[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
LEGISLATIVE HEARING ON H.R. 949, H.R. 1075,
H.R. 2698, H.R. 2699, H.R. 2879, H.R. 3926,
H.R. 4006, H.R. 84, AND THREE
DISCUSSION DRAFTS
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
__________
MARCH 25, 2010
__________
Serial No. 111-69
__________
Printed for the use of the Committee on Veterans' Affairs
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57-013 WASHINGTON : 2010
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South HENRY E. BROWN, Jr., South
Dakota Carolina
HARRY E. MITCHELL, Arizona JEFF MILLER, Florida
JOHN J. HALL, New York JOHN BOOZMAN, Arkansas
DEBORAH L. HALVORSON, Illinois BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas VERN BUCHANAN, Florida
JOE DONNELLY, Indiana DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia
Malcom A. Shorter, Staff Director
______
Subcommittee on Health
MICHAEL H. MICHAUD, Maine, Chairman
CORRINE BROWN, Florida HENRY E. BROWN, Jr., South
VIC SNYDER, Arkansas Carolina, Ranking
HARRY TEAGUE, New Mexico CLIFF STEARNS, Florida
CIRO D. RODRIGUEZ, Texas JERRY MORAN, Kansas
JOE DONNELLY, Indiana JOHN BOOZMAN, Arkansas
JERRY McNERNEY, California GUS M. BILIRAKIS, Florida
GLENN C. NYE, Virginia VERN BUCHANAN, Florida
DEBORAH L. HALVORSON, Illinois
THOMAS S.P. PERRIELLO, Virginia
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
March 25, 2010
Page
Legislative Hearing on H.R. 949, H.R. 1075, H.R. 2698, H.R. 2699,
H.R. 2879, H.R. 3926, H.R. 4006, H.R. 84, and Three Discussion
Drafts......................................................... 1
OPENING STATEMENTS
Chairman Michael Michaud......................................... 1
Prepared statement of Chairman Michaud....................... 32
Hon. Henry E. Brown, Jr., Ranking Republican Member.............. 2
Prepared statement of Congressman Brown...................... 32
WITNESSES
U.S. Department of Veterans Affairs, Gerald M. Cross, M.D.,
FAAFP, Deputy Chief for Patient Care Services and Chief
Consultant for Primary Care, Veterans Health Administration.... 23
Prepared statement of Dr. Cross.............................. 57
______
American Legion, Denise A. Williams, Assistant Director, Veterans
Affairs and Rehabilitation Commission.......................... 14
Prepared statement of Ms. Williams........................... 39
Boswell, Hon. Leonard L., a Representative in Congress from the
State of Iowa.................................................. 5
Prepared statement of Congressman Boswell.................... 36
Brown-Waite, Hon. Ginny, a Representative in Congress from the
State of Florida............................................... 7
Prepared statement of Congresswoman Brown-Waite.............. 38
Disabled American Veterans, Joy J. Ilem, Deputy National
Legislative Director........................................... 18
Prepared statement of Ms. Ilem............................... 47
Filner, Hon. Bob, Chairman, Committee on Veterans' Affairs, and a
Representative in Congress from the State of California........ 3
Prepared statement of Congressman Filner..................... 33
Giffords, Hon. Gabrielle, a Representative in Congress from the
State of Arizona............................................... 9
Prepared statement of Congresswoman Giffords................. 34
Kirkpatrick, Hon. Ann, a Representative in Congress from the
State of Arizona............................................... 11
Paralyzed Veterans of America, Blake C. Ortner, Senior Associate
Legislative Director........................................... 15
Prepared statement of Mr. Ortner............................. 41
Scalise, Hon. Steve, a Representative in Congress from the State
of Louisiana................................................... 3
Prepared statement of Congressman Scalise.................... 33
Veterans of Foreign Wars of the United States, Eric A. Hilleman,
Director, National Legislative Service......................... 17
Prepared statement of Mr. Hilleman........................... 44
SUBMISSIONS FOR THE RECORD
American Federation of Government Employees, AFL-CIO............. 65
National Association of Government Employees (SEIU/NAGE), David
J. Holway, National President.................................. 67
National Federation of Federal Employees, William R. Dougan,
National President............................................. 68
LEGISLATIVE HEARING ON H.R. 949, H.R. 1075,
H.R. 2698, H.R. 2699, H.R. 2879, H.R. 3926,
H.R. 4006, H.R. 84, AND THREE
DISCUSSION DRAFTS
----------
THURSDAY, MARCH 25, 2010
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:05 a.m., in
Room 334, Cannon House Office Building, Hon. Michael H. Michaud
[Chairman of the Subcommittee] presiding.
Present: Representatives Michaud, Brown of South Carolina,
and Boozman.
OPENING STATEMENT OF CHAIRMAN MICHAUD
Mr. Michaud. I want to thank everyone for coming out this
morning.
Today's legislative hearing is an opportunity for Members
of Congress, veterans, and the U.S. Department of Veterans
Affairs (VA) and other interested parties to provide their
views and discussions on recently introduced legislation within
this Subcommittee's jurisdiction. This is an important part of
the legislative process that will help encourage frank
discussions and new ideas.
We have a number of bills before us today. They cover a
wide range of important issues dealing with access to VA health
care; collective bargaining rights for VA employees; mental
health care and counseling for individuals discharged or
released from active duty; emotional and peer support for
family members of the Armed Services; breast cancer among
members of the Armed Forces and veterans; and rural health
issues including the unique needs of Native American veterans.
We also have draft bills before us today on reimbursement for
continuing education, mental health counseling and bargaining
rights and performance criteria.
I would ask unanimous consent that my full opening remarks
be submitted for the record. Are there any objections? Hearing
none, so ordered.
I look forward to hearing the views of the different panels
today and at this time I would like to recognize Ranking Member
Mr. Brown for any opening statement he may have.
[The prepared statement of Chairman Michaud appears on p. 32
.]
OPENING STATEMENT OF HON. HENRY E. BROWN, JR.
Mr. Brown of South Carolina. Thank you, Mr. Chairman. I
appreciate your holding this hearing today and look forward to
working with you and the rest of our esteemed colleagues on
these important legislative subjects.
The ten bills being discussed this morning cover a wide
array of veterans' issues and I look forward to learning more
about them. Of particular interest to me is H.R. 1075, the
``RECOVER Act,'' introduced by Mr. Scalise. H.R. 1075 would
provide medical service to veterans in a disaster area by
allowing VA to contract with one or more non-VA facilities.
Making sure our veterans have access to the very finest
care is always a top priority of this Committee, but in times
of real emergency, that priority takes on a whole new level of
importance. Serving a district with facilities that are
vulnerable, to the sometimes destructive whims of nature, as I
do in Charleston and along the coast of South Carolina, makes
this a personal issue for me and I support Mr. Scalise in his
efforts.
I am also excited to hear more about H.R. 84, the
``Veterans Timely Access to Health Care Act,'' introduced by my
friend Ms. Brown-Waite.
Among other provisions, this bill would make the standards
of access to care for a veteran seeking primary care from the
VA 30 days from the date the veteran contacts the Department.
Ms. Brown-Waite has long been committed to making sure
America's veterans do not have to endure long waiting periods
before they can have access to VA care and I applaud her
efforts.
To all the witnesses appearing in front of us this morning,
thank you for your dedication to improving the lives of our
veterans. Your work does not go unnoticed, and I am eager to
begin our discussion on the matters at hand.
It is only by working together to advance meaningful and
appropriate legislation that we can completely fulfill the
promise we made to provide veterans with the best care
anywhere. The men and women who served so bravely in uniform
deserve nothing less.
Again, thank you, Mr. Chairman. I yield back.
[The prepared statement of Congressman Brown appears on
p. 32.]
Mr. Michaud. Thank you very much, Mr. Brown.
So we may as well begin. I will recognize the distinguished
Chairman of the full Committee on Veterans' Affairs, Bob Filner
of California. I want to thank you, Mr. Chairman, for all the
hard work that you have done over the years fighting for our
veterans. We have made a lot of progress under your leadership
and look forward to continuing to work with you as we move
forward to take care of the needs of those who have bravely
served this great Nation of ours.
Mr. Filner.
STATEMENT OF HON. BOB FILNER, CHAIRMAN, COMMITTEE ON VETERANS'
AFFAIRS, AND A REPRESENTATIVE IN CONGRESS FROM THE STATE OF
CALIFORNIA; HON. STEVE SCALISE, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF LOUISIANA; HON. GABRIELLE GIFFORDS, A
REPRESENTATIVE IN CONGRESS FROM THE STATE OF ARIZONA; HON. ANN
KIRKPATRICK, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF
ARIZONA; HON. LEONARD L. BOSWELL, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF IOWA; AND HON. GINNY BROWN-WAITE, A
REPRESENTATIVE IN CONGRESS FROM THE STATE OF FLORIDA
STATEMENT OF HON. BOB FILNER
Mr. Filner. Thank you, sir. Mr. Chairman, we thank you for
your leadership on this Subcommittee and your fine working
relationship with Mr. Brown. We appreciate the leadership that
both of you have shown and I know I speak for all of my
colleagues in saying that we appreciate the opportunity to talk
about our legislation today.
The bill that I am speaking on, H.R. 949, would improve the
collective bargaining rights and procedures for reviews of
adverse actions of certain VA employees. This bill is about
ensuring equity amongst the health care professionals employed
at VA so that the providers such as doctors, nurses, dentists,
chiropractors, optometrists, and podiatrists who are hired
under the so-called ``pure title 38'' system have the same
rights as their fellow VA health care professionals hired under
different hiring systems.
Without this bill, the ``pure title 38'' providers do not
have the right to challenge errors in pay computations and lack
other key bargaining rights enjoyed by their colleagues at the
VA.
To address this problem, H.R. 949 would clarify that these
``pure title 38'' providers have equal rights to collective
bargaining. This means they would be able to challenge
personnel actions through such methods as grievances,
arbitrations, and labor-management negotiations.
This bill would also require the VA to review the adverse
personnel action and issue a final decision no later than 60
days after the employee appeals the adverse personnel action.
Finally, the bill would subject the VA's final decision on
the employee's appealed adverse personnel action to judicial
review in the appropriate U.S. District Court or the U.S. Court
of Appeals for the Federal Circuit.
I know the VA has some concerns with this and they are in
discussions with the stakeholders. I look forward to working
with all of them as we move forward on this legislation.
Again, thank you again for the opportunity of sharing these
thoughts with you.
[The prepared statement of Congressman Filner appears on p.
33.]
Mr. Michaud. Thank you very much, Mr. Chairman.
Mr. Scalise.
STATEMENT OF HON. STEVE SCALISE
Mr. Scalise. Thank you, Mr. Chairman and Ranking Member
Brown, as well as all the distinguished Members of the
Subcommittee for the opportunity to testify. I want to just let
you know this bill, H.R. 1075 is bipartisan legislation with
over 19 cosponsors. It seeks to maintain vital health services
to veterans in the event that a VA hospital is closed due to a
federally declared disaster.
Before I begin discussing my bill, I would like to thank
you and all of the Members of the Committee for the work that
you do on behalf of our Nation's veterans. The welfare of our
veterans and their families is of great importance to me. I
first filed this legislation during the 110th Congress when I
served as a Member of the Veterans' Affairs Committee.
Our Nation is grateful for the courage our veterans have
displayed and the sacrifices they have made in order to protect
America and the freedoms we enjoy today. I believe as you do,
that it is our obligation to provide them the same honor and
dedication that they provided us during their service.
Hurricane Katrina flooded and closed the New Orleans VA
Medical Center, leaving our veterans without the full services
of their medical home. Unfortunately, nearly 5 years later, our
VA hospital still remains closed. As a result, veterans
throughout Southeast Louisiana face increased challenges and
hardship to obtain the quality health care they deserve. The VA
made a commitment to open a new hospital, which won't occur
until as early as 2013, but with the current delays, I remain
concerned about the status of veterans health care in the
interim and want to make sure this doesn't happen again to any
of our Nation's veterans in the future.
That is why I introduced H.R. 1075, the ``RECOVER Act.'' My
bill would ensure that the VA must establish a contract with at
least one non-VA facility to provide inpatient services in the
event that a VA hospital will be closed for at least 6 months
due to any federally declared disaster.
Nothing in this bill would prevent a veteran from seeking
care within the VA system, if he so chooses.
Just last week I spoke with a veteran who had to travel to
another State for post-operative care because the New Orleans
VA Hospital is still not open. Veterans still have to travel
more than 350 miles for cardiac surgery and also have to travel
to other States for mental health care as well.
Several veterans with chronic conditions did not seek care
after the storm because they did not know what their options
were. This concerns me very much, and my bill seeks to
eliminate these hardships. The RECOVER Act will also prevent
families from having to travel hundreds of miles just to visit
their loved ones who are undergoing treatment in the hospital.
As the respected group Disabled American Veterans (DAV)
said, when they expressed their support for this Act, ``Family
support and caregiving have been shown to accelerate recovery
time and reduce costs and length of hospital stays.''
In the aftermath of a disaster, the last thing our veterans
and their families should have to worry about is where to seek
basic care. I commend the Southeast Louisiana Veterans Health
Care System for the initiative they have taken to provide
health care in light of the hospital's closure. The community
outpatient clinics have been extremely valuable in delivering
primary care and other services. We learned valuable lessons
after Hurricane Katrina, and I want to make certain that no
veteran has to travel long distances or experience long wait
times to receive basic care in the event that their local VA
hospital is closed due to a natural disaster, whether it be a
hurricane, tornado, earthquake or any other disaster.
My office is working with the veterans service
organizations (VSOs) to address any issues they have as this
bill moves through the legislative process. Let me also
emphasize that this in no way undermines our strong commitment
to the VA health care system. Our goals are the same. Veterans
and their families need to have options for receiving quality
care close to home in the most convenient way possible, all
while working to expedite the rebuilding of our VA hospital
that was closed due Hurricane Katrina.
I continue working hard to cut through the red tape and
expedite the rebuilding of the New Orleans Medical Center that
was devastated and closed by Hurricane Katrina's devastation. I
look forward to working with you and Members of the full
Committee as we move forward.
Again, I thank you for your dedication to our Nation's
military veterans and I appreciate this opportunity to testify
before the Subcommittee. I yield back.
[The prepared statement of Congressman Scalise appears on
p. 33.]
Mr. Michaud. Thank you very much for your testimony.
Mr. Boswell.
STATEMENT OF HON. LEONARD L. BOSWELL
Mr. Boswell. Thank you, Mr. Chairman and Mr. Brown. We have
spent a few hours together and I know both of you are patriots
and you care about veterans and I thank you for your service
and I appreciate the kind words you said to Chairman Filner.
This Committee has done a lot of good work the last several
years and you are to be commended.
That's why I thank you for inviting me here today to share
some of the things with you that I want to talk about. As you
know, women are currently the fastest growing veteran
population, today, representing 8 percent of the population.
As the demographics of the military continue to change, we
find our VA system is struggling to serve the unique needs of
this growing population and it is believed that by 2020, 15
percent of veterans using the VA for health care will be women,
and I would like to maybe step out of order a bit and introduce
to you, if I could, Mr. Chairman, Alexis Taylor.
Alexis, please stand up. I hope I don't embarrass her too
much, but she's my Legislative Director, she's an Iraqi veteran
and because of what I am about to share with you has a lot to
do with why I hope that this legislation will get serious
consideration.
What this means is veterans health care, which is now
primarily tailored to men needs to undergo significant changes
and needs to do it quickly. In particular, one health concern
that has been largely ignored is the prevalence of breast
cancer in our servicewomen and women veterans. So that is why
we have introduced, and I say ``we,'' Alexis and I, H.R. 3926,
the ``Armed Forces Breast Cancer Research Act.''
This legislation would require the Secretary of Defense and
the Secretary of Veterans Affairs to collaboratively study the
incidence rate of breast cancer in servicemembers and veterans.
This study would focus on the number of servicemembers who have
deployed in support of Operation Iraqi Freedom and Operation
Enduring Freedom, the demographic information of those
servicemembers and veterans, an analysis of the clinical
characteristics of breast cancer diagnosed and possible
exposures to cancer-at-risk factors.
The idea of this bill came about when a member of my staff,
which you have just met, Alexis, who is an Iraq veteran, went
back to Iowa for a 5 year post-deployment reunion with her unit
and others, and one of the women of her unit had returned home
from serving her country, and was diagnosed with breast cancer
and had to undergo a double mastectomy at age 25.
Through the course of the night, the servicemembers at the
reunion were able to piece together, talk to one another, about
six women that were deployed, they were deployed with, who had
come back from their deployment in Iraq with breast cancer, all
between the ages of 25 to 35 years old.
Also, there were another half a dozen women who returned
with new lumps in their breasts and needed additional tests
such as mammograms, ultrasounds and/or biopsies. With 70 women
deployed at the battalion of about 700, the incidence rate in
these young women seemed high and alarming as Alexis brought
this to my attention.
I would like to note that this legislation has been
endorsed by the Veterans of Foreign Wars (VFW) and the Iraq and
Afghanistan Veterans of America (IAVA) and I would like to
submit both letters, which I have here with me into the record.
Mr. Michaud. Without objection, so ordered.
Mr. Boswell. Thank you. In recent years the U.S. medical
and research communities have stepped up their efforts on
breast cancer detection, research and treatment in the
country's civilian population. However, women who have served
in our Nation's Armed Force have largely been excluded from
these studies, despite their exposure to cancer risk factors
and access to medical care.
A recent study of U.S. Department of the Defense (DoD) and
National Cancer Institute compose the prevalence of certain
types of cancer among active duty military personnel of the
general public. The study found that breast cancer among women
is more common in the military than in the general population
and that further studies are needed to confirm these findings
and explore contributing factors.
So that is our goal for this legislation, to find out if
our servicewomen do have a higher risk of breast cancer than
the rest of the women in the country and why that might be, so
that ultimately we can determine if breast cancer, as a
service-connected disability, which I truly believe it is, if
it is, we need to know.
At this moment in history it is particularly important to
consider what we can do to better serve the brave individuals
who fight for our security and liberty once they return home.
And I would like to thank you again for allowing us to come
before this Committee. And I have a personal passion about this
somewhat. As you already know and I am not going to elaborate
on it, I am a veteran, too, and I know that some of the
maladies I have shared with you and you know about is because
of a thing called Agent Orange, new at that time. This caused a
lot of problems. I was very much exposed to it.
And if something's going on in this theater of operations
that exposed our women to breast cancer and we could do
something about it and we don't, shame on us. I feel very
strong about it and I know that you do, too. So I ask you to do
everything we possibly can do to move forward on this issue,
and I would look forward to any questions you might have. Thank
you.
[The prepared statement of Congressman Boswell, and the
referenced letters, appear on p. 36.]
Mr. Michaud. Thank you very much, Mr. Boswell. And Alexis,
thank you for your service to our great country, as well as
keeping Mr. Boswell. Thank you very much.
Ms. Brown-Waite.
STATEMENT OF HON. GINNY BROWN-WAITE
Ms. Brown-Waite. Thank you, Mr. Chairman and Ranking Member
Lamborn. I, as you can tell, I have a little bit of laryngitis,
which my husband used to call ``a husband's prayers answered.''
First of all, I want to say that the Committee does great
work and I truly miss being on this Committee.
As of November 2009, there were nearly 8 million veterans
enrolled in the VA health system. With new veterans entering
the system every day and approximately 174,000 Operation
Enduring Freedom and Operation Iraqi Freedom patients receiving
VA care, it is clear that it is our duty, our Nation's duty to
serve our veterans and I believe that that duty is as strong
now as it ever was. Today, there are 153 VA medical centers and
768 community-based outpatient clinics available to serve these
veterans.
When a veteran calls to schedule an appointment in one of
these facilities, they should be able to receive an appointment
that is timely and appropriate to their medical needs.
Unfortunately, for many veterans this simply does not happen.
The VA lauds itself for completing 99 percent of primary care
appointments within 30 days of the desired date. However, this
means if their figures are accurate, that nearly 32,000
patients are still waiting beyond the 30 days.
Additionally, there is a very discernable difference
between existing patients and new patients as only 88.8 percent
of new patients complete their appointments within 30 days of
their desired date. We all know that health care delayed is
health care denied and our Nation's veterans deserve much
better than this.
In September of 2007, the VA Office of the Inspector
General found that the Veterans Health Administration's method
of calculating waiting times of new patients understates the
real waiting times. In this report, the Inspector General made
five recommendations to reduce these wait times. To date, four
of the five recommendations remain unresolved.
When I was first elected to Congress, I inquired about wait
times from my local VA community-based outpatient clinics and
hospitals. The numbers the VA gave me, both for Veterans
Integrated Services Network (VISN) 8 and nationwide, quite
honestly did not match the stories that I was hearing from my
veterans. I challenged them on it and I told them that I was
going to be in their offices watching and waiting and talking
to individuals.
What was happening was, they were making the appointments
within 30 days, but then around the 20th day they would call
and change the appointment to a later date, so it would be
maybe 40, maybe 50 days.
For this reason, I introduced the bill H.R. 84, the
``Veterans Timely Access to Health Care Act.'' It would make
the standard for a veteran seeking primary care from the
Department of Veterans Affairs 30 days from the date the
veteran actually contacts the Department with no games allowed
to be played. Veterans shouldn't have to wait more than 30 days
to receive an appointment.
The VA does provide a high level of care to all of the
veterans who are enrolled in the system. This is why the
majority of patients actually rank their care, their overall
satisfaction as ``very good'' or ``excellent,'' regardless of
whether they are receiving inpatient or outpatient care.
I want to make sure that it is clear that this bill is not
a scheme to move the VA toward privatization. I simply want to
make sure that the veterans receive care in a very timely and
appropriate manner.
As Members of Congress, we have an obligation to ensure
that those veterans do receive the best health care available
to them. If they are having problems receiving it within 30
days, then Congress needs to allow them to look for an
alternative, and that's exactly what this bill does. And I
appreciate this hearing today to determine whether the VA is
meeting the goal of timely access to health care.
You know, our Nation's veterans did not wait 30 days to
answer the call of duty. They answered the call, took up arms
and protected our very freedoms. They deserve that same
dedication and steadfastness from us.
With over 116,000 veterans living in my district, I have
the distinguished honor to meet with these true American heroes
on a regular basis. And over and over again, I still hear about
how difficult it is to schedule an appointment with a doctor in
a timely manner.
Congress recently allowed for advanced appropriations for
the VA, and I think that is an excellent idea. This new funding
structure should allow the VA to properly manage their funds
and hire the necessary staff to meet the demand at the VA
facilities.
Congress and the administration must not turn the care of
our Nation's veterans into a political issue. Instead, we must
all work together to ensure that they receive health care they
risked so much to earn. We must continue these practices that
already work and improve on those that may be failing. H.R. 84
does just that.
And with that, Mr. Chairman and Members, I yield back the
balance of my time.
[The prepared statement of Congresswoman Brown-Waite
appears on p. 38.]
Mr. Michaud. Thank you very much, Ms. Brown-Waite and also
thank you for your years serving on this Committee as well.
Ms. Giffords.
STATEMENT OF HON. GABRIELLE GIFFORDS
Ms. Giffords. Good morning, Mr. Chairman. Thank you and
Ranking Member Brown for allowing me the opportunity to
testify. I'd like to talk to this Committee because this is the
Committee that has been specifically looking at supporting the
needs of America's veterans, and I look forward to working with
all of you on this Committee toward this endeavor.
I also want to thank the veterans service organizations
that are in attendance today or perhaps watching, for their
commitment to the men and women in uniform and their lifetime
of service to our country.
The two bills that I have brought before you today that I
have sponsored, H.R. 2698 and H.R. 2699, will have a direct
impact on improving the behavioral health of our Nation's
heroes and their families in our communities.
As a Member of the House Armed Services Committee who
represents more than 25,000 servicemembers and dependents and
nearly 96,000 veterans and retirees in my southern Arizona
district, we have really seen firsthand the trials and
tribulations of our servicemembers who are returning home from
the frontlines.
I know this issue is one that is close to all of our
hearts, and I am hopeful that today's hearing signifies an
important step in moving this vital legislation forward and
passing it this Congress.
There is no cause more honorable than service to our
country. As our Nation's warriors bravely step into the breach,
we must be prepared to care for them when they return home, no
matter what condition they return home in.
In war, our soldiers, sailors, airmen and marines face
unspeakable horrors, sometimes on a daily basis, and
readjusting to every day life is a long and complicated
process. Every day thousands of our Nations bravest men and
women are suffering from different degrees of post-traumatic
stress disorder (PTSD). In recent years, diagnosed cases of
PTSD have increased by more than 50 percent for servicemembers
returning from overseas deployments, and many experts believe
that the actual number is much higher because a large number of
servicemembers are reluctant to seek care and seek treatment.
For an untold many diagnosed with the worst warning signs
of PTSD, there simply are no easy fixes. We see each month the
unfortunate and deeply saddening results of the Department of
Defense when it releases its numbers of servicemember suicides.
The trend is currently hovering slightly above the national
average, more than double what it was 5 years ago.
PTSD and other related behavioral health issues severely
affect an individual's ability to perform every day functions
that we take for granted. PTSD, though, is treatable through a
variety of methods, including behavioral therapy and medication
with the majority of servicemembers seeing an improvement after
just one or two sessions with a behavioral therapist.
Unfortunately, we all know there are not enough of these
behavioral health care providers within the military or the VA
to treat our servicemembers, their families or surviving
spouses for the anguish that they are suffering. What is worse
still is that there aren't enough therapists to treat one
another.
Ultimately, our ailing heroes or the families they leave
behind, must wait to see a caregiver, they often receive
incomplete or inadequate care or in some cases do not receive
care at all, leading to one of the few inevitable conclusions--
depression, anger management problems, substance abuse or, the
worst case, death.
This is the first of many clear signs the system is failing
our men and women in uniform and badly needs to be fixed. H.R.
2698 establishes a scholarship for service program that
provides educational benefits to those training in behavioral
health care specialties critical to the operations at Vet
Centers. These individuals would then pay back the investment
by serving as a behavioral health care specialist at Vet
Centers across the country.
Because of the unprecedented nature and a lingering lack of
understanding surrounding PTSD and its symptoms, many former
servicemembers do not realize they are suffering until long
after they have left service. My bill, H.R. 2699, would permit
our Nation's Guardsmen and Reservists to access behavioral
health care at Vet Centers even after they have been released
from active duty and it will then provide referrals to assist
them to the maximum extent possible in obtaining behavioral
health care and services from sources outside of the
Department.
H.R. 2698 and H.R. 2699 will ensure that the Veterans
Administration carries out a competitive grant program for non-
profit organizations that provide peer-to-peer emotional
support services for servicemembers, veterans, and survivors,
including members of the National Guard and Reserve who are
often left out because of the changing nature of their service
or the accessibility of care in local communities.
I underscore that.
Mr. Chairman, you have been to my district. It is over
9,000 square miles. Many of these servicemembers return home to
areas that are very far from any local Vet Center and
partnering with non-profits that have the training and
expertise so that they don't have to drive 3, 4, 5 hours to
receive treatment is critical.
The unfortunate fact is that 10 years ago, we hardly
understood the existence of PTSD, we didn't understand it quite
to the extent that we do today and today we have only a
patchwork quilt of treatments, forms and meetings, training
seminars and online courses that these servicemembers must
complete, alongside other regular recertifications and
proficiency tests.
What we are not doing is taking a comprehensive look at
this problem and designing a smarter and more realistic
solution.
I am committed to fixing these problems and I know Mr.
Chairman and Members of this Committee are committed as well,
and I just want to thank you for allowing me the opportunity to
share the story and to introduce these bills because I really
do think it would make a significant difference to our
servicemembers. Thank you.
[The prepared statement of Congresswoman Giffords appears
on p. 34.]
Mr. Michaud. Thank you, too, for your commitment to helping
our veterans.
Mrs. Kirkpatrick.
STATEMENT OF HON. ANN KIRKPATRICK
Mrs. Kirkpatrick. Mr. Chairman, Ranking Member Brown and
Members of the Committee, thank you for holding this hearing
and providing me with the opportunity to address two bills that
I have introduced, H.R. 4006, the ``Rural, American Indian
Veterans Health Care Improvement Act of 2009,'' and H.R. 2879,
the ``Rural Veterans Health Care Improvement Act of 2009.''
The Rural, American Indian Veterans Health Care Improvement
Act will make it easier for many Native American veterans
living in rural areas to access quality health care options. So
many Native Americans have sacrificed and given their lives in
service to this country throughout our Nation's history with
the brave and honorable service of the Navajo Code Talkers
being just one example.
In fact, the VA estimates that 22 percent of Native
Americans are veterans or are currently serving, more than any
other ethnic group. America has a sacred obligation to keep its
promises to them. Too often Washington has not met that
obligation and Native American veterans frequently struggle to
get the benefits they have earned.
For instance, my district is home to 11 tribal communities
spread out across an area larger than 26 States and yet it is
served by only one VA medical center. Many veterans in Arizona
who live on tribal lands have to drive for hours to get basic
care. My bill directs the VA to establish Indian Health
Coordinators in areas with a high population of Native American
veterans.
These coordinators will work directly with Native American
veterans to find innovative ways to improve outreach to tribal
communities and help those veterans work with the VA. My bill
would also explore common sense ways for the VA to coordinate
with the Indian Health Service (IHS).
At the national level, the Secretary of Veterans Affairs
would be directed to work with the Secretary of the Interior to
streamline the electronic transfer of health records for Native
American veterans between the VA and IHS.
At the local level, Indian Health Coordinators would work
with their IHS counterparts to better serve the medical needs
of veterans in tribal communities.
Finally, my bill would require a joint report by the
Secretaries of Veterans Affairs and Health and Human Services
(HHS) to find other methods to expand service to Native
American veterans including through the establishment of new
clinics.
My other bill, the Rural Veterans Health Care Improvement
Act builds on the Rural, American Indian Veterans Health Care
Improvement Act with an even more comprehensive effort at
allowing veterans living in rural areas to access medical
services.
The health care provided by the VA is undeniably among the
best in the world, but that does little good to veterans in
rural areas who have trouble making the trip to the clinic.
This bill helps them address this challenge by making it easier
and cheaper for veterans to actually get to VA health care
providers. This bill would lock in the current health care
travel reimbursement rate for disabled veterans at 41.5 cents
per mile, up from 11 cents just a few years ago.
Further, it authorizes the VA to award grants to veterans
service organizations that transport veterans to their
appointments, making it possible for them to expand and improve
these helpful services.
When I visited with our troops in Afghanistan last May, I
was told time and again that our brave men and women need
better access to mental health services. That is why this bill
also expands peer support programs and allows the VA to
cooperate with community providers already in place to ensure
that those who need care can get it.
I believe that it is our Nation's sacred duty to pay back
the eternal debt of gratitude we owe to our veterans, starting
at the very moment a citizen signs up to serve.
As the daughter and niece of veterans, this is incredibly
important to me personally and I am determined to push
Washington to live up to its responsibilities. I believe that
these two bills are important steps in the right direction.
I thank you again for this chance to discuss these measures
and I stand ready to answer any questions you may have.
Mr. Michaud. Thank you very much, Mrs. Kirkpatrick. I want
to thank all the panel members for bringing forward these very
important pieces of legislation. I look forward to working with
you as we move forward with markups later this year.
I have no questions for the panel. I understand neither
does Mr. Brown, so I would recognize the Ranking Member of the
Economic Opportunity Subcommittee, Mr. Boozman, who has done a
phenomenal job, along with Chairwoman Herseth Sandlin, in that
Subcommittee and I want to thank you for working very hard with
our Congresswoman Herseth Sandlin to move forward legislation
on your Subcommittee in such a bipartisan manner, Mr. Boozman?
Mr. Boozman. Well, thank you very much, Mr. Chairman. First
of all, I would like to introduce--I have three students here
that have come by. They are up here trying to figure out how
Washington works, which is kind of scary, but let me introduce
them real quick--Kaity Dye, Christopher Jordan and Caleb
McDaniel. And these are all students from Arkansas that are
part of a program that is learning more about--I think it is so
neat that they are here today in the Veterans' Affairs
Committee because we hear so much about all the rancor that is
going on here and the lack of working together, but truly in
this Committee, it comes down to veterans and we are totally,
Mr. Filner's left, but under his leadership and Mr. Buyer, who
truly are committed to helping veterans and I appreciate your
leadership on this Subcommittee.
I would like to just--you guys can go ahead and sit down. I
know you have to go. Again, thank you for being here.
I would like to comment just briefly on Mr. Scalise's bill,
H.R. 1075, and it brings to the forefront a very serious and
important issue regarding how VA is providing care to veterans
when a medical center is destroyed as a result of a natural
disaster. Quite honestly in such cases, the entire VISN, not
such that area but the entire VISN is impacted by the extra
resources needed to provide fee basis care. It creates a
shortfall for all of the medical facilities in the VISN. So I
ask you when a disaster creates a need for a VISN to incur a
substantial increase in fee basis care expenses, why that money
comes from the VISN's budget. I am really not directing that to
you, Congressman. I guess that--again, this a problem that I am
asking that question since this is something that we have to
figure out.
The funding should come out of VA Central, the office
budget, and I look forward to working with you, Steve, to see
if we can maybe insert something or work with you with your
legislation to really--we just have a number of different
problems that are incurred as a result of these whenever
incidents occur. So we look forward to working with you.
Mr. Scalise. Thank you and I will continue to work with you
and other groups. And I will commend--the Congresses over the
last few years after Katrina have made a strong commitment to
ensure that our VA hospital will be rebuilt and, in fact, the
moneys have been appropriated. Unfortunately, there have been a
lot of delays for a number of reasons why we haven't even still
been able to break ground.
So at the earliest it would be 2013 before this new
facility is going to be built and our veterans have been in
limbo for almost 5 years now, and you know, the funding issues
we will continue to work on. I understand there are some
agreements now that are being put in place by the VA to at
least provide some alternative sources of care in that interim.
Unfortunately, some of those agreements didn't even occur for 4
years, and so this bill is just focused on making sure that the
veterans are taking care of and can still get care without
being shuttled around to other States in some cases, but not at
the detriment of any other hospitals within the VISN. But
clearly our commitment to making sure the rebuilding occurs is
still strong. But in the meantime, we just want to make sure
our veterans have somewhere to go to get that basic care and I
will continue to work with you.
Mr. Boozman. I agree with you totally. I guess, the problem
is, is not only are you impacted in the New Orleans area by not
having that facility, but your veterans' care throughout the
entire State is impacted because instead of the money coming
from the Central Office, it comes from all of our resources in
the VISN, so it is kind of a two-edged sword. Not only are
veterans impacted but your veterans in the rest of Louisiana
and then Arkansas, the rest of the VISN, they are also impacted
because instead of the money coming, like I say, from the
Central Office, it is coming from the VISN, which is unfair. I
mean, this is----
Mr. Scalise. Right.
Mr. Boozman [continuing]. This is not a VISN problem. This
is a total----
Mr. Scalise. It is a national problem.
Mr. Boozman. It is a national VA problem, so, but we
appreciate your leadership very, very much.
Mr. Scalise. Thank you.
Mr. Boozman. Thank you. I yield back.
Mr. Michaud. Thank you very much, Mr. Boozman, and the
Veterans Equitable Resource Allocation model is another big
issue that we have been trying to get a handle on and we will
continue to look forward to seeing what we can do to improve on
that model to make sure that areas, especially rural areas, are
not hampered in that effort, so thank you. Thank you very much.
Mr. Buchanan, do you have any questions for the panel
before we dismiss them?
Mr. Buchanan. No.
Mr. Michaud. Once again, I would like to thank the panel
for coming today and for bringing forward your legislation. I
look forward to working with each of you as we move forward
later on this year. So once again, thank you very much. And
thank you for your dedication in making sure that veterans get
the help that they need. Thank you.
I would ask the second panel to come forward, please. On
the second panel we have Denise Williams from the American
Legion, Blake C. Ortner from the Paralyzed Veterans of America,
Eric Hilleman from the VFW, and Joy J. Ilem from the Disabled
American Veterans. I want to thank all of you for coming here
this morning. I look forward to your testimony and we will
start with Ms. Williams.
STATEMENTS OF DENISE A. WILLIAMS, ASSISTANT DIRECTOR, VETERANS
AFFAIRS AND REHABILITATION COMMISSION, AMERICAN LEGION; BLAKE
C. ORTNER, SENIOR ASSOCIATE LEGISLATIVE DIRECTOR, PARALYZED
VETERANS OF AMERICA; ERIC A. HILLEMAN, DIRECTOR, NATIONAL
LEGISLATIVE SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED
STATES; AND JOY J. ILEM, DEPUTY NATIONAL LEGISLATIVE DIRECTOR,
DISABLED AMERICAN VETERANS
STATEMENT OF DENISE A. WILLIAMS
Ms. Williams. Mr. Chairman and Members of the Subcommittee,
thank you for the opportunity to present the American Legion's
views on the several pieces of legislation being considered by
the Subcommittee.
I will give oral comments on three pieces of legislation in
the interest of time. H.R. 1075, timely and open access of
quality care for veterans is a major priority for the American
Legion and this legislation is consistent with our efforts in
this regard.
The American Legion does, however, have some concerns.
Although such contracts would certainly be helpful during a
disaster in which VA medical facilities are not available, we
do not want such an arrangement to become a disincentive for VA
to quickly repair or replace damaged facilities. This bill also
does not address length of the contracted care, long-term care
or how quality of care would be assessed.
H.R. 3926, the ``Armed Forces Breast Cancer Research Act.''
The American Legion fully supports this timely and important
legislation given the recent breast cancer incidents among male
veterans that were stationed at Camp Lejeune. Moreover,
according to the Clinical Breast Care Project at Walter Reed
Army Medical Center, there have been over 2,000 cases of breast
cancer diagnosed in both males and female active-duty
servicemembers within the last decade.
The Center further stated that breast cancer is the single
greatest cause of cancer death among women under 40 and is a
significant cause of mortality for women in the Armed Forces.
The American Legion would also encourage inclusion of the
Reserve component in this study.
Proposed legislation to amend title 38 concerning mental
health counselors.
The American Legion believes VA should be staffed with the
best qualified professionals to ensure this Nation's veterans
receive timely access to quality health care, especially mental
health services. With servicemembers returning from Iraq and
Afghanistan with complex and overlapping illnesses and
injuries, it is imperative VA maintains its charge to ensure
its medical professionals are properly trained and fully
qualified to provide quality care. According to the National
Institutes of Health, injuries and illnesses such as mild
traumatic brain injury (TBI) and post-traumatic stress disorder
respectively, have several symptoms in common. Among these are
irritability, concentration deficits, amnesia for the causal
event, reduced cognitive processing ability and sleeping
disturbances.
Clearly, this situation adds to the difficulty in
diagnosing PTSD in patients with TBI. The American Legion
contends that due to the complexity of these illnesses and
injuries, such as TBI and PTSD, the most qualified mental
health professionals are required. Therefore, the American
Legion is opposed to waiving current requirements relating to
mental health counselors.
Mr. Chairman, once again, the American Legion appreciates
the opportunity to address these issues and looks forward to
working with your colleagues and the staff in advancing
legislation that will make a positive difference in the lives
of our servicemembers, veterans and families. This concludes my
written statement and I welcome any questions that you or your
colleagues may have concerning the American Legion's views,
comments and recommendations.
[The prepared statement of Ms. Williams appears on p. 39.]
Mr. Michaud. Thank you very much, Ms. Williams.
Mr. Ortner.
STATEMENT OF BLAKE C. ORTNER
Mr. Ortner. Mr. Chairman, Ranking Member Brown and Members
of the Subcommittee, on behalf of Paralyzed Veterans of
America, I would like to thank you for this opportunity to
present PVA's position on the legislation before the
Subcommittee.
PVA generally supports most of the bills presented here
today. In the interest of time, I will highlight details only
for legislation with which we have specific issues.
PVA cannot support H.R. 84, the ``Veterans Timely Access to
Health Care Act,'' which would establish standards of access to
care within the VA health system. PVA has testified on similar
legislation in the past and is still unable to support it.
Under the provisions of this legislation, VA will be
required to provide a primary care appointment to veterans
seeking health care within 30 days of a request for an
appointment. If a VA facility is unable to meet the 30-day
standard, then the VA must make an appointment with a non-VA
provider, thereby contracting out the health care service.
While access is indeed a critical concern of PVA, the
number of veterans enrolled in the VA is continuing to
increase. Unfortunately, funding for VA health care in the past
has had difficulty keeping pace with the growing demand. Even
with the passage of Advance Appropriations and the record
budgets in recent years, funding is not guaranteed to be
sustained at those levels. PVA is concerned that contracting
health care services to private facilities when access
standards are not met is not an appropriate enforcement
mechanism for ensuring access to care. In fact, it may actually
serve as a disincentive to achieve timely access for veterans
seeking care.
PVA is also concerned about the continuity of care. If
veterans are shifted between the VA and non-VA facilities each
time the imposed standard is not met, how will this affect the
quality of care these veterans receive? This is neither an
effective nor efficient way to supply health care and in the
long run may be detrimental to the veteran. For these reasons,
PVA cannot support H.R. 84.
PVA supports H.R. 949 introduced by Chairman Filner that
will more quickly resolve adverse actions and set deadlines for
final decisions and strongly supports H.R. 1075, the ``RECOVER
Act.''
During periods of major disasters, ensuring veterans have
uninterrupted access to health care is critical to their well-
being. PVA would only caution that this arrangement should not
inadvertently lead to delays in repairing or replacing VA
facilities damaged during the disaster. More critically, this
contracting authority should not become the default health care
policy for meeting the needs of veterans in a disaster area.
PVA supports H.R. 2698, the ``Veterans and Survivors
Behavioral Health Awareness Act,'' and H.R. 2699, the ``Armed
Forces Behavioral Health Awareness Act.''
While the scholarship provisions in the legislation are not
targeted or reserved for veterans, PVA would encourage VA to
market the scholarships to veterans who will best be able to
relate to veterans visiting the Vet Centers or other
facilities.
PVA supports H.R. 2879, the ``Rural Veterans Health Care
Improvement Act of 2009,'' and H.R. 4006, the ``Rural, American
Indian Veterans Health Care Improvement Act of 2009.''
PVA recognizes that there is no easy solution to meeting
the needs of veterans who live in rural areas and that Native
Americans often face even tougher challenges. These rural
veterans were not originally the target population of men and
women that the VA expected to treat. However, the VA decision
to expand to an outpatient network through community-based
outpatient clinics reflected the growing demand on the VA
system from veterans outside typical urban or suburban
settings.
However, while these paths may show promise, they should
still fit within the policies that promote the use of VA
facilities and should not be used as a method to eliminate VA
facilities in rural areas. While all of these ideas are
welcome, the greatest need still is for qualified health care
providers to be located in rural settings. Only significant
incentives and opportunities for these professionals will bring
them to these often remote areas.
PVA strongly support H.R. 3926, the ``Armed Forces Breast
Cancer Research Act.'' With the growing number of women that
comprise members of the Armed Forces and their increasing
involvement in forward operating areas and combat activities,
it only makes sense to examine the potential increased risk of
breast cancer among this population.
Regarding the draft legislation before us today, PVA
supports the legislation to raise the reimbursement rate for
health professionals from $1,000 to $1,600 and cautiously
supports the legislation to waive certain requirements relating
to mental health counselors, but want to ensure that this is
done only in the circumstances that will benefit veterans and
VA health care.
Regarding collective bargaining, PVA generally supports the
provisions of the draft legislation that would improve the
collective bargaining rights and procedures for certain health
care professionals in the VA.
VA must work with their employees to achieve a less hostile
work relationship, but any changes or modifications to either
side of the issue must first address the care of veterans.
Furthermore, this care should not be used as a rallying cry on
either side as an argument for their position. Veterans deserve
better.
PVA appreciates the opportunity to comment on these bills
being considered and I would be happy to answer any questions
that you may have. Thank you very much.
[The prepared statement of Mr. Ortner appears on p. 41.]
Mr. Michaud. Thank you very much.
Mr. Hilleman.
STATEMENT OF ERIC A. HILLEMAN
Mr. Hilleman. Thank you, Chairman Michaud, Ranking Member
Brown, Members of the Subcommittee.
On behalf of the 2.1 million men and women of the Veterans
of Foreign Wars and our auxiliaries, I thank you for the
opportunity to testify before you today on the bills pending
before the Subcommittee.
The VFW supports the draft bill for continuing education at
Veterans Health Administration (VHA), of VHA staff. We also
support the draft bill to improve performance pay and
bargaining rights.
The VFW further supports H.R. 2698, the ``Veterans and
Survivors Behavioral Health Awareness Act,'' and H.R. 2699, the
``Armed Forces Behavioral Health Awareness Act.''
Further, VFW supports H.R. 2879, the ``Rural Veterans
Health Care Improvement Act of 2009,'' and we strongly support
H.R. 3926, the ``Armed Forces Breast Cancer Research Act,'' and
we support H.R. 4006, the ``Rural, American Indian Veterans
Health Care Improvement Act of 2009.''
If I may, Mr. Chairman, I would like to speak exclusively
to our support for one piece of legislation that is of
particular importance to the overall preparedness of the VA
hospital network, H.R. 1075. This bill would require the VA
Secretary to seek outside contacts in the event a VA hospital
is closed for greater than 180 days due to a national disaster.
Currently, when VA hospitals are closed, veterans must travel
long distances to other VA facilities, which may be impractical
or impossible following a disaster. This bill ensures that the
VA secures alterative arrangements for local medical care to
include non-emergency care and inpatient services.
The VFW supports this legislation. However, we feel 180
days is far too long for a veteran to wait for medical
services. We urge the Veterans' Affairs Committee to hold
hearings elevating VA's current disaster contracting
provisions. Allowing a veteran to wait 180 days for medical
care is unacceptable. Contracts to provide health care must be
in place before a VA hospital shutters its doors due to a
national disaster. The VFW believes that plans need to be
implemented immediately in the event of disasters.
Now, moving on to H.R. 84, the ``Veterans Timely Access to
Health Care Act.'' The VFW supports the intent of this
legislation, Veterans Timely Access to Health Care Act.
However, we cannot support this bill.
This legislation would require the Secretary to contract
for care for any veteran who would wait more than 30 days for
primary care. The VFW has supported guaranteed access standards
for VA health care for a number of years, but we remain
concerned about the quality and the cost of care.
With the advent of advanced appropriations, VA now has the
capacity to ensure the ability to properly plan and manage
these dollars. Additionally, on-time funding should allow VA to
recruit, train and hire doctors, nurses and other health care
providers, ensuring that VA is sufficiently staffed to keep up
with demand. Congress has made great strides in improving the
stream of veterans' health care for which the VFW applauds your
efforts, but a greater attention is needed to ensure health
care dollars are spent appropriately in each medical facility.
We strongly support the reporting requirements in H.R. 84.
The reporting mechanisms on wait times would help gain a better
accurate measure by which to analyze wait times and access to
care. Better numbers would allow us to understand the problems
and prevent them in the future.
Moving on to H.R. 949, the VFW has no position on this
legislation.
Finally, Draft Bill Waiving Requirements for Mental Health
Counselors. The VFW opposes this legislation to allow the
Secretary to waive licensure or certification requirements. The
VA may be facing shortages of mental health professionals, but
we believe making exceptions in lieu of valid State-issued
certifications undermines the quality of care and the
confidence that veterans have in speaking with VA mental health
professionals.
State licensure and certification demonstrates that an
individual meets the State requirements in which areas of
prerequisite education and knowledge and is culpable under the
law for any malpractice or abuse of the unique trust placed in
that specific position.
Thank you for the opportunity to testify today, Mr.
Chairman and we welcome any questions.
[The prepared statement of Mr. Hilleman appears on p. 44.]
Mr. Michaud. Thank you.
Ms. Ilem.
STATEMENT OF JOY J. ILEM
Ms. Ilem. Thank you, Mr. Chairman and Members of the
Subcommittee.
DAV also appreciates the opportunity to offer our views on
the bills under consideration today.
The stated goal of H.R. 84 is to provide timely access to
VA health care. Under this bill, if VA failed to substantially
comply with the 30-day standard, the facilities in that area
would be required to contract for care.
DAV has always had concerns about automatic contracting of
VA care to solely meet access standards. Those patients lose
the quality, safety and other protections VA provides in its
specialized medical programs. Additionally, we have stressed
the need for VA to develop a comprehensive and systemwide
process for contract care to ensure the quality of care of
veterans seen by contractors is on par with that provided to
veterans using VA.
While DAV does not support the automatic contract for care
mechanism in this measure, we would endorse an amendment to
H.R. 84 to enact data and reporting requirements of the bill.
We also recommend adding provisions to identify the underlying
causes for any current delays in access to VA care, an issue
that is critical to VA's developing an effective solution to
reducing and managing minimum waiting times.
H.R. 949 seeks to restore bargaining rights for certain VA
health professionals. As a partner organization in The
Independent Budget, DAV endorses the need for VA to address
employee's concerns about their working conditions to make VA a
better workplace for the best care of sick and disabled
veterans. For these reasons, we support the intent of the bill,
but continue to urge both VA and Federal unions to seek and
find a basis for compromise on these issues.
I was pleased to see in VA's testimony this morning that a
workgroup has been established to address the specific issues
included in the bill. This appears to be a positive step
forward and we are hopeful this process will lead to an
agreement that is acceptable to both sides and one that keeps
the focus squarely on the best interest of veterans' care.
H.R. 1075 requires that in the event of an officially
declared disaster where a VA medical center is unable to
provide inpatient care services for at least 180 days, VA must
contract with one or more non-VA facilities in that area to
provide those services.
This Subcommittee is aware of DAV's general cautionary
position on contract care. However in the case of a significant
disaster with long-term consequences in the affected area, VA
should establish more temporary contracts with private
facilities outside the affected city area for inpatient
services. For this reason DAV supports the purposes of this
bill as a contingency only and we recommend the issues related
to improve contract care coordination be addressed before the
bill advances.
H.R. 2698 aims to improve and enhance mental health care
benefits available to all veterans, as well as to enhance
counseling to survivors of veterans. In the fiscal year 2010
Independent Budget section on human resource challenges, we
recommend that Congress, and VA work to strengthen and energize
its human resource management programs to recruit, train and
retain qualified employees. Therefore, we support enactment of
section 2 of the bill pertaining to health professional
scholarships. We have no objection to the remaining provisions
in the measure.
H.R. 2699 would make certain active servicemembers eligible
for readjustment counseling in VA Vet Centers and enhance
counseling available to their family members. We support a
seamless transition for servicemembers to veteran status and
improved collaboration between the two Departments. Therefore,
we have no objection to this bill.
However, we ask the Subcommittee to consider amending
section 2 of the measure to require cost sharing with DoD or to
authorize additional VA resources needed to provide these
services to active duty personnel.
H.R. 2879 with some concern outlined in our full statement,
we support enactment of this bill in accordance with DAV's
resolutions related to VA's beneficiary travel reimbursement
policy and improving rural care services and access.
H.R. 3926 would direct the secretaries of DoD and VA to
jointly conduct a study on the incidents of breast cancer among
members of the Armed Forces and veterans. We support the
passage of this bill in accordance with DAV resolution 252
which urges greater collaboration between DoD and VA to share
exposure and related data for military operations in order to
address the subsequent health concerns of disabled veterans,
whatever the causes.
DAV also supports H.R. 4006, the ``Rural, American Indian
Veterans Health Care Improvement Act of 2009.'' Studies
indicate this population reports high rates of unmet need,
fragmentation of care and an overall lack of health care
coordination.
The intent of this bill appears beneficial to help resolve
the unique health care issues of this population. The DAV has
no adopted resolutions specific to the final three draft
measures under consideration, but offer no objections to these
draft bills.
Mr. Chairman, that concludes my statement. I am happy to
answer any questions.
[The prepared statement of Ms. Ilem appears on p. 47.]
Mr. Michaud. Thank you very much for your testimony, as
well as the other three panelists.
I guess I have just one question. You spoke about VA
working more collaboratively with DoD to study breast cancer.
It is my understanding that the VA currently has nine ongoing
studies on breast cancer and I believe they have already
completed three studies.
Do you agree with the VA that they have to conduct broader
studies rather than studying breast cancer in the way that is
in the legislation? We will start with Ms. Williams.
Ms. Williams. I think there needs to be definitely more
study, especially with the servicemembers on active duty that
are returning. I am not exactly sure about the studies that are
ongoing in VA regarding--maybe my fellow VSO members are aware
of that. But we would support the DoD conducting studies
because of the data that we received from Walter Reed regarding
the breast cancer incidents.
Mr. Michaud. I don't know if any other----
Mr. Ortner. Mr. Chairman, I think that the need for
expansive studies, especially in the case of breast cancer is
critical. I am not so sure, necessarily looking and saying,
well, there are nine studies ongoing, therefore, enough is
being done simply because of the wide variety of studies that
can be done, specific instances of studies. For instance, there
may be a number of studies facing just women with breast cancer
and not the incidence of men because that is an unusual or
becoming for usual, but an unusual case, so I still think there
is need for that legislation.
Mr. Hilleman. Mr. Chairman, our remarks would concur with
both previous statements. I am not personally familiar with the
number of studies or the studies' details, but this study being
both broad and including DoD and VA seems like a logical thing
to pursue.
Ms. Ilem. I would ask if any of those studies include the
data information that is in the bill you are considering with
regard to toxic environmental exposures and troop locations in
those areas or if it is just breast cancer incidents within the
veteran community because I think that would be critical. I
mean, we hear more and more about burn pits and these other
possibly toxic exposures that veterans are facing returning.
And so it would be proper to, I think include that.
With your reference to VA making this broader and not just
specific to one disease, it is noted in their testimony. I
think, you know, we would like to see, surely VA tracking any
sort of trends that should occur within the veteran population
that may be related to these toxic exposures and the different
environments that veterans are facing in these deployments. So
that takes the greater collaboration of both agencies to be
able to do that to avoid what happened in the Gulf War with
regard to, you know, ongoing studies and the concern over
health, subsequent health concerns. Thank you.
Mr. Michaud. Thank you. Mr. Boozman.
Mr. Boozman. Thank you, Mr. Chairman. First of all, I want
to thank you all. We have had a number of Members offer
suggestions as to how we can improve the VA situation, and as
always, your all's testimony in perspective is such that what
we all work toward is preventing unintended consequences of
good ideas.
But H.R. 84, trying to deal with a problem that we have
been dealing with forever, the lengthy waiting times. I guess
my question for the panel would be, we all know this is a
problem. Is there a way, do you feel like we could amend H.R.
84 in some way to make it such that waiting times are more
appropriate? I know that some of you have expressed concern
about the particular bill.
What could we do in your mind to go ahead and make it such
that we could whittle these times down even further?
Ms. Ilem. I will take a stab at that. I think Ms. Brown-
Waite made some very important points in her remarks this
morning. Obviously, she is very committed to trying to address
this problem and resolve it. One thing that I think we would
probably like to see would be to make sure that we get accurate
waiting time information from VA, which has been addressed and
she mentioned the Inspector General's report and their
recommendations so that we really have an accurate view across
the system, as well as where are there specific target areas
that really are having some access issues.
Additionally, I think we would want to have provisions in
that bill that really get at what, you know, what are the real
problems for this. We just don't see the benefit of sending
people outside the system that may be more costly care. VA can
do it in emergencies or if medically necessary and they can't
get someone seen in a timely manner. They already have that
authority and we would like to see VA take care of those
patients so they have all the benefits of the system and find
out where these waiting time issues are and if that needs to be
addressed in terms of the advanced appropriation, better
planning and that type of outcome versus just for having them
go outside the system.
Mr. Hilleman. If I might, Mr. Boozman, from a personal
experience, it seems that hospitals develop solutions for
bottlenecks in care. I seek treatment here in Washington, DC,
and I have experienced after hours of appointments for MRIs and
other bottlenecks within the system where appointments can't be
made in within 30 days, but I have also had the adverse
experience that in a 30-day referral, I couldn't get an
appointment.
There are some creative solutions that can happen locally,
but I feel, and I would think that most of the organizations
would have a similar approach that we can't solve problems
unless we understand them first.
So a comprehensive study would be something the VFW would
definitely support.
Mr. Ortner. Sir, like all the comments of my colleagues,
unfortunately when we look at this, we think the idea of
setting the 30-day standard and then sending someone off to
contract care is too simple an answer. It seems like the easy
answer and a simple way to do it.
Our greatest concern has to do with a second and third
order of facts of what that leads to. Does that then become the
standard answer, hey, if we get backed up, we are going to go
ahead and contract it out. But more importantly, I think,
especially from PVA's standpoint, the concern about the
continuity of care for our members. I know, personally, I don't
like going to a different doctor. I go to my doctor. I drive a
long distance to get my doctor because of that.
My concern would be if we do have, if we do have this
ability to contract it out, unless you are all of the sudden
going to decide that individual is now going to be contracted
to a different provider indefinitely, he is going to be jumped
back and forth between the system and we think that is just too
much of a risk to the veteran.
Ms. Williams. The American Legion, we did state that we
support this bill and that is because when we look at the
overall legislation, we felt like this would give VA an
opportunity to have a comprehensive view of the issue with
timely access to care.
So if it is enacted, our major concern is with timely
access to care. So if they do enact it, we would like for VA to
utilize this as a means to examine the long wait time for
veterans to receive care.
Mr. Boozman. Thank you. The other thing--can I do--I guess
I worry a little bit also, yeah. I alluded to this with the
situation that we have in New Orleans where the VISN becomes
responsible rather than district-wide, so you might have a VISN
where, and you correct me if I am wrong, but you might have a
VISN where you have a problem and you don't who knows why that
problem is, and then you might have a very efficient group
within that VISN, too.
But theoretically, the entire VISN would pay for that
contracted care. Is that correct? I mean--is that, would that
be correct back there? It wouldn't? So it would come out of the
system versus the VISN? Okay, good. Very good.
Thank you guys, again. I really do appreciate your
perspective on these things. Thank you.
Mr. Michaud. Mr. Perriello or Mr. Brown.
Once again, I would like to thank you for your testimony
today and I look forward to working with you as we move forward
with these individual bills. Thank you.
I would ask the third and final panel to come forward, Dr.
Cross, who is accompanied by Mr. Hall, Mr. McVeigh and Ms.
Vandenberg from the VA.
Once again, I would like to thank you, Dr. Cross, for all
the hard work you and the other panelists do to make sure that
our veterans get the help that they are entitled to and deserve
and your dedication to our veterans is to be commended. So,
without any further ado, Dr. Cross.
STATEMENT OF GERALD M. CROSS, M.D., FAAFP, DEPUTY CHIEF FOR
PATIENT CARE SERVICES AND CHIEF CONSULTANT FOR PRIMARY CARE,
VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS
AFFAIRS; ACCOMPANIED BY WALTER A. HALL, ASSISTANT GENERAL
COUNSEL, OFFICE OF GENERAL COUNSEL, U.S. DEPARTMENT OF VETERANS
AFFAIRS; BRIAN MCVEIGH, CHIEF CONSULTANT, HUMAN RESOURCES
MANAGEMENT, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF
VETERANS AFFAIRS; AND PATRICIA VANDENBERG, MHA, BS, ASSISTANT
DEPUTY UNDER SECRETARY FOR HEALTH FOR POLICY AND PLANNING,
VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS
AFFAIRS
Dr. Cross. And thank you, Mr. Chairman and the Committee
for the great work that you do and your dedication as well.
Good morning, Mr. Chairman and Members of the Subcommittee.
It is a pleasure to appear before you again today to discuss
legislation. I am accompanied by Walt Hall, Assistant General
Counsel; Brian McVeigh, Chief Consultant, Human Resources
Management; and Patricia Vandenberg, Assistant Deputy Under
Secretary for Health for Policy and Planning.
I would like to concentrate my remarks today on the three
areas covered by this legislation, first, VA's human resource
policies, including work with our union colleagues. Second, our
efforts to improve care for rural veterans, and finally, our
work to improve counseling and mental health access.
We appreciate the many positive contributions, collective
bargaining and labor management partnership make to VA's
mission. VA and its labor partners signed a charter in
September of 2009 to develop recommendations for the Secretary
to improve knowledge, understanding and consistent use of the
authorities and limitations in section 7422 of title 38.
The workgroup consists of representatives from VA's five
national unions and VA's lead representative is the new
Assistant Secretary for Human Resources in Administration. We
anticipate this workgroup will resolve the concerns that are
the basis of H.R. 949. However, we strongly oppose H.R. 949. It
would make patient care and clinical competency decisions
subject to the review of non-clinical third parties, parties
without health care expertise.
We believe that the collaborative efforts of VA and its
union partners in the workgroup can address the concerns about
the interpretation and application of section 7422. Until such
time as those efforts have been given an opportunity, we
believe that legislative changes to section 7422 are premature.
VA also does not support the draft bill that would require
VA to reimburse all title 38 health professionals for up to
$1,600 per year for their continuing medical education
requirements. The bill would, of course, be costly, diverting
resources from the veterans health care and we believe is
unnecessary. VA has no objection to the draft bill that would
create an exception to allow VA to employ mental health
counselors who have not yet completed their licensure or
certification requirements.
We know that VA currently has a parallel statutory
authority to appoint psychologists and clinical social workers
who work under supervision for up to 2 years before they have
completed their licensure or certification.
Regarding our efforts to improve care and access for rural
veterans, VA has initiated a number of programs that meet the
intent of H.R. 2879 and H.R. 4006. We have established three
Veterans Rural Resource Centers and a Veterans Rural Health
Advisory Committee to improve care and services for veterans
residing in geographically isolated areas. The centers are
operational and are conducting important work, which my written
statement describes in greater detail.
VA also is developing pilot programs to implement
innovative transportation services at various rural health care
facilities and is supporting cooperation and resource sharing
between the Indian Health Service and VA. Moreover, we are
undertaking pilot programs at the direction of Congress in
section 107 and 403 to Public Law 110-387, which will provide
millions of dollars to support expanded fee-basis care in rural
areas.
VA believes it is more appropriate to evaluate the results
of this pilot projects before beginning new initiatives so that
we can ensure resources are best used to serve veterans.
Furthermore, VA's enhancing assistance for family members.
The Vet Center Program, for example, is taking steps to enhance
access for veterans' families by hiring the additional staff
necessary to place qualified family counselors in every Vet
Center. And when it is necessary for their rehabilitation and
treatment of the veteran, VA provides education and training
prior to the veteran's discharge from care to ensure that
family members can tend capably to the veteran's health care
needs.
The final area I would like to discuss includes our efforts
to improve our counseling and mental health programs.
Specifically, VA supports section 3 of H.R. 2698, which would
direct VA to provide referrals, to assist individuals not
otherwise eligible for VA services in obtaining mental health
care and services outside VA.
In advising such individuals of their rights to apply for
review of their discharge or release, this would specifically
help former servicemembers with problematic discharges.
VA appreciates the concept of using scholarships to enhance
succession planning, but section 2 of H.R. 2698 is unnecessary.
Implementation of this provision would result in substantial
costs to VA over a long period of time with very little short-
term benefit. It takes 2 to 7 years of education to qualify to
become a VA behavioral health specialist. VA recommends
reauthorization of the Health Profession Education Assistance
Scholarship Program instead, as this program would be more
effective and include more disciplines. Moreover, VA has had
great success in hiring new counselors. In the past 3 years, VA
has hired more than 5,800 additional mental health counselors.
This concludes my prepared statement, Mr. Chairman. We
would be, of course, pleased to respond to any questions that
you have.
[The prepared statement of Dr. Cross appears on p. 57.]
Mr. Michaud. Thank you very much, Dr. Cross. I appreciate
your testimony.
What is your understanding of the current status of the
Indian Health Service's electronic health care records, their
capacity? Is it the same capacity as in the VA system?
Dr. Cross. My understanding is that we are going for the
broader solution, working with something called National Health
Information Network (NHIN), which is our strategy to move
forward, not just within VA and IHS or VA and DoD, but more
broadly with our community partners as well. This is more of a
national strategy going far beyond what we have looked at in
the past. I think that we have testified on that to some degree
before, but I think the strategy to engage with them is really
part of that broader strategy.
Mr. Michaud. Thank you. And what about with breast cancer?
We heard some discussion about working with DoD and I know that
there are nine ongoing VA studies and I think you have
completed three. How comprehensive are those studies?
Dr. Cross. First of all, we understand the importance and
the sensitivity of this subject. We are absolutely committed to
getting every bit of research done that would be beneficial to
our veterans. And by the way, the research that we do helps not
only our veterans but the Nation at large.
We do have about nine studies underway, working through
some remarkable issues that will, I think, produce dramatic
outcomes, I hope, down in years to come where, particularly
regarding the DNA component of this, genes and so forth, that
we are working on.
My understanding is that we have done some studies in the
past on prevalence and I would be happy, you know, if the
Committee prefers, to provide those for the record. But I don't
want anything that I say to show any lack of concern or lack of
intent to pursue this issue. We are very much committed to try
and help be part of the solution for this problem.
Mr. Michaud. And I appreciate it. I think sometimes Members
of Congress and VSOs might not know all the work that the VA is
doing in these different areas, so I would be interested. If
you would submit that to the Committee, I would appreciate it
very much.
[The VA subsequently provided the following White Paper
regarding studies done in the past by VA's Office of Research
and Development (ORD) on breast cancer.]
Short Descriptions of ORD Breast Cancer Studies
Cell-Cell Interactions During Breast Tumor Angiogenesis: Role of NRP-1
Metastatic or spreading breast cancer requires a pathway to allow
escape of the breast cancer cells from the breast into the general
circulation and then potentially to all tissues. This proposal will
delineate the mechanism whereby proteins made by the breast cancer
effect changes in the vascular smooth muscle that allow the cancerous
cells to escape from the breast. Understanding how these proteins
effect changes in the blood vessels surrounding the cancer will provide
potential targets for various therapy modalities, such as chemotherapy
or using the immune system to block the action of these proteins.
The Roles of WISP-2/CCN5 Signaling in Breast Cancer Development
This project will use non-invasive human breast cancer cells to
identify the mechanism that leads to inhibition of apoptosis or
programmed cell death. Once the components of the mechanism are
identified then it will be possible to identify inhibitors of one of
these components so that apoptosis or regulated cell death in the
cancerous cells would be stimulated and thereby reducing the number or
possibly even eliminating the cancerous cells.
The Role of CCN5 in Breast Cancer Progression
Breast cancer cells transition from non-invasive (non-metastatic)
cells into invasive or metastatic cells. A key element of the
transition, which requires estrogen, will be further characterized in
the hopes of developing another target for various therapeutic
approaches.
Estrogen Receptor Regulates c-Jun Activity in Breast Cancer Cells
Estrogen receptor is known to play a significant role in the
development of breast cancer. The investigator has identified a
protein, phosphorylated (the addition of a PO4 moiety from Adenosine
triphosphate (ATP), the molecule generated from the breakdown of
nutrients) c-jun, that becomes blocked from its normal action when
estrogen receptor has been activated. When c-jun action is blocked, the
cancerous cells multiply instead of dying (apoptosis), which results in
the growth of the cancer. This study will determine the mechanism to
unblock this protein, which would allow cancerous breast cells to
undergo apoptosis or death instead of being stimulated to grow.
Estrogen Receptor, p38 MAPKs and Topo IIa in Breast Cancer
There are various receptors on the outer membrane of breast cancer
cells that are activated when they bind a receptor-specific activator
or ligand. Many of the receptors in breast cancer cells are tyrosine
kinases or enzymes that are responsible for phosphorylating (putting
the terminal phosphate (PO4) from ATP onto a protein) specific
tyrosines (an amino acid) in other proteins. These tyrosine
phosphorylated proteins then mediate the transformation of a normal
breast cell into a cancerous breast cell. There have been several
clinically useful therapies based on inhibiting these receptors.
However, as time passes the receptor is no longer inhibited by these
treatments. This leads to renewed growth of the cancer. This proposal
will test the idea that another receptor protein kinase can make the
breast cancer cells more sensitive to the chemo/immuno-therapetic
agents, which would restore their ability to inhibit the growth and
spread of the cancerous cells.
STATs as Key Targets in Tumor Angiogenesis
Growth and progression of breast cancer depends on the formation of
new blood vessels (angiogenesis) to bring the blood nutrients and
oxygen to the cancer. Cancer cells secrete several growth factors that
recruit blood vessels from the surrounding tissue. Therefore, it is
plausible that targeting blood vessel growth could be an effective
cancer treatment approach. Recent clinical trials have shown that drugs
designed to inhibit a vessel-inducing factor slow down tumor growth and
prolong survival; unfortunately, blood vessels growth eventually resume
that leads to resumed growth of the cancer. This proposal will focus on
identifying inhibitors of several growth factors with the intent of
using multiple inhibitors at one time to inhibit angiogenesis to the
point that the tumor either dies or becomes much smaller because there
is a lack of nutrients and oxygen needed for breast cancer to grow.
Targeting the COX-2 Pathway to Reduce Breast Cancer Mortality
Cyclooxgenase 2 enzyme, commonly known as COX-2, is highly enriched
in breast cancers and treatment this COX-2 inhibitors limit breast
cancer growth and metastasis or spreading to other tissues. However,
COX-2 inhibitors have recently been shown to have cardiac toxicities,
which limit their use in patients with breast cancer. One of the major
compounds generated by COX-2 is prostaglandin. Prostaglandin is a major
regulatory agent and it mediates many physiological processes such as
blood clotting. Prostaglandin mediates its numerous physiological
effects through interacting with prostaglandin receptors. This proposal
will identify which of these receptors activates breast cancer growth.
Once identified, the next step will be to find inhibitors of this
receptor, which should reduce the growth of breast cancer.
Targeting Breast Cancer Metastases: Role of Chemokine Heparanase
The principal goal of this study is to investigate a possible genetic
influence on the development of secondary lymphedema (LE) in breast
cancer survivors. Lymphedema or swelling of the lymph nodes and
lymphatic vessels in breast cancer survivors leads to swollen arms,
discomfort and skin infections. This occurs because mastectomies can
remove the normal pathway for the lymph generate in the arm to return
to the general circulation. The question is of great importance, for if
a genetic predisposition to secondary LE can be identified, therapy may
be better tailored for patients or they can be made more aware of
possible complications. Improved care of breast cancer survivors is of
great significance.
Quality of Locoregional Breast Cancer Treatment for Breast Cancer in
VHA
The immediate objectives of this multi-year retrospective study are:
1) To determine if the quality of surgical care provided for women with
locoregional breast cancer in the VA is comparable to that provided in
the private sector; 2) To identify factors within the VA system that
are associated with quality of care (process and outcome measures) for
locoregional breast cancer; and 3) To provide policy recommendations
regarding how to improve the quality of treatment based on the results
of this analysis. Ultimately, our long-term goal is to improve patient
outcomes for women veterans with breast cancer.
Regulation of Breast Cancer Growth by MLK-3
A protein kinase (MLK3), an enzyme that phosphorylates another
protein, has been discovered to be highly active in breast tumors and
is involved in the activation of another protein (Pin1), which has
previously been implicated in breast cancer pathogenesis. The project
will investigate the mechanism by which MLK3 regulates Pin1, and will
examine the application of MLK inhibitors as potential therapeutic
approach for breast cancer treatment.
CARP-1: A Potential Therapeutic Agent for Breast Cancer
This study will further characterize how the cell cycle and apoptosis
regulatory protein 1 (CARP-1) inhibits transformation of normal to
cancerous breast cells. Elucidation of the mechanism of action of CARP-
1 will provide specific targets to be used in the design of
chemotherapeutic agents. These agents will provide additional means to
limit the growth of breast tumors.
Actively Targeted Nanoparticulate Paclitaxel to Treat Breast Cancer
The proposed studies will develop nanoparticles containing
Paclitaxel, a breast cancer chemotherapeutic agent. These nanoparticles
will be specifically designed to enter only breast cancer cell. This
will allow the delivery of higher doses of Paclitaxel without having
harmful effects on normal cells throughout the body. Furthermore, this
specificity will allow for much longer treatment times, which greatly
increases the likelihood arresting the further growth of the cancer and
maybe even killing all of the cancerous cells.
Identification of Breast Cancer Genes in Archival Pathology Specimens
Normal breast epithelial growth and differentiation, benign
proliferative growth and breast cancer are each under the complex
control of various growth factor genes. This study will systematically
investigate inherited genetic variation within these genes for their
contribution to breast cancer risk among women with a history of benign
breast disease. The combined genetic and pathological predictors of
elevated breast cancer risk identified in this study will enable the
identification of those women who would most benefit from more
intensive screening, those who may be at increased risk associated with
hormone replacement therapy or those who may benefit from prophylactic
therapeutic agents to alter the function of the estrogen receptor.
Mr. Michaud. You heard earlier testimony about what happens
when a disaster strikes. Could you tell us exactly what happens
when a disaster hits? How does that region get funding, if need
be, from the Central Office to deal with it then and how do you
cope with the disaster and how do you help veterans get care,
if they do lose a hospital? How quickly can you gear up to take
care of those needs?
Dr. Cross. We don't have today, as a Department, formal
comments on H.R. 1075, but I can certainly comment on what
happened during Katrina and how we respond to that and those
two elements that you talked about.
First of all, in regard to funding, certainly we first look
to the VISN for their support when we have hurricanes and so
forth, but if there's a large disaster such as a Katrina,
certainly the rest of the organization comes into play and the
Central Office typically has maintained a reserve fund just for
this kind of situation where there is a disaster of unusual
proportions to come to the rescue with funding from Washington.
In regard to New Orleans, I wanted to mention that we do
have a program there working with one of our community
partners, Tulane University, to provide hospital care, and we
have been doing that for a long time. Our average daily census
there is about 18 or 19 patients right now. And by the way, we
have a floor and our staff go over there and take care of the
patients as inpatients.
In regard to the concept, there's something called hospital
in a hospital and we used this as a solution, a partial
solution after Katrina to help maintain continuity of care and
also to have a familiar face and the same kind of technology
systems that VA is already famous for to continue that care
even in that setting. Certainly we are looking forward to our
new hospital there as well.
Mr. Michaud. Thank you. Mr. Brown.
Mr. Brown of South Carolina. Dr. Cross, are you planning to
replace the hospital in New Orleans in the location where it
exists now?
Dr. Cross. Sir, I will provide that to you for the record.
I don't have that in my testimony today, but I understand great
progress is being made and the funding worked out and I think
everybody that I am aware of at my office is very optimistic
about how this is going to move forward.
Mr. Brown of South Carolina. I know you weren't here during
that time. I know this is not part of the discussion, but it
did come up because of the way the payments are going to be
handled for lack of service; I went down with the Secretary at
that time right after Katrina, and the hospital itself was in
good sound condition, but what happened, was the water got into
the basement and that is where most of the utilities, the air
conditioning and so forth were. But it looked to me if that
could have been pumped out and the air conditioning units
repaired, that could have saved all that mold that accumulated.
But a veteran asked a question, if it was going to be torn down
and replaced by new construction.
Dr. Cross. Yeah, it is a different site, but I would rather
give you a written response on these.
[The VA subsequently provided the following information:]
The new hospital will not be in its existing location. VA has
selected a site in Mid-City New Orleans. The architect
submitted the design development package of the new medical
center in February 2010. As required by section 106 of the
National Historic Preservation Act, consulting parties met to
discuss the design. A detailed, site-specific environmental
assessment (SEA) in compliance with the National Environmental
Policy Act requirements was completed on March 31, 2010. The
Notice of Availability for the Finding of No Significant Impact
and the SEA were published on April 4, 2010. The New Orleans
City Council approved revocation of rights-of-way for the
streets within the site boundaries on April 22, 2010. VA
obtained ownership of the Pan-Am building on June 3, 2010. VA's
designers have completed the HazMat survey of the Pan-Am
building and are preparing abatement plans to incorporate into
construction documents for the building renovation.
Negotiations continue among the City, State and VA to
expedite the acquisition process and mitigate further delays. A
groundbreaking ceremony was held June 25, 2010.
Mr. Brown of South Carolina. Okay.
Dr. Cross. That plan for the old facility. You know, there
are other issues, as well, regarding that facility, the design,
the changes that have taken place in medical care to better
meet the needs of veterans currently in a more modern approach,
you know, so much more now the VA highlights outpatient
services and doing things like same-day surgery and those kind
of things, more so than we did when that facility was built.
Mr. Brown of South Carolina. And I guess if I could maybe
even do a little special ad for my location in Charleston. We
have been trying to do something to make some accommodations
between the VA and the medical university there; and it is, you
know, VA hospital is basically the same existing thing, and we
at Charleston are certainly prone to hurricanes, we had Hugo
back about 20 years ago if Hugo would hit in direct strike to
Charleston, we would have been in real trouble; that is what we
are trying to do now is to be proactive so we could have some
cross sharing between the VA and the medical university just as
a backup.
I know down in New Orleans all those hospitals were in very
low lying regions and I guess most of all the rest of those
hospitals are going to probably be replaced, too. But my
question in line with that is, I know that it sounds pretty
simple to say if you can't provide service within 30 days, then
we need to move into some kind of a private practice, but
recognizing the opposite of doing that, all the records have to
be transferred and a lot of times--I know just in my personal
case where I go from one doctor to another doctor, they have to
do a little bit of catch up procedures, too, to be sure that
they have everything in--so it is not as easy to just implement
it.
But in light of that, who pays for it? Do you all have a
national pot of money that would handle that or would that
hospital be responsible for those charges or would the VISN be
responsible?
Dr. Cross. The local facility would bear some
responsibility in terms of trying to practice efficiently in
covering those expenses, including the fee-basis care but that
is part of our overall appropriation for fee-basis care that we
spend every year.
Let me comment on what you said earlier, sir. From my
understanding first of all, the 30 days, our true objective is
to give the patients care when they need it, when they want it,
and to not be so arbitrarily focused on a number of days. I
think that is good medical care and that produces better
satisfaction.
And by the way, in regard to mental health care, we have a
15-day standard for new patients, and so we have already moved
beyond 30 days in that category because we understood the
challenges facing our veterans.
So for a new patient seeking mental health care, we do an
evaluation within 24 hours, 7 days a week. That may be by
phone, but we do some evaluation to check on them and see how
acute their need is. And then we get them a comprehensive
evaluation within that 15-day period.
Mr. Brown of South Carolina. I tell you what. I want to
compliment you for the VA hospital in Charleston. It certainly
gives a great service to the veterans in our community.
Dr. Cross. Thank you.
Mr. Brown of South Carolina. I thank you all for being part
of this discussion today.
Dr. Cross. Thank you, sir.
Mr. Michaud. I know the VA works with other agencies. For
instance, on nursing homes, you work with CMS in other areas,
we have asked you to work with the Department of Health and
Human Services on federally qualified health care clinics and
there are overlays where the care has recommended certain
access points.
My question is particularly in light of the new health care
legislation that was passed this past Sunday, in dealing with
other agencies, in this particular case Health and Human
Services, how collaborative have they been and do you find that
they are holding you back on issues that this Committee and
other Committees might have asked the VA to look at? If you saw
some of the bills we have before us today, they concern health
access issues in rural areas. I think that is part of the slow
process in getting access points up and running under the
Capital Asset Realignment for Enhanced Services (CARES)
process.
So how much delay is there, or is working with other
agencies not really a problem?
Dr. Cross. No, sir, I don't think we have any problem at
all really working with other agencies, you know, whether it be
HHS or DoD. I have often commented that I am absolutely
surprised at the degree of intense engagement and very
collaborative engagement that we have with DoD. We see the same
patients at different parts of their lives, and I think people
would be very pleased if they could see all the meetings and
all the collaboration. I know my counterparts on a first name
basis. We meet together so frequently. We share committees
together. We cochair committees together. We work through so
many issues together.
I think you should be well pleased that there is a great
deal of work at my level and many other levels in a very
collaborative framework with DoD, IHS and so forth. The head of
IHS was in my office just a few months ago talking about what
we can work on together and we have already started a project.
It regards our Suicide Prevention Hotline, and we have arranged
for the Indian Health Service staff to train my staff at the
Suicide Prevention Hotline on cultural sensitivities dealing
with Native American and American Indian veterans.
I think that there were a few things that we were missing
and just talking to her educating me about some terms that I
may use or our staff may use, they have different meanings to
them than it does to us. And so we have already started that
program working with the National Suicide Prevention Hotline to
make sure that we are very sensitive to their needs. That is an
example of the kind of collaboration that we have been working
on.
Mr. Michaud. Once again, thank you very much. I really
appreciate all the hard work and dedication that VA employees
give to our veterans and look forward to working with you as we
move forward with these pieces of legislation we have before us
today and other issues before this Subcommittee, and ultimately
full Committee. Once again, Dr. Cross, thank you, and the
panels for coming here today. I really appreciate it.
If there are no other questions, I will adjourn this
hearing.
[Whereupon, at 11:36 a.m. the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Michael H. Michaud,
Chairman, Subcommittee on Health
I would like to thank everyone for coming today.
Today's legislative hearing is an opportunity for Members of
Congress, veterans, the VA and other interested parties to provide
their views on and discuss recently-introduced legislation within the
Subcommittee's jurisdiction in a clear and orderly process. This is an
important part of the legislative process that will encourage frank
discussions and new ideas.
We have a number of bills before us today. They cover a wide range
of important issues dealing with access to VA health care; collective
bargaining rights for VA employees; mental health care and counseling
for individuals discharged or released from active duty; emotional and
peer support for family members of the Armed Forces; breast cancer
among members of the Armed Forces and veterans; and rural health
including the unique needs of Native American veterans. We also have
draft bills before us today on reimbursements for continuing education,
mental health counselors, and bargaining rights and performance pay
criteria.
I look forward to hearing the views of our witnesses on this bill
before us.
Prepared Statement of Hon. Henry E. Brown, Jr.,
Ranking Republican Member, Subcommittee on Health
Thank you Mr. Chairman. I appreciate you holding this legislative
hearing today and I look forward to working with you and the rest of
our esteemed colleagues on these important legislative subjects.
The ten bills being discussed this morning cover a wide array of
veteran's issues and I look forward to learning more about them.
Of particular interest to me is H.R. 1075, the RECOVER Act,
introduced by Mr. Scalise. H.R. 1075 would provide medical services to
veterans in a disaster area by allowing the VA to contract with one or
more non-VA facilities. Making sure our veterans have access to the
very finest care is always the top priority of this Committee, but--in
times of real emergency--that priority takes on a whole new level of
importance. Serving a district with facilities that are vulnerable to
the sometimes destructive whims of nature--as I do in Charleston and
along the coast of South Carolina--makes this a personal issue for me
and I support Mr. Scalise in his efforts.
I am also excited to hear more about H.R. 84, the Veterans Timely
Access to Care Act, introduced by my friend Ms. Brown-Waite. Among
other provisions, this bill would make the standard for access to care
for a veteran seeking primary care from the VA 30 days from the date
the veteran contacts the Department. Ms. Brown-Waite has long been
committed to making sure America's veterans do not have to endure long
waiting periods before they can access VA care and I applaud her
efforts.
To all of the witnesses appearing in front of us this morning--
thank you for your dedication to improving the lives of our veterans.
Your work does not go unnoticed and I am eager to begin our discussion
on the matters at hand.
It is only by working together to advance meaningful and
appropriate legislation that we can completely fulfill the promise we
made to provide veterans with the ``best care anywhere.'' The men and
women who served so bravely in uniform deserve nothing less.
Again--thank you, Mr. Chairman. I yield back the balance of my
time.
Prepared Statement of Hon. Bob Filner,
Chairman, Committee on Veterans' Affairs,
and a Representative in Congress from the State of California
Chairman Michaud, thank you for the opportunity to testify before
the Subcommittee on Health on H.R. 949, a bill that would improve the
collective bargaining rights and procedures for reviews of adverse
actions of certain VA employees.
This bill is all about ensuring equity among the health care
professionals employed at the Department of Veterans Affairs so that VA
providers such as doctors, nurses, dentists, chiropractors,
optometrists, and podiatrists who are hired under the ``pure title 38''
system have the same rights as their fellow VA health care
professionals who are hired under different hiring systems.
Without this bill, ``pure title 38'' providers do not have the
right to challenge errors in pay computations and lack other key
bargaining rights enjoyed by their colleagues at the VA.
To address this problem, H.R. 949 would clarify that these ``pure
title 38'' providers have equal rights to collective bargaining. This
means that they would be able to challenge personnel actions through
such methods as grievances, arbitrations, and labor-management
negotiations.
My bill would also require the VA to review the adverse personnel
action and issue a final decision, no later than 60 days after the
employee appeals the adverse personnel action.
Finally, H.R. 949 would subject the VA's final decision on the
employee appealed adverse personnel action to judicial review in the
appropriate U.S. District Court or the U.S. Court of Appeals for the
Federal Circuit.
I recognize VA has concerns and I am looking forward to working
with them and other stakeholders as we move forward on this piece of
legislation.
Thank you again for the opportunity to share my thoughts with you.
Prepared Statement of Hon. Steve Scalise,
a Representative in Congress from the State of Louisiana
Thank you, Chairman Michaud, Ranking Member Brown, and
distinguished Members of the Subcommittee.
I appreciate the opportunity to testify before your Subcommittee on
my bill, H.R. 1075. This bi-partisan legislation, with nineteen
cosponsors, seeks to maintain vital health services to veterans in the
event that a VA hospital is closed due to a federally declared
disaster. Before I begin discussing my bill, I'd like to also thank you
for your service on the Veterans' Affairs Committee, and for the work
you do on behalf of our Nation's veterans.
The welfare of our veterans and their families is of great
importance to me, and I first filed this legislation during the 110th
Congress when I served as a Member of the Veterans' Affairs Committee.
Our Nation is grateful for the courage our veterans have displayed and
the sacrifices they have made in order to protect America and the
freedom we enjoy today. I believe, as you do, that it is our obligation
to provide them the same honor and dedication that they provided us
during their service.
Hurricane Katrina flooded and closed the New Orleans VA Medical
Center, leaving our veterans without the full services of their medical
home. Unfortunately, nearly 5 years later, our VA hospital still
remains closed. As a result, veterans throughout Southeast Louisiana
face increased challenges and hardship to obtain the quality health
care they deserve. The VA made a commitment to open a new hospital by
late 2013, but with the current delays, I remain concerned about the
status of veterans' health care in the interim, and want to make sure
this doesn't happen to any of our Nation's veterans in the future.
That is why I introduced H.R. 1075, the RECOVER Act. My bill would
ensure that the VA must establish a contract with at least one non-VA
facility to provide inpatient services in the event that a VA hospital
will be closed for at least 6 months due to any federally declared
disaster. Nothing in this bill would prevent a veteran from seeking
care within the VA system if he so chooses. But last week, I spoke with
a veteran who had to travel to another state for post operative care
because the New Orleans hospital is still not open. Veterans still have
to travel more than 350 miles for cardiac surgery and also have to
travel to other states for mental health care as well. Several veterans
with chronic conditions did not seek care after the storm because they
did not know what their options were. This concerns me very much, and
my bill seeks to eliminate these hardships. The RECOVER Act will also
prevent families from having to travel hundreds of miles just to visit
their loved ones who are undergoing treatment in the hospital. As the
respected group Disabled American Veterans said when they expressed
their support for this Act, ``Family support and care giving have been
shown to accelerate recovery time and reduce cost and length of
hospital stays.'' In the aftermath of a disaster, the last thing our
veterans and their families should have to worry about is where to seek
basic health care.
I commend the Southeast Louisiana Veterans Health Care System for
the initiative they have taken to provide care in light of the
hospital's closure. The community outpatient clinics have been
extremely valuable in delivering primary care and other services. We
learned valuable lessons after Hurricane Katrina, and I want to make
certain that no veteran has to travel long distances or experience long
wait times to receive basic care in the event that their local VA
hospital is closed due to a natural disaster, whether it be a
hurricane, a tornado, earthquake, or any other natural disaster.
My office is working with the Veterans' Service Organizations to
address any issues they have as this bill moves through the legislative
process. Let me also emphasize that this in no way undermines our
strong commitment to the VA health care system. Our goals are the same:
veterans and their families need to have options for receiving quality
care close to home in the most convenient way possible, all while
working to expedite the rebuilding of our VA hospital that was closed
due to Hurricane Katrina. I continue working hard to cut through red
tape and expedite the rebuilding of the New Orleans Medical Center that
was devastated and closed by Hurricane Katrina's destruction. I look
forward to working with you and Members of the Committee as we move
forward.
Again, I thank you for your dedication to our Nation's military
veterans, and I appreciate this opportunity to testify before the
Subcommittee.
Prepared Statement of Hon. Gabrielle Giffords,
a Representative in Congress from the State of Arizona
Thank you, Mr. Chairman, and I want to thank Ranking Member Brown
as well for the opportunity to testify today.
This Committee has always been active in supporting the needs of
America's veterans and I look forward to working with you on this
endeavor.
I also want to thank the Veterans Service Organization's in
attendance today for their commitment to our men and women in uniform
and for their lifetime of service.
The two bills before you today that I have sponsored, H.R. 2698 and
2699, will have a direct impact on improving the behavioral health of
our Nation's heroes and their families.
As a Member of the House Armed Services Committee who represents
more than 25,000 servicemembers and dependants and nearly 96,000
veterans and retirees in my Southern Arizona District, I have seen
firsthand the trials and tribulations of our servicemembers returning
from the frontlines.
I know this issue is one that is close to both of your hearts, and
I am hopeful that today's hearing signifies an important step in moving
this vital legislation forward and passing it this Congress.
There is no cause more honorable than service to our country. As
our Nation's warriors bravely step into the breach, we must be prepared
to care for them when they return home.
In war, our soldiers, sailors, airmen and marines face unspeakable
horrors--sometimes on a daily basis--and readjusting to everyday life
is a long and complicated process. Every day, thousands of our Nation's
bravest men AND women are suffering from different degrees of Post
Traumatic Stress. In recent years, diagnosed cases of PTSD have
increased by more than 50 percent for servicemembers returning from
overseas deployments, and many experts believe that the actual number
is much higher because a large majority of servicemembers never seek
treatment.
For an untold many diagnosed with the worst warning signs of PTSD,
there are no simple fixes. We see each month the unfortunate and deeply
saddening results as the Department of Defense releases its number of
servicemember suicides. The trend is currently hovering slightly above
the national average, more than double what is was 5 years ago.
When I spoke with the Vice Chief of the Army, General Chiarelli, a
year ago he agreed that even one suicide is unacceptably high,
especially when there is so much more that we can be doing. Fellow
Members, there is much more we can do and, while my legislation is not
a silver bullet cure it is one round in the chamber.
PTSD and other related behavioral health issues severely affect an
individual's ability to perform everyday functions that we all take for
granted. PTSD though, is treatable through a variety of methods
including behavioral therapy and medication with a majority of
servicemembers seeing an improvement after just one or two sessions
with a behavioral therapist.
Unfortunately, there are not enough behavioral health care
providers within the military or VA to treat these servicemembers,
their families or surviving spouses for the anguish they're suffering.
What's worse still is that there aren't enough therapists to treat each
other.
Ultimately, our ailing heroes or the families they leave behind
must wait to see a caregiver, often receive incomplete or inadequate
care, or in some cases do not receive care at all leading to one of a
few inevitable conclusions--depression, anger management problems,
substance abuse or death.
This is the first in many clear signs that the system is failing
our men and women in uniform and badly needs to be fixed.
H.R. 2698 establishes a scholarship-for-service program that
provides educational benefits to those training in behavioral health
care specialties critical to the operations of Vet Centers. These
individuals would then pay back the investment by serving as a
behavioral health care specialist at Vet Centers across the country.
Because of the unpredictable nature and a lingering lack of
understanding surrounding PTSD and its symptoms, many former
servicemembers do not realize they are suffering until long after they
have left military service. My bill will permit our Nation's Guardsmen
and Reservists to access behavioral health care at Vet Centers even
after they have been released from their Active Duty service
requirement and provides for referrals to assist them to the maximum
extent possible in obtaining behavioral health care and services from
sources outside the Department.
In such cases where a servicemember may have been discharged for
actions connected to his or her PTSD, my bill would ensure that they
are apprised of their rights to petition for a review of their
discharge on those grounds, ending forever the practice of discharging
those suffering from PTSD because of the nature of their disease.
H.R. 2698 and H.R. 2699 also ensure that the Veterans
Administration carry out a competitive grant program for nonprofit
organizations that provide peer-to-peer emotional support services for
servicemembers, veterans and survivors including members of the
National Guard and Reserve who are often left out because of the
changing nature of their service or the accessibility of care in local
communities.
But what additional counselors and additional opportunities cannot
do is force a servicemember or veteran to get care. For too many, PTSD
is still an inescapable sentence. Servicemembers and vets are bound on
one side by their service and the other by the deep stigma that still
surrounds behavioral health issues. Rumors persist within the rank and
file that behavioral health disorders cause you to lose your clearance
or that PTSD treatment will be reported up the chain of command,
ruining an otherwise promising career. According to a report by the
American Psychiatric Association, an estimated 60 percent of those
surveyed feared reporting that they were suffering from behavioral
health-related problems.
The unfortunate fact is that 10 years ago we hardly acknowledged
the existence of PTSD and had no logical measure of its effects. Five
years ago, we began acknowledging it was a real problem. Today we have
in place only a patchwork quilt of forms and meetings, training
seminars and online courses that our servicemembers must complete along
with dozens of other regular re-certifications and proficiency tests.
What we are not doing is taking a comprehensive look at the problem and
designing a smarter and more realistic solution.
H.R. 2699 provides for just that by establishing a pilot program at
three Posts across the country that each house high op-tempo mission
sets--Fort Leonard Wood, home of our Military Police Corps and the NCO
Academy; Fort Carson, home of the 10th Special Forces Group, 4th
Infantry Division and 10th Combat Support Hospital; and Fort Huachuca,
the home of our Nation's Center of Intelligence Excellence that trains
and supports the best intelligence professionals in the world.
By focusing on these three bases we can ensure that a new program
focuses on the most stressed and most over-utilized units across the
force and use real-life feedback from soldiers and their families on
the best way to provide treatment and track their results.
We cannot continue to accept that what is being done is the best we
can do.
I am committed to fixing the problems we know about and uncovering
those we don't. I know that you Mr. Chairman and the Ranking Member and
the others on this Committee share my passion and my commitment to
those in service to our country and the families who serve in their own
way as well.
I look forward to receiving the feedback of the VA and from the
Veterans Service Organizations in attendance today. And I look forward
to working with the Committee to make these necessary changes into law.
Thank you.
Prepared Statement of Hon. Leonard L. Boswell,
a Representative in Congress from the State of Iowa
Chairman Michaud, Ranking Member Brown, and Members of the
Committee, I would like to thank you for inviting me to speak before
you today and for holding this hearing over many important pieces of
veteran's health legislation.
Women are currently the fastest-growing veteran population--
representing 8 percent of the population. As the demographics of the
military continue to change, we find our VA system is struggling to
serve the unique needs of this growing population. By 2020, 15 percent
of veterans using the VA for health care will be women.
What this means is that veterans' health care, which is now
primarily tailored to men, needs to undergo significant changes--and
fast.
Particularly, one health concern that has been largely ignored is
the prevalence of breast cancer in our servicewomen and women veterans.
That is why I have introduced H.R. 3926, the Armed Forces Breast Cancer
Research Act. This legislation would require the Secretary of Defense
and the Secretary of Veteran Affairs to collaboratively study the
incidence rate of breast cancer in servicemembers and veterans. This
study would focus on the number of servicemembers who have deployed in
support of Operation Iraqi Freedom and Operation Enduring Freedom, the
demographic information of those servicemembers and veterans, an
analysis of the clinical characteristics of breast cancer diagnosed,
and possible exposures to cancer risk factors.
The idea for this bill came about when a member of my staff, who is
an Iraq veteran, went back to Iowa for a 5 year post-deployment
reunion. One of the women at the reunion had returned home from serving
her country and was diagnosed with breast cancer and had to undergo a
double mastectomy, at age 25. Through the course of the night the
servicemembers at the reunion were able to piece together about six
women they were deployed with who had come back from their deployment
in Iraq with breast cancer--all between the ages of 25 to 35 years old.
Also, there were another half dozen women who returned with new lumps
in their breasts that needed additional tests such as mammograms,
ultrasounds, and/or biopsies. With 70 women deployed with the battalion
(of 700), this incidence rate in young women seemed high and alarming
to me.
In recent years, the U.S. medical and research communities have
stepped up their efforts on breast cancer detection, research, and
treatment in the country's civilian population. However, women who
serve or have served in our Nation's Armed Forces have largely been
excluded from these studies, despite their exposure to cancer risk
factors and access to medical care. A recent study of Department of
Defense (DoD) and National Cancer Institute (NCI) compares the
prevalence of certain types of cancer among active-duty military
personnel with the general public. The study found that breast cancer
among women is more common in the military than in the general
population and that further studies are needed to confirm these
findings and explore contributing factors.
That is my goal for this legislation. To find out if our
servicewomen do have a higher risk of breast cancer than the rest of
the women in the country and why that might be. So that ultimately, we
can determine if breast cancer is a service-connected disability--which
I truly believe it is.
At this moment in history it is particularly important to consider
what we can do to better serve the brave individuals who fight for our
security and liberty once they return home.
I would again like to thank Members of this Committee for allowing
me the time to speak and your diligence on this matter. I would be
happy to answer any questions you might have.
__________
Veterans of Foreign Wars of the United States
Washington, DC.
October 26, 2009
The Honorable Leonard Boswell
United States House of Representatives
1427 Longworth House Office Building
Washington, DC 20515
Dear Representative Boswell:
On behalf of the 2.2 million members of the Veterans of Foreign
Wars of the United States and our Auxiliaries, I would like to offer
our support for your proposed legislation, the Armed Forces Breast
Cancer Research Act.
Your important legislation would direct the Secretary of Defense
and the Secretary of VA to work jointly in conducting a study on the
incidence of breast cancer among our Nation's veterans. The valuable
study would provide insight on breast cancer rates of servicemembers
and document any harmful exposure the servicemembers were subjected to
during their service. The Armed Forces Breast Cancer Research Act would
provide crucial information on an important veteran issue that has
otherwise been neglected.
Representative Boswell, we thank you for proposing legislation that
would greatly benefit our Nation's heroes. We need to do everything in
our power to provide for these brave Americans who have sacrificed for
their country. The VFW looks forward to working with you and your staff
to ensure the passage of this legislation.
Thank you for your continued support of America's veterans.
Sincerely,
ERIC A. HILLEMAN
Director, National Legislative Service
__________
Iraq and Afghanistan Veterans of America
Washington, DC.
December 2, 2009
The Honorable Leonard Boswell
1427 Longworth House Office Building
Washington, DC 20515
Dear Congressman Boswell,
Iraq and Afghanistan Veterans of America (IAVA) is honored to offer
our full support for H.R. 3926, the ``Armed Forces Breast Cancer
Research Act.'' The ``Armed Forces Breast Cancer Research Act'' will
establish a collaborative effort between the Department of Defense and
the Department of Veterans Affairs to study incidences of breast cancer
among those who serve, their demographic information, possible
exposures to carcinogenic material while serving our country and any
treatments they have received.
Civilian sector advances infesting and treatments for breast cancer
have largely been determined without specific consideration of the men
and women in our Armed Forces. However, in October 2009, there have
been reports of 40 former Marines with breast cancer, who were
potentially exposed to contaminated water at Camp Lejeune. As these
reports evidence, there is a dire need for further research into the
incidences of breast cancer among the unique population of troops and
veterans.
We are proud to offer our assistance and thank you for this vital
legislation. If we can be of help, please feel free to contact Erin
Mulhall, Deputy Policy Director for Research, at (202) 544-7692 or
[email protected].
We look forward to working with you.
Sincerely,
Paul Rieckhoff
Executive Director and Founder
Prepared Statement of Hon. Ginny Brown-Waite,
a Representative in Congress from the State of Florida
Thank you, Mr. Chairman,
I appreciate the opportunity to testify before the Subcommittee
today.
As of November 2009, there were nearly 8 million veterans enrolled
in the VA health care system. With new veterans entering the system
every day and approximately 174,000 Operation Enduring Freedom and
Operation Iraqi Freedom patients receiving VA health care, it is clear
that our duty to our Nation's veterans is as strong now as it has ever
been.
Today, there are 153 VA medical centers and 768 Community Based
Outpatient Clinics (CBOC) available to serve the needs of these
veterans.
When a veteran calls to schedule an appointment in one of these 921
facilities, they should be able to receive an appointment that is
timely and appropriate to their medical needs.
Unfortunately, for many veterans, this does not happen.
The VA lauds itself for completing 99 percent of its primary care
appointments within 30 days of the desired date. However, this means
that nearly 32,000 patients still are waiting beyond 30 days for their
primary care appointment.
Additionally, there is a discernable difference between existing
patients and new patients, as only 88.8 percent of new patients
complete their appointments within 30 days of the desired date.
Health care delayed is health care denied and our Nation's veterans
deserve better.
In September 2007, VA Office of the Inspector General found that
the Veterans Health Administration's method of calculating the waiting
times of new patients understates the actual waiting times. In this
report, the Inspector General made five recommendations to reduce wait
times at VHA facilities. To date, four of these five recommendations
remain unresolved.
When I first was elected to Congress, I inquired into the wait time
numbers from Veterans Health Administration facilities in my District
and across the country. The numbers the VA gave me both for VISN 8 and
nationwide did not match with the stories I heard from my veterans. It
was clear the VA was playing games with scheduling and canceling
appointments. I fear these games are still being played today.
For this reason, I introduced H.R. 84, the Veterans Timely Access
to Health Care Act. This bill would make the standard for a veteran
seeking primary care from the Department of Veterans Affairs 30 days
from the date that the veteran contacts the Department.
Veterans should not need to wait more than 30 days to receive an
appointment from their primary care physician.
The VA does provide a high level of care to all of the veterans who
are enrolled in the system. This is why the majority of patients rate
their level of overall satisfaction with their treatment as ``very
good'' or ``excellent,'' regardless of whether they are receiving
inpatient or outpatient services.
I want to be clear: this bill is NOT a scheme to move the VA toward
privatization. I simply want to ensure that veterans receive care in a
reasonable amount of time.
As Members of Congress, we have an obligation to ensure that
veterans receive the best health care available to them. If veterans
are having problems receiving care within 30 days of contacting the
Department of Veterans Affairs, then Congress needs to allow them to
look for an alternative. That is what this bill does.
This hearing today is to determine whether the VA is meeting the
goal of timely access to care.
Our Nation's veterans did not wait 30 days to answer the call of
duty.
They answered their Nation's call and took up arms to protect our
freedom.
They deserve the same dedication and steadfastness from us.
With over 116,000 veterans living in my District, I have the
distinguished honor to meet with these true American heroes on a
regular basis. I hear about the issues they have with the VA. Over and
over again, I still hear about how difficult it is to schedule an
appointment with a doctor in a timely matter.
This is unacceptable and must be corrected. The Veterans Timely
Access to Health Care Act is an important step in fixing this
persistent problem.
Congress recently allowed for advanced appropriations for the VA.
This new funding structure should allow the VA to properly manage their
funds and hire the staff necessary to meet the demand at VA facilities.
However, when the VA still fails to meet the needs of our veterans
seeking health care, this legislation provides an effective
alternative.
Congress and administrations must not turn the care of our Nation's
veterans into a political issue.
Instead, we must all work together to ensure that they receive the
health care they risked so much to earn. We must continue those
practices that already work and improve those that are failing. H.R. 84
does just that.
Thank you again, Mr. Chairman, and I yield back the balance of my
time.
Prepared Statement of Denise A. Williams, Assistant Director,
Veterans Affairs and Rehabilitation Commission, American Legion
Mr. Chairman and Members of the Subcommittee:
Thank you for the opportunity to present The American Legion's
views on the several pieces of legislation being considered by the
Subcommittee.
H.R. 1075, RECOVER Act (Restoring Essential Care for Our Veterans for
Effective Recovery)
This bill would expand access to hospital care for veterans in
major disaster areas and for other purposes. In addition, it directs
the Secretary of the Department of Veterans Affairs (VA) to enter into
a contract with non-Department facilities located in the disaster areas
to facilitate covered medical services to veterans, if their designated
VA medical facility is unable to do so within 180 days due to the
disaster.
Timely and open access to quality health care for veterans is a
major priority of The American Legion and this legislation is
consistent with our efforts in this regard. The American Legion does,
however, have some concerns. Although such contracts would certainly be
helpful during a disaster in which VA medical facilities are not
available, we do not want such an arrangement to become a disincentive
for VA to quickly repair or replace damaged facilities. This bill also
does not address length of the contracted care, long-term care or how
quality of care will be assessed.
H.R. 84, Veterans Timely Access to Health Care Act
This legislation would seek to establish standards of access to
care for veterans seeking health care from VA. It also directs the
Secretary to set standards for timeliness and to report how these
standards were carried out.
The American Legion supports this bill and believes that this
endeavor will provide VA with a comprehensible overview of the
challenges that veterans face in gaining timely access to care. This
measure could prove to be a valuable asset in their undertaking to
improve access to care, especially among veterans living in rural and
highly rural geographic areas.
H.R. 4006, Rural, American Indian Veterans Health Care Improvement Act
of 2009
This bill would require the VA Secretary to designate Indian Health
Care Coordinators at 10 VA medical centers that serve communities with
the greatest number of American Indian veterans. Additionally, a year
after the bill has been enacted; the VA Secretary is directed to
establish a Memorandum of Understanding with the Secretary of the
Interior to authorize the electronic transfer of American Indian
veterans' health records between the Indian Health Services (IHS) and
the VA. The provisions of this bill also authorize the VA Secretary to
transfer surplus medical and information technology equipment to IHS.
The American Legion advocates timely access to quality health care
to all veterans and is on record in strong support of VA's
collaboration with other Federal health care providers to provide the
best care, at the right time, in the most appropriate medical care
setting. This legislation appears to address these goals to better
serve veterans enrolled in the VA health care delivery system.
H.R. 3926, Armed Forces Breast Cancer Research Act
This bill would direct the Secretaries of the Departments of
Defense (DoD) and VA to jointly conduct a study on the incidence of
breast cancer among members of the Armed Forces and veterans. This
study would determine the number of servicemembers and veterans
diagnosed with breast cancer; their demographic information; and any
possible exposure to hazardous elements or chemical or biological
agents.
The American Legion fully supports this timely and important
legislation given the recent breast cancer incidences among male
veterans that were stationed at Camp Lejeune. Moreover, according to
the Clinical Breast Care Project at Walter Reed Army Medical Center,
there have been over 2,000 cases of breast cancer diagnosed in both
male and female active-duty servicemembers within the last decade. The
Center further stated that breast cancer is the single greatest cause
of cancer deaths among women under 40 and is a significant cause of
mortality for women in the Armed Forces. The American Legion would also
encourage inclusion of the Reserve component in this study.
H.R. 949, Improving the Collective Bargaining Rights of Certain VA
Employees
This legislation would seek to amend section 7422 of title 38,
United States Code (USC), which would improve the collective bargaining
rights and procedures for review of adverse actions of certain VA
employees.
Although The American Legion strongly supports the recruitment and
retention of quality VA employees, it has no official position on this
legislation.
Proposed Legislation to Amend Title 38, USC, Concerning Performance Pay
and Collective Bargaining
This legislation would seek to amend section 7431 and section 7422
of title 38, USC, which would make certain improvements in the laws
relating to the performance pay and collective bargaining right for
certain VA employees.
Although The American Legion strongly supports the recruitment and
retention of quality VA employees, it has no official position on this
legislation.
Proposed Legislation to Amend Title 38, USC, Concerning Continuing
Professional Education
This bill would seek to amend title 38, USC, to improve the
continuing professional education reimbursement provided to health
professionals employed by VA. This proposal would not only maintain
VA's presence in the competitive medical professional market, but also
help decrease the attrition rate among VA medical centers' medical
professionals.
The American Legion supports this draft proposal because it will
serve to provide professional education reimbursement for eligible
health professional. The expansion of this benefit may also diminish
the attrition rate of medical professionals within VA medical
facilities because it will be an added benefit to more staff in various
disciplines.
Proposed Legislation to Amend Title 38, USC, Concerning Mental Health
Counselors
This proposal would seek to amend title 38, USC, to authorize the
VA Secretary to waive certain requirements relating to mental health
counselors.
The American Legion believes VA should be staffed with the best
qualified professionals to ensure this nation's veterans receive timely
access to quality health care, especially mental health services. With
servicemembers returning from Iraq and Afghanistan with complex and
overlapping illnesses and injuries, it is imperative VA maintains its
charge to ensure its medical professionals are properly trained and
fully qualified to provide quality care.
According to the National Institute of Health, injuries and
illnesses such as mild Traumatic Brain Injury (TBI) and Posttraumatic
Stress Disorder (PTSD) respectively, have several symptoms in common.
Among these symptoms are irritability, concentration deficits, amnesia
for the causal event, reduced cognitive processing ability and sleeping
disturbances. Clearly, this situation adds to the difficulty in
diagnosing PTSD in patients with TBI. The American Legion contends that
due to the complexity of these illnesses and injuries, such as TBI and
PTSD, the most qualified mental health professionals are required.
Therefore, The American Legion is opposed to waiving current
requirements relating to mental health counselors.
H.R. 2698, Veterans and Survivors Behavioral Health Awareness Act
This bill would seek to improve and enhance the mental health care
benefits available to veterans. The legislation would also enhance
counseling and other benefits available to survivors of veterans, and
for other purposes.
The American Legion fully supports this legislation. VA's Vet
Centers have served as one of the main catalysts that have assisted
with successfully transitioning servicemembers and veterans to VA.
Section 3 of this bill would seek to restore the authority of Vets
Centers to provide referral and other assistance upon request to
veterans currently not authorized counseling. This provision would
allow Vet Centers to cast a broader net in further minimizing veterans
who would otherwise continue to face transition challenges.
H.R. 2699, Armed Forces Behavioral Health Awareness Act
This bill would seek to improve the mental health care benefits
available to servicemembers, to enhance counseling available to their
family members, and for other purposes.
While The American Legion agrees with the intent of this bill, we
disagree with the restrictive nature of section 4, which would seek to
carry out a pilot program, for servicemembers of the Army only, to
enhance awareness of PTSD. This pilot program should be open to members
of all five branches of the Armed Services with a presence in Iraq or
Afghanistan. In addition, the locations should be expanded to include
venues near all of the respective servicemembers.
The American Legion believes the success of the Armed Forces
Behavioral Health Awareness Act, with the amendment of section 4, would
assist with timely intervention to help minimize issues plaguing
veterans and their families that possibly lead to substance abuse,
suicide, and homelessness.
H.R. 2879, Rural Veterans Health Care Improvement Act of 2009
This legislation would seek to amend title 38, USC, to improve
health care for veterans who live in rural and highly rural geographic
areas, and for other purposes.
VA's Office of Rural Health held their inaugural meeting in August
2008. During that time, VA established Rural Health Centers located in
three regions of the country:
Eastern Region RHRC: White River, Vermont
Central Region RHRC: Iowa City, Iowa
Western Region RHRC: Salt Lake City, Utah
These three regions also partner with various VA medical centers
and universities. Section 3 of this bill proposes Centers of Excellence
for Rural Health Research, Education, and Clinical Activities. The
American Legion believes there should be interaction between the
abovementioned Rural Health Centers to prevent redundancy. Due to the
vastness of rural areas, Rural Health Centers should be increased to
accommodate various issues such as lack of access to medical
facilities, lack of medical professionals, women veteran issues, and
homelessness.
This bill would also seek to increase transportation options for
rural veterans. The American Legion believes this is imperative and
will increase veterans' options of receiving timely access to quality
health care. The American Legion also believes that veterans should not
be penalized due to the geographical location in which they choose to
reside.
Mr. Chairman, once again The American Legion appreciates the
opportunity to address these issues and looks forward to working with
you, your colleagues and the staff in advancing legislation that will
make a positive difference in the lives of servicemembers, veterans and
their families.
That concludes this written statement and I welcome any questions
you or your colleagues may have concerning The American Legion's views,
comments and recommendations.
Prepared Statement of Blake C. Ortner,
Senior Associate Legislative Director, Paralyzed Veterans of America
Chairman Michaud and Members of the Subcommittee, on behalf of
Paralyzed Veterans of America (PVA), I would like to thank you for the
opportunity to present PVA's position on the legislation pending before
the Subcommittee, as well as the three draft bills you are preparing.
H.R. 84, the ``Veterans Timely Access to Health Care Act''
H.R. 84, the ``Veterans Timely Access to Health Care Act,'' would
establish standards of access to care within the VA health system. PVA
has testified on similar legislation in the past and is unable to
support H.R. 84.
Under the provisions of this legislation, the Department of
Veterans Affairs (VA) will be required to provide a primary care
appointment to veterans seeking health care within 30 days of a request
for an appointment. If a VA facility is unable to meet the 30-day
standard for a veteran, then the VA must make an appointment for that
veteran with a non-VA provider, thereby contracting out the health care
service. The legislation also requires the Secretary of the VA to
report to Congress each quarter of a fiscal year on the efforts of the
VA health system to meet this 30-day access standard.
Access is indeed a critical concern of PVA. The number of veterans
enrolled in the VA is continuing to increase. This is particularly true
as more and more Operation Enduring Freedom/Operation Iraqi Freedom
(OEF/OIF) veterans continue to take advantage of the services in VA.
Likewise, the effort of the administration to expand Priority Group 8
enrollments is increasing the workload.
Unfortunately, funding for VA health care in the past has had
difficulty keeping pace with the growing demand. Even with the passage
of Advance Appropriations and record budgets in recent years, funding
is not guaranteed to be sustained at those levels and PVA is concerned
that contracting health care services to private facilities when access
standards are not met is not an appropriate enforcement mechanism for
ensuring access to care. In fact, it may actually serve as a
disincentive to achieve timely access for veterans seeking care.
Contracting out to private providers will leave the VA with the
difficult task of ensuring that veterans seeking treatment at non-VA
facilities are receiving quality health care.
PVA is also concerned about the continuity of care. If veterans are
shifted between the VA and non-VA facilities each time the imposed
standard is not met, how will this affect the quality of the health
care these veterans receive? This is neither an effective nor efficient
way to supply health care and in the long run may be detrimental to the
veteran. We do think that access standards are important, but we
believe that the answer to providing timely care is in providing
sufficient funding in the first place in order to negate the impetus
driving health care rationing. For these reasons, PVA cannot support
H.R. 84.
H.R. 949 to Improve Collective Bargaining Rights and Procedures
PVA supports H.R. 949 introduced by Chairman Filner that will more
quickly resolve adverse actions and set deadlines for final decisions.
H.R. 1075, the ``RECOVER Act
(Restoring Essential Care for Our Veterans for Effective Recovery)''
PVA strongly supports H.R. 1075, the ``RECOVER Act (Restoring
Essential Care for Our Veterans for Effective Recovery).'' During
periods of major disasters, medical care is as critical as food or
water to protecting the lives and health of those in the affected
disaster area. Ensuring veterans have uninterrupted access to health
care during these periods is critical to their well-being. The ability
of the Secretary of VA to enter into contracts for in-patient care with
non-Department facilities for those veterans who otherwise would
normally be provided care by Department medical facilities only makes
sense. PVA would only caution that this arrangement should not
inadvertently lead to delays in repairing or replacing VA facilities
that may have been damaged during the disaster. VA facilities still
provide a unique form and quality of care that is seldom replicated in
non-VA facilities, particularly for those veterans with special health
needs such as spinal cord injury, blindness and other catastrophically
disabled veterans. Likewise, this contracting authority should not
become the default health care policy for meeting the needs of veterans
in a disaster area.
H.R. 2698, the ``Veterans and Survivors Behavioral Health Awareness
Act'' and H.R. 2699, the ``Armed Forces Behavioral Health Awareness
Act''
PVA supports H.R. 2698, the ``Veterans and Survivors Behavioral
Health Awareness Act'' and H.R. 2699, the ``Armed Forces Behavioral
Health Awareness Act.'' The scholarships and other provisions of H.R.
2698 should increase the number of behavioral health care specialists.
Additionally, we applaud provisions requiring those receiving the
scholarship to serve in Vet Centers. As the increasing numbers of OEF/
OIF veterans continues to grow, the need for behavioral specialists on
Vet Center's staff will also grow. H.R. 2698 may help generate those
additional individuals to meet this need. While the scholarships are
not targeted or reserved for veterans, PVA would encourage VA to market
the scholarship to veterans who will be best able to relate to veterans
visiting the Vet Centers.
PVA also welcomes provisions of both H.R. 2698 and H.R. 2699 which
award grants to non-profit organizations to provide emotional support
to survivors of members of the Armed Forces and veterans in the case of
H.R. 2698 and to members of the Reserves and all family members in the
case of H.R. 2699. This is in keeping with the best traditions of VA in
providing for the widow and orphans of our veterans and all family
members and members of the Reserves who are facing the significant
challenges of multiple OEF/OIF deployments.
Regarding sec. 3 of H.R. 2698 and sec. 2 of H.R. 2699, PVA supports
these provisions of the legislation, but both sections are reflected in
the recent negotiated changes in S. 1963 and as currently amended will
address the specified referral and readjustment counseling issues
making these portions of the legislation no longer necessary should the
amended legislation pass.
H.R. 2879, the ``Rural Veterans Health Care Improvement Act of 2009''
and
H.R. 4006, the ``Rural, American Indian Veterans Health Care
Improvement Act of 2009''
PVA supports H.R. 2879, the ``Rural Veterans Health Care
Improvement Act of 2009'' and H.R. 4006, the ``Rural, American Indian
Veterans Health Care Improvement Act of 2009.'' PVA recognizes that
there is no easy solution to meeting the needs of veterans who live in
rural areas and that Native Americans often face even tougher
challenges. These rural veterans were not originally the target
population of men and women that the VA expected to treat. However, the
VA decision to expand to an outpatient network through community-based
outpatient clinics reflected the growing demand on the VA system from
veterans outside of typical urban or suburban settings. The need to
determine methods to provide for these more dispersed rural veterans is
a challenge. Establishing Centers of Excellence for rural health
research, education and clinical activities may be a way to develop
better ideas for rural veteran care and help shed light on how best to
provide services in rural areas. Together with the demonstration
projects outlined in section 5, a path may be identified to provide a
greater level of health care for rural veterans.
However, while these paths may show promise, they should still all
fit within policies that promote the use of VA facilities and should
not be used as a method or course to eliminate VA facilities in rural
areas. While all these ideas are welcome, the greatest need still is
for qualified health care providers to be located in rural settings.
Only significant incentives and opportunities for these professionals
will bring them to these often remote areas. In fact, the expansion of
VA facilities may be the best way to care for special needs veterans
that seldom have the types of critical care services that they need in
rural areas. We must be sure that veterans most in need of specialized
care, provided best by VA, are not sacrificed to efficiencies
discovered through these programs.
PVA also applauds the provisions of H.R. 2879 on travel
reimbursement and transportation grants. Mobility, in particular for
those with disabilities, is often the greatest challenge to care in a
rural environment. Providing greater transportation benefits will allow
veterans a better chance of receiving health care without a
disproportionate cost often associated with the long distances traveled
in rural areas. Both reimbursement and transportation grants are
included in the recent negotiated changes in S. 1963 as currently
amended address these issues. We believe this portion of the
legislation would no longer be necessary should the amended legislation
pass.
PVA also supports the provisions of H.R. 2879 for helping our
Native American veterans through provisions for a program of
readjustment and mental health care services to veterans who have
served in OEF/OIF. PVA also supports the provisions of H.R. 4006 and
H.R. 2879 which helps our Native American veterans by establishing
Indian Veterans Health Care Coordinators. Improving outreach to this
underserved population as well as expanding access and participation by
VA, the Indian Health Service and tribal members in the Department of
Veterans Affairs Tribal Veterans Representative program may help to
bring a larger number of Native American veterans into the health care
system. Together with the integration of electronic health records in
the Indian Health Service and the authority to transfer surplus VA
medical and information technology equipment, Native American veterans
will have better access and a higher quality of health care.
H.R. 3926, the ``Armed Forces Breast Cancer Research Act''
PVA strongly supports H.R. 3926, the ``Armed Forces Breast Cancer
Research Act.'' Recent U.S. military conflicts, as happened with
Operations Desert Storm/Desert Shield, have demonstrated that members
of the military deployed to foreign areas often are exposed to agents,
chemicals and environments detrimental to their health. In many cases,
these exposures may have long-term health effects not identified during
a post deployment medical examine. With the growing number of women
that comprise members of the Armed Forces, and their increasing
involvement in forward operating areas and combat activities, it only
makes sense to examine the potential increased risk of breast cancer
among this population.
Draft Legislation to ``Improve Continuing Professional Education,''
``Waive Certain Requirements Relating to Mental Health Counselors,''
and
``Make Improvement to Performance Pay and Collective Bargaining
Rights''
PVA supports the draft legislation to raise the reimbursement rate
for health professionals from $1,000 to $1,600. In addition, PVA
cautiously supports the legislation to waive certain requirements
relating to mental health counselors, but want to ensure that this is
done only in the circumstances that will benefit VA health care and in
no way be detrimental to veterans served by a counselor whose license
or certification requirement has been waived.
Regarding collective bargaining, PVA generally supports the
provisions of the draft legislation that would improve the collective
bargaining rights and procedures for certain health care professionals
in the VA. These changes may be a positive step in addressing the
recruitment and retention challenges the VA faces to hire key health
care professionals, particularly registered nurses (RN), physicians,
physician assistants, and other selected specialists.
As we understand current practice, certain specific positions
(including those mentioned previously) do not have particular rights to
grieve or arbitrate over basic workplace disputes. This includes
weekend pay, floating nurse assignments, mandatory nurse overtime,
mandatory physician weekend and evening duty, access to survey data for
setting nurse locality pay and physicians' market pay, exclusion from
groups setting physicians' market pay, and similar concerns. This would
seem to allow VA managers to undermine Congressional intent from law
passed in recent years to ensure that nurse and physician pay are
competitive with the private sector and to ensure nurse work schedules
are competitive with local markets.
Interestingly, given the VA's interpretation of current laws, these
specific health care professionals are not afforded the same rights as
employees who they work side-by-side with everyday. For instance,
Licensed Practicing Nurses (LPN) and Nursing Assistants (NA) can
challenge pay and scheduling policies, while RN's cannot. This simply
makes no sense to us.
VA must work with their employees to achieve a less hostile work
relationship, but any changes or modifications on either side of the
issue must first address the care of veterans. Furthermore, this care
should not be used as a rallying cry on either side as an argument for
their position. Veterans deserve better.
PVA appreciates the opportunity to comment on the bills being
considered by the Subcommittee. I would be happy to answer any
questions that you might have. Thank you.
Prepared Statement of Eric A. Hilleman, Director,
National Legislative Service, Veterans of Foreign Wars of the United
States
MR. CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE:
On behalf of the 2.1 million men and women of the Veterans of
Foreign Wars of the U.S. and our Auxiliaries, I want to thank you for
the opportunity to testify at today's legislative hearing. Before us is
a wide range of health care related bills, all of which would make
improvements to the system that benefits America's veterans.
Draft Bill for Continuing Education of VHA Staff
The VFW supports this bill, ``to improve the continuing
professional education reimbursement provided to health professionals
employed by the Department of Veterans Affairs.'' Currently, only full-
time board certified physicians and dentists are eligible for $1,000
annually for continuing professional education. This bill would
increase the annual continuing education reimbursement from $1,000 to
$1,600 annually, and bar any potential duplicate compensation from
medical centers. Further, it would expand the eligible professions from
physicians and dentists to also include podiatrists, chiropractors,
optometrists, registered nurses, physician assistants, and expanded-
function dental auxiliaries. We urge further expansion of this
legislation to include education reimbursement for other health care
professionals such as mental health.
The VA has built a reputation for being an innovator in research
and a teaching institution. We are encouraged to see emphasis placed on
continuing education for medical professionals. Ongoing education of
VHA staff will help to keep VA a leader in providing high quality
medical care and attract staff that are inclined toward constant
improvement.
Draft Bill to Improve Performance Pay and Bargaining Rights
This draft legislation would further clarify performance pay
awarded to physicians and dentists. Existing law does not specify that
performance pay can only be awarded based on an individual performance.
This has led to performance rewards ambiguity. The VFW supports this
bill.
Draft Bill, Waving Requirements for Mental Health Counselors
The VFW opposes this legislation to allow the Secretary to wave
licensure or certification requirements. The VA may be facing shortages
of mental health professionals, but we believe making exceptions in
lieu of valid state-issued certifications undermines the quality of
care and the confidence that veterans have in speaking with VA mental
health professionals. State licensure and certification, demonstrates
that an individual meets the state requirements in the areas of
prerequisite education, and knowledge, and is culpable under the law
for malpractice or abuse of the unique trust placed in their position.
H.R. 84, the Veterans Timely Access to Health Care Act
The VFW supports the intent of the ``Veterans Timely Access to
Health Care Act,'' but we cannot support this bill. This legislation
would require the VA Secretary to contract care for any veteran who
would have to wait 30 days or more for primary care. The VFW has
supported guaranteed access standards for VA Health Care for a number
of years--but we remained concerned about quality and cost of contract
care.
The VFW shares the desire to see all veterans have timely access to
high-quality VA health care, which has been and continues to be our
highest legislative priority. We feel, however, that this legislation
would create more problems than it would fix. We must be mindful of the
unintended consequences of the legislation.
With the advent of advanced appropriations, VA now has the capacity
to ensure that it can properly plan for and manage these dollars
efficiently. Additionally, on-time funding should allow VA to recruit,
hire and train doctors, nurses and other health care providers,
ensuring that VA has sufficient staff to keep up with demand. Congress
has made great strides in improving the funding stream for veterans'
health care--for which the VFW applauds your efforts--but a greater
attention is needed to ensure those health care dollars are spent
appropriately at each medical facility.
We strongly support the reporting requirements of H.R. 84. The
reporting mechanisms on wait times would help gain more accurate
insight into hard numbers, which are always more informative than
anecdotal statistics. Better numbers would allow us to understand the
problem as well as see which areas are having difficulties.
H.R. 949
This bill addresses VA employee's collective bargaining rights.
Specifically, it repeals specified exceptions to rights of certain
Department of Veterans Affairs (VA) employees to engage in collective
bargaining. There by, allowing increased negotiation between VA
employees and the VA Secretary on items such as professional conduct,
competence and determination of employee compensation. It further
requires a VA final decision with respect to the review of an adverse
personnel action against an employee to be issued no later than 60 days
after such action has been appealed. Subjects such decision to judicial
review in the appropriate U.S. District Court or, if the decision is
made by a labor arbitrator, in the U.S. Court of Appeals for the
Federal Circuit. The VFW has no position on this legislation.
H.R. 1075
This bill would require the VA Secretary to seek outside contacts
in the event a VA hospital is closed for greater than 180 days due to a
national disaster. Currently, when VA hospitals are closed, veterans
must travel long distances to other VA facilities, which may be
impractical or impossible following a disaster. This bill would ensure
that the VA secures alterative arrangements for local medical care, to
include non-emergency care and inpatient medical care services as
required.
The VFW supports this legislation. However, we feel 180 days is far
too long for a veteran to wait for servicers. We urge the Veterans
Affairs Committee to hold hearings evaluating the VA's current disaster
contracting provisions. Allowing a veteran to wait 180 days for medical
care is unacceptable. Contracts to provide health care must be in place
before a VA hospital shutters its doors due to natural disaster. The
VFW believes plans need to be implemented immediately in the event of a
disaster.
H.R. 2698, the Veterans and Survivors Behavioral Health Awareness Act
VFW is pleased to support this critical legislation to improve
mental health care services for veterans and members of the Armed
Forces and their survivors. This bill recognizes that many of today's
war wounds are invisible wounds--which often take months to appear,
making the transition our service men and women face more difficult. We
believe that this bill is a good first step in making positive changes
for those suffering the invisible wounds of war.
Section 2 of the bill concerns Vet Centers. The VFW is a strong
supporter of Vet Centers and their approach to providing mental health
care to veterans. VA has done a good job expanding their reach, but
they are victims of their own success. Many Vet Centers are struggling
with difficult workloads as increasing numbers of veterans turn to them
for the unique services they provide. Provisions provided in section 2
would give some relief by offering scholarship programs for individuals
seeking education and training in health care specialties needed by the
Vet Centers. Finding qualified mental health professionals is a
challenge for VA, and the more incentives they can provide potential
employees, the more likely that these men and women will turn to VA as
their employer of choice.
Section 3 would require VA to help seek outside counseling services
for veterans who are otherwise not authorized to receive care through
VA. Many discharged OEF/OIF veterans who are beyond the 5-year dead
line of access to VA do not have access to counseling, so this is
clearly the right thing to do.
Section 4 would allow VA to provide grants to nonprofit
organizations that provide support for survivors of deceased
servicemembers and veterans. Family members may not know where to go to
seek help, and we believe that VA can help point them in the right
direction.
H.R. 2699, the Armed Forces Behavioral Health Awareness Act
This legislation would offer OEF/OIF veterans counseling services
at Vet Centers before they separate from the military. VFW supports all
the provisions of this bill.
Section 2 expands mental health services and counseling to active
duty forces and those in the Reserve Components. VFW believes this
change is important for two reasons. First, military mental health
services come with a stigma. That has been shown repeatedly to be the
greatest impediment to men and women seeking care. By allowing
servicemembers to seek care without fear of reprisal or reporting
relieves an emotional burden that can and would otherwise have a
serious impact on their career. The second reason is that the military
does not have a sufficient number of mental health care providers.
While this legislation does not absolve the military of their
responsibility to properly care for these men and women while in
service, it helps fill in the gaps in care that are often not there
when our servicemembers need it.
Section 3 would require DoD to provide grants to nonprofit
organizations that provide support for survivors of deceased
servicemembers and veterans. This provision is similar to the provision
offered in H.R. 2698. It allows DoD to expand its counseling base and
go beyond the limited services provided by the military's casualty
assistance officers, which can help ease the burden on these families
at a most difficult time in their lives.
Section 4 would require the Secretary of the Army to carry out a
pilot program in three locations to improve PTSD awareness among
members. The alarming rate of veterans and those on active duty
suffering from mental stress has been well-documented. Providing an
environment to study the neurophysiological and psychological effects
associated with the stress and trauma of combat is critical to today's
Armed Forces. With repeated deployments affecting servicemembers and
their families, this pilot program would begin to address some of the
key factors in identifying and addressing PTSD, as well as helping
those involved reintegrate back into civilian life.
H.R. 2879, the Rural Veterans Health Care Improvement Act of 2009
VFW supports this comprehensive bill aimed at improving care to
veterans living in rural areas across the country. We applaud the
provisions in the bill that would increase the travel reimbursement
rate to 41.5 cents a mile when they travel to VA facilities for
treatment, as well as language authorizing VA to establish a grant
program to provide innovative transportation options to veterans in
rural areas. The $50,000 grant to state veterans' service agencies and
veterans' service organizations goes a long way toward helping rural
veterans--oftentimes, getting to and from appointments is the largest
hurdle to care.
The bill would also allow the VA Secretary to carry out
demonstration projects to examine the feasibility and advisability of
alternatives for expanding care to veterans in rural areas. The VA
would establish partnerships with the Department of Health and Human
Services, Centers for Medicare and Medicaid Services, Indian Health
Services, and other programs to examine the best way to extend care to
these veterans. The VFW believes that VA should explore all avenues of
telemedicine for care of veterans in rural areas.
It would increase care to OEF/OIF veterans and their families by
allowing VA to establish programs to provide peer outreach and support
services. VA would be authorized to contract with community mental
health centers and/or other qualified entities offering readjustment
services in areas where those services are not adequately provided.
Further, it would establish training goals with nonprofit mental health
organizations by utilizing other veterans in providing peer outreach
and peer support in their communities. Offering readjustment services
and counseling where the servicemembers and families live is something
the VFW believes is critical to the well-being of our servicemembers
and their families.
The Rural Health Care and Improvement Act would allow the VA
Secretary to establish centers of excellence for rural health research,
education and clinical activities. These centers would research the
availability of health services in rural areas and develop specific
models for furnishing those services to veterans in rural areas.
Section 7 of the bill--Indian Veterans Health Care Coordinators,
would direct VA to employ an Indian Health Care Coordinator at 10 VA
medical centers that serve communities with large Indian populations.
This provision is the same as language found in H.R. 4006, which we
will comment on in that section of our testimony.
Last, H.R. 2879 would require the VA Secretary to submit an annual
report to Congress on the implementation of the provisions of this bill
and any amendments. VFW looks forward to the enactment of this bill to
improve the quality and access to care for veterans in rural areas.
H.R. 3926, the Armed Forces Breast Cancer Research Act
The VFW strongly supports a joint study between VA and DoD into the
occurrence of breast cancer among members of the Armed Forces. Breast
cancer remains the second leading cause of death among women, and the
rate of incidence for men have remain steady according to the American
Cancer Society. This bill would for require VA and DoD to provide
information on the number of servicemembers and veterans--male and
female--who have been diagnosed with breast cancer, the treatment they
have received and demographic information about their age and service.
The report, which would be provided to Congress in 18 months, would
also address whether Defense and VA officials see any service-related
breast cancer risk or patterns. VFW encourages immediate passage of
this bill and looks forward to reviewing the report to ensure those
veterans affected receive the proper medical services they earned.
H.R. 4006, Rural, American Indian Veterans Health Care Improvement Act
of 2009
VFW supports this bill which would improve care to American Indian
veterans. H.R. 4006 would create an ``Indian Veterans Health Care
Coordinator'' for 10 VA medical centers that serve the greatest number
of Indian veterans per capita. This coordinator would improve outreach
to tribal communities, coordinate the medical needs of Indian
reservations, and expand the access and participation of VA in the
Department of Veterans Affairs Tribal Veterans Representative program.
The bill would also require the VA and Department of the Interior
to enter into a Memorandum of Understanding to ensure the electronic
transfer of health records of Indian veterans between Indian Health
Service (HIS) and VA facilities. VA would also be authorized to
transfer to HIS any surplus medical and information technology
equipment.
This bill would also require VA and the Department of Health and
Human Services to report jointly to Congress on the advisability of the
joint VHA-IHS establishment and operation of health clinics to serve
eligible populations on Indian reservations.
Prepared Statement of Joy J. Ilem,
Deputy National Legislative Director, Disabled American Veterans
Mr. Chairman, Ranking Member Brown, and Members of the
Subcommittee:
Thank you for inviting the Disabled American Veterans (DAV) to
testify at this legislative hearing of the Subcommittee on Health. We
appreciate the Subcommittee's leadership in enhancing the Department of
Veterans Affairs (VA) health care programs on which many service-
connected disabled veterans must rely, and we also appreciate the
opportunity to offer our views on the eight bills and three draft
measures under consideration by the Subcommittee today.
H.R. 84--Veterans Timely Access to Health Care Act
The stated goal of this bill is to provide timely access to VA
health care. To accomplish this objective, a 30-day standard would be
established as the maximum time that a veteran would be required to
wait to receive a VA primary care appointment. The bill would also
direct VA to establish a standard for the maximum length of time that a
veteran would be required to wait to actually see a provider on the day
of a scheduled appointment. Under the bill, if the Secretary found that
any particular VA geographic service area failed to substantially
comply with the timeliness standards, facilities in that area would be
required to contract for the care of a veteran in each instance it was
unable to meet those standards. The contracting requirement would be
mandatory for veterans who are classified within enrollment Priority
Groups 1 through 7 and discretionary for those within Priority Group 8.
The bill would require the Secretary to carry out a one-time
examination of waiting time data for the entire VA health care system,
stratified by geographic service area. The Secretary would be required
to issue a determination regarding compliance with the standard in each
geographic service area. If the compliance rate for any area were below
90 percent, facilities located in that area would be subjected to the
requirement to contract for care whenever they were unable to meet
those standards. Facilities with a compliance rate of 90 percent or
more would be prohibited from contracting out such services.
Under the bill, VA would be required to submit two reports to the
Committees on Veterans' Affairs. The first would be an annual report
providing an assessment of its performance in meeting the timeliness
standards. The second report would be made quarterly, and would include
detailed waiting-time data for each geographic service area. The bill
would require quarterly reports to include the number of veterans in
each geographic service area waiting for care, distinguished by primary
care and specialty care, and segregated periodically by those waiting
from under 30 days to those waiting over a year, plus those who cannot
be scheduled at all. The quarterly reporting requirement would continue
through December 2010.
The bill provides that payments under these contracts could not
exceed the reimbursement rates under Medicare, and the non-VA
facilities or providers would be prohibited from billing veterans
affected by this process for the difference between the billed amounts
and the amounts of VA payments.
Mr. Chairman, we note similar bills, H.R. 3094 from the 108th
Congress and H.R 92 from the 110th Congress, were considered by this
Subcommittee in prior legislative hearings. The historical context
during which the first bill was introduced is best described by then-VA
Secretary Anthony J. Principi's reference to a ``perfect storm''
related to significantly increased demand for care and insufficient
resources to meet timely access for that demand, resulting in a backlog
or waiting list for access to VA medical services. Between October 1,
2001 and September 2002, VA enrolled an additional 830,237 veterans.
With years of insufficient funding and an overwhelming demand for VA
medical care, a July 2002 survey conducted by the Veterans Health
Administration (VHA) revealed over 310,000 veterans waiting for medical
appointments, half of whom were reported to be waiting 6 months or more
for care and the other half having no scheduled appointments at all. In
January 2003, over 200,000 were waiting 6 months or longer. At that
time, exercising its annual enrollment decision authority as required
by Public Law 104-262, VA suspended the enrollment of new Priority
Group 8 veterans.
While DAV and many others opposed this decision on the record, we
understood the reasons for it--clearly, VA was struggling from severe
underfunding across its health care programs. The run-up to that
decision also fueled our determination at DAV to seek a legislative
remedy for VA's flawed health care budget formulation and discretionary
appropriations processes.
On September 30, 2003, your Subcommittee held a legislative hearing
on H.R. 3094 (a similar version of the current bill), at a time when
about 130,000 veterans were still waiting 6 months or longer for access
to VA care. DAV testified at that hearing that veterans must have
access to timely health care and that VA must be held accountable for
meeting its own access standards. However, we were deeply concerned
that this bill to contract care in order to meet its proffered access
standards would ultimately shift medical services and veteran patients
from VA to private providers. The effect of contracting out care to
non-Department facilities and providers would encourage VA to refer
patients, and the dollars that would underwrite their care outside a
unique governmental system of care specifically created for veterans to
meet their specialized health needs. We testified at that time that if
given sufficient, timely and predictable funding, VA should be held
accountable for meeting all its demands, and that only as a last resort
would we support the broad contracting out of their medical care.
On April 26, 2007, DAV's testimony on H.R. 92 (another similar bill
to this one) recounted our position on H.R. 3094 from the 108th
Congress and included the need for consideration in the bill to
reinforce that VA must have a comprehensive, systemic process for
contracting care to ensure:
care is safely delivered by certified, licensed,
credentialed providers;
continuity of care is sufficiently monitored, and that
patients are properly directed back to the VA health care system
following private care;
veterans' medical records accurately reflect the care
provided and the associated pharmaceutical, laboratory, radiology and
other key information relevant to the episode(s) of care; and
the care received is consistent with a continuum of VA
care.
Therefore, we recommend the Subcommittee consider amending H.R. 84
to first implement the data requirements and reports required in the
current measure prior to further considering approving provisions in
the bill to automatically contract for care if the stated access
standards would not be met. Over the past several years we believe VA
has made tremendous effort to significantly reduce waiting times,\1\
and thanks to the work of the Members of this Subcommittee VA now has
the opportunity to receive timely, sufficient, and predictable funding
for VA medical care through advance appropriations (Public Law 111-81).
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\1\ Fiscal Year 2009 Performance and Accountability Report,
Department of Veterans Affairs, Office of Management. Washington, D.C.
www.va.gov/budget/report.
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In addition, DAV remains concerned about two weaknesses affecting
the impact of H.R. 84, if enacted. Despite our recommendations in The
Independent Budget (IB) over several years, VA has yet to establish a
comprehensive, systemic program of contract care coordination to ensure
that the services veterans receive in the private sector, paid for by
VA, do not represent a diminished quality of care that they would have
received otherwise from the VA.\2\ Our second concern questions the
validity of the reportable data for waiting times. DAV has raised this
unresolved issue in concurrence with a report by the VA Office of
Inspector General.\3\ Finally, we note the bill does not seek to
identify the underlying cause(s) for delays in access to care, an issue
that is critical to VA's developing an effective solution.
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\2\ The Independent Budget, Fiscal Year 2011; Contract Care
Coordination, Non-VA Purchased Care; & Timely Access to VA Health Care.
www.independentbudget.org/.
\3\ Department of Veterans Affairs, Office of Inspector General;
Semiannual Report to Congress, October 1, 2008-March 31, 2009; pg. 10.
http://www4.va.gov/oig/pubs/VAOIG-SAR-2009-1.pdf.
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H.R. 949--To Improve the Collective Bargaining Rights and Procedures
for
Review of Adverse Actions of Certain Employees of the Department of
Veterans Affairs, and for Other Purposes
This bill would repeal specified exceptions to rights of certain VA
health professional employees to engage in collective bargaining over
conditions of employment. It would also require reviews of adverse
personnel actions of VA employees be completed within 60 days after
such actions have been appealed, and would permit judicial review of
these final decisions by the appropriate U.S. District Court or, if a
decision were made by a labor arbitrator, review would occur within the
jurisdiction of the U.S. Court of Appeals for the Federal Circuit in a
manner similar to processes of the Merit Systems Protection Board in
reviewing decisions related to Federal employees under title 5, United
States Code.
Mr. Chairman, this bill would restore bargaining rights for
clinical care employees of the VHA that have been eroded over the past
several years. A similar version of this bill was introduced in both
Chambers in the 110th Congress but did not advance.
DAV did not receive an adopted resolution from our membership on
the specific VA labor-management dispute that prompted Chairman
Filner's introduction of this bill. However, as a partner organization
of the IB, DAV endorses its recommendations dealing with the need for
VA to improve its human resources management systems and programs to
make VA a better workplace for the care of sick and disabled veterans.
Also, we believe VA-recognized labor organizations that represent
employees in bargaining units within the VA health care and benefits
systems have an innate right to information and reasonable
participation that result in making VA a workplace of choice (a stated
longstanding VA strategic goal), and particularly to fully represent VA
employees on issues impacting their working conditions, ultimately
protecting the quality of care for veterans.
Congress passed section 7422, title 38, United States Code (USC),
in 1991, in order to grant specific bargaining rights to labor in VA
professional units, and to promote effective interactions and
negotiation between VA management and its labor force representatives
concerned about the status and working conditions of VA physicians,
nurses and other direct caregivers appointed under title 38, USC. In
providing this authority, Congress granted to VA employees and their
recognized representatives a right that already existed for all other
Federal employees appointed under title 5, USC. Nevertheless, Federal
labor organizations continue to report that VA has severely restricted
the recognized Federal bargaining unit representatives from
participating in, or even being informed about, human resources
management decisions and policies that directly impact conditions of
employment of the VA professional staffs within these bargaining units.
We are advised by labor organizations that when management actions are
challenged, VA officials (many at the local level) have used
subsections (b), (c) and (d) of section 7422--subsections that this
bill would repeal--as a statutory shield to obstruct any labor
involvement to correct or ameliorate the negative impact of VA's
management decisions, even when management is allegedly not complying
with clear statutory mandates (e.g., locality pay surveys and
alternative work schedules for nurses, physician market pay
compensation panels, etc.).
Facing VA's refusal to bargain or to discuss the fairness of these
policies, the only recourse available to labor organizations is to seek
redress in the Federal court system. However, recent case law has
severely weakened the rights of title 38 appointees to obtain judicial
review of arbitration decisions. Title 38 employees also have fewer due
process rights than their title 5 counterparts in administrative
appeals hearings.
It appears to DAV that the often contentious local environment
consequent to these disagreements could diminish the VA as a preferred
workplace for many of its health care professionals. As a result,
veterans who depend on VA and who receive care from VA's physicians,
nurses and others in the professional ranks can be negatively affected
by that environment.
We believe this bill, that if enacted would rescind VA's claimed
authority to refuse to bargain on matters within the purview of section
7422, through striking of subsections (b), (c) and (d), would clarify
other critical appeal and judicial rights of title 38 appointees, and
would return VA and labor to a more balanced bargaining relationship on
issues of importance to VA's professional workforce. In past hearings
before this Committee, VA clearly has indicated vigorous disagreement
with the intent of the bill, but to date has not offered to compromise
its position in refusing to bargain across a wide group of issues that
are defined by VA as ``direct patient care.'' Given the continuing
stalemate, our only recourse is to support the intent of the bill in
the spirit of the recommendations we have made in the IB, yet continue
to urge both VA and Federal labor organizations to seek and find a
basis for compromise on these matters.
H.R. 1075--RECOVER Act
(Restoring Essential Care for Our Veterans for Effective Recovery)
In the event of a declared major disaster, on or after August 29,
2005, where a VA medical facility is unable to provide covered health
care services for at least 180 days due to the disaster, this measure
would direct VA to contract with one or more non-VA facilities in that
area to provide such services to veterans who reside within 150 miles
of the affected VA facility(s). The requirement would not be applicable
to VA facilities that were closed, or were intended to be closed as
part of the Capital Asset Realignment for Enhanced Services (CARES)
process.
Nearly 4 years after Hurricane Katrina, the House Veterans' Affairs
Committee conducted a field hearing on July 9, 2009, in New Orleans,
Louisiana, to explore the challenges faced by the VA and other local
health care facilities to provide high quality safe health care to area
veterans and citizens. Believing geographic and timely access to care
is particularly important to disabled veterans in need of medical
attention, DAV testified that our Nation owes it to our veterans to
properly care for them now--and not keep them waiting.
Prior to and during the disaster, VA did an admirable job of
ensuring veteran patients were expeditiously evacuated, relocated and
kept safe, and that local veterans' medical records were available to
other VA medical facilities to meet immediate needs for medications and
specialized care. However, over the last 4-plus years, VA has struggled
to re-establish comprehensive care services in the area following the
devastating effects of Hurricane Katrina, and ensuring the immediate
health care needs of our veterans are met without undue hardship. The
network of community-based outpatient clinics and deployment of mobile
clinics have created capacity to meet veterans' basic outpatient
primary care needs; however, reports from many affected veterans
indicated that if hospitalization or inpatient treatment in a tertiary
care facility were necessary, they must still travel great distances to
the nearest VA health care facilities that can provide their needed
care. For some elderly, ill, brittle and disabled veterans this creates
a travel hardship. In addition, family members are often unable to
accompany veterans due to travel restrictions, given the cost of travel
without financial assistance for subsistence or lodging. Of note,
research has proven that family support during hospitalizations and
recovery, or during difficult or stressful medical procedures can
assist with accelerating recovery time and lowering length of stay,
both resulting in cost savings for the VA.
This Subcommittee is aware of DAV's position regarding contracting
care, specifically that it be utilized judiciously by VA. Current law
places limits on VA's ability to contract for private health care
services in instances where VA facilities are incapable of providing
necessary care to a veteran; when VA facilities are geographically
inaccessible to a veteran for necessary care; when medical emergency
prevents a veteran from receiving care in a VA facility; to complete an
episode of VA care; and for certain specialty examinations to assist VA
in adjudicating disability claims. VA also has the authority to
contract to obtain the services of scarce medical specialists in VA
facilities.
Hurricane Katrina impacted all of the major medical facilities in
the immediate city area affected and we understand most are still not
operational. However, in retrospect, it seems possible that VA could
have established more contracts with other medical facilities just
outside the affected city area. DAV is concerned that VA sparingly used
existing authority in the instance of this major disaster, to contract
with local non-VA facilities in the region to provide inpatient care
but rather required veterans who were sick and in need of inpatient
care to make long trips to the nearest VA facility in many cases.\4\ We
do not believe such actions are in the best interest of sick and
disabled veterans who rely on VA, nor are they an acceptable standard
in this instance, given the length of time it has taken to reestablish
and rebuild new VA facilities in that location. We hope, in considering
this bill, the Subcommittee will note that within mere weeks of the
disaster, Congress provided billions of dollars to restore the Gulf
Coast region. Those funds and mandates failed to include mandates for
replacement of the destroyed VA medical centers in New Orleans and
Gulfport. While Congress eventually acted to authorize the funds and
projects to replace these facilities destroyed by the storm, nearly 5
years after Katrina, sick and disabled veterans still await the opening
of the replacement facilities.
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\4\ Travel times and distances from the New Orleans VAMC to: Biloxi
VAMC--1.5 hours/85 miles; Sonny Montgomery (Jackson) VAMC--3 hours/189
miles; Alexandria VAMC--3.5 hours/199 miles; the Michael E. DeBakey
(Houston) VAMC--6 hours/352 miles; Overton Brooks (Shreveport) VAMC--
5.5 hours/319 miles.
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The delegates to our most recent National Convention passed DAV
Resolution No. 037, calling on VA to ensure timely access to quality
health care and medical services. We therefore support the purposes of
this bill as a contingency, but point out concerns that we recommend be
addressed before final passage. The operational loss of a VA medical
facility due to a major disaster and subsequent contracting with non-VA
facilities as proposed by this measure should not become a foundation
for delay of replacement facilities, or repair of the affected VA
facility. Also, the bill should reflect Congressional intent that upon
the completion of replacement or repair of an affected VA facility,
veterans who have received care under a contract arrangement with a
non-VA facility will return to the repaired or replaced VA facilities
for their continuing health care needs. Accordingly, we recommend
improvements outlined in DAV Resolution No. 232 (on the need for better
coordination of VA contract care programs), to include ensuring that
service-connected disabled veterans would not be financially encumbered
in receiving non-VA care at VA's expense; and that VA would establish a
systemic, comprehensive contract care coordination program for these
patients.
H.R. 2698--Veterans and Survivors Behavioral Health Awareness Act
The intent of this measure would improve and enhance the mental
health care benefits available to veterans as well as to enhance
counseling and other benefits to survivors of veterans.
Section 2 of this bill would direct the VA Secretary to provide
scholarships to individuals pursuing education or training leading to
licensure or other certified proficiency in behavioral health care
specialties that are critical to the operations of Vet Centers for
readjustment counseling and related mental health services for
veterans. These scholarships would assist in recruitment and in
retaining individuals within such specialties. In order to accept
scholarships, the recipients would agree to continue to serve in such a
capacity for defined periods the Secretary specified in agreements--
including repayment of the scholarships if encumbered individuals
subject to these scholarships failed to fulfill the service
requirements of the aforementioned agreements. The VA Secretary would
determine the amount of the scholarships and amounts under the program
would be derived amounts available to the Secretary for readjustment
benefits--but would not exceed $2 million in any fiscal year (FY).
Section 3 of this bill would stipulate that upon receipt of a
request for counseling from an individual discharged or released from
active service, but who would not be otherwise eligible for such
counseling, the Secretary would be required to (1) provide referrals to
assist the individuals in obtaining mental health care and services
outside the VA to extent practicable; and (2) if pertinent, would
advise such individuals of their rights to apply for review of their
military discharge documentation.
Section 4 would direct the Secretary to award grants to nonprofit
organizations that provide emotional support services for survivors of
deceased members of the Armed Forces (including National Guard and
Reserves) and deceased veterans through peers of such survivors. The
Secretary would establish the criteria for nonprofit organizations'
eligibility through an application process to be specified by the
Secretary as well as the amounts for such awards.
While the DAV has no specific resolution pertaining to section 2 of
the measure, related to scholarships, we have two national resolutions
that apply to the main intent of this section of the bill. The first is
DAV's resolution number 101, which calls for adequately funding and
sustaining the successful readjustment counseling services of the VA
and its highly effective Vet Center programs. The second DAV resolution
is number 243, which strongly supports program improvement and enhanced
resources for VA mental health programs to achieve readjustment of new
war disabled veterans and continued effective mental health care for
all enrolled veterans needing such services.
In addition, the FY 2011 IB contains a section on human resources
challenges facing VA. We remain concerned about the current status of
human resources challenges faced in the VA and the need to consider
creative and alternative programs to ensure veterans have access to the
best medical and mental health services for rehabilitation of their
service-related injuries. We have recommended that Congress and VA
continue to work to strengthen and energize VA's human resources
management programs to recruit, train, and retain qualified VA
employees and to identify new tools to enable VA to gain equality with
other employers in attracting a new generation workforce for veterans.
Therefore, since the intent of the section is to recruit and retain
mental health care providers at VA's Vet Centers, we support enactment
of this section of the bill.
DAV has no objection to the provisions in section 3 of H.R. 2698
related to referrals to assist individuals, who are not otherwise
eligible for Vet Center counseling services, in obtaining mental health
care and services outside the VA or to advise such individuals of their
rights to apply for review of their military discharge determinations.
The DAV does not have a specific resolution related to section 4 of
the bill that pertains to Federal funding through a grant program for
nonprofits to provide emotional support through peer groups to
survivors of deceased servicemembers and veterans. We do support the
peer-to-peer initiatives that have been employed in the VA's Vet Center
program. However, DAV would not be able to participate in the program
that would be authorized in this section of the bill because, as a
matter of principle, DAV does not accept federally appropriated grants
to provide services to disabled veterans.
H.R. 2699--Armed Forces Behavioral Health Awareness Act
The purpose of this measure would be to improve the mental health
care benefits available to members of the Armed Forces, including
Reserve components, and to enhance counseling available to
servicemembers' family members.
Section 2 of this measure would make any servicemember of the Armed
Forces who deploys in support of Operations Enduring Freedom or Iraqi
Freedom (OEF/OIF) eligible for readjustment counseling and related
mental health services through VA Vet Centers, regardless of the
member's duty status.
Section 3 would require that the Secretary of Defense award grants
to nonprofit organizations that provide emotional support services for
family members of members of the Armed Forces, including members of the
Reserve components. The amount of each grant and duration of the
program would be determined by the Secretary based on the scope of the
proposed program. Such funding would be derived from the amounts
authorized to be appropriated to the Department of Defense (DoD) for
military personnel.
Section 4 would require the Secretary of the Army to carry out a 3
year pilot program to enhance awareness and understanding of post
traumatic stress disorder (PTSD) among members of the Army at three
military base locations: Fort Huachuca, Arizona, Fort Carson, Colorado,
and Fort Leonard Wood, Missouri, and for the family members of
servicemembers covered under the bill in order to assist the families
in recognizing and addressing PTSD. No later than 2 years after the
date of enactment, the DoD Secretary would be required to submit a
report to Congress assessing the effectiveness of the pilot program.
DAV takes no position on provisions in H.R. 2699 related to
enhancement of post-deployment mental health services for active duty
servicemembers, Reserve components or their family members. These
matters are under the jurisdiction of the Committees on Armed Services.
We do provide the following comments on section 2 of the bill related
to expansion of eligibility of readjustment counseling services at Vet
Centers under section 1712 A of title 38, United States Code.
DAV's resolution number 243 strongly supports program improvement
and enhanced resources for VA mental health programs to achieve
readjustment of new war disabled veterans and continued effective
mental health care for all enrolled veterans needing services. Although
we do not have a resolution specific to expanding eligibility for Vet
Center services to active duty status servicemembers, we have supported
seamless transition for servicemembers and veterans and improved
collaboration between the two Departments to achieve this goal.
Therefore, we have no objection to such expansion, since it would
likely be most beneficial for certain servicemembers to obtain early
interventions of any deployment-related mental health concerns to avoid
more complicated health challenges and costly treatment interventions
at a later date. We note similar provisions are included in Title IV of
the proposed negotiated agreement on an omnibus VA health care bill,
the vehicle for which will be S. 1963, the Caregivers and Veterans
Omnibus Health Services Act of 2010.
Should the Subcommittee plan to report this measure to the full
Committee, we ask you to consider amending section 2 of the bill to
include provisions to authorize either a cost sharing agreement with
DoD, as envisioned in Public Law 97-174, to cover the VA's costs of
servicemembers' care based on data verifying the number of
servicemembers who access such counseling, or to authorize additional
VA resources in the bill specifically for this care of the active
force, as well as the cost of the additional staff needed to provide
such services. Additionally, consideration should be given to include
provisions to provide proper outreach to active servicemembers about
this exceptional service and assured confidentiality when accessing
such care at a VA Vet Center, to ensure the intended purpose of the
program is achieved.
H.R. 2879--Rural Veterans Health Care Improvement Act of 2009
Section 2 of this bill would amend section 111, title 38, USC, to
insert a fixed rate of 41.5 cents per mile in reimbursement for the
purposes of VA's travel beneficiary program. Reimbursement at this rate
may exceed the cost of travel by public transportation regardless of
medical necessity. A report is required no later than 14 months after
enactment of the Act.
Section 3 of this bill would require VA to establish at least one
and no more than five centers of excellence for rural health research,
education, and clinical activities.
Section 4 would require the Secretary to establish a transportation
grant program to veterans service organizations to allow for other
transportation options to assist veterans residing in highly rural
areas to travel to VA facilities.
Section 5 would require the VA's Office of Rural Health to conduct
demonstration projects with the goal of expanding care in rural areas.
Section 6 of the bill would require the VA to establish a contract
care program through community mental health centers and other
``qualified entities'' for the provision of certain readjustment,
mental health, peer counseling and similar services to OEF/OIF veterans
and their dependents in rural and remote regions. The program would be
restricted to areas determined by the Secretary to be inadequately
served by direct VA services.
Section 7 of the bill would establish a Native American health care
coordination function in the 10 VA medical centers that serve the
greatest number of Native Americans per capita, with specification of
the duties associated with the new function. Also, the bill would
require the Secretary and the Secretary of the Interior to execute a
memorandum of understanding that would ensure the health records of
Indian veterans may be transferred electronically between the Indian
Health Service (IHS) and the VHA.
Section 8 would require an annual report to Congress as a part of
the President's budget on a variety of matters concerned with rural
veterans.
The DAV appreciates the intent of this measure to improve health
care for veterans residing in rural and remote areas. With some concern
outlined below, we support enactment of this bill as consistent with
DAV resolution numbers 240 (related to VA's beneficiary travel
reimbursement policy) and 247 (related to improved health care services
and access for veterans living in rural areas), adopted by our
membership at DAV's 2009 National Convention.
As this Subcommittee is aware, the conference report accompanying
the Consolidated Appropriations Act of 2008 (Public Law 110-161),
specified that $125 million of the funds provided for veterans medical
services should be used to increase the travel reimbursement rate. The
Consolidated Security, Disaster Assistance, and Continuing
Appropriations Act of 2009 (Public Law 110-329), provided an additional
$133 million to increase the beneficiary travel reimbursement mileage
rate to 41.5 cents per mile, while freezing the deductible at current
levels. Subsequently, the Veterans' Mental Health and Other Care
Improvements Act of 2008 reduced the mileage deductible to $3 for each
one-way trip; $6 per round trip; with a calendar month cap of $18 as
specified in title 38, United States Code, Subsection 111(c)(1) and (2)
for travel expenses incurred on or after January 9, 2009.
DAV supported the increase in mileage reimbursement afforded under
Public Law 110-329. However, by prescribing in law the current travel
reimbursement rate of 41.5 cents per mile without any mechanism for
annual adjustment may lead to the situation that occurred prior to
enactment of Public Law 110-161 to break the long period where the
beneficiary travel mileage reimbursement rate had not been changed in
over 30 years.
Additionally, in eliminating title 38, USC, Subsection 111(g), we
are concerned this bill does not replace the required report from VA
containing full justification (including the ramifications of diverting
funds not provided for in appropriations, such as those in Public Laws
110-161 and 110-329, from direct medical care for the purpose of
increasing mileage) when exercising its authority to increase or
decrease the rates of allowances or reimbursements. We refer the
Subcommittee to section 305 of the recently reached proposed negotiated
agreement on an omnibus VA health care bill, the vehicle for which will
be S. 1963, the Caregivers and Veterans Omnibus Health Services Act of
2010. In amending title 38, USC, Subsection 111(g), S. 1963 provides
certain flexibility to the Secretary as it relates to investigating and
determining the actual cost of travel for establishing VA mileage
reimbursement rates.
Finally, should Congress decide to strike Subsection (g) of title
38, USC, Subsection 111, as is proposed by this measure, we recommend a
technical correction be made to Subsection 111(b)(1) because it
references Subsection (g)(2)(A).
H.R. 3926--Armed Forces Breast Cancer Research Act
This Act would direct the Secretaries of DoD and VA to jointly
conduct a study on the incidence of breast cancer among members of the
Armed Forces, including National Guard and Reserve components, and
veterans and report those study results to Congress.
H.R. 3926 would also require demographic information on study
participants including information on possible exposure to hazardous
elements or chemical or biological agents (including vaccines),
locations in which the servicemembers or veterans were deployed, and
analysis of breast cancer treatments received by Armed Forces members
and veterans.
DAV Resolution No. 252 urges greater collaboration between DoD and
VA to share necessary deployment, health and exposure data from
military operations and deployments, in order to timely and adequately
address the subsequent health concerns of disabled veterans, whatever
the causes of those disabilities. Additionally, this resolution urges
Congress to provide adequate funding for research to identify all
disabling conditions and effective treatment for such disabilities that
may have been caused by exposure to environmental hazards and man-made
toxins while serving in the Armed Forces of the United States.
DAV is committed to ensuring veterans disabled by exposure to
environmental hazards and toxins receive effective high quality health
care and that the biomedical research and development programs of the
Department are fully addressing their needs. For these reasons we are
pleased to support H.R. 3926, the Armed Forces Breast Cancer Research
Act, and urge its passage.
H.R. 4006--Rural, American Indian Veterans Health Care Improvement Act
of 2009
The Rural, American Indian Veterans Health Care Improvement Act of
2009 directs the Secretary of VA to assign an Indian Veterans Health
Care Coordinator for each of the ten VA facilities that serve
communities with the greatest per capita number of Indian veterans. The
Indian Veterans Health Care Coordinator would be tasked with: (1)
improving outreach to tribal communities; (2) coordinating the medical
needs of Indian veterans on Indian reservations with the VHA and the
IHS; and (3) acting as an ombudsman for Indian veterans enrolled in the
VHA health care system.
The bill would require the VA and the Department of the Interior to
enter into a memorandum of understanding to ensure the electronic
transfer of health records of Indian veterans between IHS and VA
facilities. Moreover, VA would be authorized to transfer to IHS any
surplus medical and information technology equipment.
This measure would also require VA and the Department of Health and
Human Services (HHS) to report jointly to Congress on the advisability
of the joint VHA-IHS establishment and operation of health clinics to
serve populations of Indian reservations, including Indian veterans.
Since 2003, the IHS and the VHA have collaborated using a
memorandum of understanding (MOU) to promote greater cooperation and
resource sharing to improve the health of American Indian/Alaska Native
(AI/AN) veterans. The MOU encourages VA and IHS programs to collaborate
and improve beneficiaries' access to health care services, improve
communications between IHS and VHA and to create opportunities to
develop strategies for sharing information, services, and information
technology. In some areas, this coordination between IHS and VHA has
improved while in other areas, such coordination needs improvement.
A recent study examined AI/AN veterans' utilization of the IHS and
VA health services. Based on the study's survey, 25 percent of AI/AN
veterans receive care through both IHS and VA, while over 25 percent of
AI/AN veterans accessed care through VA only and nearly 50 percent of
AI/AN veterans accessed care through IHS only.\5\ Those AI/AN veterans
who used both VA and IHS for medical care actively matched health care
resources to their medical needs, generally use IHS for primary care
and VA for specialty care, thus using VA as a form of supplemental
coverage. The report also indicates that AI/AN veterans report a high
rate of unmet health care needs and experience a lack of coordination
of health care.
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\5\ B.J. Kramer, M. Wang, et al; Veterans Health Administration and
Indian Health Service--Healthcare Utilization by Indian Health Service
Enrollees, Medical Care, Vol. 47, No. 6. June 2009.
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Another study concluded fostering closer alignment between VHA and
IHS would reduce care fragmentation and improve accountability for
patient care.\6\ This study found coordination between VA and IHS
providers occurred on an ad hoc basis. Although both VA and IHS could
share information through medical releases, veterans were dissatisfied
with the burdensome process when it was made available as an option.
Since medical information was not routinely shared, treating chronic
health conditions was challenging, especially when providers were
unaware of their counterpart's recommendations of treatments, including
medications and dosage. Appropriate referrals to VHA from the IHS would
be a significant step toward resource sharing that would benefit both
organizations financially. By displaying leadership in coordination of
care, VHA and IHS can demonstrate how to overcome technical, policy and
administrative challenges in implementing the Institute of Medicine
recommendations to enhance quality through data sharing and care
coordination.\7\
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\6\ B.J. Kramer, R.L. Vivrette, MA, et al; Dual Use of Veterans
Health Administration and Indian Health Service: Healthcare Provider
and Patient Perspectives, Gen Intern Med. 24(6): 758-764. Published
online April 18, 2009.
\7\ Institute of Medicine, Committee on Enhancing Healthcare
Quality Programs. Leadership by Example: Coordinating Government Roles
in Improving Health Care Quality; National Academy Press. 2002.
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As with section 7 of H.R. 2879, the Rural Veterans Health Care
Improvement Act of 2009, DAV supports this measure based on DAV
Resolution No. 247 (supporting improved access to rural health care
services for veterans residing in those areas), adopted by our
membership at DAV's 2009 National Convention. We are aware that better
collaboration between VA and IHS is critical, particularly in the
behavioral health understanding and accommodation of the cultural needs
of American Indian, Alaska Native and Pacific Islander veterans--and
that culturally traditional treatments should be considered as an
option for tribal veterans.
Draft Bill--To Amend Title 38, United States Code, To Make
Certain Improvements in the Laws Relating to Performance Pay and
Collective Bargaining Rights for Certain Employees of the
Department of Veterans Affairs
This measure would amend section 7431(d)(2) of title 38 by
inserting ``individual'' after ``dentist's'' and by inserting ``in
accordance with regulations'' after ``objectives,'' in addition to
editing section 7422 by inserting ``rates'' after ``employee
compensation.'' Further, ``patient care'' would be inserted in
subsection (c)(1) after ``not including procedures or appropriate
arrangements as such terms are used in section 7106(b) of title 5l and
in subsection (d) by inserting ``rates'' after ``employee
compensation.''
Section 1 of this bill would clarify Congressional intent in
establishing performance pay elements for VA physicians and dentists in
Public Law 108-445, the VA Health Care Personnel Enhancement Act of
2004, by sharpening its intent to measure performance of individual
physicians and dentists, rather than groups of these key VA
professionals in establishing performance pay. The bill would also
require the Secretary to establish by published regulation (presumably
in the Federal Register) in advance the performance objectives that VA
would use to justify awarding performance-based salary increments, or
performance bonuses, to VA physicians and dentists who chose to
function under those performance objectives. Under the bill, such
regulations would be required to be published within 60 days post-
enactment of this bill.
The DAV has no adopted resolution on these particular matters, but
we again refer the Subcommittee to the FY 2011 IB discussion on the
need for VA to improve human resources programs. Publishing performance
objectives for VA physicians and dentists in the Federal Register in
advance of their use would be a novel but probably effective way to
guarantee VA would be required to consider their views before adopting
new procedures that impacted their conditions of employment. We believe
this bill's enactment would be consistent with our views in the IB.
Thus, we would have no objection to passage of this section.
Section 2 of the bill would make a series of amendments to section
7422 of title 38, USC, in subsections (b), (c) and (d), to narrow the
definition of exclusions from collective bargaining dealing with the
interests of certain health professional employees of the Department.
Again, DAV refers the Subcommittee to our human resources discussion in
the IB for FY 2011. These changes would afford recognized employee
units more ability to bargain with VA on policies that would make VA a
preferred workplace for clinical professional staffs. DAV would offer
no objections to enactment of this section of the bill. However, we
remind the Subcommittee of our comments on H.R. 949, a bill that would
repeal each of the subsections of title 38 that this bill would amend.
Draft Bill--To Amend Title 38, United States Code, To Improve the
Continuing Professional Education Reimbursement Provided to
Health Professionals Employed by the Department of Veterans Affairs
This bill would expand from VA physicians and dentists to a wider
group of VHA professional employees who are eligible for annual
continuing education allowances, and would increase such allowances
from $1,000 to $1,600 per annum per employee. amendments to effect this
change would be made to section 7411(1) of title 38, USC, by striking
``physician or dentist'' and replacing it with ``health professional''
employees appointed under paragraph (1) or (3) of section 7401 of the
title. The bill would also specify that no health professional could
receive reimbursement under this section in addition to any other
reimbursement for expenses incurred for education provided by a
Department medical center.
While we have no resolution adopted on this specific matter from
our membership, the purpose of the bill is consistent with VA's
maintaining technical proficiencies of VA clinical professionals. On
that basis, DAV would offer no objection to its enactment into law.
Draft Bill--To Amend Title 38, United States Code, To Authorize the
Secretary of Veterans Affairs to Waive Certain Requirements
Relating to Mental Health Counselors
This bill would amend section 7202(b)(11)(B) by inserting ``except
that the Secretary may waive the requirement of licensure or
certification for an individual licensed professional mental health
counselor for a reasonable period of time recommended by the Under
Secretary for Health'' before the period where it appears. We noted a
technical error in the text in that it refers to ``section 7202,'' a
section that does not exist in title 38, rather than section 7402, a
section that refers to ``Qualifications of appointees'' in the VHA.
Assuming it would apply to section 7402, this bill would grant the
VA Secretary a temporary period to retain VA mental health professional
employees while they sought professional certifications and state
licensures within their fields. Given the shortage of mental health
professionals today in general, and given VA's need to continue to
prepare for a major growth of mental health workloads due to the
anticipated end of wars in Iraq and Afghanistan and the mental health
legacy associated with these wars, this proposal seems reasonable as a
needed human resources flexibility. Also, given VA's massive academic
programs in which tens of thousands of professional and technical
students rotate in VA facilities each year as a part of their practica,
this tool might help VA with a number of its chronic recruitment
challenges. Thus, while DAV has no adopted resolution from our
membership on this particular issue, we would not object to enactment
of this bill.
Mr. Chairman, this concludes DAV's testimony. Again, we thank the
Subcommittee for its leadership, and for requesting our views on the
legislation under consideration by the Subcommittee at this hearing. I
would be pleased to respond to any questions from you or other Members
of the Subcommittee on these issues.
Prepared Statement of Gerald M. Cross, M.D., FAAFP, Deputy Chief for
Patient Care Services and Chief Consultant for Primary Care,
Veterans Health Administration, U.S. Department of Veterans Affairs
Good Morning, Mr. Chairman and Members of the Subcommittee:
Thank you for inviting me here today to present the
administration's views on several bills that would affect Department of
Veterans Affairs (VA) benefits programs and services. Joining me today
are Walter A. Hall, Assistant General Counsel; Brian McVeigh, Chief
Consultant, Human Resources Management; and Patricia Vandenberg,
Assistant Deputy Under Secretary for Health for Policy and Planning.
Unfortunately, we do not yet have views and costs for H.R. 84, H.R.
1075 and a draft bill regarding performance pay and collective
bargaining. We will forward them as soon as they are available.
H.R. 949--Repeal of 38 U.S.C. Sec. 7422 Collective Bargaining
Exclusions; Adverse Action Decisions and Appeals; Disciplinary
Appeals Board Transcripts
When Congress first authorized VA clinicians to engage in
collective bargaining in 1991 it did so acknowledging that clinical
decisions and clinical management decisions should not be decided
through the collective bargaining process. Congress provided that only
the Secretary, and by delegation the Under Secretary for Health may
decide when one of the statutory bargaining exclusions in section 7422
applies. However they did provide that, if a party believes that the
Under Secretary for Health has acted arbitrarily or capriciously in
issuing a 7422 decision, the party may seek judicial review of the
decision pursuant to section 7422(e).
The key provision of H.R. 949 would make matters relating to direct
patient care and the clinical competence of clinical health care
providers subject to collective bargaining. It would repeal the current
restriction on collective bargaining, arbitrations, and grievances over
matters that the Secretary determines to concern or arise out of the
professional conduct or competence, peer review, or compensation of
title 38 employees. In addition, the bill would impose a very tight
time limit on the issuance of final agency decisions on employee
grievances and would make such decisions subject to judicial review.
Finally, the bill would require VA to provide employees who appeal
adverse actions under section 7462 with a full and correct copy of the
Disciplinary Appeals Board transcript at least 21 days before post-
hearing briefs are submitted, despite the existence of a 120-day
deadline for the issuance of Disciplinary Appeals Board decisions.
We appreciate the many positive contributions collective bargaining
and labor-management partnership make to VA's mission. H.R. 949 would
have an adverse impact on VA's ability to deliver quality patient care.
Consistent with our views on a similar Senate bill, we strongly oppose
it. Section 1 of H.R. 949, if enacted, would imperil VA's ability to
furnish timely and quality care for veterans. H.R. 949 would open VA's
responsibility under title 38 to (1) make direct patient care and
clinical competency decisions, (2) assess title 38 professionals'
clinical skills, and (3) determine discretionary compensation for title
38 professionals, to review other non-clinical third parties who lack
the clinical training and health care expertise to make such
determinations.
In September 2009, following extensive discussions with the
American Federation of Government Employees (AFGE) regarding friction
over differences of interpretation over collective bargaining
authorities, VA and its labor partners signed a charter for a 38 U.S.C.
7422 Workgroup, with the purpose of formulating recommendations for the
Secretary to improve knowledge, understanding, and consistent use of
the authorities and limitations in section 7422. The Workgroup consists
of representatives from VA's five national unions (AFGE, National
Federation of Federal Employees, National Association of Government
Employees, Service Employees International Union, and United American
Nurses). VA's team is headed by the Assistant Secretary for Human
Resources and Administration, Mr. John Sepulveda, and includes subject
matter experts from the Veterans Health Administration, Office of
General Counsel, and Office of Labor Management Relations. The
Workgroup charter charged its members with: (1) establishing a dialogue
about the meaning of the 7422 bargaining and grievance exclusions; (2)
making recommendations to the Secretary regarding consistent use of
section 7422; (3) developing joint training about the section 7422
exclusions and decision process; (4) identifying strategies for
enhancing collaborative efforts to resolve disputes at all levels; (5)
recommending approaches for capturing data reflecting informal and
formal efforts to resolve section 7422 disputes; and, (6) developing a
strategic communication plan for the results of the Workgroup. Over the
past 6 months, the 7422 Workgroup has held a series of multi-day face-
to-face sessions, conducted in a partnership manner, where the parties
engaged in a productive dialog. We are hopeful this process, when
concluded, will result in actions and understandings that will address
many of the unions' concerns about the manner in which section 7422
exclusions are applied.
H.R. 949 would create a number of significant problems that would
impede VA's ability to operate a safe, effective and responsive health
care system. The rules for collective bargaining often lead to
protracted negotiations and third-party proceedings. On average, it
takes 120 days to negotiate national Memorandums of Understanding (MOU)
with VA's largest union, the AFGE. The 120-day average does not include
local level bargaining over facility-specific aspects of a change,
which can add another 30-60 days. While this kind of timeline may be
acceptable for most workplace matters, it is not when it comes to
patient-care matters. If H.R. 949 is enacted, critical changes in
patient care, safety procedures, and policies could not be implemented
until national and local bargaining had been completed. This could
result in less than optimal care for veterans. Such delays, and the
very practice of negotiating clinical matters, are inconsistent with
patient-centered medicine.
H.R. 949 would allow title 38 professionals to grieve matters or
file unfair labor practice charges on clinical matters currently
exempted from collective bargaining. Grievances not resolved at the
informal stage are decided by a third-party arbitrator and may be
subsequently appealed to the Federal Labor Relations Authority. Labor
grievance arbitrators, the Federal Labor Relations Authority, and the
Federal Service Impasses Panel would have considerable discretion to
impose a clinical or patient care resolution on the parties. VA would
have limited, if any, recourse if such an external party erred in its
consideration of a clinical or patient care issue; VA would be bound by
that third-party's decision. VA opposes this change in the strongest
possible terms--clinicians must be able to make the clinical decisions
to ensure care is furnished in compliance with VA and prevailing
medical practice standards. Actions concerning direct patient care and
the clinical competence of VA providers must be made and reviewed by
clinicians, not arbitrators.
Moreover, non-clinical third-parties are not accountable for
ensuring the health and safety of the veterans receiving their care
through the Department. If the Secretary and the Under Secretary for
Health are going to be held responsible and accountable for the quality
of care provided to veterans, they must be able to make decisions
relating to patient care and the clinical competence of VA providers.
Decisions must be based on what is best for our veterans from a medical
perspective rather than what is the best that can be negotiated through
collective bargaining, or on what a non-clinical arbitrator or the
Federal Labor Relations Authority decides is appropriate in the context
of collective bargaining. Our veteran patients cannot be expected to
understand why their VA providers--a group of highly qualified,
trained, and trusted professionals--have no option but to follow the
decisions of third-parties with whom they disagree on matters affecting
patient care.
This provision would also require collective bargaining related to
VA's Peer Review process by which VA assess the clinical skills of
title 38 health care professionals and assesses whether our patients
are receiving the high standard of care they deserve. Matters relating
to peer review are now expressly exempted from collective bargaining
under section 7422. H.R. 949 would change that, again subjecting the
process of assessing the clinical skills of title 38 professionals and
determining whether they are clinically competent in their area of
practice to review by non-VA, non-clinical third-parties.
In addition to clinical-care issues, H.R. 949 would permit unions
to bargain over, grieve, and arbitrate subjects that are even exempted
from collective bargaining under title 5, including the determination
of the amount of an employee's compensation. Permitting title 38 staff
to negotiate the discretionary aspects of their compensation would be
at complete odds with a basic premise of Federal labor management
relations.
Section 2 of the bill would establish a new section 7463(f)(1),
which would require VA to decide grievance appeals no later than 60
days after a grievance is filed and would subject such decisions to
judicial review. VA opposes section 2 of H.R. 949. In many cases,
because of the complexity of the issues, the need to develop and review
evidence, or secure the availability of witnesses, a grievance
examiner's review can take most or all of those 60 days, leaving no
time for a VA higher level official to review, and decide upon, the
grievance examiner's findings and recommendations as called for in
section 7463(d)(3). Sixty days is not sufficient for this process.
Finally, section 3 of the bill would amend the Disciplinary Appeals
Board or DAB statute in section 7462 to require the provision of a full
and correct copy of a DAB transcript to an employee at least 21 days
before the submission of post-hearing briefs. DABs are conducted when a
title 38 employee appeals a major adverse action arising out of a
question of professional conduct or competence. VA opposes section 3 of
H.R. 949 because it would unnecessarily constrain the time available to
DABs to make their decisions, which by law must be rendered within 45
days of the DAB hearing and no later than 120 days after commencement
of the appeal. There may be instances where it will be impossible to
provide the transcript to an employee within 21 days and meet the 120-
day statutory time limit because of the timing of the oral hearing or
the length of time it takes to prepare a full and complete transcript.
Cases can involve complex clinical issues and extensive medical and
expert testimony and evidence. Moreover, post-hearing briefs are
neither necessary for nor required by many DABs because the issues are
sufficiently fleshed out in the DAB's oral hearing, the written notices
provided to the employee, and the employee's written reply, oral reply,
and DAB appeal.
In sum, VA's ability to manage its health care facilities and to
monitor the professional conduct and competence of its employees must
be reserved for the VA professionals and clinicians who are responsible
for delivering quality patient care. Current law provides the
appropriate balance between rightful subjects for collective bargaining
and clinical need, and, as noted above, VA and its unions are engaged
in a productive dialog to resolve issues of interpretation of the
contours of how 7422 is applied.
H.R. 2698--``Veterans and Survivors Behavioral Health Awareness Act''
VA does not support section 2 of H.R. 2698 which would direct VA to
provide scholarships to individuals pursuing education or training in
behavioral health care specialties in order to recruit and retain
individuals for service in Vet Centers. In exchange for the
scholarship, an individual would be required to fulfill a service
obligation with VA. The total amount available for scholarships could
not exceed $2,000,000 in any fiscal year.
VA appreciates the concept of using scholarships to enhance
succession planning. However, this section is unnecessary. Under
existing authority, VA can establish a special scholarship program to
identify, educate and hire individuals for difficult-to-recruit and
difficult-to-retain health care positions including individuals
pursuing degrees in mental health specialties. Additionally,
implementation of section 2 of H.R. 2698 would result in substantial
costs to VA over a long period of time with little short-term benefits.
It takes 2 to 7 years of education to qualify to become a VA behavioral
health specialist. Congress has authorized and VA has taken other
actions to promote recruitment and retention of qualified health
professionals, including the Education Debt Reduction Program and the
Employee Incentive Referral Initiative. VA takes this opportunity to
again endorse reauthorization of the Health Professional Educational
Assistance Scholarship Program. This program would be a more effective
and broader program to support recruitment and retention efforts in a
variety of career fields, including mental health counselors.
VA has not had difficulties hiring new counselors, and in the past
3 years, VA has hired more than 5,800 additional mental health workers.
VA has also expanded funding for mental health training by supporting
the expansion of training positions in psychology by 206 positions.
Seventy percent of current VA psychologists participated in a VA
training program, demonstrating that these initiatives are an
exceptional resource for addressing future recruitment needs. The
legislation also appears to duplicate provisions from the Montgomery GI
Bill and the Post-9/11 GI Bill, which already provide mechanisms for
funding graduate and post-graduate degree programs for eligible
veterans. These measures do not include a specific service obligation,
but do allow veterans to pursue an advanced education in the behavioral
health sciences.
We have not formulated costs at this time, but will provide them
for the record when they become available.
VA supports section 3 of H.R. 2698, which would direct VA, on
receipt of a request for counseling from an individual who has been
discharged or released from active service but who is not otherwise
eligible for such counseling, to: (1) provide referrals to assist the
individual in obtaining mental health care and services outside VA; and
(2) if pertinent, advise such individual of the individual's rights to
apply for review of the discharge or release.
This provision would allow VA to provide referral services to
veterans with problematic discharges by referring them to services
outside VA and by advising such veterans of their right to apply for a
discharge upgrade. There are no significant costs associated with
enactment of this section.
Section 4 of H.R. 2698 would direct VA to carry out a program to
award grants to nonprofit organizations that provide emotional support
services (i.e., bereavement counseling) for survivors of deceased
members of the Armed Forces and deceased veterans through the
survivors' peers.
VA currently has authority to provide bereavement services to the
surviving military family members of servicemembers who die while on
active duty, and to family members of veterans who die while receiving
VA treatment for a service connected condition in a VA facility.
Section 4 would expand bereavement services to family members of all
veterans. VA has not had time to develop costs for this section, but
will provide our views and costs as soon as they are available. With
regards to bereavement services provided to families of servicemembers,
Vet Centers have adopted standards of care to ensure that family
members are contacted the same day as the referral is received, and to
schedule an appointment with a counselor at the nearest Vet Center
within 24 to 48 hours of receiving the referral. Through February 2010,
Vet Centers have assisted the families of 1,939 fallen servicemembers;
1,152 (60 percent) were in-theater casualties in Operation Enduring
Freedom/Operation Iraqi Freedom (OEF/OIF).
H.R. 2699--``Armed Forces Behavioral Health Awareness Act''
Section 2 of H.R. 2699 would make members of the Armed Forces,
including the Reserve components, who are deployed in support of OEF/
OIF eligible for readjustment counseling and related mental health
services operated by VA as authorized under 38 U.S.C. Sec. 1712A. The
Department will provide its views and the cost estimate for section 2
soon.
VA defers to the Department of Defense concerning section 3 of H.R.
2699 and to the Department of the Army concerning section 4 of H.R.
2699.
H.R. 2879--``Rural Veterans Health Care Improvement Act of 2009''
Section 2 of H.R. 2879 would amend 38 U.S.C. Sec. 111 by setting
the beneficiary travel allowance rate at 41.5 cents per mile and
repealing the requirement that allowances be determined using the
mileage reimbursement rate under 5 U.S.C. Sec. 5707(b) for the use of
privately owned vehicles by government employees on official business.
In addition, this section would repeal VA's authority to modify the
allowances or reimbursement amounts in excess of the rate determined by
5 U.S.C. Sec. 5707(b). This section would also repeal the requirement
that certain beneficiaries must be unable to defray the expenses of
such travel pursuant to regulations; repeal the requirement that
payments may not exceed the cost of such travel by public
transportation if accessible and not medically inadvisable; and repeal
the requirement that payments must not exceed the actual expense
incurred as certified in writing by the person. Last, this section
would require that the Veterans Health Administration (VHA) Handbook on
beneficiary travel be revised to clarify that a travel allowance based
on mileage may exceed the cost of such travel by public transportation
regardless of medical necessity.
VA does not support section 2 of H.R. 2879. While 41.5 cents per
mile is the current reimbursement rate, VA would lose the authority to
decrease or increase the rate using the mileage reimbursement rate
under 5 U.S.C. Sec. 5707(b). VA would also lose the flexibility to
exceed the section 5707(b) rate should funding and circumstances
warrant. The requirement to allow for mileage reimbursement greater
than the cost of travel by public transportation regardless of medical
necessity would eliminate VA's authority to pay only for the most cost-
effective available and appropriate mode of transport. As a result, in
some cases VA would reimburse more than the veteran actually expended
for transport.
VA estimates the cost of implementing this section to be $16.24
million over 5 years, and $35.56 million over 10 years.
Section 3 would require the establishment of one to five centers of
excellence for rural health research, education, and clinical
activities, through the Director of the Office of Rural Health. The
centers would be required to conduct research, develop specific models
for furnishing health services, provide education and training for
health care professionals, and develop and implement innovative
clinical activities and systems of care.
VA does not support section 3 of H.R. 2879 because the ``Centers of
Excellence'' proposed in this provision would be duplicative of the
Veterans Rural Health Resource Centers (VRHRC) and of the efforts of
VA's Veterans Rural Health Advisory Committee.
VA established the VRHRCs to improve care and services for veterans
residing in geographically isolated areas. The VRHRCs conduct policy-
oriented studies and analyses; function as field-based clinical
laboratories for policy-relevant pilot projects and evaluations; serve
as regional rural health experts organizing and sharing information
within and across Veterans Integrated Service Network (VISN)
boundaries; and serve as an educational repository and academic and
clinical information clearinghouse. The VRHRCs are operational and
conducting important work, such as a pilot project designed to develop
a simulation tool for modeling rural health care access; telephone-
based telehealth initiatives for diabetes, hypertension, and chronic
pain; rural workforce development; utilization of mobile clinics as an
alternative care delivery model; and a study on clinical practice
intensity to compare VA to private sector physicians in urban and rural
settings. VA's Veterans Rural Health Advisory Committee membership
includes affected veterans, rural health experts in academia, State and
Federal professionals who focus on rural health, State-level veterans
affairs officials, and leaders of Veterans Service Organizations. The
purpose of the Advisory Committee is to examine ways to enhance VA
health care services for veterans in rural areas by evaluating current
programs and identifying barriers to health care.
VA estimates the minimum cost of implementing section 3 to be
$10.76 million over 5 years and $23.67 million over 10 years.
Section 4 would require the establishment of a grant program to
provide innovative transportation options to veterans in rural areas.
Under this section, grants awarded could be used by State Veterans'
Service Agencies and Veterans Service Organizations to assist veterans
in highly rural areas with travel to VA medical centers, or otherwise
assist in providing medical care to these veterans. A grant awarded
under this section could not exceed $50,000.
VA agrees with the intent of this legislation and agrees that
veterans in rural areas need more transportation options when seeking
VA health care, but VA does not support section 4 of H.R. 2879. The
specific provisions of this legislation are unnecessary, and VA already
has efforts underway that will address this problem more quickly than
new legislation would. VA is currently developing pilot programs to
implement innovative transportation services at various rural health
care facilities. Funds that would be spent for grants would be more
effectively and efficiently used by VA to develop these initiatives
that would include but not be limited to integrating the services of
networks of volunteer, community, state and other transportation
providers with veteran transportation services offered in its health
care facilities. Furthermore, the administration of the grant program
proposed in this section would be costly, diverting resources from
either supporting new transportation options or health care for rural
veterans.
VA estimates the cost of this section to be $3 million per year,
and $15 million over 5 years.
Section 5 would require demonstration projects to examine the
feasibility and advisability of alternatives for expanding care for
veterans in rural areas, through the Director of the Office of Rural
Health, at facilities that are geographically distributed throughout
the United States. The required projects would include (1) a
partnership between VA and the Centers for Medicare and Medicaid
Services of the Department of Health and Human Services (HHS) to
coordinate care for veterans in rural areas at critical access
hospitals, (2) a partnership between VA and HHS to coordinate care for
veterans in rural areas at community health centers, and (3) expanding
coordination between VA and the Indian Health Service (IHS) to expand
care for Indian veterans. It would authorize the appropriation of
$350,000,000 for each of fiscal years 2009 through 2011 to carry out
the projects.
VA does not support section 5 of H.R. 2879 for three reasons.
First, VA already is encouraging and examining strategies to improve
collaboration to increase service options for veterans in rural areas;
examples include the Patient Navigator Pilot in VISN 5 that is focusing
on expanding and developing public-public collaborations, and the
community-based outpatient clinic (CBOC) partnership for improving
rural mental health in VISN 16 that is focused on establishing
collaborations within the rural health community. Second, additional
legislation would impose burdens and specific restrictions upon our
ability to explore these opportunities and may impede us from pursuing
the best health care options for veterans. Finally, VA already is
undertaking pilot programs at the direction of Congress in sections 107
and 403 of Public Law 110-387, and VA believes it is more appropriate
to evaluate the results of these pilot projects before beginning new
initiatives so that we can ensure resources are best used to serve
veterans. Section 107 of that law requires VA to carry out a pilot
program to assess the feasibility and advisability of providing peer
outreach, peer support, readjustment counseling, and other mental
health services to Operation Iraqi Freedom and OEF/OIF veterans, with
readjustment counseling and other mental health services provided to
certain rural veterans through community health centers, IHS, or other
appropriate entities. Section 403 requires VA to conduct a pilot
program under which VA provides covered health services to certain
highly rural veterans through qualifying non-VA health care providers.
These pilots will be exploring opportunities for collaboration.
VA estimates the cost of implementing section 5 to be $3.04 billion
through fiscal year (FY) 2011, as indicated in the legislation.
Section 6 would require a program to provide peer outreach, peer
support, readjustment counseling, and mental health services to OEF/OIF
veterans, particularly veterans who served in OEF/OIF while in the
National Guard and Reserves, to be established no later than 180 days
after enactment. The program would also provide education, support,
counseling, and mental health services to immediate family members of
OEF/OIF veterans during the 3 years after the veteran's return from
deployment. The services provided to immediate family members would
assist in the readjustment of the veteran to civilian life, the
recovery of the veteran (if the veteran incurred an injury or illness
during deployment), and the readjustment of the family following the
return of the veteran.
In carrying out this program, this section would require contracts
with community mental health centers and other qualified entities only
in areas not adequately served by VA health care facilities. In
addition, this section would require a training program for clinicians
of those community mental health centers or entities to ensure that the
clinicians recognize the unique experiences of OEF/OIF veterans, and
utilize best practices and technologies when providing services under
this section. This section would also require a contract with a
national not-for-profit mental health organization to carry out a
national training program for OEF/OIF veterans to be trained to provide
peer outreach and peer support services. Finally, this section would
require reports to the House and Senate Committees on Veterans'
Affairs.
VA opposes section 6 of H.R. 2879 because this provision duplicates
existing authorities and is unnecessary. Section 107 of Public Law 110-
387 requires VA to carry out a pilot program to assess the feasibility
and advisability of providing OEF/OIF veterans with peer outreach, peer
support, readjustment counseling, and other mental health services,
with readjustment counseling and other mental health services provided
to certain rural veterans through community health centers, IHS, or
other appropriate entities. VA is implementing this pilot. Section 6
proposes a plan similar to that outlined in section 107. VA believes
that results from the section 107 pilot will provide experience and
information on how best to serve the mental health needs of the rural
OEF/OIF veteran population.
In addition, VA's authority to furnish readjustment counseling
services already includes authority to furnish limited mental health
services to family members necessary for effective treatment of
veterans' readjustment issues. The Vet Center program is also taking
steps to enhance access for veterans' families. Within the context of
the Vet Center mission, family members are central to combat veterans'
readjustment. VA is implementing a plan to enhance its capacity to
serve families by hiring the additional staff necessary to place a
qualified family counselor in every Vet Center.
Vet Centers provide professional counseling for combat-related PTSD
and co-morbid conditions such as depression and substance abuse. When
necessary for the treatment of more complex mental health conditions,
Vet Centers refer veterans to VA medical facilities. For veterans
leaving a VA facility after receiving care for an injury or illness
sustained during deployment, VA provides education and training prior
to the veteran's discharge from care to ensure that family members can
tend capably to the needs of the veteran. As a result, the authority to
provide readjustment counseling and education to family members is
unnecessary.
Further, VA is expanding access to mental health care to assist
rural veterans. VA is integrating mental health into all of its primary
care clinical settings and is significantly expanding the number of Vet
Centers to almost 300 by the end of the fiscal year. VA has already
deployed 50 Mobile Vet Centers to provide services and outreach to
veterans, including rural veterans. Moreover, VA continues to expand
the use of telemental health to connect veterans in rural areas with
clinical experts from across the country. In addition, VA contracts for
mental health treatment and for readjustment counseling and related
readjustment services, as needed with private-sector community mental
health agencies and other qualified professional entities. Most of
these contract providers are located in rural areas. Section 6 is also
duplicative and unnecessary because the Vet Center's model for veteran-
centric services already utilizes veteran peer outreach and counseling.
Almost 70 percent of all Vet Center staff members are veterans, and
more than 30 percent of Vet Center staff members are OEF/OIF veterans.
VA estimates the cost of implementing section 6 to be $115.58
million over 5 years and $253.46 million over 10 years.
Section 7 would address improving care for American Indian
veterans. Because section 7 is almost identical to H.R. 4006, VA views
on this bill are addressed under our discussion of H.R. 4006 (which
follows below).
Section 8 would require an annual report to Congress on the
implementation of the provisions of this bill and the establishment and
function of VA's Office of Rural Health. VA does not support section 8
of H.R. 2879. VA already provides a number of periodic reports
(including quarterly and annual reports) to Congress on the status of
our programs for rural and highly rural veterans. For example, Senate
Report 110-428, which accompanied the Military Construction and
Veterans Affairs and Related Agencies Appropriations Act, 2009
(Division E of Public Law 110-329), directed VA to provide a quarterly
report to Congress on rural health initiatives funded through rural
health appropriations. A Conference Report (H. Rept. 110-424),
accompanying the Consolidated Appropriations Law, 2008, required a
report to Congress on access to health services in rural areas. If the
Committee would like additional information on any of our programs, VA
staff members are available to conduct a briefing at your request.
VA estimates the cost of implementing section 8 to be $70,596 over
5 years, and $155,173 over 10 years.
H.R. 3926--``Armed Forces Breast Cancer Research Act''
H.R. 3926 would direct the Department of Defense (DoD) and VA to
conduct a joint study on the incidence of breast cancer within the
Armed Forces and among veterans. VA supports the objective of H.R.
3926, but cannot support the bill as proposed. H.R. 3926 would provide
only an estimate of incidence of one disease at one point in time. A
broader study of health care outcomes would be much more cost effective
and useful. A broader study would provide information regarding the
frequency of occurrence of breast cancer as well as other illnesses and
chronic disease outcomes of interest to veterans. For less than the
costs required to conduct such a study, we could support a longitudinal
study that considers breast cancer as one condition among many. This
would be accomplished by collecting information on a representative
sample of veterans, including demographic variables such as age,
gender, era of service, and frequency of occurrence of various health
outcomes of concern to veterans. Establishing a survey mechanism of
this type would allow VA to repeat the study and identify trends over
time, such as increases or decreases in the occurrence of various
diseases, such as breast cancer.
In order to satisfy the complex requirements of H.R. 3926, the
study requirements currently proposed in the bill would demand much
more time than the 18-month timeframe envisioned. We estimate it would
take 3 to 5 years to accomplish this work.
The total cost of this study is estimated to be $6.34 million.
H.R. 4006--``Rural, American Indian Veterans Health Care Improvement
Act of 2009''
Section 2(a) would require that an Indian Veterans Health Care
Coordinator be assigned at each of the ten VA medical centers that
serve communities with the greatest number of Indian veterans per
capita. The coordinators would be responsible for improving outreach to
tribal communities; coordinating the medical needs of Indian veterans
on Indian reservations with VA and IHS; expanding the access and
participation of VA, IHS, and tribal members in the VA Tribal Veterans
Representative program; acting as an ombudsman for Indian veterans
enrolled in VA for health care; and advocating for the incorporation of
traditional medicine and healing in the VA treatment plans for Indian
veterans. This section would define ``Indian'' as defined in 25 U.S.C.
Sec. 450b (`` `Indian' means a person who is a member of an Indian
tribe'').
VA does not support section 2(a) of H.R. 4006 because VA's Office
of Rural Health (ORH) is already providing support to American Indian/
Alaskan Native (AI/AN) veterans specifically as it relates to ongoing
rural health initiatives. VA is also working to address the unique
health care needs of all enrolled veterans residing in rural areas,
including AI/AN veterans. VA encourages cooperation and resource
sharing between IHS and VA to deliver quality health care services and
enhance the overall health of AI/AN veterans. Most VISNs are engaged in
a variety of outreach activities including: meetings and conferences
with IHS program and tribal representatives; VA membership in the
Native American Health Care Network; VA participation in traditional
Native American ceremonies; and transportation support to AI/AN. The
Veterans Rural Health Resource Center, Western Region, established a
partnership with IHS and is currently working on several fronts to
support expanded benefits and services, such as tele-psychiatry clinics
for AI/AN veterans on rural reservations, infrastructure focused on the
needs of AI/AN veterans, and a Memorandum of Understanding with IHS
concerning telemental health services for AI/AN veterans.
VA estimates the cost of implementing section 2(a) to be $5.30
million over 5 years, and $11.65 million over 10 years.
Section 2(b) would require an MOU no later than 1 year after
enactment, between VA and the Department of the Interior to ensure that
the health records of Indian veterans may be transferred electronically
between IHS and VA facilities. VA agrees with the objectives of section
2(b), but notes that implementation would not be possible without
legislative changes to 38 U.S.C. Sec. 7332. That law restricts the
ability of VA to provide health information concerning human
immunodeficiency virus (HIV), sickle cell anemia and drug abuse or
alcohol abuse. VA does not object in principle to requiring a MOU, but
notes that VA and IHS have already taken the position that sharing of
VA and IHS electronic health records should be done through the
Nationwide Health Information Network (NHIN). As a result, the MOU
would be unnecessary, because each party participating in the NHIN will
be required to be a signatory to the Data Use and Reciprocal Support
Agreement. We note that section 2(b) of H.R. 4006 refers to the
Secretary of the Interior, rather than the Secretary of Health and
Human Services. VA believes this is a clerical error, since IHS is
responsible for providing Federal health services to AI/AN.
VA estimates there will be no costs associated with this provision.
Section 2(c) would permit VA to transfer surplus VA medical and
information technology equipment to IHS as is considered appropriate
for IHS purposes by the Secretaries of VA and HHS jointly. VA does not
object to the authority to provide surplus medical and information
technology equipment, but notes that VA generally only surpluses
equipment when it can no longer reasonably be used; IHS is unlikely to
find such equipment of practical use. While the title of the section
refers to medical equipment per se, the text of the section refers to
both medical and information technology equipment. VA estimates there
would be negligible costs associated with this provision.
Section 2(d) would require a report to Congress, no later than 1
year after enactment, jointly submitted by VA and HHS on the
feasibility and advisability of VA and IHS jointly establishing and
operating health clinics on Indian reservations to serve the
populations of those reservations, including Indian veterans. VA does
not support this requirement because it is unnecessary. VA would
welcome the opportunity to provide a briefing to address current
collaborations with IHS and efforts to support AI/AN veterans.
VA estimates that the cost of implementing this section would not
be substantial.
Draft Bill--``Expanding VA Reimbursement of Continuing Medical
Education Expenses to VA Health Professionals''
This bill would require VA to reimburse any full-time board
certified health professional for expenses, up to $1,600 per year, for
continuing professional education, but prohibits VA from reimbursing
for education provided by a Department medical center.
VA opposes this draft bill because of the cost of implementation
and because our current programs are sufficient to address this need.
There are currently over 170,000 health care professionals in VHA. The
total cost of implementing this legislation would be $282,000,000 per
year for the next 10 years. Moreover, VA's Employee Education Service
provides continuing education credits (those needed to maintain current
licensure or certifications) through online learning, content
distribution network and face-to-face sponsored training. In addition,
medical centers host on-site training to provide continuing education
credits and purchase online products that allow health care
professionals to gain needed continuing education. Medical centers also
have a mechanism in place for all employees (not just health care
professionals) to request funding or reimbursement for training and
education.
The potential cost to provide up to $1,600 to each health care
professional would be $272 million.
Draft Bill--``Authority to Waive Requirements for Mental Health
Counselors''
This bill would create an exception to the statutory requirements
for eligibility for employment of licensed professional mental health
counselors by allowing the Secretary to waive the licensure or
certification requirement for a reasonable period of time recommended
by the Under Secretary for Health. VA does not oppose the legislation.
VA currently has a parallel statutory authority to appoint
psychologists and clinical social workers for up to 2 years before they
have completed their licensure or certification. These employees are
closely supervised by a licensed mental health professional when
administering care. These are temporary, conditional appointments, and
VA believes a similar model would be appropriate if this legislation is
enacted.
This proposal would be cost neutral.
This concludes my prepared statement. Mr. Chairman, we would be
pleased to respond to whatever questions you may have.
Statement of American Federation of Government Employees, AFL-CIO
Mr. Chairman and Members of the Subcommittee:
The American Federation of Government Employees (AFGE) appreciates
the opportunity to submit a statement for the record on H.R. 949 and
draft bills relating to performance pay and collective bargaining
(draft dated March 8, 2010 (2:49 p.m.) and continuing professional
education (draft dated December 9, 2009 (11:42 a.m.).)
AFGE represents nearly 200,000 employees in the Department of
Veterans Affairs (VA), more than two-thirds of whom are proud employees
of a world class health care system that provides unsurpassed
specialized care to the men and women who have served our Nation.
The VHA workforce includes in its ranks many physicians, registered
nurses (RN), physician assistants (PA) and other clinicians who bring
to this great health care system invaluable experience and compassion
from their own military service where they provided medical care on the
battlefield.
Sadly, back home, these fine clinicians face work environments
plagued by fear, disrespect and exclusion. Their deep desire to care
for veterans is challenged every day by personnel policies that
demoralize them and deprive them of the basic rights and dignity
provided to their colleagues working outside the VA. VA's ability to
recruit and retain professionals who want to build a career in the VA
is getting more difficult every day.
H.R. 949 and Draft Collective Bargaining Language
H.R. 949
Two years ago, this Subcommittee considered this legislation to
restore equal collective bargaining rights to these dedicated VA
clinicians. At that time, the VA's arguments in opposition to the
legislation were riddled with fear and distortion, claiming it would
``jeopardize[e] the lives of our veterans'' (Senate Committee on
Veterans Affairs, May 21, 2008 hearing).
A great deal has changed in the past 2 years and the Department
appears ready to embrace a 21st century transformation of VHA labor-
management relations. We urge this Subcommittee to capture that
momentum through passage of H.R. 949.
The most recent example of the Department's shift away from its
former, counterproductive interpretation of title 38 collective
bargaining law (38 U.S.C. Sec. 7422, or ``7422'') is evident in the
implementation plan provided to the White House pursuant to Executive
Order (EO) 13522. Its plan to fulfill this White House goal, i.e.
``Creating Labor-Management Forums to Improve Delivery of Government
Services,'' recognizes that ``[c]ooperative, constructive working
relations between labor and management are essential to achieving
common labor-management goals and objectives.'' (Link: http://
www.lmrcouncil.gov/plans/index.aspx).
The Implementation Plan also specifically addresses bargaining and
negotiation rights:
``[T]he Department is committed to pre-decisional involvement
in workplace matters, without regard to whether those matters
are negotiable subjects of bargaining under 5 U.S.C. Sec. 7106.
. . . The Department is committed, wherever appropriate, to
engage the labor partners on issues that historically have been
outside the scope of bargaining.'' (emphasis added).
Equally significant, last fall, the Department supported
legislation to provide full bargaining rights for 2 years to VA
physicians and RNs converting from the Defense Department (DoD)
personnel system at the joint DoD-VA medical facility in North Chicago
(P.L. 111-84). Despite all its past allegations that full bargaining
rights will endanger patients, the Department agreed to give full title
5 rights to new VA clinicians treating veterans and active duty
personnel at a unique joint facility that is designed to serve as a
national model for the future. These clinicians, will full rights to
grieve and negotiate over routine employment matters such as schedules,
assignments, and additional pay for good performance or weekend shift
work, will be working side by side with VA clinicians with the same
titles and duties who have very limited rights because of ``7422.''
Therefore, AFGE urges this Subcommittee to vote for H.R. 949. It is
time to align the law with VHA's new workforce goals. It is time to put
an end to VHA personnel policies that have decimated valuable
legislation that Congress passed to improve recruitment and retention.
It is time to end the inequality and arbitrariness that keep new
physicians and RNs from seeking VA careers. It is time to end the
demoralization of long term, valuable VA physicians, dentists, RNs,
PAs, chiropractors, optometrists, and podiatrists who must work without
a voice and without redress for unfair and illegal management actions.
It is time to end the senseless inequality between VA clinicians
without full rights and VA ``hybrid'' clinicians, such as pharmacists,
psychologists and practical nurses with full rights. It is time to end
the equally senseless inequality between physicians and nurses who
treat veterans and physicians and nurses who treat active duty
personnel and Federal prisoners at other Federal facilities.
Draft Collective Bargaining Language
In the alternative, AFGE asks the Subcommittee to support section 2
of the March 8, 2010 draft. This draft language is significantly
narrower than H.R. 949 which also addresses bargaining rights in peer
review matters, the rights of title 38 clinicians to appeal final
agency decisions and arbitration decisions to Federal court, and needed
changes in the Disciplinary Appeals Boards process. However, the March
8th draft focuses on the two most harmful VA ``7422'' exclusions to
bargaining: compensation and patient care. Enactment of this draft
language will yield significant benefits for workplace morale and VHA
recruitment and retention.
More specifically, Subsection 2(a)(1) inserts a single word--
``rates''--in 38 USC Sec. 7422 to clarify what Congress intended in
1991 when it enacted title 38 bargaining rights. This proposed change
addresses opponents' assertions that employees will try to set pay
rates, in violation of Federal law. Compensation issues other than pay
rates cover pay issues that Congress has specifically addressed in
legislation to help the VA recruit and retain such as nurse locality
pay and physician performance pay. Compensation issues other than pay
rates also cover wage law violations that public and private employees
throughout this country have a right to challenge, such as failure to
pay overtime or shift differential pay for weekend work.
AFGE notes that the VA has never offered an example of an
employee's attempt to use bargaining rights to set Federal pay rates,
and that there are no Under Secretary of Health 7422 cases involving
such an attempt.
Subsection 2(a)(2) also clarifies Congressional intent in
established routine bargaining rights for title 38 clinicians for
matters only indirectly related to patient care--rights that are no
greater than the routine bargaining rights of Federal employees covered
by title 5, including hybrid title 38 VHA health care professionals and
DoD and BOP clinicians with the exact same job titles and scopes of
practice. This subsection will not allow employees to interfere with
management rights to determine the best medical procedures or skill
sets for patient care, or its right to take needed actions during
medical emergencies. Rather, Subsection (2)(b) only makes clear that
these Federal employees have the same, routine rights to a voice in
scheduling and assignment policies that other Federal employees have
when they care for patients in hospitals and clinics.
Again, AFGE notes that the VA has never offered an example of
labor's attempt to use bargaining rights in scheduling and assignment
matters to interfere with management's choice of medical procedures,
determination of needed medical skills or other direct patient care
matters. VA has never offered an example of labor's attempt to prevent
management from responding timely to emergency medical needs. We
further note that there is no Under Secretary of Health 7422 case
involving any such attempts.
Draft Language on Physician and Dentist Performance Pay Criteria
AFGE supports the enactment of the December 9, 2009 draft language
to provide a long overdue fix to problematic performance pay polices at
local facilities. Such policies have virtually stripped this valuable
recruitment and retention tool any benefit.
The problem is twofold. First, local management does not issue
performance criteria in accordance with deadlines set by Congress, and
in many cases, never issues them. Second, when management does set
criteria, they very widely from facility to facility, and/or they
measure improper factors beyond the individual clinician's control,
such as missed appointments, clinical utilization and patients'
satisfaction with their overall hospital experiences.
This draft language will improve the uniformity and effectiveness
of these measures, which in turn, will improve recruitment and
retention. First, section 1(a) clarifies that these criteria should
measure individual, not group, performance--a clarification that is
already in VA regulations (but regularly ignored.) Second, section 1(b)
ensures that the Secretary fulfills a requirement that Congress put on
the books 6 years ago that has been ignored to date, specifically, to
prescribe specific goals at performance objectives at the national
level (``Performance pay shall be paid to a physician or dentist on the
basis of the physician's or dentist's achievement of specific goals and
performance objectives prescribed by the Secretary.'') (emphasis added)
(P.L. 108-445).
Draft Language on Continuing Professional Education Reimbursement
AFGE urges the Subcommittee to approve this draft language to
increase the annual reimbursement for continuing professional medical
education (``CME''). The CME amount provided under current law has not
increased since 1991 and other health care employers currently offer
much higher reimbursement to their clinicians. We also support draft
language extending CME reimbursement to other title 38 clinicians who
need to meet licensing and certification requirements and update their
skills.
AFGE urges the Subcommittee to add additional language to clarify
the following: at facilities where some, but not sufficient internal
CME courses are offered to maintain licensure, the law should clearly
state that reimbursement for outside CME is still available.
Thank you for the opportunity to share AFGE's views on these
critical recruitment and retention legislative proposals.
Statement of David J. Holway, National President,
National Association of Government Employees (SEIU/NAGE)
Mr. Chairman and Members of the Subcommittee:
On behalf of the National Association of Government Employees
(SEIU/NAGE), and the more than 100,000 workers we represent, including
20,000 at the Department of Veterans Affairs (VA), I would like to
thank you for the opportunity to submit testimony regarding pending
legislation before the Subcommittee.
H.R. 949
SEIU/NAGE strongly supports H.R. 949. This bill would restore a
meaningful scope of bargaining for title 38 health care providers at
the VA, a critical necessity to boost morale and strengthen recruitment
and retention at the agency. Giving health care providers a meaningful
voice in their workplace will without question lead to better care for
the American veteran.
In 1991, Congress amended title 38 to provide VA medical
professionals with collective bargaining rights (which include the
rights to use the negotiated grievance procedure and arbitration).
Under sec. 7422 of title 38, covered employees can negotiate, file
grievances, and arbitrate disputes over working conditions, except for
matters concerning or arising out of professional conduct or
competence, peer review, or compensation. In recent years, VA
management has interpreted these exceptions very broadly, and refused
to bargain over virtually every significant workplace issue affecting
medical professionals. The broad interpretation sec. 7422 has created
significant dissatisfaction among rank-and-file VA health care
providers.
We have heard from our members across the country, and they have
urged our union to make passage of H.R. 949 our top legislative
priority for legislation impacting the VA workforce. Their concern is
that too many highly qualified, outstanding health care professionals
have left the VA for other employment because they were unsuccessful in
getting someone of authority at the agency to listen to or address
legitimate concerns because managers claimed the issue fell under the
ever-growing umbrella of sec. 7422.
The agency has been unwilling to address those issues that are most
important to title 38 employees, including time schedules, shift
rotations, evaluations, fair and equal opportunity to be considered for
a different position within the facility, and fair treatment among
colleagues. Rather than suffer under a system where they have no
mechanism to provide input or air grievances, disenfranchised VA
employees simply move on to other employment. This has gone on too
long, and it has to stop.
VA medical professionals have extremely limited collective
bargaining rights in the first place, and the broad interpretation of
sec. 7422 of title 38 is narrowing the scope of bargaining to the point
that it is practically meaningless. As a result, RNs, doctors, and
other impacted employees at the VA are experiencing increased job
stress, low morale and burnout. This in turn exacerbates the VA's well-
documented recruitment and retention problems. Chronic short-staffing
has been shown to adversely impact quality of care, patient safety, and
workplace safety, leading to costly stopgap measures such as the
overuse of contract nurses and doctors.
Passing H.R. 949 would help to address many of these concerns. This
bill would restore a meaningful scope of bargaining for title 38 VA
professionals by eliminating the ``7422 exceptions'' (conduct,
competence, compensation, and peer review) under the law.
Eliminating these exceptions will provide these health care
providers with the same rights as other VA providers, including
psychologists, LPNs, and pharmacists, as well as other Federal
employees. Title 5 health care providers at the VA have full collective
bargaining rights. Even nurses and doctors at Army medical centers such
as the Walter Reed Army Medical Center, who perform the same exact
function as nurses and doctors at the VA, have full collective
bargaining rights. Many private sector health care providers have a
meaningful voice on working conditions and are allowed participation in
hospital affairs. There is no reason for title 38 VA workers to have
these critical rights taken away.
Late last year, the VA engaged SEIU/NAGE and other unions in
discussions to produce recommendations we hope will reduce the VA's
invocation of sec. 7422. Our discussions through the 7422 Work Group
are ongoing. Though we continue to hope that the 7422 Work Group will
produce reforms, it cannot address the fundamental issue of limited
collective bargaining rights. Only Congress can address that issue.
Restoring meaningful bargaining rights will greatly increase morale
at the VA. It will also address recruitment and retention issues, which
are critical at this time, given the veterans returning home from
conflicts abroad. All this will lead to better care for our Nation's
veterans.
SEIU/NAGE strongly urges the Congress to pass H.R. 949. I greatly
appreciate the Subcommittee's decision to hold this hearing. I thank
the Subcommittee for the opportunity to provide this statement.
Statement of William R. Dougan,
National President, National Federation of Federal Employees
On behalf of the National Federation of Federal Employees (NFFE)
and the 110,000 Federal employees our union represents throughout the
United States and abroad, including more than 5,000 Department of
Veterans Affairs (VA) health care providers, I thank you for the
opportunity to submit this statement regarding H.R. 949.
Summary of NFFE's Position on H.R. 949
Over the last several years, Department of Veterans Affairs (VA)
health care professionals have seen their collective bargaining rights
diminish appreciably. Agency management's improperly broad
interpretation of a certain provision in Federal labor law has allowed
them to circumvent the bargaining process on numerous critical issues,
and the effect is taking its toll on the morale of VA health care
providers. It is time for Congress to do what is right for VA workers
and the veterans for whom they provide care by passing H.R. 949, which
will eliminate the collective bargaining exceptions under sec. 7422 of
title 38.
Background on Collective Bargaining for VA Title 38 Health Care Workers
In 1991, title 38 was amended by Congress to give health care
providers at the VA collective bargaining rights. This was a necessary
change that was supported by our union. This change allowed title 38
health care providers access to basic collective bargaining rights,
including a negotiated grievance procedure and the ability to take an
unsettled grievance to arbitration. However, under sec. 7422 of title
38, VA health care providers are permitted to negotiate contracts,
arbitrate disputes, and file grievances over working conditions except
for matters concerning or arising out of professional conduct or
competence, peer review, and compensation. We refer to these as ``7422
exceptions.''
In the years immediately following the change in law, these 7422
exceptions were interpreted narrowly, which in our view was an
appropriate interpretation of the law. However, over the past decade,
the VA has greatly expanded their interpretation of sec. 7422 of title
38 so that practically any matter the VA wished to avoid bargaining
with the union over could be circumvented. When you take away the right
to collectively bargain over conduct, competence, peer review, and
compensation, you make the negotiated grievance procedure all but
meaningless. The VA's broad interpretation of sec. 7422 has been a
great disservice to VA health care providers that we represent. It has
also been a disservice to the American veterans for whom our members
provide care.
Why H.R. 949 Should Be Passed Into Law This Congress
For the following reasons, NFFE believes that it is critical for
Congress to pass H.R. 949 in this session of Congress:
Veterans' care suffers from the toxic labor-management
climate caused by sec. 7422.
The 7422 exceptions are completely unnecessary and
inconsistent with the health care industry.
Health care providers use collective bargaining to
maintain fairness in the workplace and improve patient care; bargaining
does not hurt patient care.
There are veterans groups that support this legislation;
veterans groups do not tend to support legislation that will hurt
veterans' care.
Only legislation can solve the 7422 problem permanently.
With thousands of veterans returning from conflicts
abroad, the time to address this cancer at the VA is now.
Veterans' Care Suffers from the Toxic Labor-Management Climate Caused
by Sec. 7422 of Title 38
I would classify the labor-management atmosphere throughout most of
the VA as toxic. Our members from across the country, who provide care
to the American veteran, report that the VA's willingness to use the
7422 exceptions to circumvent their bargaining obligations and avoid
legitimate employee grievances is an enormous problem that is taking a
very large toll on the morale of VA health care providers.
A year ago, we were optimistic that a new Administration might
usher in a new approach to labor-management relations at the
Department. It is with great disappointment that I report that the
labor-management relations climate at the VA is unchanged from a year
ago. In fact, from many accounts we get from the field, labor-
management relations at the VA are currently at an all-time low.
We believe that the failure of the VA to establish effective labor-
management relationships stem from sec. 7422 of title 38. VA management
have grown quite accustomed to standing behind the 7422 exceptions to
avoid bargaining over workplace issues or to settle legitimate
grievances that involve management's wrong-doing, including the
improper firing of VA employees or the failure to provide employees
with due process. The VA's broad interpretation of the 7422 exceptions
has given management the ability to trump almost any action taken by
the union to enforce workplace rules or defend employees against
adverse actions. It is no surprise that VA employees are feeling great
frustration over the practice.
Many of the issues that VA employees lose the ability to bargain
over because of the 7422 exceptions are very important to the VA rank-
and-file workforce. Some of these issues include: time schedules, shift
rotations, evaluations, fair and equal opportunity to be considered for
promotion, and fair treatment among colleagues. VA management
frequently handles issues like these in ways that warrant grievances
from VA employees, but workers have their efforts to maintain fairness
blocked by the VA's 7422 exceptions. VA employees experience great
frustration when they have no mechanism to demand fairness in the
workplace.
This toxic labor-relations climate results in many title 38 health
care providers being terrified to come forward with concerns--some that
directly impact patient care--because VA employees know that if they
are retaliated against by management, there is little that the union
can do to protect them. For many VA employees, this kind of atmosphere
is more than they are willing to tolerate, especially when the health
care skills they have are in demand, and in all likelihood, they can
get paid more elsewhere.
Poor recruitment and retention rates at the VA are well documented,
and these problems adversely impact patient care. The elimination of
the 7422 exceptions, which would be accomplished by passing H.R. 949,
would lead to a substantially improved labor-relations climate at the
VA. Improved labor-relations would lead to a fairer workplace, a
happier workforce, and better recruitment and retention of VA health
care providers. Improved recruitment and retention would lead to fewer
staffing problems, and ultimately, better care for American veterans.
The 7422 Exceptions are Completely Unnecessary and Inconsistent with
the Health Care Industry
Eliminating the 7422 exceptions to restore the scope of bargaining
for title 38 employees at the VA would bring VA health care providers
in line with the collective bargaining and grievance rights already
enjoyed elsewhere in the health care industry. The VA is unique in its
ability to avoid bargaining over issues concerning conduct, competence,
compensation, and peer review. The rest of the roughly 12 million
health care workers in the United States have a full scope of
bargaining should they choose to be represented by a union; and yes,
they can bargain and file grievances over issues concerning conduct,
competence, compensation, and peer review.
Eliminating the 7422 exceptions under title 38 would level the
playing field with regard to collective bargaining for title 38 and
title 5 employees of the VA. Some of the title 5 VA health care
providers include psychologists, LPNs, pharmacists, and those holding
other positions. These VA employees enjoy a broader scope of bargaining
because they are under title 5. It is only title 38 VA employees who
are singled out under the law, and have their scope of bargaining
limited by sec. 7422 of title 38.
Even Federal employees who have the exact same positions as title
38 VA employees, but work in other Federal agencies, have a broader
scope of bargaining. For example, nurses and doctors at the Army
medical centers such as Walter Reed, who perform the very same function
as nurses and doctors at the VA, have broader collective bargaining
rights. Even VA physicians and RNs converting from a Department of
Defense personnel system at the joint DoD-VA medical facility in North
Chicago will be granted broader bargaining rights. All these federally
employed health care providers have basic bargaining rights that the
majority of Federal employees enjoy under title 5.
The bottom line is, VA title 38 health care providers are in the
same basic positions as those working at DoD medical facilities, joint
DoD-VA facilities, and private sector hospitals. Title 38 VA employees
are just treated differently because the VA is taking advantage of, and
in our opinion abusing, an outdated provision that should be eliminated
from the law.
There is no real reason for title 38 VA workers to be singled out
in the health care community and forced to have their critical rights
taken away. There are, however, many compelling reasons to eliminate
the disparity in treatment that title 38 VA health care providers are
experiencing. The VA is at a distinct disadvantage to employers in
other sectors of the economy, and even elsewhere in the Federal
Government, where employees have a meaningful voice in the workplace on
critical conditions of employment. The VA would be in a better position
to recruit and retain a talented workforce if H.R. 949 was passed into
law, and the 7422 exceptions under title 38 were eliminated.
Health Care Providers Use Collective Bargaining to Maintain Fairness in
the Workplace and Improve Patient Care; Bargaining Does Not
Hurt Patient Care
The VA, over the last several years, has perpetuated the
misconception that collective bargaining would imperil the VA's ability
to provide timely and quality care for veterans. This is 100 percent
false, and it is offensive to the tens of thousands of dedicated VA
health care providers who provide this service to veterans.
For example, last year, Gerald M. Cross, Principal Deputy Under
Secretary for Health testified before the Senate Veterans' Affairs
Committee on April 22, 2009 at a hearing on pending health-related
legislation. Mr. Cross's testimony includes grossly inaccurate
statements such as ``[S. 362/H.R. 949] would give [union members]
bargaining rights on clinical care matters that would clearly and
foreseeably endanger the well-being of our veteran-patients'' and
``would thwart VA's ability to immediately re-assign staff from direct
patient care duties to administrative duties based on an allegation
that the staff committed patient abuse.''
These claims are nothing but fear tactics. Millions of health care
providers in the private sector and elsewhere in government have full
collective bargaining rights, and those rights do not lead to
endangering the well-being of patients. They would not lead to the
endangering of veteran-patients at the VA either.
The reality is that collective bargaining improves patient care
because VA health care providers have the best interest of their
patients at heart. When employees have protections, they come forward
when they see a practice that could be endangering veteran-patients. On
the other hand, if they are intimidated by management and worried that
coming forward will lead to retaliation, they will think twice about
coming forward. Veterans deserve to have their care administered by
employees who have basic workplace rights.
Eliminating the 7422 exceptions, which would give title 38 VA
employees a sense of fairness in the workplace, would give VA employees
peace of mind in speaking up about patient care problems. Not giving VA
employees basic protections is, in my opinion, what leads to situations
like the one experienced in the VA medical center in Marion, IL, where
nine patients died due to surgical mistakes and poor post-surgical
care. Giving employees the peace of mind to come forward when they see
problems like these will help keep these problems from occurring. Right
now, sec. 7422 of title 38 is preventing it from happening throughout
the VA. Veterans deserve better.
There are Veterans Groups that Support this Legislation; Veterans
Groups Do Not Tend to Support Legislation that Will Hurt
Veterans' Care
The fact that some veterans groups support this legislation
demonstrates that the VA's assertions that collective bargaining will
hurt patient care are preposterous. Plain and simple, veterans groups
do not support legislation that is going to hurt veterans' care.
The Paralyzed Veterans of America (PVA) have endorsed H.R. 949. The
Disabled American Veterans (DAV) have indicated that they support the
intent of the bill.
Only Legislation Can Solve the 7422 Problem Permanently
The VA and five VA employee unions, including NFFE, have assembled
a 7422 Work Group to make a recommendation to the Secretary of the VA
aimed at improving the consistent use of the authorities and
limitations on sec. 7422 of title 38. While we hope to make some
improvements, we do not expect to reach a permanent solution from this
7422 Work Group. Regardless of what changes the VA agrees to, the Work
Group recommendation would not be binding on future Administrations
without a change in law. The 7422 problem is a significant one that is
hurting veterans' care. We should address this issue permanently by
passing H.R. 949. A non-statutory fix will have very little impact on
the ability to maintain a fair workplace for title 38 VA employees over
the long-term.
With Thousands of Veterans Returning From Conflicts Abroad, the Time to
Address This Cancer at the VA is Now
The VA is anticipating a large increase in the number of veteran-
patients to whom it provides service as American veterans return from
conflicts abroad. The VA should take necessary steps to improve labor-
relations in anticipation of the increased demands on the Department's
workforce. Our veterans deserve the best care this nation can provide
them. Let's take the necessary steps to ensure the nurse or doctor who
actually provide care to veterans are given basic protections under the
law.
Conclusion
By passing H.R. 949, many of the concerns that that I have
described would be sufficiently addressed. This bill would restore a
meaningful scope of bargaining for title 38 VA health care
professionals by eliminating the 7422 exceptions (conduct, competence,
compensation, and peer review) under the law that the VA has continued
to exploit.
The restoration of meaningful bargaining rights for title 38 VA
employees will increase the morale at the VA greatly. It will also
serve to improve recruitment and retention rates, issues which have
been areas of great concern at the VA. With thousands of veterans
returning home from conflicts abroad, the time to address this critical
issue is now. Restoring a broader scope of bargaining will lead to
better care for our Nation's veterans.
NFFE greatly appreciates the Subcommittee's decision to hold a
hearing on this matter. I thank the Subcommittee for the opportunity to
provide this statement.