evaluation
Board. The Department of Defense and the Department of Veterans Affairs
use the Veterans Administration Schedule for Rating Disabilities.
The Veterans Administration Schedule for Rating Disabilities
(VASRD) is primarily used as a guide for evaluating disabilities
resulting from all types of diseases and injuries encountered as a
result of, or incident to, military service.
Not all the general policy provisions set forth in the rating
schedule apply to the military. Consequently, disability ratings
consistently vary between the Department of Defense and Department of
Veterans Affairs. The Services rate only conditions determined to be
physically ``unfitting,'' compensating for loss of a military career.
The Department of Veterans Affairs may rate any service-connected
impairment, thus compensating for loss of civilian employability.
Additionally, the term of rating is different among the Department of
Defense and the Department of Veterans Affairs. The Services' ratings
are permanent upon final disposition. The Department of Veterans
Affairs ratings may fluctuate with time, depending upon the progression
of the condition. Further, the Services' disability compensation is
determined by years of service and basic pay; while Veterans Affairs
compensation is a flat amount based upon the percentage rating
received.
Recommendations:
1. The Under Secretary of Defense (Personnel & Readiness) should
completely overhaul the physical disability evaluation system to
implement one Department of Defense level Physical Evaluation Board/
Appeals Review Commission with equitable Service representation and
expand what is currently the Disability Advisory Council.
According to a Government Accountability Office report, a
problem with the current organization is that the Council only ``aims''
to meet quarterly, but did not meet for a full year, to discuss issues
raised by the Services. This recommended concept would have
consolidated operational oversight and responsibility of the Physical
Evaluation Board process, including the current Service level Physical
Evaluation Board and Appeals Review levels of jurisdiction. This action
allows for streamlining of personnel and resources, and eliminates the
intra and inter-Service disparities of the disability ratings and
provides a forum for implementing immediate corrective action. This
recommended concept incorporates Veterans Affairs representation and
ensures a seamless transition from the Department of Defense into the
Department of Veterans Affairs health system.
2. The Under Secretary of Defense (Personnel & Readiness) should
conduct a quality assurance review all (Army, Navy/Marine Corps, and
Air Force) Disability Evaluation System decisions of 0, 10, or 20
percent disability and Existed Prior to Service (EPTS) cases since 2001
to ensure consistency, fairness, and compliance with applicable
regulations.
3. The Secretary of Defense and the Secretary of Veterans Affairs
should establish one solution. Develop and utilize one disability
rating guideline that remains flexible to evolve and be updated as the
trends in injuries and supporting medical documentation/treatment
necessitate. Revise the current process of updating the disability
ratings system to include an operation update that pushes changes to
the field on a weekly, or as needed basis.
Finding:
A common automated interface does not exist between the clinical
and administrative systems within the Department of Defense and among
the Services, causing a systemic breakdown of a seamless and smooth
transition from Department of Defense to the Department of Veterans
Affairs.
Discussion:
Servicemembers should not be burdened with the arduous navigation
requirements of our current system. The complexity of the physical
disability evaluation system is further perpetuated as the
servicemembers transition into the Veterans Affairs system. Currently
there is not a seamless transition.
A ``seamless transition'' from military service to veteran status
is especially critical in the context of health care, where readily
available, accurate, and current medical information must be accessible
to health care providers.
For the administrative aspects of this process, no one system
currently exists. The Department of Defense does not have an integrated
automated system that supports the standardization of the clinical and
administrative requirements of the physical disability evaluation
system. Absent a corporate solution, the Services have created
individual systems to track the servicemembers within the physical
disability evaluation system. This exacerbates the process variation.
The Air Force currently does not have an automated system. The Army
currently uses the Medical Evaluation Board Internal Tracking Tool
(MEBITT). The Navy uses the Medical Board On Line Tri-Service Tracking
System (MedBOLTT). Each system serves its Service independently for
Medical Evaluation Board processing; yet do not interface with the next
step of the Physical Evaluation Disability System, or Physical
Evaluation Board.
The Army Physical Evaluation Board uses the Physical Disability
Case Processing System (PDCAPS) to track Army cases once they enter the
Physical Evaluation Board stage of the process. Using the Army as an
example of the lack of interface between systems, during the Medical
Evaluation Board phase of the process, the Medical Evaluation Board
Internal Tracking Tool is used. During the Physical Evaluation Board
phase, the Physical Disability Case Processing System is used. These
two systems, unique to one Service, result in numerous disparities
within the Army since the systems do not interface. From a clinical
perspective, all medical documentation should be available to the
servicemembers' providers throughout the entire process. This includes
the transition into the Veterans Affairs system where there is no
continuity other than what records the servicemember carries to the
Veterans Affairs. This issue has been continually addressed without
resolution.
``The Department of Veterans Affairs and the Department of Defense
should develop and deploy, by fiscal year 2005, electronic medical
records that are interoperable, bidirectional and standards-based''.
[Refer to Recommendation 3:1 of President's Task Force. (2003) Final
report to improve health caredelivery for our Nation's veterans.
Washington, DC.] The same report recommends a single separation
physical and electronic transmittal of the Department of Defense Form
214 (DD214) to the Department of Veterans Affairs. These
recommendations have yet to come to fruition and as a result, there is
a significant amount of redundancy still required at this point
starting at the physical examination.
Recommendation:
The Secretary of Defense, in conjunction with the Secretary of
Veterans Affairs, should direct the transition process be streamlined
for the servicemember separating from the Department of Defense and
entering the Department of Veterans Affairs.
As already identified in the Government Accountability
Office report (2004), implement the single physical exam. Review the
1998 Department of Defense memorandum of understanding (MOU) between
the Department of Defense and Department of Veterans Affairs, implement
a common physical for use by the Services and the Department of
Veterans Affairs for those servicemembers in the physical disability
evaluation system, and allow flexibility in the timelines test or
procedures that would eliminate redundant efforts.
Rapidly develop a standard automated systems interface for both
clinical and administrative systems that allows bilateral electronic
exchange of information. Review and implement the recommendations of
the 2003 President's Task Force.
Chairman Akaka. Thank you very much, Secretary West.
We have some questions for you. General Scott, we have seen
proposed legislation that would require the Secretary of
Veterans Affairs to conduct a 6-month study relating to
disability benefits, and after providing Congress with the
results of the study, to write regulations to implement the
study's findings so as to create a total change to the VA
disability system. Based on your Commission's review of VA's
disability process, do you believe that a total system reform
can be carried out in 6 months and be done on an administrative
basis with no Congressional hearings or legislative action?
General Scott. Mr. Chairman, you are going to have to find
a whole lot faster moving commissioners than the group that I
represented was if you can get that done in 6 months.
I am not sure how long it would take to do the study that
you mentioned. There was a question before about whether a
study be completed in a brief period of time to take a look at
quality of life. Quite frankly, one of the reasons that our
Commission recommended an immediate interim fix to quality of
life, which is upping the payment based on level of disability,
was that we didn't have a lot of confidence that a quick study
could be done that would address it and it might drag on and on
and on. We recognize, as did Dole-Shalala, that some of these
people need some more immediate help than might occur a few
years down the line.
In regards to a complete study of the Veterans' Disability
Rating System, we offered in our Commission report some
priorities. One of them was to sort out the TBI, PTSD, and
other contributing mental ailments, so that it was clearer as
to how diagnosis and evaluation might occur in that. And then
we offered some other priorities, such as those parts of the
schedule that had not been touched in many years might need
some attention.
But our estimate was that a system as complex as the
schedule of disabilities was going to take a significant amount
of time to--I don't know whether the term is, ``redo it,''
``change it,'' whatever; but I think we all recognize there is
a significant challenge involved.
So, in my personal view, sir, it probably couldn't be done
very well in 6 months. We recommended that the Congress put a
time line on the VA that the entire schedule of disabilities be
redone within a 5-year period. That was our guess as to how
long it might take to do the entire thing. But again, sir, we
offered some priorities where one might start and we would hope
that those would be done in a more expeditious fashion.
Chairman Akaka. Part of my question was whether it can be
done on an administrative basis without Congressional hearings
or legislative action.
General Scott. Sir, I think that from my own experience as
a military officer over the years and my experience since that
time, it would be that it was going to take all branches of
Government working together to make this thing work. So, it
appears to me, my personal opinion, that Congress has an
important role in overseeing this rewrite, not micromanaging,
but overseeing. I believe it is the responsibility of this
Committee and the like Committee in the House to do just that,
sir.
Chairman Akaka. Thank you. Secretary West, the Independent
Review Group endorsed the consolidation of the DOD and VA
disability systems so as to create a single comprehensive
medical exam resulting in a single disability rating. However,
the Independent Review Group did not recommend reforms to DOD
disability retirement pay. What are your views on the Dole-
Shalala recommendation that DOD disability retirement pay be
based solely on rank and years of service and not on the degree
of disability?
Mr. West. Mr. Chairman, I looked at those recommendations.
I speak for myself. The IRG has not taken a position on it. But
they are reasonable. The division of labor is reasonable. And
so, I don't have a problem with it. I think that makes sense. I
understand that this Committee is trying to work through
competing, or not necessarily competing, but several different
recommendations in that area. I think for us, what is important
is that we move as quickly as possible to get the clearest
possible resolution for retiring and for veterans.
I have some other views about some other parts of that, but
let me just confine my answer to what you asked me.
Chairman Akaka. Thank you very much.
Admiral Dunne, in my opening remarks, I stated how pleased
I was that the Under Secretaries of VA and DOD were meeting
weekly to address many of the issues we are discussing today.
Would you please comment on all the things that SOC has done
and is planning to do to address the recommendations of the
Dole-Shalala Commission, the Independent Review Group, and the
VA Task Force?
Admiral Dunne. Mr. Chairman, the Senior Oversight
Committee, in order to deal with the recommendations, has
created eight different groups and assigned them their
recommendations based on those responsibilities.
The first work group is the Disability Evaluation System.
In response to the recommendations on a single comprehensive
physical--at yesterday's weekly meeting we actually came to a
final decision on that single comprehensive physical and that
will be used in the pilot for the DES system, which we will
commence during the month of November.
Another work group is looking at TBI and psychological
health. The Senior Oversight Committee has been briefed on and
approved the National Center of Excellence for TBI and
Psychological Health and the intent is to have the ribbon-
cutting for that at the end of November.
We have also overseen the development of clinical practice
guidelines for PTSD, for major depressive disorder, and for
substance abuse disorders, and also the Senior Oversight
Committee has reviewed programming of some $900 million to
support TBI and psychological health prevention, treatment, and
continued research.
Another work group is looking at case management. They are
working now on the development of the Recovery Coordinator
Program, working together with HHS as well as DOD and VA. The
Memorandum of Understanding between the three agencies is
already in existence and has been approved. The memorandum
establishing the program will be approved this month. And we
are also in the process of developing what we are calling a
Federal Individual Recovery Plan, which will take the
servicemember or veteran from their first point of entry back
into the United States where they start their care and
recovery, all the way through their reintegration into the
community or their return to duty, if they are able to recover
sufficiently to return to duty.
The fourth work group is looking at data sharing between VA
and DOD, and the Senior Oversight Committee is monitoring all
the actions that are in place right now to have all essential
health and administrative data viewable between our two
agencies by October 31, 2008, which would meet the criteria
that was mentioned earlier this morning of getting it done
within a year's time.
We also have a contract in place to develop an analysis of
alternatives for an Electronic Inpatient Health Record, and we
are looking to the possibility of having some head start
opportunities coming out of that contract in advance of the
final deliverable, where we could do just that--get a head
start on complete interoperability--so that, instead of just
having viewable records, we have computable records between the
two agencies.
The data sharing group is also developing a plan for a
single web portal that the Dole-Shalala Commission recommended
so that veterans could go online and see all the benefits that
are available to them, and track their own progress.
And we are also developing an IT plan to support the
Federal Recovery Plan, which the case management group is
putting into place. This IT plan would be within the Web site
that is being created so that those personnel who need to track
an individual soldier or sailor could go online and review that
and keep up to date with the progress.
The facilities work group has approved the DOD housing
inspection standards for medical hold and holdover personnel,
and they are also in the process of preparing the inspection
report on all medical hold and holdover facilities, which will
be submitted to Congress later this year.
A sixth work group is looking at a complete clean sheet
review of the entire process: disability process; benefits
process; et cetera; to say, what if there wasn't anything in
place right now? What if there weren't any laws? What would you
see as the ideal organization's benefits package to put in
place?
Another work group is working on legislation, and you have
the immediate product of their work now--creating the
legislation to implement the Dole-Shalala recommendations.
And an eighth work group is looking at personnel pay and
financial benefits. Some examples there are: DOD and VA are now
sharing information--patient administrative data--when an
active duty servicemember comes to a VA facility. We have seen
problems in the past where, administratively, pay purposes, et
cetera, have been complicated, because they somehow seem to
fall through the cracks. We believe that we have taken care of
that now.
We are also looking at implementing what we have learned to
be the best practices for operating the TSGLI insurance system
for the benefit of the severely injured veterans.
Chairman Akaka. Thank you very much.
Senator Burr?
Senator Burr. Thank you, Mr. Chairman.
General, Admiral, Mr. Secretary, welcome. We can't thank
you all enough and your Commission members that are here and
those that aren't here for their time and commitment.
I want to take an opportunity to voice a personal
frustration. This is the most powerful country in the world.
Between our military and our veterans, we have some of the
brightest people that exist on the planet. We are going to be
tasked with helping to do the hard part--that 10 percent that I
think everybody agrees legislatively has to be done, whether
you just can't get there, you can't get the critical mass
administratively--somehow the authority of Congress says, OK,
we are going to do this.
The sad part is that I don't get a sense even if we did the
legislation, that it happens tomorrow--I would only share with
you my frustration. What takes so damn long? As powerful, as
bright as we are, we are still talking about the DOD
technologically getting up to where a community hospital is
today. We have got community hospitals across the country that
do remote monitoring of congestive heart patients that save
money, increase the quality of life, yet we can't track
somebody in the system and hand it off electronically to
another system, and both have existed for decades.
I share that with you only because it is a frustration, I
think, of all of us, as I know it is with you. I feel like we
put you in an untenable position to sit in front of the table
knowing that your reluctance is--well, history tells us, you
can't do it that quick.
My only suggestion to all of us in the room and to those
that read the testimony from this hearing is: we don't have any
choice. We have to do it and we have to do it quick. If we
don't, then we are the ones that have caused a quality of life
issue with the veterans that are in the system. We have to fix
it and we have to fix it now.
Now let me move to some very quick questions, if I can.
General, the Commission recommends that all applicants for
individual unemployment benefits first be screened by
vocational rehabilitation and employment counselors. In support
of this recommendation, the Commission cited a 2005 GAO report
that found only 495 of 219,000 veterans in receipt of
individual unemployment benefits had been evaluated by
vocational counselors. My specific question is, what happens
if, after being screened, the VA determines that employment is
feasible, but only if a veteran receives vocational
rehabilitation services?
General Scott. Well, in our report, we made a number of
recommendations to how we could enhance the VR&E services to
disabled veterans. Our thinking on the screening process is
that, basically, before we award individual unemployability to
a veteran, that the person should be screened to see if he or
she is employable. In other words, we should----
Senator Burr. I guess my question, going right to the heart
is, if the determination is that they are employable, but they
choose not to do the vocational rehabilitation proposals that
have been laid out for them to become employable, then what do
we do?
General Scott. Well, we talked about that in a different
context. When we talked about PTSD, we said that treatment,
compensation, evaluation and VR&E should all occur, and they
should be linked. So, I would say that if the problem happened
to be recalcitrance, in many cases, I think we should link
treatment with compensation. Now, I have no information that
leads me to believe that recalcitrance is a problem, but if it
is, that is a way that it might be addressed.
Senator Burr. Most of, I think, the recommendations of the
Commission have overwhelming support. I want to go to one where
Commissioner Brady had a different view and it dealt with
different compensation levels being appropriate for some
veterans based upon the circumstances of their injury. For
example, Commissioner Brady wrote the sacrifice made by
soldiers entered in combat is greater than the sacrifice made
by servicemembers injured in an off-duty motorcycle accident.
Can you enlighten us on why the Commission did not recommend
that compensation rates take into account the veteran's injury
or the circumstances of the veteran's injury?
General Scott. Senator Burr, I will be happy to. First of
all, let me say that all the Commissioners made major
contributions to the final document. I can also say--and I
think the Commissioners that are present will back me up--that
we did not all agree on every aspect of every issue. We were
able to achieve a consensus, which is found in the report.
There are a few things in there that I can assure you that
almost all the Commissioners would have worded a different way.
So, having said that, the Commission as a group views
service kind of like this: we are in a 24-hour a day, 7-day a
week service environment. I will use myself as an example.
During the 32 years that I was on active duty, I was subject to
the Uniform Code of Military Justice: 24/7; on leave; on duty;
in the U.S.; out of the U.S. If we are going to continue to
require our servicemembers to work to a 24/7 standard, then we
have to look after them in that way--24/7. That is the
consensus of the Commission.
Not to get too far afield here, but, we could be like the
Dutch army, where everybody is a union member. They all work
from eight to four and get a couple of hours off for lunch. If
we went to a standard like that instead of the 24/7, I think
there would be a case for looking at some sort of
differentiation. But, if you are on duty 24 hours a day, then
you should be protected 24 hours a day, and so----
Senator Burr. Rest assured, I am not a proponent of the
Dutch system, nor am I questioning the recommendation and the
fact that you didn't draw that distinction. I am trying to
short-cut the process we will go through, because I am sure an
issue will arise dealing with, ``is there an off-duty
difference versus combat.'' Understanding where the Commission
was, as a whole, is extremely important.
Admiral, very quickly, a common theme among the Commissions
that testified today and mentioned in your report is the need
for a formal system of case management or a central individual
to coordinate all the servicemembers' needs as they transition
from DOD to VA. Real specifically, from what you have seen on
the task force, do you feel that VA's recent move to create
Recovery Coordinators, and I think you mentioned Federal
Recovery Plans, as well--is that a silver bullet, or, is this
just another piece of the process that we have got to get
right?
Admiral Dunne. Well, I think it is an essential part of the
process, Senator. We have already moved out, and put on the VA
side, Transition Patient Advocates in place. 106 of them have
been hired so far, and I think they are essential to helping
the family focus on recovery, and let the Transition Patient
Advocates worry about those administrative things that have to
happen in order for the recovery to take place properly. But,
that is at the scene.
We also need the Recovery Coordinators who are going to be
the next level up, Federal Recovery Coordinators who will start
at day one with that servicemember and track them through all
the way to the end. And they will be overseeing and monitoring
the efforts of the Transition Patient Advocates or the Army
Triad, et cetera, who also have key and essential jobs to make
sure that our veterans and servicemembers are taken care of.
So, they are going to have to be working together.
Senator Burr. Admiral, as you are well aware, the VA-
assigned case managers to our service personnel when they came
in. I think Senator Dole was the one that said one of his
Commission members who went through the process had so many
case managers they couldn't remember the last one's name, so
they wouldn't have known who to call. I only point that out to
you to say we have been here before. We have had the right
focus. For whatever reason, I think the administrative side of
it didn't recognize the need for that personal bond, much the
same as a patient-doctor relationship. Somebody without a
medical home has a very difficult time accessing preventative
care. Somebody who doesn't have an entryway into the VA today
has a very difficult time, and we know that to be the fact. It
is another challenge that we have got to address in a different
forum.
Mr. Secretary, I am delighted to be reminded that you
remember your home of North Carolina. I am sure your mother
would be proud to know that.
I am going to give you an opportunity to expand on your
answer to the Chairman. You had possibly some additional
observations about the Dole-Shalala legislation. You limited
your answer to just the specific area. If there are other areas
you would like to address, I would like to give you that
opportunity.
Mr. West. Thank you, Senator. I didn't mean to sort of
appear to promise some areas of disagreement. I don't have any,
just some reactions. But I am reminded, before I do, of
something you said about your frustration with hearing that
whatever we say has to be done, it seems to take forever to do
it in a Nation like this.
When we try to change these huge institutions like VA and
DOD, you have heard the analogy before, I am reminded with the
Admiral sitting here, about trying to turn a huge ship and it
looks like it never happens. It doesn't mean that we take our
hands off the wheel. It doesn't mean that we lessen our efforts
to turn, because we know eventually we get it turned.
And so frustrating as it may be when I recite how far DOD
has in some respects against it, at the same time, when I
listen to these task forces that are meeting, there are two, it
seems to me, big areas of optimism. One is the fact that the
two Gordons continue to meet on this. Gordon England has a
reputation as a problem solver and a doer at DOD. He has
certainly got the confidence of the President, who has had him
in two different departments and in two different parts of the
Department of Defense, Navy, DOD, Homeland Security, and the
like, and we all know Gordon Mansfield and his record of
achievement at VA. That is not the point, though. The point is
the power of their offices. They run those departments for
their principals who are trying to do other things, and as long
as they are engaged, we will make progress on these things.
The other is, there are no good things about what happened
at Walter Reed except that it caused us as a Nation to focus on
the problems you are discussing. I was just listening to the
caseworker discussion. We found at Walter Reed that part of the
problem that was discussed in the press about soldiers who were
expected to keep their appointments when they were in
rehabilitation and they had had the kind of surgery that made
it very difficult for them to know who was their doctor that
they had to go see and what their appointments were and who was
going to help them to do it and how unfair it is to the
families is that you needed someone who was following that
whole thing throughout. The solution, of course, could be if it
were the same person who could follow the servicemember and
family all the way through. That is why this focus on
caseworkers is a continuing thing that we need to try to do and
to get right.
In terms of the various recommendations by the Dole-Shalala
report, they had the opportunity to hear from us. We completed
our work as they were starting. That was the time line that had
been given us and the idea was that our stuff should--it is
going to be available to inform them, and we are very happy
with their elements. I did not mean to suggest anything. I
think it was the particular topic that was being addressed at
the time, responsibilities between DOD and VA as we looked at
the joint scheme.
One reaction I had was the discussion between who should do
the physical examination. This effort is combined into one
thing. I am reminded that one of the things we found as we
talked to servicemembers at Walter Reed, also at Bethesda and
elsewhere, was their mistrust of the system, of the doctors in
the system, that the doctors somehow were biased against them--
certainly the Army doctors, in some way, that perhaps their
notes weren't reflecting everything that they should reflect.
An important part of the treatment and the determinations is
what is in the notes of the attending physicians as they look
at them along the way. It has a big impact on decisions that
later get made by reviewing authorities.
It may be well that servicemembers would be more inclined
to see VA doctors doing that one single examination. I think
the better answer is the one I heard given here, which is that
even more, it may be even best if we look to see what the
abilities are in a given area where the examination is to be
given between the two services. It may not be so good as to
make it an iron-clad process where it is a DOD physician every
time that does it. I think there is a little area there we want
to be careful about. I am sorry I took so much time.
Senator Burr. No, and I didn't mean to infer that you had
disagreements with Dole-Shalala. I thought you had some
additional things you wanted to say. You are in a unique
situation, having served as Secretary of the Army and the
Secretary of the Veterans Administration, but all of you are in
a unique situations from the standpoint of the studies you have
just done and the service that you have given.
Mr. Chairman, I hope that they will continue to make
themselves available to the Committee relative to questions
that we might have that help us to sort through this at a
faster pace than what Senate historical standards are, as well.
I thank the Chair.
Chairman Akaka. Thank you very much, Senator Burr.
Senator Murray?
Senator Murray. Yes. Mr. Chairman, thank you very much. I
think none of us want to have the sound and fury of the Walter
Reed scandal to be the sound and fury of this year, then 2
years come back here and we have done nothing. So, I think we
all want to see progress made, and to that point, General
Scott, you, in your recommendations with your Commission, seek
to establish an oversight group to make sure that the
Commission recommendations are followed on. That is not part of
what we heard from the Dole-Shalala Commission. Can you tell us
why you believe an oversight commission is important?
General Scott. This goes back, Senator, to an earlier
comment about how long is it going to take to get some of these
things done. It seemed to our Commission that oversight at a
couple of levels was critical. One of them: is we thoroughly
endorse the SOC with Deputy Secretary England and Deputy
Secretary Mansfield. But, we also believe that there are some
specific areas where additional oversight may be needed and we
suggested that the Congress may wish to establish an oversight
group or committee to keep up with these many, many
recommendations from all these groups, to make sure that none
of the important ones fall in the cracks. We don't want to find
ourselves all back here in 2 years saying, well, gee, we talked
about this before but nothing ever happened.
So, taking nothing away from the two departments and taking
nothing away from the Senior Oversight Council, it seems to us
that in some of these areas, oversight--you can call it
independent oversight or you could call it another level of
oversight--might be valuable to make sure that some of these
things don't just go away. That was the intent of the
recommendation, ma'am.
Senator Murray. OK. Thank you very much for that.
Secretary Dunne, the Senate has acted on legislation. We
came together--the VA and the DOD Committee. We put together
the Dignified Treatment of Wounded Warriors Act. It has passed
out of the Senate. Has the administration taken a position on
that legislation?
Admiral Dunne. Senator, I think the best way I can describe
reaction to the legislation is based on my experience of the
past 7 months and looking at the comprehensive plan that the
Senior Oversight Committee is putting in place right now to
address such activities as the TBI, PTSD, case management, et
cetera, and creating a Center of Excellence--putting that into
action already on PTSD and TBI.
My best understanding is with the legislation which I
participated in drafting, which was sent over here yesterday,
to reflect the recommendations of the Dole-Shalala Commission,
and what I have learned as a member of the Senior Oversight
Committee. I think that I would say, that is the best
legislative approach to take.
Senator Murray. So, they are not commenting, or they are
commenting in opposition to it?
Admiral Dunne. I don't believe that we have an
administrative position right now.
Senator Murray. OK. One other quick question. All of the
other task forces emphasized and talked about family support
except for the President's Task Force. I understand you were
limited in your scope. The President said he didn't want to
spend any new money, so you were not looking to expand
anything. I know that put a big damper on it. But, can you tell
me what the VA's recommendations are on family support
programs?
Admiral Dunne. Well, one of our key assets is using the Vet
Centers, which we have over 200 of them throughout the country,
and they are available, legislatively have been made available
to families and dependents, as well as servicemembers, for
counseling; dealing with the challenges of deployments; et
cetera; and also, where necessary, bereavement counseling for
the families.
Senator Murray. I am sure you have seen the other reports.
They focus a lot on what the real stresses for families today
in the current military are and how families are the support
groups, and all the issues from health care to being there for
someone who is critically ill for a long period of time. Did
your task force not look at all at some of this extra support,
additional support, needed support, for those families?
Admiral Dunne. The task force responded to the request that
we received from the different information sources we sought,
including our Web site, e-mails coming in, et cetera, and----
Senator Murray. That sounds so bureaucratic. I am just
asking you, don't you think that there are a lot of families
out there who, in today's world, really need additional
services?
Admiral Dunne. I absolutely do, and one of the ways we are
dealing with that is with the Transition Patient Advocates, who
have the ability to communicate with the family and determine
where there is a need, where there is a special circumstance,
et cetera, and for them to find an answer to that special
circumstance anywhere within VA--that they need to go to get
the answer.
Senator Murray. Well, don't you think a lot of them are
getting lost today because they don't know where to go?
Admiral Dunne. I am confident that my fellow workers at VA
are doing their utmost to make sure that nobody falls through
the cracks.
Senator Murray. And you wouldn't think that the VA needs
today to look differently at veterans' families than they have
in the past?
Admiral Dunne. We need to continue to emphasize that the
family is a very essential element to the recovery of our
veterans and active duty personnel and we need to work with
them to make sure that they can focus on recovery and not on
administrative procedures.
Senator Murray. Mr. Chairman, my time has expired, but I do
think in today's world, with what we are asking of our men and
women who serve us and the fact that many of them have families
today, they end up being the caregivers. That is something we
have to really focus on. Thank you very much, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Murray.
I want to thank this panel very much for your testimony,
your responses, as well as your recommendations. It will be
helpful to our Committee as we proceed here. In case we receive
any further questions, we will be submitting them to you for
the record. So, thank you again, and thank you to the rest of
the Commissioners who are here for your service to our country.
I now welcome our third and final panel and want to extend
our welcome to each of you.
I extend a welcome and aloha to Ms. Ariana Del Negro, the
wife of an Army Ranger who suffered a Traumatic Brain Injury
while serving in Iraq in 2006. Ms. Del Negro traveled all the
way from my home State of Hawaii to testify before the
Committee today. Ms. Del Negro also testified at a field
hearing I held this August in Honolulu where she shared the
challenges that she and her husband have faced in obtaining
proper medical care for his injuries. I thank Ms. Del Negro for
traveling a great distance to share her and her husband's
experience with us and for the record.
Also testifying on the third panel are Colonel Peter Duffy,
who is the Deputy Director of Legislative Programs for the
National Guard Association of the United States; Gerald Manar,
the Deputy Director of VFW's National Veterans Service, who is
representing the views of the Independent Budget; Meredith
Beck, National Policy Director of the Wounded Warrior Project;
and Colonel Steve Strobridge, Director of Government Relations
for the Military Officers Association of America.
I thank all of you for being here today and look forward to
hearing your perspectives on the proposals and recommendations
put forth in the reports of those who appeared on today's
earlier panels. Of course, your full statements will appear in
the record of the hearing.
May I ask Ms. Del Negro to begin with your statement.
STATEMENT OF ARIANA DEL NEGRO,
WIFE OF 1LT CHARLES GATLIN
Ms. Del Negro. Thank you very much. As you mentioned, my
name is Ariana Del Negro and I am here representing most of the
families who are entering the awkward transition stage between
active duty and veteran status.
As Chairman Akaka mentioned, my husband, Charles Gatlin, a
First Lieutenant and scout platoon leader of his infantry
battalion, was wounded September 28, 2006, after a vehicle-born
improvised explosive device detonated less than 20 yards from
where he was standing. My husband is a very accomplished
soldier. His prior service was in the Old Guard. He deserved
better care when he came home.
He was subsequently returned to Hawaii approximately 4
weeks after his injury. It was immediately frustrating. At our
first doctor's appointment they didn't know what a VB-IED was;
they also took no initiative to get him the care he needed. My
husband, an Army Ranger, a 200-pound man who was responsible
for collecting intelligence to ensure the safety of his fellow
soldiers, admitted he was having anxiety at his first
neurologist appointment. The response from the neurologist,
``See me in 2 weeks,'' was inappropriate--absolutely
inappropriate.
My husband could not drive when he came home. He had severe
vertigo. He leaned to the left. He had hand and facial tics and
he couldn't keep eye contact when speaking. My husband used to
work in the Pentagon in the public tour program. There was no
room for error with speech. He developed a stutter and it
significantly compromised his communication abilities. I had to
act on his behalf as his agent. He was unable to follow
conversations. He did not receive any education about his
injury.
I work in the health care field and made sure to
familiarize myself with the complexities of the injury and the
required standard of care that should be delivered. Throughout
this process, initially at Tripler Army Medical Center, that
standard of care was not administered. There was no
coordination of care. There was no communication between
providers. And the providers we were able to see, and only able
to see after we demanded that those appointments be made, did
not have any consensus between them.
Subsequently--this was January of 2007--we finally had a
meeting with my husband's providers. They still did not have a
coordinated care plan established, and it was at that time that
we continued with our insistence that he be referred to the
Defense and Veterans Brain Injury Center in San Diego for
treatment. Our request for referral was finally granted January
31, 2007, 5 days before the Washington Post articles were
released.
Our experience represents exactly what those articles
captured. It was humbling to see that we were not an exception
but more the rule, and it was very sad. I am from Bethesda,
Maryland. I work in the health care industry for a very large
online health care resource. We have no children and I
telecommute to New York for work. The responsibilities that me
and my husband were asked of were not fair. If they were not
fair for us, who were more independent and capable, what does
that mean for these other families, for those whose husbands
return far worse off than my husband, for those with children
who have to work to supplement the family's income and who
don't know that the care they are receiving is not what they
need?
I urge you to continue to support these families,
specifically by extending resources to them. I would not have
known about the Defense and Veterans Brain Injury Center had I
not done extensive research and actively reached out to those
providers.
I must mention that we received care at the Sharp
Rehabilitation Program, which coordinated with Balboa Naval
Medical Center. The treatment at Sharp was impeccable. It
represented the complete antithesis of the treatment we
received at Tripler and my husband came home a husband. I am no
longer a caregiver, I am a wife. Because of Sharp, which was a
civilian program--because they had 20 years of experience, we
managed to survive as a family. That is the bottom line. That
is the most important message. We can sit here all day and
discuss the importance of policy, but unless some of these
things are implemented immediately, we will continue to fall
through the cracks.
Thank you.
[The prepared statement of Ms. Del Negro follows:]
Prepared Statement of Ariana Del Negro, wife of 1lt Charles Gatlin
Mr. Chairman, Committee Members, thank you for allowing me the
opportunity to participate in this vital forum on the issue of
providing coordinated care to servicemembers, veterans, and their
families. My name is Ariana Del Negro and I represent one of the many
families with a loved one injured in Iraq or Afghanistan who are now
entering the awkward and unfamiliar transition phase between active
duty and veteran status. I am here today not only to tell you about the
numerous obstacles my husband and I faced when he first returned home
from Iraq, but also to describe the excellent care he ultimately
received for his Traumatic Brain Injury (TBI). My husband and I believe
that there is much work to be done and hope that sharing our
experiences will help create a model of care for servicemembers and
veterans with TBI and their families that establishes: (1) strong
support networks and access to information; (2) timely, comprehensive,
and coordinated care; and (3) appropriate funding for the continued
research and training required to provide a high standard of long-term
care to the ever-increasing numbers of warriors suffering from TBI.
The wounds suffered from these injuries extend beyond the soldier;
the frustrations with gaps in care and lack of support also wound the
families fighting for their loved ones. These servicemembers, veterans,
and families need our help, and the responsibility to provide them with
that help falls on the Nation for whom these warriors bravely fought.
our story
My husband, 1LT Charles Gatlin was the Scout/Sniper Platoon Leader
of his Infantry Battalion. He was honored to hold this highly coveted
position, one which was reserved for the ``best'' lieutenant in the
Battalion. He took pride in having the degree of skill and
professionalism required for the position, particularly because his
work gathering intelligence helped both to ensure the safety of his
fellow soldiers and to meet the larger objective of unifying a
politically and religiously diverse area. My husband commands deep
respect from his soldiers and continues to perform his job (albeit in a
different capacity) with the highest degree of excellence and
professionalism.
On September 28, 2006 in Kirkuk, Iraq, my husband suffered a
closed-head TBI after a very large vehicular-borne improvised explosive
device (VBIED) detonated less than 20 yards from where he was standing.
He was exposed to three concussive forces: first, the explosion; then
the engine block from the vehicle which struck him on the back of the
head as he was thrown into the air; and finally when he hit his head
again after falling to the ground on his back, where he remained
unconscious for at least 10 minutes.
The screening and care my husband received in the battlefield and
in the theater was excellent, proficient, and per protocol. Within 1
hour of his injury, my husband was medevaced to Balad Medical Hospital
where he was admitted in serious condition. After 3 days in the
intensive care ward, he was eventually discharged from the hospital and
returned to his base in Kirkuk in hopes that his initial TBI symptoms
would subside enough that he could return to the field of combat within
a few weeks. I believe that my husband was returned to his base in
Kirkuk instead of being medevaced to Landstuhl Regional Medical Center
in Germany because of his insistence that he be back with his men in
the field. During the 4 weeks my husband spent back in Kirkuk, he had
to depend on his medic and roommate, CPL Joshua Harmon. CPL Harmon
tended to him, helped him dress, assisted him when moving from room to
room, and checked his pupils each night. (Sadly, on August 22, 2007,
CPL Harmon and nine of his fellow Scout platoon members died in a
helicopter crash outside of Kirkuk, Iraq. To CPL Harmon and his family,
and to the families of his fallen comrades, thank you.)
After spending approximately 4 weeks in Kirkuk without resolution
of his symptoms, my husband was returned back to his home base in
Hawaii. He could barely keep his balance, let alone figure out where he
was supposed to go and whom he was supposed to see for his medical
care. Unfortunately, the system he reported to, Tripler Army Medical
Center, did not know either.
My husband had sustained what is now known as the ``signature
wound'' of the Global War on Terror. However, he was injured before
this phrase was coined and before the full implications of the injury
were recognized. The general lack of awareness of TBI at the time of
his injury, coupled with its ``silent'' symptoms, were significant
barriers when my husband first sought medical treatment upon his return
from Iraq.
A closed-head TBI is literally a hidden injury; an injury with the
potential for subtle yet devastating symptoms that go unnoticed by
those who are unfamiliar with the individual's functioning prior to his
or her injury. Health care professionals are used to having physical
evidence of an injury, but mild, closed-head TBIs typically do not show
up on brain scans and referrals for treatment must be made on the basis
of neurological exams, self- and family-reported symptoms, and the
results of neuropsychological testing.
When he first returned home from Iraq, my husband complained of
debilitating headaches, chronic vertigo, memory lapses, anxiety, and
hearing loss. He leaned to the left, developed hand and facial tics,
and could not maintain eye contact when speaking. Two weeks later, as
some symptoms worsened, new symptoms emerged. He developed a
significant stutter, had difficulty recalling words, and frequently
dropped objects. Unable to drive, this fiercely independent man lost
his autonomy and was forced to depend upon others for his basic needs.
It was also at this time that he began to withdraw socially, avoiding
public and busy areas. His time was mostly spent sitting, staring
blankly. Watching my husband, an exceptionally accomplished and strong
man, struggle with such simple tasks was very difficult.
early disappointments
The phrase ``twice wounded,'' often used to describe the struggles
wounded warriors face when seeking care in the military health care
system may seem cliched, but it is exactly what my husband experienced
after he returned from Iraq. He describes the struggles we encountered
at Tripler as being as painful as sustaining the injury itself.
Treating TBI requires a multidisciplinary approach from as many as
nine specialists. However, the single most important component of
treatment is effective communication and coordination among these
providers. Although Tripler had the resources required to effectively
treat TBI, they lacked that crucial coordination. Coupled with
Tripler's lack of experience managing TBI and post-concussive syndrome
(a diagnosis made when a patient continues to exhibit symptoms from TBI
beyond 1 month), this lack of coordination compromised and slowed my
husband's recovery. Despite his worsening symptoms, we had to fight for
every referral he needed--audiology, vestibular testing, ophthalmology,
speech therapy, etc. And, even after we were referred to and met with
these specialists, no two specialists agreed about what my husband
needed; we spent our days shuttling from one appointment to the next,
only to discover that the recommendations made by one provider were
deemed unnecessary by another.
Many of the providers we saw had little or no experience with
blast-related TBI. When my husband told the doctors treating him at
Tripler that his injury was caused by a VBIED, they asked him what a
VBIED was. Likewise, when my husband--the brave infantryman who had
insisted on remaining in Kirkuk after his injury--actually summoned up
the courage to acknowledge to his neurologist that he was experiencing
anxiety, his neurologist simply responded: ``See me in 2 weeks.'' Had
this neurologist instead taken the time to find out what my husband's
responsibilities were in Iraq and what he witnessed, he would perhaps
have realized that exposure to these stressors meant my husband was at
increased risk for depression, anxiety, and other psychological issues.
In my husband's case, these risks were exponentially compounded by the
fact that several symptoms associated with post-concussive syndrome
secondary to TBI are psychological in nature. Whether due to a lack of
combat experience, poor training, or overwhelming caseloads, these
doctors simply did not have the knowledge or skills to treat my
husband's injuries.
Similarly, because doctors cannot see physical evidence of TBI,
they sometimes wrongly conclude that servicemembers suffering from TBI
are malingering and trying to shirk their duties and avoid returning to
Iraq or Afghanistan. One of the physicians treating my husband in
Hawaii made exactly this kind of accusation against my husband, which
added salt to an already open wound.
My husband was unable to drive, which placed responsibility for
taking him to each and every one of his appointments and to and from
work on me, his lone caregiver. Because of the adverse cognitive and
communication effects of his injury, I also had to act as his
representative, speaking and processing information on his behalf. But
the system at Tripler was far from encouraging and supportive of my
efforts. Many of the people we encountered seemed to be less than
pleased with a wife who was outspoken, informed, and persistent. One
physician even went so far as to suggest that my husband was receiving
poor care because of my outspokenness.
Finally, after 14 long and frustrating weeks of struggling with the
system to get my husband the care he needed, our request for referral
to the Defense and Veterans Brain Injury Center (DVBIC) at Balboa Naval
Medical Center in San Diego, CA, for thorough evaluation and
comprehensive treatment was granted. After waiting another 6 weeks for
the paperwork to be finalized, we finally arrived in San Diego. All
told, it took us more than 5 months to get access to this excellent
level of specialized health care. These were five valuable months lost
in the crucially important acute rehabilitation stage of TBI.
fine example of excellent care and invaluable education
The care in San Diego represented the complete antithesis of what
we received in Hawaii. The DVBIC at Balboa coordinates its care with
the Community Re-Entry Program at Sharp Rehabilitation Center, a center
with more than 20 years of experience in rehabilitative care. The
providers at Sharp and at Balboa addressed all of my husband's needs
(physical, occupational, and speech therapy), integrated our requests
into their rehab program, and provided amazing support to both of us.
My husband finally received the care he should have received all along.
He underwent intensive rehabilitation 7 hours a day, 4 days a week. We
had biweekly coordination meetings with all of my husband's providers
who met with us to discuss his progress, make suggestions, and ask for
feedback.
The care my husband received in San Diego represented what we
should have been receiving all along. I use the term ``we'' because the
caregiver and family unit are integral to a successful rehabilitative
process. In stark contrast to the care in Hawaii, where my involvement
was discouraged, the program in San Diego integrated the caregiver into
the rehabilitative process.
And, importantly, they educated us. We learned that our situation
was not unique and that many closed-head TBI patients face similar
obstacles and frustrations that compound their symptoms. Shortly after
coming home from Iraq, for example, my husband commented that because
he was not missing a limb and/or did not have scars on his head or
body, he questioned whether he was as seriously wounded as those with
visible injuries; a question reinforced by his experiences with some of
the doctors he encountered at Tripler. The education we received at the
DVBIC and Sharp provided affirmation to my husband that he was
seriously injured and deserved the best care possible. They explained
that the adverse effects of his injury would have resolved faster had
some of the frustration with his medical care been avoided. They also
explained that my husband probably would have made greater progress
during rehabilitation had he been referred earlier in the treatment
process. Although he likely would have recovered to the same degree, he
would have done so at a much faster rate. Importantly, they also
explained that there may be some symptoms that will never resolve and
that the success of his rehabilitative therapy depends on our ability
to set reasonable goals and maintain realistic expectations.
My husband left San Diego a changed man. He regained his ability to
accomplish complex tasks, his speech was fluid, he was able to run, and
he passed a driving evaluation. He was able to regain his autonomy,
enabling me to (semi-) retire from my roles of caregiver and chauffeur.
Now I can be a wife and he can be a husband. He has since returned to
duty in an administrative capacity as his Battalion's Rear-Detachment
Executive Officer in Hawaii. Although he still suffers from
intermittent headaches, vertigo, fine motor skill deficits, and some
memory problems, they are less intense than when he first came home. He
has applied the lessons we learned in San Diego and is learning to
accept and compensate for his limitations.
Throughout this process, my husband and I have done our best to
keep a sense of perspective, returning time and time again to our sense
that we are one of the lucky families. My husband and I are both well-
educated and make a good living. Working in the health care industry, I
have been able to rely upon my medical background to find appropriate
resources. My husband was also fortunate to receive remarkable support
from his Command. His Commander, MAJ William J. O'Brien, in the spirit
of a true Infantryman, dedicated a significant amount of time and
effort to ensure that my husband received the care he rightly deserved.
Without MAJ O'Brien's support, and the support of the 25th Infantry
Division, it's likely that I would be sharing a different story with
you today.
However, if it has been this difficult for my husband and me, we
cannot imagine what it must be like for the other families--those with
warriors who return far worse off than my husband; families with
children; families with mothers who have to work outside the home to
help support their families; and those who do not know that the care
they are receiving is far inferior to what they need and, importantly,
deserve.
support for families at all stages in the recovery process
The success we had at Sharp Rehabilitation demonstrated that in
addition to providing adequate funding and training, it is important
that systems be created to provide support for servicemembers,
veterans, and their families. Our frustrations with my husband's
initial care alienated us; we had nothing to compare our own experience
with, and had no communication with other families in similar
situations. Less than 1 week after our request for referral to the
DVBIC was honored, The Washington Post published the first in its
series of articles on Walter Reed, chronicling the frustrations wounded
servicemembers, and their families faced trying to navigate through a
complicated and bureaucratic system. The Washington Post articles were
bittersweet: the sweet of knowing we were not alone coupled with the
bitter of knowing we were not an exception. These articles also
validated my belief that it is not just the individual servicemember
who bears the brunt of injury. The unrealistic expectations that the
system places on the caregiver add further burden to an already
stressful and taxing situation.
It is critically important that servicemembers and their families
are proactively made aware of the resources that are available to them;
they should not have to seek them out. I would not have known about the
DVBIC unless I had actively sought out information and made contact
with both Walter Reed and San Diego. I would not have known that my
husband was not getting the appropriate standard of care if I did not
have a medical background and if I hadn't done extensive research to
educate myself on TBI. I made sure that I was armed with knowledge for
each doctor's appointment and I did the best I could to educate my
husband. What is clear from our own experience is that there are many
families in need. These families need immediate access to resources,
they need advocates, and they need support. It is one thing to develop
resources but it is another to actually utilize them. If the families
do not know that these resources exist, they are unlikely to ever be
able to reap benefits from those programs.
I am pleased that the reports from The President's Commission on
Care for America's Returning Wounded Warriors (commonly referred to as
the Dole-Shalala Commission), as well as the Veterans Disability
Benefits Commission, recognize the pivotal role of family in the
treatment process and I strongly advocate for an amendment to the
Family Medical Leave Act, extending unpaid leave from 12 weeks to 6
months for caregivers tending to the needs of a servicemember. I
believe, however, that the legislation should go one step further to
include those tending to the needs of wounded veterans, particularly
since many of the diagnoses for TBI and PTSD are made after
servicemembers are separated from active duty.
the importance of timely and coordinated care
Our success with Sharp's Community Re-entry Program was the result
of receiving excellent individualized care and education from a
multidisciplinary group of providers who worked well together and
integrated the family unit into the decisionmaking process; in essence,
they practiced ``relationship-based health care''. This medical model
is outlined in pending legislation, such as the Veterans Traumatic
Brain Injury Rehabilitation Act of 2007 (S. 1233).
My husband was very high-functioning after his injury and was not
an injured servicemember for whom the military typically considered
intensive rehabilitation necessary. However, the increasing awareness
of the deleterious and long-term consequences of TBI--namely through
the adoption of the DVBICs across the country--my husband was finally
properly identified as someone who could benefit from such care.
Our experience at the Sharp Rehabilitation Center also demonstrates
the importance of extending civilian health care services to
servicemembers and veterans. Programs such as the one at Sharp have
experience with these types of injuries, have an effective program in
place, and clearly yield excellent results. More initiatives need to be
taken to institute similar programs partnering military, veteran, and
civilian health care services. In addition, consideration must be given
to properly pairing the offerings of a rehabilitation center with the
specific needs of a servicemember/veteran with TBI. Employing the
valuable resources of these non-Department facilities could help reduce
the heavy burden on the Department of Veterans' Affairs (VA)--a burden
likely to grow in parallel with the number of wounded.
staffing shortages and lack of training compromise care
As noted in Dole-Shalala Commission Report, the chances of recovery
from TBI are greatest when prompt and correct care is administered.
Communicating this message to health care providers is pivotal to
ensure that all servicemembers and veterans have immediate access to
care. Meeting this objective, however, is contingent on providing
appropriate, timely, and comprehensive training to health care
professionals, with an emphasis on the signs and symptoms of TBI and
PTSD. It is also dependent upon adequate long-term funding.
This also speaks to the staffing shortages of health care providers
in the military and VA systems. Tripler Army Medical Center is the
largest military medical treatment facility in the entire Pacific
Basin, covering an eligible population of 400,000 servicemembers,
veterans, and their families. Yet, when my husband first arrived at
Tripler for care, there were only three neurologists in the entire
hospital. Furthermore, there was only one full-time neuropsychologist,
a provider described in a Veterans Health Initiative as ``the key
player in diagnosing cognitive impairments'' in patients with post-
concussive syndrome. Neuropsychological testing is a labor-intensive
process and the results of the testing require careful and detailed
analysis to ensure a fair assessment. Given the recent findings of the
Neurocognition Deployment Health Study that deployment to Iraq
increases the risk of neurological compromise, the caseload for these
neuropsychologists will undoubtedly increase.
more research is needed!
There is little doubt that more research on blast-related TBI is
needed, particularly as it relates to the effects of exposure to
multiple primary blasts and long-term outcomes. TBI in a combat
environment is a complex injury. A thorough understanding of the
nuances of the injury, whether physically evident or otherwise, is
absolutely essential to identify effective therapies and maximize
outcomes. Currently, much of the evidence on blast-related TBIs is
derived from animal studies, which have helped researchers understand
the pathophysiologic effects of the injury; however, the implications
of these findings in the clinical setting have not been well studied.
As the number of closed-head TBI wounds increase, so too does the need
for allocated funding to support clinical research and new practice
guidelines.
For example, much of the data on TBI are largely based on older
studies, evaluating outcomes of patients who sustained a TBI in an
automobile accident, a fall, or a sports injury. These studies do not
take into consideration that a blast-related TBI may injure cells at a
more severe, microscopic, sub-cellular level. Injury to this fine of a
degree may influence outcomes and possibly require longer periods for
maximum recovery than TBIs suffered in a non-combat setting.
Although much has been learned about the recovery and treatment
process for TBI, much remains unknown, particularly about the long-term
effects of these injuries. For example, how long should care be
administered? When is a patient considered fully recovered? What will
the long-term consequences of closed-head TBI be--epilepsy?
Parkinson's? Alzheimer's? Answers to these questions remain ambiguous
at best. Applying the tragic lessons learned from exposure to Agent
Orange, we should prepare for the likelihood of long-term adverse
effects from this conflict as well.
transitioning from active duty to veteran status--action is needed
Although my husband is still on active duty, our experience
represents what many young veterans suffering TBI have had to face
before being discharged from the service. We fear that without major
reform, the obstacles and frustrations we faced within the Army's
medical system will not be significantly different from those we may
encounter when we enter the VA health care system. Although the VA and
Department of Defense (DOD) systems are separate entities, the two
departments share similar bureaucratic problems. We need to learn from
the experiences of servicemembers and families such as ours in order to
avoid similar obstacles within the VA system. The continuum of care
must begin on the battlefield, move to the military health care system,
and continue through the VA.
We are encouraged by recent initiatives proposed by Congress, the
DOD and the VA to improve the care and support for servicemembers,
veterans, and their families, particularly as it relates to developing
a strong collaboration between the two departments to streamline the
transition process. There is little doubt that the systems to
accomplish these goals are in place; however, they are still in the
early stages of implementation and, as with any natural process, it
will take time for them to mature to the degree desired. While the
development of these initiatives are imperative for the future, we must
not lose focus and overlook the fact that today's servicemembers and
veterans continue to face a number of obstacles and hardships. Unless
immediate action is taken, these individuals will continue to fall
through the large cracks borne of years of neglect and empty promises.
conclusion
Although The Washington Post articles in February 2007 have turned
much-needed public attention to the hardships that both servicemembers
and veterans face, they were hardly the first warnings about these
problems. For years, the Government Accountablity Office has issued
reports documenting the significant backlog in the VA disability
system, the outdated nature of the VA Schedule for Rating Disabilities,
and the incompatibility of electronic health records between the VA and
DOD systems. Concerns regarding blast-related TBIs were also addressed
prior to The Washington Post articles. On August 11, 2006, the Armed
Forces Epidemiology Board presented its findings on the acute and long-
term health implications of TBI in military servicemembers to the
Assistant Secretary of Defense for Health Affairs. The Board's
recommendations closely mirror those made in the Dole-Shalala
Commission Report.
I ask of you: why did it take a series of articles in The
Washington Post for these concerns to suddenly be regarded as serious?
And, if only little progress has been made in response to reports over
the course of the past few years, why should we believe that
recommendations in the new reports will suddenly transform the status
quo? Reform has been needed for years and some of the recommendations
made in these reports will take still more years to implement. Where
does that leave today's and tomorrow's generation of veterans?
I am aware that this continues to be an ongoing learning process,
but I also believe that measures need to be put in place to ensure that
these changes are made, to assess the efficacy of these programs, and
to set specific benchmarks. Thus far, we have a wealth of data and an
abundance of recommendations. However, until these recommendations are
actually integrated into the existing system and successfully applied,
they will remain nothing more than notes on a page.
In the end, my husband and I hope that you and your colleagues will
work to make other returning servicemembers and veterans just as
fortunate by implementing systems that: (1) provide family members with
support and assistance navigating the system; (2) that facilitate
coordinated care; and (3) that fund further long-term research of the
devastating injuries of TBI and PTSD. It is time that the excellence
that these servicemembers and veterans dedicated and displayed in the
field of combat be matched by the system for which they sacrificed.
Chairman Akaka. Thank you very much, Ms. Del Negro.
Colonel Duffy?
STATEMENT OF COL. PETER J. DUFFY, USAR (RET.), DEPUTY DIRECTOR
OF LEGISLATIVE AFFAIRS, NATIONAL GUARD ASSOCIATION OF THE
UNITED STATES
Colonel Duffy. Chairman Akaka, Ranking Member Burr, and
Members of the Committee, it is my distinct pleasure to appear
before you on behalf of the National Guard Association of the
United States (NGAUS), to address certain recommendations of
particular concern to the welfare and benefit of our wounded
National Guard members and their families, as set forth in the
report of the President's Commission on Care for America's
Returning Wounded Warriors, hereinafter referred to as the
report.
This brief submission will address four recommendations of
the report relative to improving care for our wounded members.
NGAUS supports all recommendations of the report with
additional recommendations of its own to improve the subject
care. NGAUS urges this Committee to continue to differentiate
between the medical needs of our active duty members and our
veterans, particularly with respect to geographical barriers.
It is important to note that National Guard members
returning from deployment can be extended on active duty for
treatment by military treatment facilities before being
discharged. In most cases, our members, upon returning from
deployment, are quickly discharged from active duty and then
eligible as veterans for care at the Department of Veterans
Affairs health facilities. Once discharged, most of our members
continue in the Selected Reserve and, as such, are eligible to
enroll in TRICARE Reserve Select beyond the six-month
Transitional Assistance Management Program. However, once
discharged, our members are no longer eligible for treatment at
military treatment facilities.
Report recommendation one.--Immediately create
comprehensive recovery plans to provide the right care and
support at the right time in the right place. The needs of our
wounded National Guard members and their families are
geographically spread across the full area of our country, its
Commonwealths and Territories. Once released from medical hold,
our wounded members return to their civilian communities, not
to military installations. These communities are often in areas
isolated from a Department of Veterans Affairs treatment
facility. Obtaining continuing treatment at a DVA facility for
many of our veterans will mean having to travel significant
distances. This travel may require the veteran and possibly an
accompanying family member to take time off from work, thereby
further straining an employer-employee relationship already
stressed by previous deployments.
Although perhaps most often associated with States west of
the Mississippi, geographical barriers to treatment can occur
in States as small as Rhode Island and as far East as Maine.
Maine Representative Michael Michaud, Chairman of the Health
Subcommittee of the House Veterans Affairs Committee, indicated
this session at a hearing of his Subcommittee that some of his
veterans in the State of Maine must travel 9 hours to be
treated at facilities in Boston. In recommending the creation
of Comprehensive Recovery Plans to provide the right care and
support at the right time, in the right place, the report
speaks to the need to expand DVA treatment for our National
Guard members in their communities. If necessary, this may mean
authorizing DVA to contract with civilian health care providers
and other facilities to remove the geographical barriers
peculiar to the National Guard veterans. Our members and their
families deserve no less.
Report recommendation three.--Aggressively prevent and
treat Post Traumatic Stress Disorder and Traumatic Brain
Injury. Without a shifting of care to the communities, the
geographical barriers to treatment may be insurmountable for
the psychologically wounded and for those suffering from
Traumatic Brain Injuries (TBI). Experts have written that
individuals experiencing moderate to severe brain injuries
require a continuum of care that, at some point, will involve
community-integrated rehabilitation that will include
neurobehavioral programs, residential programs, and home-based
programs.
For those requiring behavioral readjustment or treatment
for Post Traumatic Stress Disorder and willing to seek the
same, eliminating time and distance factors will intuitively
expedite and ease the transition from non-recognition to
treatment. Physicians say that the sooner these behavioral
conditions can be recognized and treated, the more successful
and mitigating the treatment will be. DVA needs to have access
to all available behavioral health care resources in
communities throughout the country to provide the care our
National Guard veterans and their families are requiring in a
convenient location.
In addition to removing geographical barriers for
psychological health, it is essential that mandatory cognitive
screening both pre- and post-deployment be implemented to
establish a baseline against which any delta in cognitive
functioning occurring during deployment can be determined for
purposes of expeditiously diagnosing and treating TBI and
possibly PTSD conditions. The screening technology exists and
needs to be implemented immediately.
Report recommendation four.--Significantly strengthen
support for families. NGAUS strongly supports amending the
Family and Medical Care Leave Act as recommended in the report
to authorize family caregivers for our wounded members to take
leave from employment for up to 6 months. A visit to Walter
Reed will quickly show that our seriously wounded National
Guard members are actively attended by family members for
extended periods. These family members should not be penalized
with the loss of employment for attending to the needs of our
heroes with their care and support.
Under current law, an employee would only be allowed a
total of 12 weeks during a 12-month period to provide such
care. In too many cases, the serious injuries suffered in the
Global War on Terror are requiring far more than 12 weeks of
treatment. As our members convalesce in military treatment
facilities or in their communities over these extended periods,
the care of their loved ones is an irreplaceable comfort to
them and an immeasurable aid in the recovery process. Extending
the 12-week period to 26 weeks under the FMLA would provide the
caring family members with the assurance that he or she will
not be terminated from reemployment during that extended period
of care should it be needed.
Report recommendation five.--Rapidly transfer patient
information between DOD and VA. The recommendation that DOD and
the VA must move quickly to transfer clinical and benefit data
to users will require interoperability of the AHLTA and VISTA
electronic recordkeeping systems used by DOD and DVA,
respectively. Although this moment of interoperability is
reported by DOD's contractors to be close at hand, the medical
needs of our National Guard members have been overlooked with
this effort that does not require the records of civilian
health care providers treating our members to be entered into
the DOD AHLTA database.
Currently, although the technology exists, there is no
mandate from DOD to scan or otherwise enter hard copies of our
National Guard members' medical records from their civilian
health care providers into the DOD AHLTA database. Please keep
in mind that our National Guard members in a non-deployed
status do not receive their medical care from military
treatment facilities but from civilian physicians.
Failure to scan National Guard members' civilian treatment
records into the AHLTA database will continue to keep military
physicians in the dark when treating our members relative to
preexisting conditions and medication histories found in their
civilian medical records. Lack of ready access to this
information in emergency treatment situations during
deployments puts the National Guard patient at risk while being
treated by military physicians.
The recommendation of the report needs to go further to
include the mandatory transfer of all MTF treatment records for
National Guard members into the DOD and DVA electronic records
system. If these records were required to be entered into the
AHLTA system, then they would also be accessible to the DVA
once interoperability of the DOD and DVA systems is attained.
In conclusion, we at NGAUS hope that we have both
reinforced and amplified, where needed, the recommendations of
the report of the President's Commission on Care for America's
Returning Wounded Warriors relative to the needs of the
National Guard.
Thank you again for this opportunity to address this
Committee and for all that you do for our Nation's veterans.
Thank you.
[The prepared statement of Col. Duffy follows:]
Prepared Statement of Col. Peter J. Duffy, USAR (Ret), Deputy Director
of Legislative Affairs, National Guard Association of the United States
Chairman Akaka, Ranking Member Craig, and Members of the Committee,
it is my distinct pleasure to appear before you on behalf of the
National Guard Association of the United States (NGAUS) to address
certain recommendations of particular concern to the welfare and
benefit of our wounded National Guard members and their families as set
forth in the Report of the President's Commission on the Care for
America's Returning Wounded Warriors (hereinafter referred to as the
Report). This brief submission will address four recommendations of the
Report relative to improving care for our wounded members. NGAUS
supports all recommendations of the Report with additional
recommendations of its own to improve the subject care. NGAUS urges
this Committee to continue to differentiate between the medical needs
of our active duty members and our veterans particularly with respect
to geographical barriers.
It is important to note that National Guard members returning from
deployment can be extended on active duty for treatment at Military
Treatment Facilities before being discharged. In most cases our members
upon returning from deployment are quickly discharged from active duty
and then eligible as veterans for care at the Department of Veterans'
Affairs health facilities. Once discharged, most of our members
continue in the Selected Reserve and as such are eligible to enroll in
TRICARE Reserve Select beyond the 6 month Transitional Assistance
Management Program (TAMP). However, once discharged, our members are no
longer eligible for treatment at Military Treatment Facilities
report recommendation 1--immediately create comprehensive recovery
plans to provide the right care and support at the right time in the
right place
The needs of our wounded National Guard members and their families
are geographically spread across the full area of our country, its
Commonwealths and territories. Once released from medical hold, our
wounded members return to their civilian communities not to military
installations. These communities are often in areas isolated from a
Department of Veterans Affairs (DVA) treatment facility. Obtaining
continuing treatment at a DVA facility for many of our veterans will
mean having to travel significant distances. This travel may require
the veteran and possibly an accompanying family member to take time off
from work thereby further straining an employer/employee relationship
already stressed by previous deployments.
Although perhaps most often associated with states west of the
Mississippi, geographical barriers to treatment can occur in states as
small as Rhode Island and as far east as Maine. Maine Representative
Michael Michaud, Chairman of the Health Subcommittee of the House
Veterans' Affairs Committee, indicated this session at a hearing of his
Subcommittee that some of his veterans in the state of Maine must
travel 9 hours to be treated at facilities in Boston.
In recommending the creation of comprehensive recovery plans to
provide the right care and support at the right time in the right
place, the Report speaks to the need to expand DVA treatment for our
National Guard members in their communities. If necessary, this may
mean authorizing VA to contract with civilian heath care providers and
other facilities to remove the geographical barriers peculiar to the
National Guard veteran. Our members and their families deserve no less.
report recommendation 3--aggressively prevent and treat post traumatic
stress disorder and traumatic brain injury
Without a shifting of care to the communities, the geographical
barriers to treatment may be insurmountable for the psychologically
wounded and for those suffering from Traumatic Brain Injuries (TBI).
Experts have written that individuals experiencing moderate to
severe brain injuries require a continuum of care that at some point
will involve community integrated rehabilitation that will include
neurobehavioral programs, residential programs, residential programs
and home based programs.
For those requiring behavioral readjustment or treatment for Post
Traumatic Stress Disorder and willing to seek the same, eliminating
time and distance factors will intuitively only expedite and ease the
transition from non recognition to treatment. Physicians say that the
sooner these behavioral conditions can be recognized and treated, the
more successful and mitigating the treatment will be. DVA needs to have
access to all available behavioral health care resources in communities
throughout the country to provide the care our National Guard veterans
and their families are requiring in a convenient location.
In addition to removing geographical barriers for psychological
health care, it is essential that mandatory cognitive screening both
pre and post deployment be implemented to establish a baseline against
which any delta in cognitive functioning occurring during deployment
can be determined for purposes of expeditiously diagnosing and treating
TBI and possibly PTSD conditions. The screening technology exists and
needs to be implemented immediately.
report recommendation 4--significantly strengthen support for families
NGAUS strongly supports amending the Family and Medical Leave Act
(FMLA) as recommended in the Report to authorize family care givers for
our wounded members to take leave from employment for up to 6 months. A
visit to Walter Reed will quickly show that our seriously wounded
National Guard members are actively attended by family members for
extended periods. These family members should not be penalized with the
loss of employment or attending to the needs of our heroes with their
care and support.
Under current law an employee would only be allowed a total of 12
weeks during a 12 month period to provide such care. In too many cases
the serious injuries suffered in the Global War on Terror are requiring
far more than 12 weeks of treatment. As our members convalesce in
military treatment facilities or in their communities over these
extended periods, the care of their loved ones is an irreplaceable
comfort to them and an immeasurable aid in the recovery process.
Extending the 12 week period to 26 weeks under the FMLA would provide
the caring family member with the assurance that he or she will not be
terminated from reemployment during that extended period of care should
it be needed.
report recommendation 5--rapidly transfer patient information between
dod and va.
The recommendation that DOD and the VA must move quickly to
transfer clinical and benefit data to users will require
interoperability of the AHLTA and VISTA electronic recordkeeping
systems used by DOD and DVA respectively. Although this moment of
interoperability is reported by DOD's contractors to be close at hand,
the medical needs of our National Guard members have been overlooked
with this effort that does not require the records of civilian health
care providers treating our members to be entered into the DOD AHLTA
database.
Currently, although the technology exists, there is no mandate from
DOD to scan or otherwise enter hard copies of our National Guard
members' medical records from their civilian health care providers into
the DOD AHLTA database. Please keep in mind that National Guard members
in a non deployed status do not receive their medical care from
Military Treatment Facilities (MTF) but from civilian physicians.
Failure to scan National Guard members' civilian treatment records into
the AHLTA database will continue to keep military physicians in the
dark when treating our members relative to pre existing conditions and
medication histories found in their civilian medical records. Lack of
ready access to this information in emergency treatment situations
during deployments puts the National Guard patient at risk while being
treated by military physicians.
This recommendation of the Report needs to go further to include
the mandatory transfer of all non MTF treatment records of our National
Guard members into the DOD and DVA electronic record systems. If these
records were required to be entered into the AHLTA system, then they
would also be accessible to the DVA once interoperability of the DOD
and DVA systems is attained.
In conclusion, we at NGAUS hope that we have both reinforced and
amplified, where needed, the recommendations of the Report of the
President's Commissions on Care for America's Returning Wounded
Warriors relative to the needs of the National Guard.
Thank you again for the opportunity to address this Committee and
for all that you do for our Nation's veterans.
______
Response to Written Questions Submitted by Hon. Daniel K. Akaka to Col.
Peter J. Duffy, USAR (Ret.), Deputy Director of Legislative Affairs,
National Guard Association of the United States
Dear Chairman Akaka, Ranking Member Burr and Members of the
Committee, thank you for the opportunity to respond to the following
question:
mental health contracting
Question. The Dole-Shalala report very broadly notes that
``Congress should enable all veterans deployed in Afghanistan and Iraq
who need PTSD care to receive it from VA.'' While the Dole-Shalala
report did not include specifics on this recommendation, your
organization believes this should take the form of contracting with
outside providers. In your view, are there other options, such as
bringing on more mental health providers and positioning them in
communities that would address this concern?
Response. PTSD among our Reserve Component veteran population has
reached alarming levels. A JAMA article released November 14, 2007
entitled, ``Longitudinal Assessment of Mental Health Problems Among
Active and Reserve Component Soldiers Returning from the Iraq War''
identified 42 percent of Reserve component veterans of Operation Iraqi
Freedom (OIF) and 20.3 percent of active duty personnel as requiring
mental health treatment based upon their responses to the Post
Deployment Health Re-Assessment completed 3-6 months after return from
deployment.
The medical community says that PTSD is treatable but stresses that
early recognition and treatment offer the best opportunities for
success. Although veterans suffering from PTSD can receive 2 years of
care from the VA, many face geographical barriers in rural areas that
delay and even frustrate their efforts to obtain the same. In serious
cases of PTSD, this delay can prove fatal. The most desirable option
for successfully treating veterans suffering from PTSD is the
supplemental mental health contracting afforded by S. 38 that would
allow veterans under the auspices of the VA to be treated conveniently
and expeditiously in or near their communities by qualified mental
health care providers within and without the VA.
According to a roster compiled by the VHA Office of Public Health
and Environmental Hazards, 751,273 Operation Enduring Freedom (OEF) and
Operation Iraqi Freedom (OIF) veterans with out-of-theater dates
through May 2007, have left active duty and have become eligible for VA
health care. According to the subject roster, 389,036 of these new
veterans (52 percent) are from the ranks of our Reserves and National
Guard while 362,237 (48 percent) are from the ranks of our active
forces.
Applying the percentages from the JAMA study, 42 percent of the
population of 389,036 OIF and OEF Reserve Component veterans (163,395)
and 20.3 percent of the population of 362,237 OIF and OEF active duty
veterans (73,737) are arguably requiring or have required mental health
treatment from the VA through May 2007. The treatment needs of this
growing new veteran group and the mental health care needs of the pre-
2002 veteran population have overwhelmed mental health care facilities
of the VA. They will continue to do so unless all mental health care
providers in the country can be engaged in treating our veteran
population.
The need for the rapid delivery of mental health care in the widely
scattered communities of our surging veteran population is urgent.
Unfortunately, the VA does not and will not have that capability
without mobilizing all mental health providers in every community with
a nearby veteran population. Because it is impractical for the VA to
hire all mental health providers or to build clinics in every
community, the solution must lie in authorizing the VA to contract,
when necessary, with mental health care providers in remote areas
having a veteran population in need of mental health care. This is what
S. 38 would provide for veterans and their families.
S. 38 is modeled after similar programs operating in Montana,
Washington and South Dakota where the VA has been contracting
successfully with Community Mental Health Centers in delivering
behavioral health care to our members in those expanded geographically
areas. Because the mental health contracting program has been proven
effective, it should be made available to all areas of the country
where it is needed. The pilot program proposed by S. 2162 is
appreciated but it will only serve to delay nationwide implementation
of a necessary program that has already been successfully piloted.
Please note that S. 38 already builds into its matrix the features
of the proposed pilot program of S. 2162. If the civilian provider
effectively addresses the needs of our members, the VA will continue to
use that provider, but only as long as the need persists. Any decision
to contract with outside mental health care providers would be driven
by need recognized by the VA. Each regional VA facility would be able
to evaluate the effectiveness of any contracted behavioral care
provider. The VA would retain oversight and control of the process.
Five years into this war, the geographically dispersed behavioral
needs of our members and families are not being met by the VA. Those
needs cannot endure another pilot program in ten regions. Veterans in
rural areas outside the pilot areas would still be neglected. Denying
those veterans and their families outside of the ten pilot regions the
same treatment options as those within the ten regions is neglectful
and unfair. Moreover, without participation across the country,
information on the availability of the pilot programs will be difficult
to disseminate. For the VA to claim that it alone can address these
needs in house is admirable, but ultimately neglectful of our veterans'
mental health needs.
The question may arise within the Committee that if the contracting
programs in Montana, Washington and South Dakota have worked work so
well, why have they been they limited to those states? The answer to
that question lies in the reluctance of the VA to contract with local
care providers, not in the lack of quality care available in the
civilian community. The Committee should recall the testimony of Tammy
Duckworth on this point.
This Committee heard testimony from witnesses on November 6 about
the difficulty the VA has had in finding qualified physicians in the
remote area of Marion, Illinois. Ms. Duckworth, Director of the
Illinois Department of Veterans' Affairs, testified about a lack of
health care consistency across the VA especially in rural communities.
She criticized the reluctance of the VA to access local physicians
despite having the authority to do so. S. 38 would send a clear message
that it may be necessary for the VA to care for the behavioral needs of
our veterans by contracting with mental health care providers in the
civilian community.
Contracting with local health care providers will not toll the
death knell for the VA. S. 38 does not seek to tear down the brick and
mortar of the VA but to offer an affordable and viable alternative in
addressing the historical surge of PTSD cases in our veteran
population. Using civilian providers in remote areas when necessary
will save the VA the costs of hiring staff and acquiring space in
remote areas not otherwise having a large veteran population.
Using local civilian providers when necessary would also give the
veteran consumer a closer and more immediate choice once he or she
overcomes the reluctance to recognize the need for treatment. That
reluctance, once overcome, could return to the detriment of the veteran
if time and distance barriers delay treatment. A distant VA facility
might also require the veteran and family members to take time off from
work which would only further stress an employment relationship already
stressed by a previous deployment. Local treatment would avoid leaving
the veteran and family member the choice of distant treatment for a
poorly understood illness or continued employment. It is in the best
interest of the veteran to remove the time and distance barriers to
make mental health treatment as convenient as possible.
It is important to reemphasize that S. 38 does not require the DVA
to contract with civilian providers. It only authorizes the VA to do so
with the force of a statute that breaks internal and perhaps regional
adhesions that are blocking innovation and response in this crisis.
The downside risk posed by S. 38 is minimal. PTSD is not unique to
the military. Licensed civilian psychiatrists are fully capable of
recognizing and treating PTSD without having to enter an employment
relationship with the VA to do so. To require them to be employed with
the VA as a condition to treat our veterans at government expense would
waste a needed capability.
There is a sense that the VA and some veteran support organizations
are pushing back against this legislation out of fear that it would
diminish the VA when the contrary would be true. S. 38 would expand the
outreach of the VA throughout a state in a qualitative and cost-
effective manner that would inure to the benefit of our veterans and
their families. Insistence on the VA's paternal model of delivering
health care, although very effective in most cases, should yield, in
this instance, to the behavioral health care needs of our veterans and
families who need the geographical outreach in mental health treatment
that S. 38 would provide.
NGAUS is and will remain a staunch supporter of the Department of
Veterans Affairs (DVA). The DVA is and will remain the backbone of
service and benefits to our veterans. NGAUS is committed to a robust
DVA that would only be made more robust by authorizing it to engage all
available behavioral health care providers within and without DVA to
enable it to provide the necessary surge capacity in meeting the
burgeoning behavioral health care needs of our veterans and their
families.
Chairman Akaka. Thank you very much, Colonel Duffy.
Mr. Manar?
STATEMENT OF GERALD T. MANAR, DEPUTY DIRECTOR, NATIONAL
VETERANS SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED
STATES, ON BEHALF OF THE MEMBERS OF THE INDEPENDENT BUDGET
Mr. Manar. Mr. Chairman and Members of the Committee, thank
you for the opportunity to speak with you about transition
issues affecting the men and women who serve our Nation with
perseverance, courage, and honor.
For more than 20 years, the members of the Independent
Budget--AMVETS, Paralyzed Veterans of America, the Disabled
American Veterans, and the Veterans of Foreign Wars--have
annually assessed the state of the VA and made recommendations
to Congress, which would, if adopted, better help the
Department of Veterans Affairs help veterans. Interestingly, in
recent years, many of our recommendations on the VA budget,
health care, construction, and other issues have been closer to
VA's actual needs than were reflected in the budgets submitted
to Congress. We are not new to this work. Our organizations
have been working with and serving America's veterans for more
than 100 years.
With this as background, I would like to take a few minutes
to discuss the recommendations of the President's Commission on
Care for America's Returning Wounded Warriors, and in contrast,
the recommendations of the Veterans Disability Benefits
Commission.
The President's Commission was created in March 2007 and
ended its work in July 2007. They did a significant amount of
work in a little over 4 months. Where they were strongest was
in those areas of their principal interest--care for injured
servicemembers at the end of their military service and their
transition from active duty to civilian life. Where they were
weakest, in our view, is in the area of reforming the VA
compensation program.
Our written testimony outlines in great detail those
transition recommendations we believe are most effective, and
most likely to help disabled servicemembers. We would like to
use our short time this morning discussing some of the problems
we note with the President's Commission and the alternatives
provided by the Disability Commission.
The President's Commission recommends creation of a two-
tiered system of benefits, one for combat veterans and one for
all other veterans. We find this an unacceptable distinction,
one which is not supported in history, law, or the veteran
community.
We are all veterans equally. This is not a new concept. The
Bradley Commission adopted a guiding principle in April 1956,
which said, in part, that providing compensation on a uniform
basis to people with equal handicaps is the best possible way
to discharge our obligation to them. Fair and equal treatment
of all veterans, disabled and non-disabled, according to their
service-connected needs should be the guiding principle in all
our programs.
The Veterans Disability Benefits Commission, in their
Guiding Principle Three, stated that compensation must be based
on severity of disability and not where or how it was incurred,
and Congress, no less, supports this principle since it
eliminated separate compensation for disabilities incurred in
combat with legislation in 1972.
This does not mean that distinctions cannot be made among
veterans. In fact, the opposite is true, and this is a theme
that runs through the Disability Commission report--that the
more seriously disabled a veteran is, the more treatment,
support, and benefits he or she should receive.
The President's Commission recommends the creation of
transition payments, and with this we concur--not necessarily
in the form that they propose, but rather as a separate
benefit, totally unrelated to compensation. All of us in this
room who are veterans have had the opportunity to be released
from active duty, and after the first joy of the moment has
passed, we wonder what we are going to do. Now, some of us have
planned ahead and we have lined up jobs, but many veterans come
home, they take a break, and then they start looking for work.
There is every reason to support a recommendation that
Congress create a specific transition benefit, unrelated to
compensation. The idea that was proposed by the President's
Commission to have a transition benefit for 3 months in lieu of
compensation from VA for service-connected disabilities is
unacceptable to us; but a transition benefit focused on helping
bridge the few months following service is certainly within the
realm of our support.
In addition, the President's Commission, their proposals,
if adopted, would require a new rating schedule--a new rating
schedule which, in their view, could be done in 6 months. I
submit to you that I could sit down and in a matter of a week
or two come up with a new rating schedule. That doesn't
necessarily mean that it is better, it would simply be
different.
The Veterans Disability Benefits Commission, on the other
hand, has provided in their report an ordered and deliberate
process for evolving and reforming the ratings schedule that
the VA currently uses, and we commend their recommendations for
your consideration.
In addition, the President's Commission would, under their
new separate program for compensating our future veterans,
create a new rate schedule. It is totally devoid of any
suggestion of what this rate schedule would look like or how it
would be made up.
Finally, there are so many other things that the VA does,
and should be looked at from time to time, that the President's
Commission has not even addressed. For instance, the Veterans
Disability Benefits Commission, with the help of the Institute
of Medicine, has come up with a plan, a scheme, for
regularizing, if you will, the designation of disabilities that
are presumptively related to service. Although we don't agree
with the entire proposal, the point is that they come up with a
process for reform, for evolving into something which is better
than what currently exists, and that is what we support.
If we adopt--if you adopt--the President's Commission's
recommendation to create a second separate disability
compensation program, what you are forcing the VA to do is to
run two disability compensation programs for at least the next
70 years. Imagine that, two separate programs with a workforce
either required on an individual basis to master both programs
or to separate the workforce to deal with both. This is an
unnecessary imposition on the VA and on America's veterans.
I would like to leave you with this thought. The
President's Commission served 4\1/2\ months to arrive at their
recommendations. In our view, nearly all of the recommendations
dealing with VA compensation are mere bullets. They are hollow.
They lack substance and definition. If their program is simple,
it is because the things that make a compensation program work
have not been added to it yet.
On the other hand, the Veterans Commission served, studied,
argued, and decided everything in public for 30 months. They
did the heavy lifting necessary to support their
recommendations with substance and process. Its report has been
described today as 600 pages of band-aids. Well, this 544-page
document lays a solid foundation and a clear path forward for
reform of the VA compensation program. We do not agree with all
the recommendations, but we can say, conclusively, that we
agree with the framework that they have laid down to effect
change in an ordered, evolutionary way.
Thank you for your time this afternoon and I will take
questions when you have them.
[The prepared statement of Mr. Manar follows:]
Prepared Statement of Gerald T. Manar, Deputy Director, National
Veterans Service, Veterans of Foreign Wars of the U.S.
Thank you for this opportunity to provide the views of the members
of the Independent Budget--AMVETS, Disabled American Veterans,
Paralyzed Veterans of America and the Veterans of Foreign Wars of the
United States--on VA and DOD collaboration, the Report of the
President's Commission on Care For America's Returning Wounded
Warriors, the Report of the Veterans Disability Benefit Commission and
other related reports.
It seems that every few years another study is commissioned to
examine some of the problems involving benefits and delivery of
benefits available to service disabled veterans. With the Veterans
Disability Benefits Commission (VDBC), a pattern has emerged that our
Nation requires a more comprehensive review every 50 years or so to
help us all refocus on the entire system of benefits, note the things
that are working well and devise solutions to those that no longer
fully address the needs of the men and women who stood ready in both
peace and war to defend our Nation, even at the possible cost to
themselves of disability or death.
Six years after terrorists attacked us on American soil, we remain
deeply embroiled in armed conflict in both Iraq and Afghanistan. Over
3,800 men and women have been killed and nearly 28,000 wounded. Another
29,000 were treated for diseases and injuries not arising from combat,
disabilities so debilitating that they required air transport from the
region in order to receive appropriate medical treatment.\1\ There is
no accounting for the thousands of other service men and women who were
treated and returned to duty in that troubled region of the world.
---------------------------------------------------------------------------
\1\ http://icasualties.org/oif/; October 12, 2007.
---------------------------------------------------------------------------
Thousands of soldiers, Marines, sailors and airmen have returned
home with catastrophic injuries. It was their difficulty in obtaining
treatment, proper housing, adequate benefits and services, as well as
basic help in the transition from military service to civilian life
that caught our attention earlier this year. What was most disturbing
was that the problems coming to light in 2007, while perhaps
exacerbated by the current conflict, have existed to some extent for
decades. The Presidents Commission on Care for America's Returning
Wounded Warriors (PCCWW), created in March 2007 and reporting 4 months
later, examined how the Armed Services treat those with serious
injuries and help them through discharge from service and transfer to
the Department of Veterans Affairs.
While this testimony will focus primarily on the recommendations of
the PCCWW and VDBC on transition issues, we will also address the
recommendations of both commissions on benefits provided by the
Department of Veterans Affairs for disabilities arising while
performing military service.
You have before you enough ideas, suggestions and recommendations
to create another title in the U.S. Code and keep regulation writers at
both the Department of Defense and the Department of Veterans Affairs
busy for the next 10 years. It is little wonder that you have asked
those of us at this table to help you parse the cornucopia of proposals
and make coherent the competing voices.
There are many good things presented in these reports: some are
simple, others complex beyond imagination. Some will help DOD and VA
help service men, women and veterans while others would create more
problems. Some are inexpensive while others will place additional
burdens on the Treasury.
We offer you our views, not to make your task easier, but rather,
to help make the correct path more visible.
they are all veterans equally
One of the Guiding Principals adopted by the VDBC was that benefits
should be awarded based on the severity of the service-connected
disability and not on the circumstance under which it was acquired.
This principle is not new. At one time VA paid higher benefits to
veterans with service connected disabilities incurred in combat.
However, Congress recognized the inequity of paying veterans with
identical disabilities different amounts of compensation solely because
one received his injury in combat and the other did not; as a
consequence, Congress equalized the rates for all veterans in 1972.
The Veteran Service Organizations we represent today endorse the
current government policy and completely reject the notion that
injuries acquired in combat are any more disabling, any more worthy of
compensation, than those incurred elsewhere in service to our country.
We agree with the VDBC that benefits should be based only on the
severity of disability.
transition
Care for seriously disabled servicemembers.--We support the PCCWW
recommendations which would:
Develop integrated care teams
Create individualized recovery plans
Develop and assign Recovery Coordinators
However, we oppose the idea that Recovery Coordinators
should be Public Health Service employees. We believe that properly
trained VA employees, with substantial support from both DOD and VA,
can be effective in supporting seriously disabled servicemembers and
veterans.
We believe that these services should be provided to all seriously
disabled servicemembers regardless of where their disabilities were
acquired. A soldier paralyzed from the neck down from an accident in
Germany or Korea is no less deserving of these services than is someone
who was paralyzed by an IED in Iraq.
Transfer of patient information across systems.--We support the
PCCWW recommendations that would:
Make patient information available to all personnel who
need it
Continue efforts for a fully interoperable information
system between DOD and VA
Provide internet access to personal treatment records and
health care information through secure Web sites for servicemembers and
veterans.
Strengthen support for families of seriously disabled
servicemembers and veterans.--We support the PCCWW recommendations that
would:
Expand eligibility for TRICARE respite care and aid and
attendance
Expand caregiver training for families
Cover family members under the Family Medical Leave Act
(FMLA)
However, TRICARE, caregiver training and expanded coverage
under the FMLA should be available to all seriously disabled
servicemembers and not just OIF/OEF servicemembers.
Improve care for servicemembers with Post Traumatic Stress Disorder
(PTSD) and Traumatic Brain Injury (TBI).--We support the PCCWW
recommendations that would:
Address the shortage of mental health professionals in
both DOD and VA
Establish and expand networks of experts in PTSD and TBI
Improve dissemination of clinical practice guidelines
Increase availability of treatment for PTSD for Iraq and
Afghanistan veterans from the VA
While we support increased availability of mental health
providers through the VA for veterans suffering from PTSD, the PCCWW
recommendation that ``all Iraqi and Afghanistan veterans who need PTSD
care [should] receive it from VA'' is problematic. First, all veterans
who are discharged today may receive free treatment for virtually any
problem within 2 years of discharge. In addition, this recommendation
would allow any new veteran, regardless of the source of PTSD (e.g.
pre-service car wreck) to move ahead of veterans with service related
PTSD. Further, we are already receiving complaints from older veterans
who believe that they are being forced to wait longer for appointments
because of priorities given to newer veterans.
We believe the better approach would be to vastly increase the
numbers of mental health professionals at VA to provide better and
timelier service to all veterans with PTSD. While increasing mental
health staff, VA should use its fee-basis authority whenever old or
young veterans must receive care immediately.
Finally, VA should improve its ability to triage veterans with
mental health symptoms to ensure that those who might be a danger to
themselves or others are seen immediately and by an appropriate
professional.
Again, we believe that every disabled servicemember should be
eligible for every benefit and service required by the severity of the
disability they have and not by the place or circumstance under which
it was incurred.
Enhance the Joint Executive Council (JEC).--We support the
recommendation of the VDBC to:
Develop a strategic plan with specific milestones
Designate lead officials responsible for each milestone
Include DOL and SSA in the JEC
VA and DOD should develop a joint intensive case management program
for severely disabled veterans with an identifiable lead agent.--We
support the recommendation of the VDBC.
Congress should adequately fund and mandate the Transition
Assistance program DOD-wide.--We support the recommendation of the
VDBC.
Benefits Delivery at Discharge (BDD) should be available to all
disabled servicemembers including Guard, Reserve and medical hold
patients.--We support the recommendation of the VDBC.
DOD should mandate separation examinations for all servicemembers;
the examination should conform with VA protocols and directives.--We
support the recommendations of the VDBC.
DOD should provide TRICARE free of charge for severely injured
servicemembers and their families.--We support the recommendation of
the VDBC.
We commend the other recommendations from the VDBC dealing with
transition issues to you for consideration.
post service transition
Both the PCCWW and the VDBC understand the need to ensure that
services and benefits do not stop as disabled servicemembers make the
transition to civilian life. Too often, the only ``transition''
disabled servicemembers received was a Transition Assistance Program
briefing or a bit of counseling from the VA or a veteran service
officer at a BDD site. The recommendations discussed earlier, if
adopted, should make the transition process much better for disabled
servicemembers.
However, most veterans are not seriously disabled at discharge and
are not processed through the Disability Evaluation System. While they
know what their education benefit eligibility might be, they have
little knowledge of vocational rehabilitation, home loan guarantees and
the like from VA.
Vocational rehabilitation.--Both the PCCWW and the VDBC recommended
changes in vocational rehabilitation which, in our view, should be
seriously considered for implementation.
Veterans with service connected disabilities causing
employment handicaps should be encouraged to undertake and complete
training that will help them find not just gainful employment but a
career for life.
Further, vocational rehabilitation should not be a one-
time benefit. Disabilities often worsen throughout life and some
veterans may need vocational rehabilitation services a second time.
Helping a disabled veteran remain productively employed should be a
goal of VA. We believe that a disabled veteran should be able to
utilize vocational rehabilitation more than once.
Vocational rehabilitation subsistence allowance rates are
inadequate to support veterans as they obtain the training needed to
help them adjust to the employment handicap caused by their service-
connected disabilities. We support increases in subsistence allowance
rates.
Transition payments.--As the claims backlogs have increased at the
VA, it seems that a growing number of people, including some Members of
Congress, have voiced the opinion that these veterans should not be
made to wait for VA to decide their claims for benefits. Their greatest
concern has been for the recently discharged veteran who often has
little income, perhaps some disability and no job. In the last year,
some have even suggested that VA should simply pay the veteran whatever
it is they claim.
We oppose the use of the disability compensation program to pay
what amounts to a transition benefit or bonus. We do, however, support
the idea of a transition payment independent of VA compensation. We
urge Congress to consider creating such a payment, a form of deferred
compensation, independent and separate from VA compensation, to help
men and women during the initial few months following their discharge
from service.
reengineering va disability compensation--revolution or evolution?
In 2004 the Congress enacted legislation creating the Veterans
Disability Benefits Commission:
``The purpose of the Veterans' Disability Benefits Commission
is to carry out a study of the benefits under the laws of the
United States that are provided to compensate and assist
veterans and their survivors for disabilities and deaths
attributable to military service, and to produce a report on
the study.'' \2\
---------------------------------------------------------------------------
\2\ Public Law 108-136, Section 1502. See also, http://
www.vetscommission.org/index.asp. Charter.
The first few meetings of the Veterans Disability Benefits
Commission (VDBC) (starting in May 2005) were met with skepticism and
wariness by some of us in the veteran community. We were well aware of
the forces which led to the creation of that commission and were deeply
concerned that at least some Commissioners harbored secret agendas
which, if adopted, would lead to the dismantling of programs designed
to help treat and compensate veterans for the residuals of disabilities
incurred or aggravated while in service to our country.
During the 28 public sessions spanning 55 days of public hearings,
it became apparent that Commissioners were willing to work hard to
learn about compensation benefits: what they are; how the program
evolved to where it is today; and what problems exist. Further, we were
gratified to note that Commissioners were willing to reconsider their
opinions as facts were brought to light by the Center for Naval
Analyses and the Institute of Medicine. We watched extensive fact
gathering and more extensive debates on issues that were critical to
the establishment of a foundation for later decisions.
While we have disagreed with some decisions made by the commission
we could tell the veterans we represent that the commission was well on
the way to producing a thoughtful and constructive report which
addressed many problems without harming veterans.
A few weeks ago the VDBC released its final report. Of the
commission's 114 recommendations, fully 83 percent deal with
compensation benefits or factors related to compensation benefits. Even
when the commission drifted a little afield and made recommendations
dealing with transition issues, it is clear that most deal with
ensuring that VA has the information it needs as soon as possible to
process claims from veterans.
The President's Commission on Care for America's Returning Wounded
Warriors, on the other hand, was created in March 2007 and delivered
its report less than four and a half months later. It produced 24
recommendations; 8 of the 24 recommendations were focused on discarding
the current compensation program and substituting a new program
requiring a new rating schedule, new rates for disability benefits, new
theories of what could be service connected, how long compensation
payments would continue and so on.
While there are a few ideas presented by the PCCWW that may have
merit, the discussion, below, describes those that are most
objectionable.
Two-tiered system.--The PCCWW recommends the creation of a
two-tiered system of compensation for service connected disabilities,
one for combat injured veterans and one for all others. Under their
proposal, combat injured veterans would be eligible for quality of life
payments while those not injured in combat would be denied. This means
the paralyzed veterans mentioned earlier in this paper would receive
substantially disparate compensation even though their quality of life
would be the same.
Delay of compensation.--The PCCWW would delay compensation
benefits for a minimum of 3 months and possibly for years while the
veteran receives ``transition'' payments. In our view, it is for
Congress to decide whether newly discharged veterans should be granted
a transition benefit for a short period following service. Since the
transition benefit is not based on disability but would be, in fact,
available to all new veterans, it should not replace compensation paid
for disability incurred or aggravated while in military service. If
Congress agrees that vocational rehabilitation rates are too low and do
not encourage veterans to remain in vocational rehabilitation, then it
should raise those rates to appropriate levels.
Average impairment of earnings capacity.--In its report,
the PCCWW says that:
``Congress has directed that the VA disability compensation
system should replace lost civilian earnings.'' \3\
---------------------------------------------------------------------------
\3\ PCCWW Report, pg. 109.
---------------------------------------------------------------------------
What the law actually says is:
``The ratings shall be based, as far as practicable, upon the
average impairments of earning capacity resulting from such
injuries in civil occupations.'' \4\
---------------------------------------------------------------------------
\4\ 38 U.S.C. 1155.
---------------------------------------------------------------------------
The seemingly subtle difference between ``earnings'' and ``average
impairment of earning capacity'' is significant. We commend to you the
discussion in the VDBC report on this topic. We can say, however, that
this focus on earnings rather than average impairment of earning
capacity opens the door for some of the draconian recommendations by
the PCCWW discussed below. What the commission recommends is nothing
short of throwing out a compensation program, designed, refined and
tested over 70 years to pay disabled veterans based on the average
impairment of earnings capacity to one based solely on loss of
earnings. This, in turn, opens the door for means testing, taxing and
curtailing compensation.
Means testing compensation.--The PCCWW would substitute a
payment scheme that is means tested in place of the current
compensation program (``. . . the amount would be recalculated
periodically as veterans' condition or earnings change.'' Figure 11)
(``. . . once transition payments end, disabled veterans should receive
earnings-loss payments--to make up for any lower earning capacity
remaining after training.'' Draft, page 6). This means that veterans
with identical disabilities would receive different benefits or, in
some cases, no compensation at all. The commission suggests that the
DOD disability annuity payment, as well as the quality of life payment,
would continue for life. However, only about 10 percent of all veterans
(those discharged through the DES) would receive the annuity. While not
all veterans have service-connected disabilities for which they receive
compensation, a significant percentage of those receiving compensation
today would not be eligible for the annuity.
Further, since the PCCWW proposes that only combat injured veterans
would be potentially eligible for quality of life payments, those non-
combat injured veterans no longer eligible for compensation because of
means testing would receive nothing at all.
Taxing compensation.--The PCCWW would tax disability
compensation payments to veterans. In a word, we find this proposal to
be outrageous. We are speaking of men and women who sacrificed not only
their time and energy in defense of our Nation but who continue to
suffer from the residuals of injury or disease incurred during that
service. Under this proposal, veterans would be taxed to marginally
mitigate a reduction of their benefits when they can no longer work.
Outrageous.
Termination at retirement.--The PCCWW proposes the
termination of compensation benefits at ``retirement'' to be followed
by Social Security. A recent article in the Washington Post showed that
more people work past ``retirement'' than ever before; and the trend is
increasing. Further, a Center for Naval Analysis study conducted for
the VDBC shows that current compensation rates generally replace lost
earnings if paid over a veteran's lifetime. If the PCCWW recommendation
is adopted, veterans will not have earnings replaced by compensation
prior to ``retirement'' unless compensation rates are substantially
increased.
Abuse of reexamination process.--The PCCWW recommends that
veterans be recalled for examination every 3 years throughout their
lifetime to determine whether their disability has worsened or
improved. VA already has the authority to reexamine veterans whose
disabilities could improve. This authority has existed for many
decades. If it is not often used now it is more a function of VA trying
to manage its workload by reducing review examinations in the face of
extremely high backlogs than it is anything else.
Further, this proposal is a transparent attempt to not just
identify those individuals whose disabilities may improve over time but
to harass those veterans whose disabilities are static. And since
failure to report for an examination is a basis for terminating
compensation, this practice would, if adopted, result in the
termination of benefits to many veterans whose disabilities are either
static or worsened primarily because they do not always notify the VA
when they move.
For these reasons, and others, we strenuously object to the
proposals by the PCCWW to throw out the current compensation program
and put in its place a program which will be harmful to the vast number
of men and women who have volunteered to serve our Nation, and who are
fighting even now in Iraq and Afghanistan.
The Veterans Disability Benefits Commission has exhaustively
examined the current compensation program, affirmed its strengths and
pushed forward many thoughtful and constructive recommendations for
evolving it into a mechanism to better serve America's new generations
of veterans. Their approach is to retain the best parts of the
disability compensation program and create a process for measured and
deliberate reform and improvement. We urge you to carefully consider
their recommendations.
We trust that this is the first of several hearings on these
reports and other proposals affecting the transition of servicemembers
from warrior to respected veteran. We appreciate the opportunity you
have afforded us today.
I will be happy to answer any questions you may have for me.
______
Response to written questions submitted by Hon. Daniel K. Akaka to
Gerald T. Manar, Deputy Director, National Veterans Service, Veterans
of Foreign Wars of the United States, on behalf of the Members of the
Independent Budget
easy access to care
Question. The Dole-Shalala Commission recommends that veterans with
PTSD have immediate access to VA evaluations and treatment. You noted
in your testimony that such an opportunity does, in fact, exist now in
the two year window of easy access to VA care and treatment following
release from active duty. In your view, how well is this two-year
authority working?
Response. According to VA, by the end of FY 2007 nearly 800,000 OIF
and OEF veterans left active duty and became eligible for VA health
care since FY 2002. Nearly 300,000 (37 percent) of those veterans
obtained VA health care since their discharge. Further, slightly more
than 120,000 veterans (40.1 percent of those seeking treatment) were
seen for complaints of a mental disorder. Finally, half of those seen
for mental health issues were diagnosed with PTSD.
Clearly, OIF and OEF veterans know that health care is readily
available from VA as demonstrated by the 37 percent who obtain it.
Further, they know that they can receive free health care for virtually
any condition without the need to demonstrate a connection with their
military service.
While some observers may be concerned that more OIF/OEF veterans
have not sought treatment from VA, we must be mindful of the fact that
most of these men and women are in the prime of their lives when it is
significantly less likely that they will have medical or psychological
conditions requiring treatment.
We believe that the current law opening up VA health care to all
OIF/OEF veterans for 5 years following discharge is working and no
additional legislation will likely result in greater participation by
these men and women.
If Congress is concerned that this group of veterans is
underutilizing VA health care opportunities, it could provide an
increase in funds for advertising and outreach.
Chairman Akaka. Thank you very much, Mr. Manar.
Ms. Beck?
STATEMENT OF MEREDITH BECK, NATIONAL POLICY DIRECTOR, WOUNDED
WARRIOR PROJECT (WWP)
Ms. Beck. Thank you, sir. Mr. Chairman, thank you for the
opportunity to testify today regarding the various reports,
commissions, and task forces completed to date addressing the
needs of our Nation's wounded servicemembers. The Wounded
Warrior Project has direct daily contact with these wounded
warriors and we have a unique perspective on their needs and
the obstacles they face as they attempt to reintegrate into
their communities. With respect to the reform of the Disability
Evaluation System, the Wounded Warrior Project strongly
supports the spirit and intent for which the Dole-Shalala and
the Veterans Disability Benefits Commissions were established.
WWP agrees with the finding of both reports that the current
benefits system places too little emphasis on veterans'
recovery, rehabilitation, and reintegration into the community.
For those who are able, incentives to participate in vocational
rehabilitation programs, educational opportunities, and
reintegration to the workforce could lead to a better,
healthier life. In addition, under the current system,
individual unemployability ratings are necessary for some, but
others are often burdened at a young age to choose between
potentially beneficial vocational experience and needed
compensation.
Periodic evaluation, gradual reduction in compensation
rather than abrupt termination, and improvements in the
compensation structure for warriors with PTSD or TBI would
result in a more effective system that enables wounded warriors
to successfully reintegrate to civilian life. WWP believes
these principles must be taken into consideration during
discussions on modernizing the current disability compensation
system and any significant changes should require ultimate
Congressional approval.
WWP also strongly supports removing the Department of
Defense from the disability ratings process. DOD and the VA
ratings systems are currently confusing and overly-burdensome.
Currently, DOD assesses the veteran's fitness for duty.
Following this determination, the VA performs yet another
physical to rate the veteran for all service-connected
injuries. Unfortunately, these ratings are not assigned in a
vacuum. Lost records, lack of resources, ineffective training,
and inconsistencies in the interpretation of regulations by
both agencies are often cited as reasons for the extended
period of time required to assign a disability rating. A system
such as that proposed by the Commissions would encourage a more
efficient and fair evaluation and remove one of the most
frustrating aspects of an already difficult process.
WWP agrees that comprehensive changes are needed within the
compensation and benefits delivery system. However, we are
deeply concerned that the inclusion of provisions to overhaul
the existing veterans disability compensation system in the
same package as health and transition-related recommendations
would be a distraction from these important health proposals.
Any legislation implementing compensation-related
recommendations must be carefully crafted through a thoughtful
and deliberate process to ensure the most beneficial outcome
for those who have sacrificed in service to this country.
However, as many of us recognize, the current disability
ratings system suffers from significant shortcomings which have
become more apparent with the passage of time. We must use our
passion to encourage honest discussion to resolve these issues.
WWP is very pleased that the Dole-Shalala panel recognized
the need for education and training of family members.
Specifically for the family members of those with severe TBI,
who often have to leave their jobs. WWP also supports payments
to caregivers similar to those already in place in the San
Diego VA Medical Center for Spinal Cord Injury patients. This
program offers training and makes eligible for payment those
family members who have become certified as personal care
attendants. This often removes at least part of the financial
burden incurred by those with severe injuries.
WWP also strongly supports the Dole-Shalala recommendation
to implement a recovery plan that promotes prompt care in,
quote, ``the most appropriate facility.'' With respect to
Traumatic Brain Injury, legislation currently exists to
facilitate such a recommendation. Section 203 of the Senate
version of H.R. 1538, the Dignified Treatment of Wounded
Warriors Act, would allow the Secretary of the VA to refer
patients to non-department facilities if the Secretary is
unable to provide the required treatment or, even more
importantly, when the Secretary determines that such a referral
is optimal for recovery and rehabilitation. In order to comply
with our obligation to offer these wounded warriors the best
care possible for their respective injuries, these facilities
must be readily available as an option for their care.
With respect to DOD-VA collaboration, there are still many
issues to address, but WWP has been very impressed with the
level of involvement of the leadership of both DOD and VA in
the Senior Oversight Committee formed to address these issues.
As recommended by the Dole-Shalala Commission, the SOC is in
the process of improving the case management process through
the creation of a Recovery Coordinator. However, the Recovery
Coordinator can only be successful if he or she has the
authority to break through the current barriers within both
agencies.
Part of that authority would have to include the overlap of
benefits and services about which WWP and other organizations
have previously testified and which is included in the Senate
version of H.R. 1538, as well. An overlap would allow the
Recovery Coordinator to access DOD and VA systems necessary to
ensure the proper care and rehabilitation of severely injured
servicemembers. Each agency has its own strengths. Why would we
base their access to care on the status of the servicemember as
active duty or retired, rather than on his medical condition?
The skills and previous experience of the Recovery
Coordinator are extremely important to their success. In the
past, both agencies have based their hiring criteria for
similar positions solely on education level. WWP is concerned
that the agencies will once again rely on education level alone
and exclude eminently qualified candidates with good problem-
solving skills and institutional knowledge.
It is not only DOD and VA who need to cooperate more fully
or collaborate more fully. Others, such as the Social Security
Administration, Medicare, and the Department of Labor and
private entities need to be included more fully in these
discussions. For example, an injured servicemember recently
contacted WWP because he was understandably confused. He had
been rated as unemployable by the VA, but was told he did not
qualify for Social Security disability benefits because he was
able to work. Additionally, the Social Security Administration
has had a difficult time accessing DOD records necessary to
evaluate his claim. These agencies must work together to
resolve inconsistencies in their policies, or the often-stated
goal of seamless transition will never be achieved.
Finally, it is imperative that a joint permanent structure
be in place to evaluate changes, monitor systems, and make
further recommendations for process improvement. This office
must be structured to minimize bureaucracy and must have a
clearly defined mission with the appropriate authority to make
necessary changes or recommendations as warranted. With the
passage of time, as veterans' issues fade from the national
spotlight, it will be necessary to have that joint structure in
place to ensure the future agency coordination.
Thank you, and I look forward to your questions.
[The prepared statement of Ms. Beck follows:]
Prepared Statement of Meredith Beck, National Policy Director, The
Wounded Warrior Project (WWP)
Mr. Chairman, Senator Burr, Members of the Committee, thank you for
the opportunity to testify today regarding the various reports,
commissions, and task forces completed to date addressing the needs of
our Nation's wounded servicemembers. My name is Meredith Beck, and I am
the National Policy Director for the Wounded Warrior Project (WWP), a
non-profit, non-partisan organization dedicated to assisting the men
and women of the U.S. Armed Forces who have been injured during the
current conflicts around the world. As a result of our direct, daily
contact with these wounded warriors, we have a unique perspective on
their needs and the obstacles they face as they attempt to reintegrate
into communities across America.
Due to the broad range of topics covered by this hearing, I would
like to limit my comments to those that WWP finds most pressing.
Commission Reports:
With respect to the reform of the disability evaluation system, the
Wounded Warrior Project strongly supports the spirit and intent for
which the Dole-Shalala and Veterans Disability Benefits Commissions
were established. WWP agrees with the finding of both reports that the
current benefits system places too little emphasis on veterans'
recovery, rehabilitation, and reintegration into the community. For
those who are able, incentives to participate in Vocational
Rehabilitation programs, educational opportunities, and reintegration
into the workforce could lead to a better, healthier life. In addition,
under the current system, Individual Unemployability ratings are
necessary for some, but others are often burdened at a young age to
choose between a potentially beneficial vocational experience and
needed compensation. Periodic evaluation; gradual reduction in
compensation rather than abrupt termination; and improvements in the
compensation structure for warriors with Post Traumatic Stress Disorder
(PTSD) or Traumatic Brain Injury (TBI) would result in a more effective
system that enables wounded warriors to successfully reintegrate to
civilian life. WWP believes these principles must be taken into
consideration during discussions on modernizing the current disability
compensation system. Any significant changes should require ultimate
Congressional approval.
WWP also strongly supports removing the Department of Defense (DOD)
from the disability rating process. DOD and the Department of Veterans
Affairs rating systems are currently confusing and overly burdensome.
Currently, the Department of Defense assesses a servicemember's fitness
for duty and then assigns a rating based on the injury that made him/
her unfit. Following this determination, the Department of Veterans
Affairs performs yet another physical examination to rate the veteran
for all service-connected injuries, and, depending on the rating level,
the veteran could then become eligible for a myriad of benefits.
Unfortunately, ratings are not assigned in a vacuum--lost records, lack
of resources, ineffective training, and inconsistencies in the
interpretation of regulations by both agencies are often cited as
reasons for the extended period of time required to assign a disability
rating. A system such as the ones proposed by the Commissions would
encourage a more efficient and fair evaluation and remove one of the
most frustrating aspects of an already difficult process.
WWP would like to make another recommendation. A servicemember
should not be retired until he or she has a VA rating in place. This
would prevent severely injured servicemembers from experiencing a long
gap between their military retirement and eventual receipt of VA
compensation. Additionally, as DOD would be responsible for paying
servicemembers until their retirement, DOD would be encouraged to
quickly share medical records to expedite the process.
WWP believes that a comprehensive review of the disability
compensation and benefits delivery system is needed. However, we are
deeply concerned that the inclusion of provisions to overhaul the
existing veterans' disability compensation system in the same package
as health and transition-related recommendations is an unnecessary
distraction from these important health and transition proposals. Any
legislation implementing compensation-related recommendations must be
carefully crafted to ensure the most beneficial outcome for those who
have sacrificed in service to this country. However, as many of us
recognize that the current disability ratings system suffers from
significant shortcomings, which have become more apparent with the
passage of time, we must use our passion to encourage honest discussion
to resolve these issues. Veterans deserve a thoughtful and deliberate
process for reform of the disability compensation system, with
appropriate Congressional oversight.
WWP is very pleased that the Dole-Shalala panel recognized the need
for education and training of the family members. Specifically for the
family members of those with severe TBI who often have to leave their
jobs. WWP also supports payments to caregivers similar to those already
in place at the San Diego VA Medical Center for Spinal Cord Injury
patients. This program offers training and makes eligible for payment
those family members who become certified as personal care attendants.
This often removes at least part of the financial burden incurred by
those with severe injuries.
WWP also strongly supports the Dole-Shalala recommendation to
implement a recovery plan that promotes ``prompt'' care in ``the most
appropriate facility.'' With respect to Traumatic Brain Injury,
legislation currently exists to facilitate such a recommendation.
Section 203 of the Senate version of HR. 1538 would allow the Secretary
of the VA to refer patients to non-department facilities if the
Secretary is unable to provide the required treatment, OR, even more
importantly, for whom the Secretary determines that such a referral is
optimal for their recovery and rehabilitation. In order to comply with
our obligation to offer these wounded warriors the best care possible
for their respective injuries, these facilities must be readily
available as an option for their care.
dod/va collaboration
With respect to DOD/VA collaboration, while there are still many
issues to address, WWP has been very impressed with the level of
involvement of the leadership of both DOD and the VA in the Senior
Oversight Committee (SOC), formed to address these issues. As
recommended by the Dole-Shalala Commission, the SOC is in the process
of improving the case management process through the creation of a
recovery coordinator. However, the recovery coordinator can only be
successful if he/she has the authority to break through the current
barriers within both agencies. Part of that authority would have to
include the overlap of benefits and services about which WWP has
previously testified, and which is included in the Senate version of
H.R. 1538, The Dignified Treatment of Wounded Warriors Act. An overlap
would allow the recovery coordinator to access DOD and VA systems
necessary to ensure the proper care and rehabilitation of severely
injured servicemembers. Each agency has its own strengths. Why base
access to care on the status of a servicemember as active duty or
retired, rather than on the medical condition?
The skills and previous experience of the Recovery Coordinator are
extremely important to their success. In the past, both agencies have
based their hiring criteria for similar positions solely on education
level. WWP is concerned that the agencies will, once again, rely on
education level alone and exclude eminently qualified candidates with
good problem solving skills and institutional knowledge.
It is not only DOD and VA who need to collaborate more fully.
Others such as the Social Security Administration, Medicare, the
Department of Labor, and private entities need to be included in these
discussions. For example, an injured servicemember recently contacted
WWP because he was understandably confused. He had been rated as
unemployable by the VA, but was told he did not qualify for Social
Security Disability benefits because he was able to work. Additionally,
the Social Security Administration had a difficult time accessing DOD
records necessary to evaluate his claim. These agencies must work
together to resolve inconsistencies in their policies or the often
stated goal of ``seamless transition'' will never be achieved.
Finally, it is imperative that a joint, permanent structure be in
place to evaluate changes, monitor systems, and make further
recommendations for process improvement. This office must be structured
to minimize bureaucracy and must have a clearly defined mission with
the appropriate authority to make necessary changes or recommendations
as warranted. With the passage of time, as veterans issues fade from
the national spotlight, it will be necessary to have a joint structure
in place to ensure future agency coordination.
Mr. Chairman, thank you again for the opportunity to testify before
you today, and I look forward to answering your questions.
Chairman Akaka. Thank you very much, Ms. Beck.
Now we will hear from Colonel Strobridge. Colonel?
STATEMENT OF COL. STEVEN P. STROBRIDGE, USAF (RET.), DIRECTOR,
GOVERNMENT RELATIONS, MILITARY OFFICERS ASSOCIATION OF AMERICA
Colonel Strobridge. Thank you, Mr. Chairman, Ranking Member
Burr, and distinguished Members of the Committee. Thank you for
this opportunity to present the Military Officers Association's
views on the needs of America's returning warriors.
I would start by recognizing the tremendous efforts by this
Committee and by the Armed Services Committee, as well, to
ensure that we do the right thing by these veterans. Senior DOD
and VA leaders also deserve great credit for their
unprecedented cooperation in working to address the many
serious problems encountered by these members and their
families.
As you know, most of the problems aren't new. They have
been identified in multiple previous studies. What is different
now is the degree of leadership involvement and commitment to
finding fixes. That kind of top-down leadership is the only way
to break down the barriers of departmental parochialism, and it
is gratifying to us to see it happening.
But, we are concerned about ensuring continuity of those
efforts into next year and beyond, when most of the leaders who
have been driving those efforts will be departing. Often, a new
administration faces a lag in installing new leaders and many
new appointees face a significant learning curve. That raises
the potential for the change process to lose momentum during
the transition. For that reason, the continuing leadership and
oversight of this Committee will be crucial to sustaining long-
term success.
The Committee has seen the findings of all the various
study groups on the wounded warrior issues and MOAA thinks they
have been pretty much on target with most of their
recommendations. We strongly endorse the use of a single DOD
and VA separation physical and reform of the Military
Disability Retirement System as recommended by the Veterans
Disability Benefits Commission. In that regard, we very much
support the pilot program now being implemented by DOD and VA
under which the services determine fitness for continued
service, the VA is the single agency assigning disability
ratings, and DOD must accept those ratings for military
disability retirement purposes.
We strongly agree with the findings of all the panels on
case management needs, the importance of TBI and PTSD screening
assessments, care and rehabilitation, and updating the VA
ratings system to more appropriately reflect those conditions'
effect on veterans and their families.
We are concerned that there are a number of gaps, as
Meredith mentioned, in coverage between DOD active duty retired
and VA health programs. Some of the examples are: cognitive
therapy; and per diem for caregivers, which ceases when a
member is retired and is not available from the VA. Those
significantly detract from disabled veterans' continuity of
care. Rather than trying to chase down all the individual
shortfalls, we think it is essential to authorize temporary
overlap of both coverages. To us, that means continuing active
duty-level TRICARE coverage for at least 3 years for all
service-disabled personnel and their families and also
authorizing VA care for active duty wounded warriors.
As the Committee considers possible benefit adjustments or
recommends against creating a differential benefit system for
members who are disabled in combat versus other service-
connected causes, I think you have heard the different panel
members. I think we have all kind of said the same things--that
there is a little bit of confusion, I think, in terms of what
some people mean when they say, ``combat disabled.'' When we
have asked people, everybody has pretty much said, anything
that is service-connected should be compensated. If a member
becomes a quadriplegic in service, the effect on the member's
life is the same whether that was caused by a bullet or a
military vehicle or a slip on an icy street. Similarly, we
should sustain the longstanding principle that military service
is 24/7 duty that we discussed earlier for the purposes of
determining service connection in disabilities.
Like Meredith said, we believe it will be particularly
important to establish a Joint Seamless Transition Office,
permanently staffed with full-time personnel from both DOD and
VA to oversee development, fielding, and sustainment of
initiatives such as the Electronic Medical Record and the
Electronic Separation Document. It is ironic that when I worked
in DOD in 1988, I was initiating action for a joint DD Form
214. I got promoted and left the office a year later, called
back and said, what is the status, and the answer was, ``huh?''
That is the problem that you have. We have to build a structure
of responsibility that won't evaporate with the departure of
the incumbent or the departure of the incumbent's boss.
Finally, we urge the leaders of the Veterans Affairs
Committees and Armed Services Committees to continue that
example of top-down leadership collaboration in addition to the
recent efforts in the Executive Branch. We know all of the
committees and staffs are working hard to do the right thing,
but we also know that frustration with past joint efforts and
some of their lack of success can foster skepticism about the
future, and that is a big concern. A renewed commitment by
committee leaders to bipartisan, bicameral collaboration would
establish an important guideline for the difficult road ahead.
We appreciate this opportunity to offer our comments and
pledge our continued support on all of these issues to ensure
the Nation completes its obligations to our wounded warriors
and their families. Thank you.
[The prepared statement of Col. Strobridge follows:]
Prepared Statement of Col. Steven P. Strobridge, USAF (Ret.), Director,
Government Relations, Military Officers Association of America
Mr. Chairman and distinguished Members of the Committee, I am
honored to appear before you today on behalf of the Military Officers
Association of America (MOAA), to present our views on various
Commission recommendations on the wounded warrior care, transition
support, the disability evaluation process and related matters.
MOAA does not receive any grants or contracts from the Federal
Government.
executive summary
Urgency of Joint Congressional Action and Oversight.--Military and
VA systems have been caught unprepared for the large wave of wounded
and traumatized veterans returning from Iraq and Afghanistan, and these
veterans' needs will only grow in the future. Sustained bipartisan,
bicameral congressional leadership focus and cooperation will be vital
to successfully address continuing problems, especially with a change
of leadership coming soon in the Executive Branch, and attendant
introduction of new DOD and VA leaders who will be far less sensitized
to the urgency of leadership-driven changes currently underway or
contemplated.
VA-DOD Disability Evaluation Reform.--MOAA strongly endorses the
recommendation of the Veterans' Disability Benefits Commission (VDBC)
that DOD and VA should realign the disability evaluation process so
that the Services determine fitness for duty, and servicemembers who
are found unfit are referred to VA for the disability rating.
All conditions that are identified as part of a single,
comprehensive medical exam should be rated and compensated. In
revamping the DES, the Services must include all unfitting conditions
as rated by the VA in assessing whether the servicemember is to be
medically retired or separated. (See Items 6, 12 and 46 in the attached
matrix.)
MOAA does not support elimination of the military disability
retired pay system, as some would interpret the Dole-Shalala
recommendations as implying. Rather, we support DOD's acceptance of VA-
determined disability percentages in calculating military disability
retired pay.
Traumatic Brain Injury/PTSD Care, Treatment and Service
Connection.--MOAA strongly supports the recommendations of the Dole-
Shalala Commission and other panels on TBI/PTSD care, coordination and
rehabilitation. (See Items 3, 4, 15, 22, 23, 33, 37 and 38 in the
matrix.)
Establish Joint Seamless Transition Agency/Office.--MOAA strongly
supports establishment of a separate, joint DOD-VA Seamless Transition
Agency staffed with full-time DOD and VA professionals to oversee the
development, fielding, completion and assessment of seamless transition
imperatives. (See Item 50 in the matrix.)
Overlap in Active Duty and VA Health Coverage.--MOAA strongly
recommends authorization of at least 3 years of eligibility for active
duty TRICARE benefits for wounded warriors after leaving service. This
will protect them from loss of urgently needed services--such as
cognitive therapy and caregiver per diem--that now terminate when they
leave active duty. (See Item 34 in the matrix.)
Caregiver Support and Case Management.--MOAA strongly endorses the
recommendations of the commissions and task forces on caregiver
support/assistance and case management for wounded warriors. (See Items
2, 10, 13, 21, 29, and 34 in the matrix.)
Reaffirmation of the ``24-7'' Principle in Assessing Service-
Connection of Disabilities.--MOAA strongly recommends the Committee
reaffirm its longstanding commitment to the principle that all service
men and women who are disabled in the line of duty--the ``24/7'' rule--
are entitled to service-connected compensation, or if eligible,
military retirement, if the disability did not result from misconduct.
Collaboration and Oversight of Congressional Committees.--MOAA
notes that parochial departmental concerns in the past have extended
beyond the executive branch, and strongly recommends that leaders of
the Committees on Veterans Affairs and Armed Services make a concerted
effort with their House counterparts to develop a more collaborative
framework to assess, oversee, prioritize, and fund cross-jurisdictional
issues affecting wounded warriors and their families who are having
such unacceptable difficulties getting fair and effective outcomes from
DOD and VA bureaucracies.
introduction
Last February, a series of articles in the Washington Post titled
``The Other Walter Reed'' profiled shocking cases of wounded
servicemembers who became lost in military health care and
administrative systems upon being transferred to outpatient
rehabilitative care.
Subsequently, the national media were flooded with stories of
seriously wounded troops warehoused in substandard quarters, waiting
weeks and months for medical appointments and evaluation board results,
confused by a maze of benefit and disability rules, and lowballed into
disability separations rather than being awarded the higher benefits of
military disability retirement.
There were interviews with family members--spouses, children, and
parents--who quit their jobs and virtually lived at military hospitals
to become caregivers to seriously wounded troops. Left with diminishing
resources and unfamiliar with military benefit and disability rules,
they were severely disadvantaged in trying to represent the interests
of their wounded spouses and children who couldn't stand up for
themselves.
These issues drew the attention of the President and Congress,
leading to the appointment of special commissions and task forces
charged with investigating the problems and identifying needed
solutions. The details of sorting out the multiple overlapping
proposals to fix the bureaucratic snafus among multiple Federal
departments can be mind-numbing, whether you're a legislator, a
lobbyist, a Federal administrator, or an average citizen.
The key to success will be to stay focused on the top priorities,
and recognize that the government must bear responsibility for these
long-term costs of war.
MOAA is very grateful for the work of the Dole-Shalala Commission,
the Veterans Disability Benefits Commission, the Marsh-West Independent
Review Group, VA Interagency Task Force on Returning Veterans, and the
Mental Health Task Force. Attached to this statement is a summary of
the major recommendations of these panels and MOAA's positions and
recommendations on them. We are very pleased to say that with
relatively few exceptions, as noted, MOAA endorses the vast majority of
these groups' recommendations.
urgency of joint congressional action and oversight
Military and VA systems have been caught unprepared for the large
wave of wounded and traumatized veterans returning from Iraq and
Afghanistan, and these veterans' needs will only grow in the future.
Sustained bipartisan, bicameral congressional leadership focus and
cooperation will be vital to successfully address continuing intra- and
inter-agency problems. With a change of leadership coming soon in the
Executive Branch, and attendant introduction of new DOD and VA leaders
who have not been a party to developing urgent leadership-driven
changes currently underway or contemplated, the importance of
congressional oversight cannot be overstated.
disability evaluation system (des) reform
Current gross disability rating disparities between the services
and between DOD and the VA must be resolved. The Independent Review
Group appointed by the Secretary of Defense found huge disparities
between the disability retirement (vs. separation) statistics between
the services for returning veterans. The percentage of returning
veterans who received military disability ratings of 30 percent or
higher (and thus qualified for lifetime retirement benefits) was far
lower among the Army and Marine Corps, who had the greatest exposure to
combat injuries. The disability retirement rate for the Navy was nearly
three times higher than the Army's, feeding perceptions that seriously
combat-wounded soldiers were being ``low-balled'' to save the
government money, as shown on the following chart.
disability retirement disparity
Percent of disabled members awarded disability retirement (30+
percent DOD disability rating)
Army 13%
Navy 36%
USMC 18%
USAF 27%
MOAA believes strongly that members with significant, lifelong,
service-caused disabilities should be retired rather than separated
with no military benefits. There must be a common rating standard that
accounts for all service-connected disabilities and provides fair
compensation and benefit packages commensurate with the level of
disability. Wounded members should be retained on active duty until the
disabling condition is stabilized, rather than expediting separation
and shifting care responsibility to the VA.
Further, the process of assigning fair and consistent disability
ratings is too important to be left to five independent agencies (four
services and the VA). While the services need to be the arbiters of
what conditions render a soldier, sailor, airman or Marine unfit for
continued service, the percentage disability rating should be
determined by the VA, and the VA system must be made as uniform as
possible across the country. (In this regard, MOAA is concerned at
studies that have shown large disparities in disability ratings by VA
offices in different states/regions.)
MOAA strongly endorses the recommendation of the Veterans'
Disability Benefits Commission (VDBC): that DOD and VA should realign
the disability evaluation process so that the Services determine
fitness for duty; and servicemembers who are found unfit are referred
to VA for the disability rating.
All conditions that are identified as part of a single,
comprehensive medical exam should be rated and compensated. MOAA
strongly recommends that in revamping the DES, the Services must
include all unfitting conditions as rated by the VA in assessing
whether the servicemember is to be medically retired or separated. (See
Items 6, 12 and 46 in the attached matrix.)
MOAA does not support elimination of the military disability
retired pay system, as some would interpret the Dole-Shalala
recommendations as implying. Rather, we support DOD's acceptance of VA-
determined disability percentages in calculating military disability
retired pay.
wounded warrior care and treatment: focus on traumatic brain injury
(tbi) and post traumatic stress disorder (ptsd)
TBI and PTSD affect 25% to 50% of returning veterans, according to
a number of government and other studies. And the percentage rises with
prolonged and repeated exposure through multiple and extended
deployments. But reluctance to disclose mental health conditions deters
many members and families from testing and treatment.
Traditional military ``can-do'' and ``tough-it-out'' attitudes that
are the pride of the warrior ethos actually work against the future
well-being of the warrior who doesn't understand the potential long-
term consequences of failing to at least find someone to talk to.
Officers and senior NCOs who fear that acknowledgement of such
conditions may affect their security clearances or future leadership
opportunities are particularly vulnerable through such reluctance.
Even less visible and likely to go unidentified are the secondary
effects on family members who also suffer the long-term effects of
living with victims of war-related stress.
We must get a better handle on cause and effect, starting with
crash efforts to destigmatize mental health conditions and publicize
opportunities for confidential discussions.
We also must dramatically improve diagnosis and treatment capacity
and methodology. One key is to dramatically improve testing for the
effects of Traumatic Brain Injury, including routine baseline pre- and
post-deployment neurocognitive assessments; and testing as soon as
possible after any exposure to high-risk blast or concussive events.
MOAA strongly endorses the recommendations of the commissions/task
forces on Traumatic Brain Injury and PTSD care and rehabilitation. (See
Items 3, 4, 15, 22, 23, 33, 37 and 38 in the matrix.)
joint seamless transition agency needed
Widely reported breakdowns in the management of care at Walter Reed
Army Medical Center reflect the fact that policies and administrative
procedures for the care, rehabilitation, outprocessing and
transitioning of our wounded warriors are not working ``seamlessly''
for them and their families.
DOD and VA have critical, complementary roles in the transition
process. The pace of the two departments' collaborative and cooperative
efforts continues to be hampered by bureaucratic and parochial
barriers.
The key, we believe, is a coordinated top-down strategy which
engages both departments' leadership from a single point of attack.
Recent leadership initiatives generated at the secretarial level have
had galvanizing effects on the two agencies' staffs, and there has been
unprecedented cooperation and progress in recent months.
However, MOAA is very concerned for the viability of these newly
energized efforts beyond the next 15 months, given the inevitable
leadership turnover that will attend any new administration.
The JEC does not appear to have the authority to direct change in
both departments, only to forge broad agreements and report to
Congress. We are into the fifth year of the war on terror, and the
hand-off between the departments for those who are in the greatest need
is far from seamless, despite recent, more strenuous leadership
efforts.
This effort is too important to be someone else's part-time job.
MOAA believes strongly that there is an overriding need to establish a
permanent joint office, with permanently assigned staff from both
departments, whose full-time mission is to devise, implement, oversee
and sustain the joint mission of serving our warriors rather than
serving their respective departments' bureaucratic prerogatives.
Acting Secretary of Veterans Affairs, Gordon Mansfield, a
distinguished disabled Vietnam veteran, endorsed a joint transition
agency in testimony before the House Veterans' Affairs Committee on 28
September 2006.
Some elements of seamless transition oversight and implementation
that should come under this office include:
Bi-Directional Electronic Medical Records
A Single Separation Physical and Electronic Separation
Document (DD-214)
Coordination of Policy/Procedures for Special Needs Health
Care, including implementation of a case management system and patient-
centered recovery plan program
Coordination of multiple agency inititiatives on Traumatic
Brain Injury (TBI) and PTSD diagnosis, treatment and Rehabilitation
Expansion of Joint DOD-VA Research
Improvement and Expansion of the Benefits Delivery at
Discharge program.
Joint Bi-Directional Electronic Health Record
MOAA and our colleagues in The Military Coalition recently were
briefed on efforts underway to improve the transfer of medical records
between DOD and the VA. There are significant signs of progress, in our
view, on this complex issue. However, we are concerned that full
electronic record ``jointness'' won't be completed until 2012 at best.
That is just too long to wait. MOAA strongly endorses accelerated
completion of this critical seamless transition function.
Joint DOD-VA Physical
A ``one stop'' separation physical supported by an electronic
separation document (DD-214) is a cost-saving initiative that is an
essential component of the seamless transition model. Although
prototypes exist in some facilities, one has yet to be accepted as a
standard throughout the two departments. It must become the ``gold
standard'' of effective and efficient transitions.
Polytrauma Centers and Traumatic Brain Injury
TBI is the signature injury of OIF/OEF--its impact on combat
veterans ranges from mild to severe. Developing best practices for
identification and treatment is essential, including research on the
long-term consequences of mild TBI. The goal of achieving optimal
function of each individual TBI patient requires improved interagency
coordination between VA and DOD.
MOAA is pleased to note that the VA is establishing a fifth Level
One polytrauma center. The new center and the four existing VA
Polytrauma Rehabilitation Centers require special attention in order to
ensure the needed resources are available, to include specialized
staff, technical equipment and adequate bed space in order to ensure
top-quality care for severely injured servicemembers and veterans.
MOAA strongly supports establishment of a separate, joint DOD-VA
Seamless Transition Agency to oversee the development, fielding,
completion and assessment of seamless transition imperatives. (See Item
50 in the matrix.)
assistance for family caregivers
The unprecedented quality and rapid delivery of battlefield health
care, along with widespread use of body armor and other protective
equipment, means that unprecedented numbers of warriors who would have
died of their wounds in previous wars are surviving to return to their
families. Unfortunately, many of these heroes face long and arduous
recovery periods, and many require significant levels of care for
months or years, and some, for the rest of their lives.
In this tragic situation, many spouses, parents, siblings, and
other family members find themselves having to take on roles as full-
time caregivers and representatives of severely injured/disabled
personnel who are unable to navigate military and VA personnel and
compensation bureaucracies on their own. Many give up their jobs and
careers to care for a loved one, in come cases having to rely on the
goodwill of charities and communities to meet various necessities of
their loved ones' new lives.
MOAA believes strongly that the government has an obligation to
change this situation and develop new programs to meet the extreme
needs of these special cases. There must be institutionalized outreach
programs to provide information and navigation assistance on
administrative proceedings, appeal options, and benefit programs. In
the more severe cases, compensation is appropriate and essential to
recognize family members' sacrifice of their own incomes and careers to
care for service-disabled members.
For the longer term, the VA needs to establish fair compensation
for caregivers forced into hardship situations. For the short term,
MOAA strongly recommends authorization of at least 3 years of
eligibility for active duty TRICARE benefits for wounded warriors after
leaving service. This will protect them from loss of urgently needed
services--such as cognitive therapy and caregiver per diem--that now
terminate when they leave active duty. (See Item 34 in the matrix.)
MOAA strongly endorses the recommendations of the commissions and
task forces on caregiver support/assistance and case management for
wounded warriors. (See Items 2, 10, 13, 21, 29, and 34 in the matrix.)
retroactive case review
In addition to making more sensitive decisions in the future,
equity demands a review of discharge and retirement cases already
completed for warriors wounded or otherwise disabled in Iraq or
Afghanistan, while their case histories are still fresh. Multiple
examples of severely disabled soldiers whose separation with zero
disability ratings created the pressure for change, but that change
can't just be prospective. It must include retroactive review and re-
adjudication for those whose examples brought the inequities to public
attention.
In the same vein, an even more sensitive situation is coming to
light. There are numerous cases of exemplary soldiers and marines who,
after multiple tours in Iraq or Afghanistan, became ``changed men''--
disciplinary cases who experienced demotion, incarceration, and adverse
separation characterizations that now bar them from eligibility for VA
treatment, compensation and rehabilitation for conditions many would
not have incurred if not for their wartime service.
lengthy claims processing delays are intolerable and must be fixed
The workload and complexity of VA disability claims continues to
increase. As of mid-February 2007, there was a backlog of 626,429
claims. VA projects that by the close of this year there will be at
least 800,000 claims in the system. Moreover, disability claims
processing time rose to nearly 6 months (177 days) on pending claims in
2006 against an original performance goal of 100 days. It's our
understanding that VA has moved the goalposts and its new performance
goal for completing initial claims is 125 days.
MOAA endorses the VDBC's recommendation on improving the VA claims
processing system. (See Item 48.) MOAA recommends that the Committee
work with its Armed Services Committee counterparts to ensure this
review is completed as soon as possible. (See Item 8 in the matrix.)
moaa concerns
MOAA applauds the work of the commissions and task forces that have
examined wounded warrior care, treatment, transition, and services. As
indicated elsewhere in this statement, MOAA endorses most of the major
recommendations of these panels. We do, however, have some concerns
about certain recommendations, while recognizing that in some cases a
commission's recommendation was limited by its charter and time.
military service is a ``24/7'' enterprise, and is substantively
different from civilian employment
Under current law, the term ``service-connected'' means generally,
``with respect to disability or death, that such disability was
incurred or aggravated, or that the death resulted from a disability
incurred or aggravated, in the line of duty in the active military,
naval, or air service.'' (38 U.S.C. Sec. 101(16)) An injury or disease
incurred ``during'' military service ``will be deemed to have been
incurred in the line of duty'' unless the disability was caused by the
veteran's own misconduct or abuse of alcohol or drugs, or was incurred
while absent without permission or while confined by military or
civilian authorities for serious crimes.'' (38 U.S.C. Sec. 105)
This statutory framework has withstood the test of time and
thorough past reviews. MOAA is confident that the statutes reflect the
will of Congress and the American people regarding the unique nature
and the inherent sacrifices involved in military service.
Disability and survivor benefits should continue to reflect the
unique nature of that service in defense of the Nation.
MOAA understands that the Dole-Shalala Commission was empowered to
examine only wounded warrior issues. However, we cannot support
establishment of separate disability evaluation processes and benefit
differentials for combat or operations-related disabilities vs. other
service-connected disabilities. (See Items 6, 30 and 46 in the matrix.)
MOAA strongly recommends that the Committee reaffirm its
longstanding commitment to the principle that all service men and women
who are disabled in the line of duty--the ``24/7'' rule--are entitled
to service connected compensation, or, if eligible, military
retirement, unless the disability was a result of misconduct.
collaborative congressional leadership needed
MOAA was pleased to note that a rare joint hearing was held earlier
this year between the Senate Veterans Affairs and the Armed Services
Committees to receive the views and preliminary recommendations of the
Veterans Disability Benefits Commission. In the House, there have been
joint hearings on educational benefits under the Montgomery GI Bill.
But it's no secret that on some issues, jurisdictional firewalls in
the Legislative Branch as well as the Executive Branch inhibit
effective collaboration on some of the core issues affecting VA and DOD
interaction. In this regard, we have been dismayed on many occasions at
the continuing skepticism of Veterans Affairs and Armed Services
Committee staffs in both chambers about the extent of joint cooperation
between the committees that's likely or feasible on various topics of
common interest.
We recognize the enormous challenges involved in crafting and
revising public laws that cross jurisdictional lines. We also can
appreciate the budgetary and political histories that have arisen from
difficult interactions over multiple past congresses.
But MOAA believes strongly that there is bipartisan, bicameral
agreement among all of the committees on the need for far greater
communication and collaboration between DOD and VA to achieve positive
outcomes for wounded veterans in such great need.
We've been extremely encouraged by the personal efforts of the
Secretaries of Veterans Affairs and Defense, demonstrating that
determined leadership initiative can, in fact, cut through longstanding
parochial red tape and generate a genuine cooperative effort among
staffs whose main experience has been colored by ``stove-piped''
perspectives.
But those efforts can be undermined in the longer term if there is
not decisive, determined, top-down congressional leadership direction
to develop joint congressional staff consensus on priorities, policy
direction, and funding responsibilities on these vital matters.
MOAA strongly recommends that leaders of the Senate Committees on
Veterans Affairs and Armed Services make a concerted effort with their
House counterparts to develop a more collaborative framework to assess,
oversee, prioritize, and fund cross-jurisdictional issues affecting
wounded warriors and their families who are having such unacceptable
difficulties getting fair and effective outcomes from DOD and VA
bureaucracies.
______
Response to Written Questions Submitted by Hon. Daniel K. Akaka to
Colonel Steven P. Strobridge, USAF (Ret.), Director, Government
Relations, Military Officers Association of America
retroactive review of dod ratings
Question. The Disability Benefits Commission report suggests that
many servicemembers may have been given low ratings by the DOD Physical
Disability Evaluation System to save DOD from having to pay them
medical retirement benefits. Your testimony supports retroactive case
review for certain veterans who are dissatisfied with the rating
assigned them by DOD. What criteria would you suggest be used to
determine who is eligible for a reevaluation?
Response. At a minimum, we believe there should be a retroactive
review of all medical separations since Oct. 7, 2001--that is,
servicemembers who had service-caused or service-aggravated medical
conditions that precluded further service and whose disabilities were
rated by the service as less than 30 percent disabling. This would
catch the most egregious situations in which a member was wrongly
denied a medical retirement and the attendant annuity, health coverage
and other benefits associated with military retirement.
Other members who were medically retired with less than 20 years of
service should be notified of their right to appeal to their service
Board for Correction of Military Records if they believe the physical
disability evaluation by their parent service inappropriately denied
consideration of any service-caused condition(s) that also would have
precluded their continued service in uniform.
Chairman Akaka. Thank you very much, Colonel.
I have a question for all of our panelists. If the VA
disability system is revised from the current form, should
different consideration be given to those veterans whose
disability was incurred in a combat zone versus those who were
disabled elsewhere? Let me start with Ms. Del Negro.
Ms. Del Negro. I have conflicting feelings about that.
During the initiation of the MEB process for my husband, we
were in a room. Actually, the first time he showed up for Part
I of his physical, the soldiers were sitting on the floor. They
didn't even take them into the back. Some of them were combat-
wounded soliders. It was very appalling to my husband to see
these gentlemen sitting on the floor.
At the same time, however, while I would like to think that
combat-related injuries would receive greater compensation, I
think that creating a second line of differentiation between
veterans will create even more bureaucratic obstacles, slowing
down the process. By virtue of that, I would say that I would
discourage the making differences between combat and non-combat
injuries. Perhaps a caveat to that would be that if one is a
Purple Heart recipient, that there would be some sort of
additional severance associated with it, but that it would not
influence health care benefits.
Chairman Akaka. Thank you. Colonel Duffy?
Colonel Duffy. Yes, sir. I agree with Ariana. I thought
that was very well said. In creating another category that the
veteran has to prove, you are creating more work for the
veteran, more work for the administration in judging a claim. A
servicemember is under the care and custody of the military 24/
7. Any injury that occurs during that period should be
compensated.
In the civilian world, if an employee is hurt at work,
there is a Workers' Compensation system that covers that
employee as a work-related injury. Anything that happens during
the day is work-related for a servicemember and should be
compensated.
Chairman Akaka. Thank you. Mr. Manar?
Mr. Manar. Simply said, ditto. I have talked about this. We
have all, I think, arrived at the same conclusion--that the
distinction here should be based on the severity of disability,
the level of disability, not where or how it was incurred. If
someone spends a year in Iraq and comes back with Post
Traumatic Stress, are they any more or less deserving of
treatment than the female soldier who was raped in Germany or
Japan? If someone steps on an IED and has a leg amputated below
the knee in Falujah, are they any more or less worthy of
compensation and benefits and care than someone who has their
leg amputated because of diabetes in the U.S. or because of an
automobile accident while they were serving in Japan?
So, our view is that there is no distinction. The
distinction is on the level of severity. With greater severity
of disabilities, then they should receive greater compensation,
greater care, of course, for their service-connected
disabilities.
Chairman Akaka. Thank you, Mr. Manar.
Ms. Beck?
Ms. Beck. My brother is a Marine Corps helicopter pilot,
and whether he is deployed or at home with his children, they
still share the same fear and anxiety of when he would be
deployed or a possible accident whether he is deployed or not
in combat. As a result, as General Scott said, if you are
covered by the UCMJ, you should be covered by the good things,
too.
Chairman Akaka. Colonel Strobridge?
Colonel Strobridge. Sir, we very strongly believe there
should be a single system. Let me give you one example of a
real case of a person to show how good intentions can go awry.
This individual was disabled preparing for a combat mission out
on the wing of an airplane doing pre-flight, slipped off the
wing, fell on a piece of equipment, broke his back, became a
paraplegic. When he applied for combat-related special
compensation under this new program, it was denied. Even though
he was preparing for a combat mission, the determination was
the reason he broke his back was the ice, so it was weather,
not combat, that caused the disability.
I don't think that was ever envisioned when Congress
established combat-related special compensation, but that is
what can happen to these kinds of determinations. And to us, it
is to avoid that kind of hair-splitting that it is very
important to say it is the disability, not how you got it. As
long as it was service-connected: if it was service-connected,
you deserve the same compensation.
Chairman Akaka. Ms. Del Negro, are there any issues that
were not addressed by today's other witnesses that you think
merit attention?
Ms. Del Negro. Do you have a few minutes? No, I am just
kidding. [Laughter.]
There are a number of issues, and I will do my best to keep
this brief. As I said, my husband and I endured this process
before the Washington Post articles came out, which seemed to
bring the onslaught of all these reports and recommendations,
even though the same reports and the same recommendations had
been around for a decade.
However, when my husband is released from active duty, the
recommendations that are made in this report--given the amount
of time they will take to implement--will not be available to
my husband because he will have already been separated from
active duty. So, I would like to see that some of these changes
be made retroactive to affect and benefit some of those
recently separated.
In addition, the Recovery Coordinator plan proposed by the
Dole-Shalala Commission report is difficult because you are
already dealing with staffing shortages, as documented by a GAO
report dated September 27, showing that over 50 percent of the
Warrior Transition Units that are being employed by the Army
have less than--or are missing--two or one of the critical
triad positions, including case managers. So, if you can't even
fill slots of case managers, how are you proposing to fill
slots of Recovery Coordinators that are also going to require
training?
Furthermore, I would like to reiterate previous comments
regarding the Family Medical Leave Act. I think it is
absolutely imperative that it be extended. I had the
opportunity to meet with President Bush, my husband and I both,
in Hawaii; and he was generous enough to ask how he could help,
and my response was that he could sign that amendment when it
graced his desk. I emphasized that that was one way he could
help servicemembers and their families. However, I also think
it will benefit the veterans and their families in the long-
term. We do not know the long-term implications of the injuries
sustained in this conflict.
Traumatic Brain Injury, the focus today primarily mentions
moderate to severe brain injury. We don't know the implications
of mild Traumatic Brain Injury, particularly as it is related
to blast injuries. The basis of conclusions so far on mild
Traumatic Brain Injury are based on pre-clinical studies
evaluating rats. We need more data before we can conclude that
those individuals are not going to require long-term care.
In addition, there is no definition of severely injured.
What is severely injured? If you are admitted to a military
hospital or classified as SI, does that mean that you will get
all these benefits? I think that that really places us in a
precarious situation, to define what severely injured is.
Lastly, the integration of the data between the DOD and VA
systems, no one mentioned today the security of the data. In
the last few years, there have been reports about problems with
the VA and release of data, and while developing an e-benefits
page and what-not may help, it does not address the security
issues. Thank you.
Chairman Akaka. Thank you very much.
I am going to now call on Senator Burr. I may have a second
round, but Senator Burr?
Senator Burr. Thank you, Mr. Chairman. We may both have
second rounds, but I know we have kept our witnesses here too
long and let me thank all of you.
Ms. Del Negro, thank you for your family's sacrifice, your
husband's service to the country. How is he doing?
Ms. Del Negro. He is doing fantastic.
Senator Burr. Great.
Ms. Del Negro. Absolutely great.
Senator Burr. I apologize that you have had to weave your
way through and navigate through a system that took some time
getting the right degree of benefit. I can only say that we are
learning. The Committee is well aware of the progress that
needs to be made and we are committed to work with the Veterans
Administration. Armed Services is committed to work with the
Department of Defense, which seems to be the area that your
husband was in through his transition.
To try to understand that it is a little different today
and that we are dealing with different injuries; that we have
got to have the right responses; let me ask you just to expand
on one thing that I didn't quite understand--the distinction of
seriously injured. When we have an injured veteran, there is no
difference in the treatment, the health care that is delivered
to them. What was the purpose of highlighting seriously
injured?
Ms. Del Negro. I believe the Veterans Commission report
identified that basis of service, as Mr. Manar addressed,
should not be based on whether or not the injury was combat or
not combat-related, but it should be related to----
Senator Burr. OK. I just wanted to make sure I hadn't
missed something relative to----
Ms. Del Negro. Sorry.
Senator Burr. Colonel Duffy, thank you for being here. Your
testimony regarding unique issues surrounding the seamless
transfer of medical records for Guard and Reserves has
intrigued me. I went to your testimony and I will read from it,
``Although this moment of interoperability is reported by DOD
contractors to be close at hand, the medical needs of our Guard
members have been overlooked with this effort that does not
require the records of civilian health care providers treating
our members to be entered into the DOD AHLTA database.'' Is
that a HIPAA problem that we have? Is there a privacy health
insurance, health privacy issue?
Colonel Duffy. There is potentially a HIPAA problem with
any medical record, but to overcome a HIPAA problem, the
patient only needs to consent--and the military could certainly
require that consent--for a soldier to be deployable.
Senator Burr. So could this----
Colonel Duffy. They would need to know all the medical
information on that servicemember.
Senator Burr [continuing]. Could this be as simple as we
are not asking Guard and Reserves to sign a release on their
health care privacy, or is it--go ahead.
Colonel Duffy. It is at least a two-fold issue. Yes, any
HIPAA issue would have to be overcome with an authorization,
which could be voluntarily given, or, in the case of a
servicemember, I suppose involuntarily, required to be given.
But, there is also the technology. The contractor who runs
the AHLTA program, Northrop Grumman, has informed us the
technology is there. They have just not been asked to do it.
Civilian medical records--and there is some concern that any
treatment within the Guard is not being scanned into the DOD
AHLTA system--not just civilian medical records, but should any
treatment be given at a Guard medical installation. The
technology is there. They are just lacking the mandate. Tell us
to do it and we will do it.
Senator Burr. You have triggered the right degree of fault.
So, let us take it from here and see what we can do to try to
find a solution to something that I would think would be
extremely helpful, not only to Guard and Reservists, but on the
back end of the system--to have within DOD, within VA, the
complete records of individuals that will end up back in the
system.
Colonel Duffy. Absolutely. And sir, may I say just one
thing. I think at a hearing earlier this year, you had patients
at Walter Reed come, one of whom testified that when he was
sent from Iraq to Walter Reed, his medical records were placed
on his stomach. I think we all heard that. And then they were
not there when he returned Stateside--a big concern if he is
later filing a disability claim with the Veterans
Administration and doesn't have those records.
Senator Burr. We share your concern.
Mr. Manar, let me say from the start, I have looked at all
these proposals on disability changes and I am, hopefully like
the Chairman, I am in neutral. I am in the middle somewhere
still trying to assess them. But, you made a statement that I
have just got to ask you some questions on. If the President's
Commission recommendations were adopted, the VA would have to
run a dual system for 70 years, and you alluded to the fact
that they couldn't do that. Did I----
Mr. Manar. They are having difficulty running the current
program.
Senator Burr [continuing]. Let me just say this. If a dual
system is better for future veterans, which has not been
determined yet, but were it, would you object to a dual system?
If you were convinced that it would benefit the next
generation?
Mr. Manar. First, let me answer that by saying I will be
speaking for myself here. If it could be shown to me, proven,
if you will, that a new system is better for future veterans,
then I wouldn't oppose it. But, I would also ask, why not make
it available to all veterans?
Senator Burr. That is certainly something the Dole-Shalala
Commission threw out within the organizations and felt that
there was enough push-back, according to Senator Dole, that
they would make it available to the future generations and an
option to the past. I agree with you. If it is better, then
everybody ought to be offered it.
But let me just share with you, 13 years ago when I got to
Washington, we have this--government employees all have an
opportunity for their retirement funds in the TSP, whatever
that stands for, and it had three options as far as I can
invest in. I remember the first day I asked, why are there not
more options, and they said, well, that is what there has
always been. [Laughter.]
And they made a change in the head of the TSP and we now
have, Colonel, nine or something different options--
international funds and all this--and now Federal employees are
actually in better shape about their retirement funding because
of the additional options that were added to the Thrift Savings
Plan.
I only point that out to you because what we have is a
unique opportunity, a unique opportunity to look at the
population that is the most affected right now and figure out
how do we integrate them through the system? How do we deliver
the best quality of care and learn what we have been doing
wrong and transition it for the ones that are still in the
system? How do we look at the disability process and try to
figure out, is there a better way to do it? Is there a way that
is fairer? Is there a way that is more efficient? And that we
take the opportunity to make that transition.
I wish I could tell you how many man hours my office spends
with veterans on disability claims because nobody understands
how the process happens. And its usually on the close calls,
which requires a call from me, or a call from the Senator from
Hawaii, and if I fail, I am going to get the Senator from
Hawaii to call on my behalf.
But it shouldn't happen like that. It is pretty clear cut.
Clearly, when you have got two different entities making
disability determinations, one has to look at it and say, how
can two different entities come up with two different
conclusions? Because they are judging two different things. We
understand that now. Is that right? Probably not for the
future. Colonel, I was glad to hear you say, one is great.
Ms. Beck, let me ask you, you support the idea of Recovery
Coordinators. As you know, these coordinators hopefully would
overcome the barriers of DOD and VA. The Commission's
recommendation is that these coordinators be employees of an
independent Public Health Service, but the decision has now
been made that the coordinators are to actually be VA
employees.
One, what do you feel about Recovery Coordinators? Two,
what do you feel about them as a VA employee versus an
independent entity, and would they be able to exert a
sufficient amount of authority over DOD employees if they are
VA employees?
Ms. Beck. Regarding the Public Health Service question--in
an ideal world, that might work; but in the real world, having
a Marine going to a Public Health servant before he can go to
another Marine--it is not going to happen. So, the idea of
having them be a VA employee and their authority would actually
probably rely on, one, as I mentioned, that overlap of benefits
to be able to legally access both sides. We can talk about it
all day, but if they have legal obstacles to doing that, then
they are not going to be able to do it.
The other issue is, that Steve and I have discussed, is the
option to allow to have that oversight structure in place--to
ensure that they have the ability to maneuver within the
Department of Defense and within the VA; and honestly, within
the Social Security Administration, Medicare, and the
Department of Labor. So, you are going to have to have those
entities in place because these problems are going to happen.
We all know they are going to happen. And, without some sort of
ability to address those problems in the future, we are going
to find ourself in the same place 5 years from now.
So yes, we do support the idea of a Recovery Coordinator.
You are going to have to find someone who has the ability and
the initiative and problem solving skills to do this because it
is not easy. Sarah, as you mentioned, she is her husband's
recovery coordinator and that is not fair. She is his wife and
she should be. So, that would be our one concern--that they not
be able to have that buy-in from the other agencies.
Senator Burr. I thank you for that. I also thank you for
the fact that it was clear from your testimony, you are focused
on outcome and not process. I am not sure that we can say that
enough up here, because this is about outcome. It is not about
whether we follow what the process is. It is about what comes
out on the other end. And I think there is a tendency that we
look at things from the wrong end. Maybe it is time we work
backwards a little bit and say, what is the optimum outcome
that we want and how do we get it?
I actually think we are going through that process on a lot
of things right now. It is difficult to absorb it all. I know
it is for all of us who are asked to play a part in it. So, I
implore all of you to stick with it, because anything short of
attempting to do this, somebody will lose.
Colonel, let me ask you one last thing. You raised, I
think, a very important issue and that is without some type of
permanent transitioning structure, how can any of us leave the
jobs we are in and believe that: (1) a task will be completed,
or (2) it will continue to evolve into what it should over
time. Let me ask it from another side. Do you have any worry
that creating a new bureaucracy within this difficult hand-off
between DOD and VA will impede our ability to actually make
this transition?
Colonel Strobridge. Well, sir, I guess the only thing you
can go by is based on experience, and not having one doesn't
work. So, having been in OSD and looking at the structures now
and talking with the folks there, you have some folks for whom
this is a part-time job--they have other things to do, and you
never know when something else is going to crop up that pulls
them away from this. Right now, there is a lot of leadership
emphasis on making sure this gets done.
Senator Burr. How quick would this have to happen from your
standpoint? What is the time line that it would have to happen
where you would say, you know what? It has happened. We don't
need another bureaucracy.
Colonel Strobridge. Well, there is a provision in the
Senate version of the defense authorization bill that would
establish a joint office specifically to oversee the Joint
Medical Record, which we certainly think is a good start. There
would be some other things that probably ought to come under
that, not the least of which is the Transition Coordinators.
One of the issues that you have right now, you can have the
greatest person in DOD who is assisting these folks through the
DOD system; then, they hand them over to the VA and they are
done; and now somebody picks them up at the VA who doesn't have
the background. So, to us, part of that office's responsibility
should be saying, what do we need to do to get them through--
not just to the point of VA--but until they are stable in the
VA system.
Senator Burr. Well, as somebody said, we are hopeful that
Gordon and Gordon are actually mapping out all the transitional
things that need to exist, and then it is an implementation and
an oversight function.
Colonel Strobridge. And a maintenance, yes, sir.
Ms. Beck. Sir, can I make one point on that? It would be
imperative that if you create such a structure, and to avoid
the bureaucracy that you are talking about, that you actually
absorb the functions of all the little offices that have popped
up throughout the Department of Defense and the VA. Because
right now, the VA doesn't normally know where to go when they
have a problem within the Department of Defense, because there
are so many different areas where they could try to resolve
their problems.
Senator Burr. Nor do we sometimes. Thank you.
Chairman Akaka. Thank you very much, Senator Burr.
I have more questions, but at this point, I just looked at
the time and I want to praise all of you for your patience
today. In a few minutes, it will be 4 hours that we have been
here, and thanks so much for all of that. I am going to submit
my questions for the record.
Again, thank you so much for your time, for traveling this
far. All of your testimonies and your responses will be helpful
to this Committee and what we will be doing in the future and I
thank you very much. I thank all the witnesses today. It is not
every hearing that we get to hear from so many distinguished
guests like you.
I want you to know that we really appreciate you taking the
time to give us a better understanding of the recommendations
of the various groups so that we have a clearer sense of what
is needed to move closer to making the transition back to
civilian life as seamless as possible. You have been a big help
in doing this.
With all of that and just about 4 hours, this hearing is
now adjourned.
[Whereupon, at 1:25 p.m., the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Barack Obama, U.S. Senator from Illinois
Mr. Chairman, I want to thank you as well as Ranking Member Burr
for holding this important hearing today. I also want to welcome and
thank distinguished Members of the various commissions as well as our
partners and friends in the VSO community.
While there are different views in Congress about the war in Iraq,
there should be no disagreement about the tremendous sacrifice being
made by the men and women who are serving in Iraq and Afghanistan. They
have performed valiantly under exceedingly difficult circumstances.
They have done everything that we have asked of them. And when they
come home, they should be able to expect the care and benefits they so
richly deserve. Our military families and recovering servicemembers
should not have to wage a second war at home to get that next doctor's
appointment or receive that first disability check.
Like most Americans, I was outraged to learn of the disgraceful
conditions and obstacles confronting those who have served us with
honor. That is why I am proud to have introduced bipartisan
legislation, the Dignity for Wounded Warriors Act of 2007 (S.713), to
address both the immediate and systematic problems uncovered in a
recent Washington Post series about Walter Reed Army Medical Center.
This comprehensive legislation addresses problems not only at
Walter Reed but throughout the military medical system. The bill sets
new standards for all outpatient medical facilities--including a ``zero
tolerance'' policy for pest infestations and overdue work orders;
streamlines the paperwork and red tape currently imposed on
servicemembers and their families--especially with regard to the
disability review process; increases caseworker ratios to provide extra
support to servicemembers and their families; increases access to
mental health services, including a new 24-hour hotline; and provides
important new protections for family members, including health care and
mental health services while on invitational job orders--as well as
Federal employment protections for their jobs. In my view, a mother
should never have to choose between caring for an injured son and
keeping her job.
I am proud that many of these provisions passed the Senate recently
in a larger package focused on helping our wounded warriors, and I hope
the House and Senate will complete its conference soon and submit this
legislation for the President's signature. But more action is needed.
The pace of change is too slow within the Pentagon and VA, and we have
to consider other fundamental reforms that will help ensure our wounded
warriors and our veterans are getting the care and benefits they
deserve.
I look forward to hearing from the panelists, especially the
recommendations from the President's Commission on Care For America's
Returning Wounded Warriors and the Veterans Disability Benefit
Commission. I think we can all agree on the need to pursue some of
these recommendations, such as the Dole-Shalala commission's call for
better prevention and treatment of PTSD and TBI; and for providing much
more robust support for our recovering warriors as they transition from
the military to the VA. But Congress must also avoid ceding its
important role in revising other complicated policies, such as the
current disability rating system within the military and the VA. I
share the Chairman's concerns, for example, over any proposal that
would effectively cut Congress out of this important work.
Mr. Chairman, we owe it to our returning servicemembers and
veterans to get this right. I look forward to working with you and our
panelists to consider the range of options and find the best approach
to giving these heroes what they deserve.
Thank you.