[House Hearing, 110 Congress]
[From the U.S. Government Printing Office]



 
              LEGISLATIVE HEARING ON H.R. 1448, H.R. 1853,

              H.R. 1925, H.R. 2005, H.R. 2172, H.R. 2173,

             H.R. 2192, H.R. 2219, H.R. 2378, and H.R. 2623

=======================================================================


                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                             JUNE 14, 2007

                               __________

                           Serial No. 110-27

                               __________

       Printed for the use of the Committee on Veterans' Affairs



                        U.S. GOVERNMENT PRINTING OFFICE

37-465                         WASHINGTON : 2008
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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     RICHARD H. BAKER, Louisiana
Dakota                               HENRY E. BROWN, Jr., South 
HARRY E. MITCHELL, Arizona           Carolina
JOHN J. HALL, New York               JEFF MILLER, Florida
PHIL HARE, Illinois                  JOHN BOOZMAN, Arkansas
MICHAEL F. DOYLE, Pennsylvania       GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada              MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado            BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas             DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana                GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California           VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota

                   Malcom A. Shorter, Staff Director

                                 ______

                         SUBCOMMITTEE ON HEALTH

                  MICHAEL H. MICHAUD, Maine, Chairman

CORRINE BROWN, Florida               JEFF MILLER, Florida, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
PHIL HARE, Illinois                  JERRY MORAN, Kansas
MICHAEL F. DOYLE, Pennsylvania       RICHARD H. BAKER, Louisiana
SHELLEY BERKLEY, Nevada              HENRY E. BROWN, Jr., South 
JOHN T. SALAZAR, Colorado            Carolina

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.


                            C O N T E N T S

                               __________

                             June 14, 2007

                                                                   Page
Legislative Hearing on H.R. 1448, H.R. 1853, H.R. 1925, H.R. 
  2005, H.R. 2172, H.R. 2173, H.R. 2192, H.R. 2219, H.R. 2378, 
  and H.R. 2623..................................................     1

                           OPENING STATEMENTS

Chairman Michael Michaud.........................................     1
    Prepared statement of Chairman Michaud.......................    53
Hon. Jeff Miller, Ranking Republican Member, prepared statement 
  of.............................................................    53

                               WITNESSES

U.S. Department of Veterans Affairs, Hon. Michael J. Kussman, 
  M.D., MS, MACP, Under Secretary for Health, Veterans Health 
  Administration.................................................    38
    Prepared statement of Hon. Kussman...........................    80

                                 ______

American Legion, Shannon Middleton, Deputy Director for Health, 
  Veterans Affairs and Rehabilitation Commission.................    23
    Prepared statement of Ms. Middleton..........................    62
American Veterans (AMVETS), Kimo S. Hollingsworth, National 
  Legislative Director...........................................    25
    Prepared statement of Mr. Hollingsworth......................    65
Disabled American Veterans, Adrian M. Atizado, Assistant National 
  Legislative Director...........................................    26
    Prepared statement of Mr. Atizado............................    68
Herseth Sandlin, Hon. Stephanie, a Representative in Congress 
  from the State of South Dakota.................................     6
    Prepared statement of Congresswoman Herseth Sandlin..........    53
Hodes, Hon. Paul W., a Representative in Congress from the State 
  of New Hampshire...............................................    14
    Prepared statement of Congressman Hodes......................    60
Lowey, Hon. Nita M., a Representative in Congress from the State 
  of New York....................................................    17
    Prepared statement of Congresswoman Lowey....................    61
Miller, Hon. Jeff, a Representative in Congress from the State of 
  Florida........................................................    18
    Prepared statement of Congressman Miller.....................    58
Moran, Hon. James P., a Representative in Congress from the State 
  of Virginia....................................................     3
    Prepared statement of Congressman Moran......................    55
Paralyzed Veterans of America, Carl Blake, National Legislative 
  Director.......................................................    28
    Prepared statement of Mr. Blake..............................    72
Rodriguez, Hon. Ciro D., a Representative in Congress from the 
  State of Texas.................................................     2
    Prepared statement of Congressman Rodriguez..................    54
Salazar, Hon. John T., a Representative in Congress from the 
  State of Colorado..............................................    16
    Prepared statement of Congressman Salazar....................    56
Veterans of Foreign Wars of the United States, Dennis M. 
  Cullinan, Director, National Legislative Service...............    30
    Prepared statement of Mr. Cullinan...........................    76
Vietnam Veterans of America, Barry Hagge, National Secretary.....    31
    Prepared statement of Mr. Hagge..............................    77
Watson, Hon. Diane E., a Representative in Congress from the 
  State of California............................................     5
    Prepared statement of Congresswoman Watson...................    56

                                 ______

                       SUBMISSIONS FOR THE RECORD

National Rural Health Association, Andy Behrman, Chair, Rural 
  Health Policy Board, statement.................................    85
Reyes, Hon. Silvestre, a Representative in Congress from the 
  State of Texas, statement......................................    87
United States Ombudsman Association, Ruth Cooperrider, President, 
  and Deputy Ombudsman, State of Iowa--Office of Citizens' Aide/
  Ombudsman, letter..............................................    89

                   MATERIAL SUBMITTED FOR THE RECORD

Hon. R. James Nicholson, Secretary, U.S. Department of Veterans 
  Affairs, to Hon. Bob Filner, Chairman, Committee on Veterans' 
  Affairs, letter dated August 19, 2007, views on H.R. 2623 and 
  H.R. 2699......................................................    91
U.S. Department of Veterans Affairs, Veterans Health 
  Administration, report entitled: ``Plan to Increase Access to 
  Quality Long-Term Care and Mental Health Care for Enrolled 
  Veterans Residing in Rural Areas,'' January 10, 2008...........    96
Job Description for Program Analysis Officer, Office of the 
  Assistant Deputy Under Secretary for Health for Policy and 
  Planning, Veterans Health Administration, U.S. Department of 
  Verterans Affairs..............................................   103


LEGISLATIVE HEARING ON H.R. 1448, H.R. 1853, H.R. 1925, H.R. 2005, H.R. 
     2172, H.R. 2173, H.R. 2192, H.R. 2219, H.R. 2378 AND H.R. 2623

                              ----------                              


                        THURSDAY, JUNE 14, 2007

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

    The Committee met, pursuant to notice, at 10:00 a.m., in 
Room 340, Cannon House Office Building, Hon. Michael Michaud 
[Chairman of the Subcommittee] presiding.

    Present: Representatives Michaud, Brown of Florida, Snyder, 
Hare, Miller, Brown of South Carolina.

             OPENING STATEMENT OF CHAIRMAN MICHAUD

    Mr. Michaud. This hearing will now come to order. I'd like 
to thank everyone for coming today. I ask unanimous consent 
that all written statements be made part of the record. Without 
objection, so ordered.
    I also ask unanimous consent that all members be allowed 
five legislative days to revise and extend their remarks. 
Without objection, so ordered.
    Today's legislative hearing will provide members of 
Congress, Veterans, the U.S. Department of Veterans Affairs (VA 
and other interested parties the opportunity to discuss 
legislation within this subcommittee's jurisdiction in a clear 
and orderly process. While not necessarily in agreement or 
disagreement with the bills before us today, I do believe that 
this is an important process that will encourage frank 
discussion and new ideas.
    We have ten bills before us that seek to improve healthcare 
for the Nation's veterans and I look forward to hearing the 
views of our witnesses. I also look forward to working with 
everyone here to continue to improve the quality of care 
available for our veterans.
    There are two draft discussions that are not before us 
today. There is a discussion draft on homelessness, and a 
discussion draft on mental health services. Congressman Patrick 
Murphy of Pennsylvania has also introduced H.R. 2699. I'd ask 
that the members of the third panel, the veterans service 
organizations (VSOs), and the fourth panel, VA, provide 
comments and views on these three items for the record once 
they are made available. We'd like to have the written comments 
submitted to the Committee by June 21st of this year.
    We may as well begin, starting off with Mr. Rodriguez.
    [The prepared statement of Chairman Michaud appears on p. 
53.]

   STATEMENTS OF HON. CIRO D. RODRIGUEZ, A REPRESENTATIVE IN 
   CONGRESS FROM THE STATE OF TEXAS; HON. JAMES P. MORAN, A 
  REPRESENTATIVE IN CONGRESS FROM THE STATE OF VIRGINIA; HON. 
DIANE E. WATSON, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF 
       CALIFORNIA; AND HON. STEPHANIE HERSETH SANDLIN, A 
     REPRESENTATIVE IN CONGRESS FROM THE STATE SOUTH DAKOTA

              STATEMENT OF HON. CIRO D. RODRIGUEZ

    Mr. Rodriguez. Mr. Chairman, thank you very much. And 
members of the Committee thank you for this opportunity to be 
here before you. I have my bill, H.R. 2173, a bill introduced 
by myself and my colleague Congresswomen Grace Napolitano, 
provides for increase in the capacity for mental health 
services through contracts with qualified community health 
centers.
    This is an opportunity for veterans in rural communities, 
especially to be able to get access to services, not to mention 
in those areas where we don't have access to mental health 
services within our VA system. It's also a great opportunity to 
follow up on individuals that need the services.
    Recent surveys show that one in eight returning Iraqi war 
veterans report symptoms of post traumatic stress disorder 
(PTSD). The same studies also report high incidents of major 
depression and anxiety disorders among returning members of the 
Army and Marine combat unit. As a member of this Committee, we 
have long identified mental health services as a major issue 
facing returning soldiers as well as the Department of Veterans 
Affairs.
    Experts note that the manifestation of clinical symptoms of 
post traumatic stress disorder and other mental health 
disorders often occurs over several years. With the increase of 
active duty, guardsman and reservists returning from combat, 
the necessary capacity to provide mental health services is 
relatively unknown. It is difficult to know if our large number 
of returning veterans will need mental health services beyond 
what the VA is capable of providing.
    My bill, H.R. 2173, authorizes the VA to contract with 
community mental health centers to increase the capability. In 
my opinion the need has out paced the capacity of the VA to 
provide mental health services in out patient clinics. 
Contracting out to the community mental health centers is 
already been done successfully in some States, and could serve 
as a model for the VA-wide implementation.
    Mr. Chairman, in my previous career, I worked as a mental 
health field social worker. I am fully aware of the great 
services provided by the community health centers. And if there 
is any doubt of the quality of the care they can provide, I can 
tell you of the hundreds of families who's lives have been 
changed by the treatment received during my professional career 
in the field, but you don't have to take my word.
    Each year community health centers have nearly six million 
children, adults, families and communities across this country 
the chance to recover and lead productive lives. Our returning 
soldiers deserve nothing less and we hope that we can provide 
them with that opportunity.
    As I mentioned before, it is clear that our soldiers 
returning with an increased need for mental health services, 
but after this long war, it is unclear what the VA capacity to 
fulfill this need will be. It is my hope that H.R. 2173 can 
provide the VA with the tools to continue to provide top notch 
mental health services to our veterans in their own 
communities.
    Mr. Chairman, once again I would like to thank you for 
allowing me this opportunity, and I urge your support, and just 
indicate that this piece of legislation, I think, will help 
enhance the quality of care for our veterans especially in 
rural communities and in those areas, urban areas, where 
there's a large number of our veterans.
    Thank you.
    [The prepared statement of Chairman Rodriguez appears on p. 
54.]
    Mr. Michaud. Thank you very much. As you know I am very 
concerned about access to healthcare benefits for veterans 
particularly in rural areas that need that access.
    Mr. Moran?

                STATEMENT OF HON. JAMES P. MORAN

    Mr. Moran. Thank you Mr. Chairman, and Mr. Miller, Mr. 
Salazar, Mr. Brown. I want to thank you for holding this 
important hearing today and commend the Subcommittee for the 
work that it has already undertaken on behalf of our Nation's 
veterans.
    The problem of suicide among our veterans is one of the 
most serious issues that we have to address as we care for our 
older veterans and prepare for a new generation of returning 
soldiers.
    The Centers for Disease Control recently released very 
troubling statistics. Each year approximately 115,000 veterans 
attempt suicide. This accounts for nearly 20 percent of all 
suicide attempts, and yet the veteran population only accounts 
for 11 percent of the entire population. So in other words, 
veterans are much more likely to attempt suicide as other 
groups of our society.
    This disproportionate prevalence of suicide among veterans 
suggest that in addition to our overall national strategy on 
suicide prevention, particular attention should be paid to 
preventing suicide among this special population. 
Unfortunately, I expect this trend to continue as more of our 
brave men and women return from multiple deployments with the 
symptoms of post traumatic stress disorder.
    As we have learned, the staggering 20 percent of soldiers 
returning from Iraq are experiencing depression, sleep 
depravation, anxiety, and other symptoms of PTSD. I am proud 
that this Congress has already acknowledged the growing problem 
of PTSD and dedicated substantial resources to it. Still, I 
believe as scientific evidence suggests, that as our returning 
soldiers are increasingly susceptible to PTSD, they are at an 
elevated risk for suicide attempts.
    My bill, the ``Veterans Suicide Prevention Hotline Act of 
2007,'' would create a 24-hour National toll-free hotline to 
assist our Nation's veterans in crisis. It would be staffed 
predominately by veterans trained to appropriately and 
responsibly answer calls from other veterans. The hotline would 
follow the models of the national suicide, sexual assault, and 
domestic violence hotlines who have volunteers trained in 
active listening and crisis de-escalation respond to a variety 
of crisis calls.
    I believe that this cultural competency, the ability to 
connect to another veteran who understands what the caller may 
be experiencing can make a real difference in crisis 
counseling. It is difficult to connect on this level with 
anyone else, even trained doctors or other professionals.
    So to build this capacity nationwide, my bill calls for a 
3-year competitively awarded grant for two and a half million 
dollars in the next three fiscal years. The funding will be 
made available to a qualified non-profit crisis center to 
establish, publicize, and operate the hotline including 
developing curricula to train and certify volunteers.
    We have reached out to the Department of Veterans Affairs 
and are encouraged that the Veterans Health Administration 
(VHA) is undertaking new efforts to establish a suicide hotline 
and address mental health needs. Their plan is to divert 
callers from the national suicide prevention hotline to a VA 
facility staffed by doctors, psychologists, and other certified 
counseling professionals. On the surface, the VHA's effort may 
appear duplicative of what I am proposing, but there are some 
very important differences that I feel need to be highlighted.
    First, my legislation requires that the people answering 
the phones, those dealing directly with the veterans are 
veterans themselves. There are times when speaking with someone 
who has the cultural competence and the empathy to really 
understand the experiences of veterans in crisis can help make 
the difference between successful integration to mental health 
treatment and failure to reach a veteran in dire need of 
services.
    Second, the VHA has many responsibilities for providing the 
highest quality of healthcare for our veterans. However, they 
have experienced stressed budgets and staffing shortages in 
recent years. Because the demands placed on any veterans 
hotline may be much greater as our Nation redeploys from Iraq 
in the future, I have concern that the VHA may not have the 
capability and commitment to the hotline that a non-profit 
organization dedicated to suicide prevention as its sole 
purpose might be able to provide.
    Third, there are times when a person in crisis doesn't want 
to talk to a doctor. They want to talk to a volunteer. Mentally 
ill individuals all face societal stigmas associated with 
seeking care. Research from the Air Force's suicide prevention 
effort suggest that this is perceived to be even more profound 
in the military and veteran communities. Fear of the system, of 
an un-friendly mental health establishment or of potential job-
related consequences keep many from seeking care. One of the 
motivations behind the National Suicide Hotline and this bill 
is to give people in crisis another option, an anonymous 
hotline that can respond to their immediate crisis.
    To conclude, our vets deserve as much support when they 
return from combat as they receive while in battle. Too many of 
our veterans are struggling to make the difficult adjustment 
back to society and need someone they can talk to, someone who 
has walked a mile in their shoes. This legislation will offer a 
caring voice at the end of the line when it feels that there is 
no where else to turn.
    Thank you, Mr. Chairman.
    [The prepared statement of Congressman Moran appears on p. 5
5.]
    Mr. Michaud. Thank you very much. Ms. Watson?

               STATEMENT OF HON. DIANE E. WATSON

    Ms. Watson. Thank you so much, Mr. Chairman, for holding 
today's hearing and letting me speak on the bill H.R. 1853, the 
``Jose Medina Veterans Affairs Police Training Act of 2007.''
    I believe this legislation is vital to protect our heroes 
and who have sacrificed their minds and bodies to protect our 
freedoms. And I feel the two previous bills presented will be 
complimented by this legislation.
    Mr. Chairman, too many veterans are suffering from mental 
health problems after returning from combat, and they are not 
receiving the proper treatment they deserve. Congress has a 
responsibility to provide quality healthcare for our veterans. 
We must analyze every aspect of services associated with the 
treatment of post traumatic stress disorder or PTSD for our 
vets.
    So I have introduced H.R. 1853, the ``Jose Medina Veterans 
Affairs Police Training Act of 2007,'' a bill that will force 
the Department of Veterans Affairs to better prepare it's 
police force to interact with patients and visitors at the VA 
medical facilities who suffer from mental illnesses.
    Jose Medina is a constituent of mine. He is a Vietnam vet 
who suffers from PTSD. In January of 2006, Mr. Medina was 
assaulted by two west Los Angeles VA police officers who kicked 
him and forced him to the ground after he isolated himself and 
fell asleep in a hallway at a VA medical center in Los Angeles.
    After a physical altercation ensued, this 56-year-old 
veteran was forced to lay first face down on the hospital 
floor. The officers injured Mr. Medina, and after the 
altercation they did not allow him to use the hospital's 
emergency room. Instead, the officers handcuffed him and 
detained him for an hour before sending him home and gave him a 
loitering ticket.
    This is not the way we should be treating veterans who have 
served and protected this country. What bothers me the most is 
that when we see someone sitting on a hospital floor, one would 
think law enforcement would have hospital staff come and 
question the individual to see if that individual was all right 
or in need of assistance. Instead, in this case, Mr. Medina was 
without medical treatment and was mistreated at the same time.
    This is happening to too many of our brave veterans out of 
sheer ignorance. As we look to the future, thousands of 
veterans will be entering the VA healthcare system. We must 
ensure that the VA has the ability to administer quality 
healthcare services to veterans that suffer from mental 
illnesses. With over 20 percent of the one and a half million 
veterans that served in Iraq or Afghanistan showing signs of 
PTSD, we do not want any of them to endure what Mr. Medina went 
through. They simply deserve better.
    So, Mr. Chairman, the Department of Veterans Affairs 
believes this legislation is unnecessary, but the story of Jose 
Medina and other veterans from around the country who have 
contacted my office with similar problems have confirmed that 
this training is indeed necessary.
    As Congress debates funding strategies and time lines for 
our military missions, we must not overlook the fact that they 
not only--that we not only need for our vets to have the 
resources for results from the battlefield, but they must also 
be treated with dignity and respect once they resume their 
lives after combat. We must ensure that this occurs.
    So, Mr. Chairman, I thank you for this opportunity to 
explain what this bill would do, and I urge the members to 
support H.R. 1853. Thank you.
    [The prepared statement of Congresswoman Watson appears on 
p. 56.]
    Mr. Michaud. Thank you very much. Appreciate your 
testimony. Ms. Herseth Sandlin?

          STATEMENT OF HON. STEPHANIE HERSETH SANDLIN

    Ms. Herseth Sandlin. Thank you, Chairman Michaud and 
Ranking Member Miller. I appreciate the opportunity to discuss 
here today the Services to Prevent Homelessness Act, a bill 
which I introduced May 17, 2007, to provide supportive services 
to very low income veterans.
    The U.S. Census Bureau estimates that 1.5 million of our 
Nation's veterans live in poverty, including 702,000 veterans 
with disabilities and 404,000 veterans in households with 
children. Six hundred and thirty-four thousand of the 1.5 
million poor veterans live in extreme poverty. These poor 
veterans face residential insecurity due to their low income 
levels or their past episodes of homelessness. They also face 
health and vocational challenges and access barriers to 
supportive services, which limit their ability to sustain 
housing and maintain independence for more costly public 
institutional care and support.
    These poor veterans may benefit from flexible and 
individualized support services provided at home based 
settings. The services to prevent Veterans Homelessness Act 
would authorize the Secretary of Veterans Affairs to provide 
financial assistance to non-profit organizations and consumer 
cooperatives to provide and coordinate the provision of 
supportive services that addresses the needs of very low-income 
veterans occupying permanent housing.
    The financial assistance shall consistent of per diem 
payments for each household provided supportive services. 
Supportive services that may be offered include physical and 
mental health, case management, daily living, personal 
financial planning, transportation, vocational counseling, 
employment and training, education, assistance in obtaining 
veterans benefits and public benefits, child care, and housing 
counseling.
    Veterans sub-populations expected to benefit from the 
program include veterans transitioning from homelessness to 
permanent housing, poor disabled and older veterans requiring 
supportive services in home-based settings, and poor veterans 
in rural areas with distance barriers to centrally located 
services.
    While Federal programs exist to help create veterans home 
ownership, there is no national housing assistance program 
targeted to low-income veterans. Permanent housing 
opportunities for veterans ready for independent living are 
limited.
    In addition, the VA currently is not permitted to provide 
grants to create affordable permanent housing and the resources 
that are available for providers are inadequate and highly 
sought by competing housing projects.
    Thank you again for the opportunity to be here today. I 
look forward to continuing to work with the Chairman and the 
Ranking Member to support efforts to meet the housing 
assistance needs of our Nation's low income veterans through 
the establishment of a permanent housing assistance program for 
this population.
    I am happy to take any questions that you may have.
    [The statement of Congresswoman Herseth Sandlin appears on 
p. 53.]
    Mr. Michaud. Thank you very much. I have a couple of 
questions on some of the bills. The first one is to Ms. Watson.
    You so eloquently explained the problem you had with one of 
your constituents at the VA facility. Is this typical? Is this 
the first case or is it really ongoing out there? Have you 
heard from the different VSOs?
    And my second question, what type of training do you think 
additional training they need?
    Ms. Watson. Yes. To address your first concern, it is one 
of our top calls that comes in to my office and I had my 
staffers in here who could supply the actual numbers. But in 
Los Angeles, our homeless population on any given night is 
somewhere between 80,000 and 90,000. Those people who are 
homeless, 33 percent of them, are vets in need of mental health 
services.
    So it is a pervasive problem that we must address. And I 
hope in Markup to put a provision in this bill that would say 
that the training must come from highly trained professionals. 
And the kind of training that it will supplement what is 
already called for in prior legislation is the handling and the 
respect for dealing with mentally ill patients.
    And so we get in to the actual behavior of law enforcement 
and other personnel that deal with the mentally ill.
    Mr. Michaud. Great. Thank you. My next question is for Mr. 
Moran. You had mentioned setting up this separate hotline. Do 
you know if there is currently a national hotline for suicide 
prevention? How many calls go in to that hotline that actually 
deal with veterans? Do you have any idea of that?
    Mr. Moran. I don't have the numbers, Mr. Chairman. The way 
I came up with this idea was that I was talking with some 
people that are involved with a group called Crisis Link that 
provides suicide prevention throughout the Washington 
Metropolitan area. And one gentleman I was asking what is going 
on and he said, ``Well when veterans found out that we had a 
veteran volunteer that they could talk to, that veteran become 
overwhelmed with calls.'' He is spending overtime. It is taking 
up much of his life, because the word spreads. And there is a 
clear indication that most veterans would like to talk to 
another veteran that can empathize with them. That is what is 
distinct.
    And I think that the numbers don't necessarily reflect 
that, but the fastest increasing number of calls with this 
group was because of the presence of that veteran on the other 
end of the line, but I don't have any specific numbers as you 
have asked.
    Mr. Michaud. Great. Thank you. My last question actually 
goes back to Ms. Watson. Is the police force at VA facilities, 
is that a contracted service or are they regular VA employees?
    Ms. Watson. They are employees that have come in under a 
contract and I don't know whether they are paid from the 
contract or from the VA. Would you know that information? They 
are Federal officers.
    Mr. Michaud. Okay. Great. And hopefully the VA officials 
here will be able to let us know of all facilities whether they 
are VA Federal officers or contracted positions.
    Mr. Miller?
    Mr. Miller. Thank you, Mr. Chairman. Mr. Moran, I think we 
agree that the end result of what you are trying to have done 
is what we are trying accomplish, though I do have a question. 
We passed H.R. 327, the Joshua Omvig Veterans Suicide 
Prevention Act, earlier this year that required an in-house 24-
hour hotline. Can you expand a little bit on why we would need 
this hotline. H.R. 327's hotline is veterans, these are members 
of the VA Office, and they are specially trained, why we would 
need to go outside and do this independently?
    Mr. Moran. That is a very good question. I think the 
difference, and I address this in my testimony, is that the VHA 
line is designed to get people into the VA system, it's doctors 
and psychologists who are not necessarily veterans that are on 
the other end of the line.
    What this is, what I am suggesting is a volunteer 
organization. These organizations exist in many of our 
districts. People who are not necessarily professionals, but 
get specific training. And many people have found that they can 
relate better to the veteran. They are not trying to get them 
in to necessarily a mental health establishment immediately and 
there is some stigma to calling the VA. And while the VA does 
wonderful work, and the professionals associated with the VA do 
a great job, the veteran that may be attempting suicide is not 
necessarily wanting to get in to what they consider to be the 
establishment to talk to necessarily a professional who has an 
objective. We find that in other situations.
    And what we are going to try to do if this is established, 
if it is not then groups will try to do it on their own, is to 
find a great many veterans who are willing to volunteer to get 
the training to be there for other veterans on a volunteer 
basis. So it is a different kind of thing.
    One is professional. It is an official arm of the 
Department of Veterans Affairs. It is designed to get people in 
to the VA system. Another is volunteer hotline for people that 
can perhaps empathize to a greater extent with who will be 
there for them if they are having difficulty coping.
    And so it is different personnel. It is a differently run 
organization. The ultimate purpose, of course, is the same; to 
save people's lives and to be there for people in crisis.
    Mr. Miller. Thank you, I had some other questions, but all 
of you did such a good job. Ms. Watson?
    Ms. Watson. Yes. If I can extend the response. I mention 
that we have 33 percent homeless vets on the streets, and so 
this service nationally will allow them an opportunity. They 
are not necessarily in-house, but wherever they are and I was 
just thinking as Representative Moran was speaking, that we 
might want to locate these services in homeless shelters, on 
skid rows, and places that will be assessable.
    What we find in Los Angeles is that many of our people who 
are homeless are committing suicide through overdoses of drugs. 
And they really need someone to talk to. They don't know how to 
access that. So I think the idea of having them locate it where 
homeless people or homeless vets would go on the streets is 
something that we need to fill in our chain of services.
    Mr. Miller. I think, if I am correct, Mr. Moran's proposed 
legislation is a single provider, a single hotline. That is why 
I was asking the questions in regards to the single hotline 
that is already provided or will be provided under the Omvig 
bill that we passed earlier this year.
    There may be a desire to expand it, but then you are 
talking about other mental health providers. Now we are really 
beginning to go far beyond what I think the original intent and 
scope, which is to provide a single call that that veteran can 
make to somebody when he or she is at their very darkest, 
lowest moment.
    That was what my question was. Again, I think we are all 
trying to get to the same place, and I salute everybody here. 
My other questions you have already answered in your opening 
statements. Thank you.
    Mr. Michaud. Mr. Salazar?
    Mr. Salazar. Thank you, Mr. Chairman. I just have a 
question for, let's see, Ms. Watson, Mr. Moran, and Mr. 
Rodriguez. Most of your issues deal with mental health issues 
of veterans. Is there a way to be able to coordinate your three 
bills into one bill, which might be a little more effective way 
of addressing the issue of veterans and mental health issues?
    Mr. Rodriguez. Let me just indicate that the need for us to 
provide especially in mental health settings to provide 
training for those officers to treat people and to recognize 
them is essential. And that has got to happen. That has to 
occur. Those people that are law enforcement, first responders, 
need to be aware of that whether they are public sector or 
private sector.
    Secondly, the area of mental health we just have one too 
many veterans that are committing suicide. So we need to 
provide that access. And you yourselves and your offices I have 
had veterans come in to my offices that threaten our office and 
they are mentally ill. And they need services. And that is why 
we really need to push forward, and because we are just having 
one too many of them committing suicide.
    The contracting out to the community mental health centers 
throughout this country, those are the ones that provide the 
most access to mental health than anyone else in this country. 
Those were created in the sixties. It is a great opportunity to 
provide that access. Major metropolitan areas have crisis 
intervention centers that have 1-800 numbers.
    But one of the ways to look at it is maybe in some of the 
rural communities, there is one thing to provide the access, 
but the other thing is the referral that are needed and the 
follow up that is required in order to respond to those needs. 
And some how we have to fill those gaps.
    And I think a comprehensive program that allows that to 
occur, and especially in rural America where you don't have as 
much and some of those mental health services are available 
where you don't have VA services. So I think a comprehensive 
program is needed and the sooner we can do that the better.
    Mr. Salazar. Mr. Moran?
    Mr. Moran. Mr. Salazar, everything that we have recommended 
is complimentary and deliberately complimentary of everything 
that the Department of Veterans Affairs is doing. Mine is 
pretty limited in scope. It is simply to have one single 
national hotline number that is available any time that 
veterans can memorize and call and find another veteran at the 
other end of the phone to expand it to include these, which is 
fine. The dollar amount that is being recommended over a 3 year 
period would have to be substantially greater to do it right. 
That is why the amount of resources that I suggested is pretty 
limited.
    So they are all fine things, it is just that as you expand 
them you would have to contribute provide more money to make 
them work properly.
    Ms. Watson. And in response, we gave a name to our bill 
because we want to send a message out there. So we are naming 
the Jose Medina. And if it would fit in to other pieces of 
legislation that is to be considered as well. But we wanted to 
tag this with his name to send the word out there like the 
Miranda Act, and so, it comes out of an event. And we want to 
let the veterans know that these incidents are very important. 
We are sensitive to them so we put his name on it.
    And so I guess we could integrate this in to another piece 
of legislation and we can talk about that.
    Mr. Salazar. Thank you. Ms. Herseth Sandlin, your bill 
talks about housing and the transition from homelessness toward 
someone who can actually live in a home. Does your bill address 
the issue of those who are almost at the transition point of 
becoming homeless? They have a home, but because of their 
income they are almost there or are in danger of becoming 
homeless?
    Ms. Herseth Sandlin. I think the bill is more focused on 
the transition of the veterans subpopulation that has had 
episodes of homelessness, has transitioned to temporary housing 
programs of which we may be familiar with in our districts, but 
then addresses really that next hurdle of moving to more 
permanent housing.
    So your question is a good one. I think that we could 
certainly as the Secretary would have the authority in 
establishing the criteria for the non-profit organizations or 
cooperatives, consumer cooperatives, that would be utilized to 
extend the service that certainly it could address those that 
might be at danger of homelessness, although I think we are 
catching them already to a degree, at least a significant 
percentage of them in the subpopulation that has previously had 
episodes of homelessness.
    So I appreciate the question and it is something that we 
could pursue I think more if we were to get this enacted with 
the Secretaries. We work with them to establish a formula and 
the criteria as it relates to contracting with the non-profits.
    Mr. Salazar. Thank you. I yield back, Mr. Chairman.
    Mr. Michaud. Mr. Brown?
    Mr. Brown of South Carolina. Thank you, Mr. Chairman and I 
thank the witnesses for coming and bringing testimony to solve 
a problem that we have been trying in this Committee for a long 
time to connect to the homeless veteran. We recognize that 
there are many homeless veterans that do have a mental 
condition.
    We have tried to provide resources, and I believe they are 
adequate resources out there if we could just match the 
homeless veteran to the resource. I appreciate the effort that 
you are trying to do that.
    Ms. Watson. If I might respond, Mr. Chairman? One unique 
feature of our bill is that we address police brutality. We 
have received complaints from not only the West Los Angeles 
Medical Center, which is just right next to my district it is 
coterminous, but from Michigan, San Antonio, Texas and so on 
and it is all referring to the police brutality. So we address 
that issue uniquely in our bill.
    Mr. Brown of South Carolina. I know, Mr. Moran, in your 
bill and I appreciate that for the trying to reach out to those 
veterans that need particularly care. And I know in our region 
we have like the 2-1-1 number where they can call and talk to 
some counselor that is online all the time.
    Is part of your bill to require that there be some voice at 
the end of that line all the time?
    Mr. Moran. Thank you, Mr. Brown, for asking that question. 
The answer is yes. Many of these suicide prevention hotlines 
are very good and they have very fine people, but I notice that 
the volunteers tend to be young, single people who have the 
time to provide. They don't necessarily tend to be veterans. 
And what this would do is to put a special emphasis upon 
getting trained veterans on the other end of the line.
    Now, they are not veterans who have the career choice or 
interest, ability, whatever, to become doctors or psychologists 
or specific mental health counselors. They are trained simply 
to be there to listen and to try to get help, get somebody to 
get through a crisis. So we would be going out to veterans 
organizations just trying to get recruits to volunteer to help 
them to be there and have one single line nationally that would 
be toll free that people could call.
    That is why it is fairly limited in scope, but it is 
particularly designed to get a veteran on the other end of the 
phone.
    Mr. Brown of South Carolina. Thank you. Thank you, Mr. 
Chairman.
    Mr. Michaud. Mr. Hare?
    Mr. Hare. Thank you, Mr. Chairman. Thank you for holding 
this hearing this morning, it is very important. Let me thank 
my four colleagues for being here today and for proposing 
various legislation. You know we have seen a lot and heard a 
lot about all wounds that people have aren't necessarily wounds 
that people can see. So I am really delighted that you have 
come together on this and I want to commend you all for that.
    I have a question, if I could, for Mr. Rodriguez as soon as 
I find it. Sir, like you, I have a lot of rural area in my 
district. I know your district is extremely large, probably one 
of the largest in the country. And I wonder if you could tell 
me a little more about how the bill that you have would address 
the problems that your constituents face accessing mental 
healthcare particularly in a geographic area that is so 
incredibly large?
    Mr. Rodriguez. First of all, the one of the few 
organizations that is responsible for that and that provides 
some degree of access to healthcare to in mental health 
throughout this country is the community mental health centers.
    And so to provide services, and this is one of the few 
areas that where we can provide that access and the follow up. 
The purposes of the community mental health centers were 
basically were to try to get the mentally ill out of the 
institutions in the sixties. So they were created to reach out 
to the community throughout America and meet those needs.
    And so these centers are trained to do that. And I really 
believe that we have some figures that we have seen of three 
million veterans committing suicide every year directly are 
tied in to the VA and there is a larger number that are not 
tied to them. And so we really need to you know, provide those 
services as quickly as possible. And I really believe I would 
of preferred it under the VA System, but I really believe that 
they don't have the capability at the present time to meet the 
massive need that is needed out there.
    And so I really believe that this is one of the few ways of 
meeting that need and that is reaching out through the 
community mental health centers that exist throughout the 
country, even in rural communities. And they can reach out and 
get some kind of professional treatment that is required. There 
are some areas where we don't. I got one psychiatrist in one 
community and I think it was a contract that was out there in 
the private sector, but the community health center there is 
actually a little better equipped to handle that.
    Now the urban areas have the crisis centers and have the 
for the homeless and others, but in those other areas you know 
we have got to do more to those individuals that are out there, 
especially the ones who have hit the bottom of the totem pole 
which is the homeless veterans that find themselves without 
anything and find themselves without access. And you have got 
to have those outreach workers that do that.
    And I think that that is one of the better ways. Now we 
still have a problem in that in rural America in terms of how 
do we, you know, in those areas where you have to provide that. 
I have that problem in terms of trying to provide offices. I 
have five offices right now and I don't have the manpower to 
provide the staffing throughout my office. And so there is 
still a need to provide some mobile units to go out in to rural 
America.
    Mr. Hare. Thank you. And I just have a question for my 
colleague Ms. Herseth Sandlin. And I apologize for coming in 
just a bit late, I was on the floor. But you know we see the 
stand downs that we have throughout the country every year to 
help homeless veterans. The problem is that is a weekend, 
excuse me, that is a weekend opportunity. And I was amazed in 
my district that when Congressman Evans was hosting these and 
working on them, that the number of veterans that would use, 
you know, the stand down and be able to come in.
    I am wondering could you just expand a little bit on what 
your bill would do to establish assistance program so that we 
can move homeless veterans into, to give them some decent 
housing that they clearly, ``A,'' need; and ``B,'' deserve?
    Ms. Herseth Sandlin. Well thank you for the question. And 
you are right. With the weekend stand downs one of the 
wonderful things about that is that you have generally this a 
centralized location that offers a whole host of other services 
that are either important to veterans who are interested in 
what they can access to avoid homelessness, if they are very 
low income veterans, but certainly those that have had episodes 
of homelessness that have perhaps been in transitional housing 
but the eligibility is 24 months of transitional housing and 
then what more may be needed in terms of financial counseling, 
access to other benefits to which they are eligible to have a 
more holistic approach, comprehensive approach to what the 
needs of the veterans are on a more consistent basis than the 
weekend stand downs where they look forward to that opportunity 
and word gets around the veteran population of a particular 
community or particular region of a district or a State.
    And so what the bill does is I think it addresses a gap 
that currently exists in what the VA can provide in setting up 
a grant program, establishing a formula and the criteria for 
non-profit organizations and consumer cooperatives to access 
the grant and provide these services, particularly targeted 
toward veterans and their families who are very low income who 
are in that transition period.
    But as Mr. Salazar asked earlier, I think that the 
availability of support services for very low income veterans 
and their families that may already be in housing but at great 
risk for homelessness can also be provided within the terms of 
this bill.
    So I think it addresses a significant gap that exists and I 
think especially at this time in our country's history when we 
have many veterans returning who have very young children, who 
are very young themselves, this is an important grant program 
that needs to be established.
    Mr. Hare. Thank you very much. And once again, Mr. Moran 
and Ms. Watson, thank you very much for your legislation. I 
think they are wonderful pieces of legislation. I yield back.
    Mr. Michaud. Dr. Snyder, you have any questions?
    Once again, I would like to thank our first group of 
panelists for your testimony today and look forward to working 
with you as we look at this legislation later on. Thank you.
    Mr. Moran. Thank you.
    Mr. Rodriguez. Thank you.
    Mr. Michaud. I would now like to welcome our second panel.
    The first individual I will ask to give his statement is 
Mr. Hodes. I want to thank you, Mr. Hodes, for your interest in 
veterans issues. I know you have been a strong advocate for 
veterans issues, we have dealt with your legislation earlier in 
the year as well. So thank you very much for coming here today. 
Mr. Hodes?

STATEMENTS OF HON. PAUL W. HODES, A REPRESENTATIVE IN CONGRESS 
   FROM THE STATE OF NEW HAMPSHIRE; HON. JOHN T. SALAZAR, A 
  REPRESENTATIVE IN CONGRESS FROM THE STATE OF COLORADO; HON. 
 NITA M. LOWEY, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF 
 NEW YORK; AND HON. JEFF MILLER, A REPRESENTATIVE IN CONGRESS 
                   FROM THE STATE OF FLORIDA

                STATEMENT OF HON. PAUL W. HODES

    Mr. Hodes. Thank you, Chairman Michaud, and Ranking Member 
Miller for holding this important hearing today. I appreciate 
the opportunity to come before this Subcommittee to testify 
about H.R. 2192, the bipartisan bill I introduced establishing 
an Office of the Ombudsman in the Department of Veterans 
Affairs. I also want to thank Chairman Filner, who is not here, 
for his support of the bill.
    This bill grew out of the visits I made to Walter Reed Army 
Medical Center and the hearings held by the Oversight and 
Government Reform Committee on which I sit. I talked with 
numerous soldiers about the problems they experienced 
transitioning out of active duty and into the VA. I also talked 
with numbers of veterans organizations within my own State, New 
Hampshire, and numbers of veterans.
    Veterans in my district have repeatedly told me their 
compelling stories of the great difficulties and challenges 
they have faced in understanding and receiving all the benefits 
and services to which they are entitled. The ombudsman's 
office, which as proposed in this bill, should serve as the 
outreach master office. A coordinating and coordinated center 
for benefits and health information services available both 
within and outside of the VA.
    I am not interested in creating another meaningless layer 
of bureaucracy. Instead, I would like the Ombudsman Office to 
become a one stop shop for veterans. A CENTCOM for veterans 
benefits information. I applaud the VA for their hard work in 
providing information that veterans need. The VA has numerous 
hotlines and support services available to veterans. I have 
counted ten different 1-800 numbers on the VA's website to help 
with different types of benefits. One for disability pension, 
another for healthcare benefits, another for life insurance, 
etc.
    And while the VA provides veterans benefits and services 
information, the veterans may not know where they put their 
informational pamphlets 6 months or one year down the road when 
they have a question or a problem. Our veterans are falling 
through the cracks and do not know where to turn.
    It was very interesting to me, recently a number of both 
active duty wounded soldiers and veterans came to the floor of 
the House to talk with a number of Members of Congress. There 
were seven or eight members of Congress there and we heard 
compelling stories there on the floor from veterans who 
described what they--described as their ordeal working through 
the bureaucratic maze and the red tape in the Veterans 
Administration. And this office is designed to provide that one 
stop shop that would help them cut through the red tape.
    It would provide a focal point of information within the 
VA. The office should head up the advocacy and information 
campaigns that the VA already has in place and consolidate the 
information services with an 800 number to address all the 
veterans needs and complaints. For a veteran who has just 
returned from active duty an Operation Iraqi Freedom (OIF) or 
Operation Enduring Freedom (OEF) with traumatic brain injury, 
it would be a whole lot simpler and easier to have only one 
office to call to receive the information he or she needs.
    The VA has a patient advocacy program for healthcare but a 
lot of brave men and women need help with loans for their homes 
and schooling too. They shouldn't have to run around asking the 
same ten questions to ten different offices. The Ombudsman's 
Office can help the veteran figure out all the services in the 
benefit system not just the healthcare and not just about 
disability.
    I have reviewed the testimony of the esteemed panelists, 
the VA and VSOs who have presented written testimony before 
this Subcommittee. And just in the six testimonies that 
specifically discuss the Ombudsman's Office, the panelists 
referred to 14 different programs both within and outside of 
the VA that veterans could turn to for help with benefits 
coordination. That is good news and the bad news.
    The good news is the services are available. The bad news 
is there are so many of them which can be confusing. These 14 
programs are extremely important to our veterans in providing 
specialized services. But as a healthy member of Congress and 
not a PTSD patient or an ailing elderly veteran, I am even 
confused to some degree about which programs to use and under 
which circumstances.
    So, Mr. Chairman, I am not trying to make redundant 
services. The VA provides advocacy and resources and many VSOs 
provide advocacy and resources. I look forward to working with 
the Honorable Members of the Committee to mold the Office of 
the Ombudsman in to a viable helpful resource for veterans. I 
believe that this consolidation of various information sources 
in to a coordinated center of information will help make sure 
the veterans receive the care they need and cut through the 
seemingly endless amounts of bureaucratic red tape.
    I would like to point out to the Subcommittee that 
especially with respect to the duties section as it is 
currently set forth in the draft bill, I believe that through 
markup and working with the expertise of the Committee, that 
section probably didn't come back as complete to me from 
legislative counsel as it ought to be and should be expanded so 
that the duties include coordination of services and benefits 
both within the VA and also that may be available through VSOs 
and or the communities in which the veterans are so that it is 
a comprehensive coordination effort.
    Thank you again for giving me the opportunity to testify 
before this Subcommittee and I look forward to working with the 
Committee to help veterans understand and access the benefits 
they deserve.
    [The prepared statement of Congressman Hodes appears on p. 6
0.]
    Mr. Michaud. Thank you very much, Mr. Hodes. Mr. Salazar?

               STATEMENT OF HON. JOHN T. SALAZAR

    Mr. Salazar. Thank you Chairman Michaud and Ranking Member 
Miller and Members of the Subcommittee. I want to first of all 
thank you for your interest in rural veterans healthcare and I 
know that you have both been major leaders in this fight.
    Mr. Chairman, today I am happy to bring H.R. 2005 to the 
Subcommittee. I am looking forward to discussion of this 
important legislation. This bill called the Rural Veterans 
healthcare Improvement Act seeks to improve healthcare services 
to veterans in rural areas.
    As many of you have heard over the last several years in 
this Committee that a study of more than 767,000 veterans by 
researchers working for the Department of Veterans Affairs 
shows vets in rural areas are in poorer health than vets living 
in the cities.
    The VA found that the health of rural veterans still 
persist even after researchers adjusted for social economic 
factors such as race, education, and employment status. It was 
identified in this study that access is a care--to care is a 
key factor. The study suggested that in addition to 
establishing more clinics in rural areas VA should consider 
coordinating services of Medicare and other healthcare services 
based in rural areas similar to what Mr. Rodriguez was talking 
about earlier in the earlier panel.
    As a way to begin addressing some of these issues, the 
Veterans Benefits Health Care and Information Technology Act of 
2006, which passed at the end of the 109th Congress created the 
office of Rural Health within the VA. Dr. Kussman's testimony 
will tell you that the VA is opposed to this legislation 
because the Office of Rural Health is charged with these tasks.
    I would like to make the point that even though Congress 
directed VA to establish this office it has not yet been 
implemented. This new office, when the VA decides to set it up, 
needs support, direction, and resources in order to fulfill its 
mission of coordinating care in this vital constituency. The 
Rural Veterans Health Care Improvement Act of 2007 would task 
the director and the Office of Rural Health with developing 
demonstration projects, centers of excellence, and a 
transportation grant program. And the bill would also more 
fairly reimburse veterans in rural areas for traveling expenses 
they incur when driving long distances to VA medical clinics.
    Mr. Chairman, with both an ailing veteran population to 
care for and a new generation of veterans returning from 
service in Iraq and Afghanistan, we immediately need to address 
access to care issues in rural areas. It is estimated that 
nearly 45 percent of all new recruits are coming from rural 
America and with a large percentage of this war burdened on our 
national Guard, the number is only going to increase.
    Many vets must travel hundreds of miles to access medical 
care that we promised and they do so almost entirely at their 
very own expense. Currently we reimburse veterans at the rate 
of 11 cents a mile. The rate has not been increased since 1978. 
In 1978 the average price of a gallon of gasoline was 63 cents 
a gallon. Today in rural America, in rural Colorado, the 
average is right around $3.39 a gallon.
    This legislation would increase the reimbursement rate to 
48 cents a mile the same rate paid by--to Federal employees. 
This legislation also establishes a transportation grant 
program called Vet's Ride. Vet's Ride encourages veteran 
service organizations to develop innovative transportation 
options to vets in rural areas. With a grant up to $50,000, the 
VSO can purchase a van or find other ways to assist veterans to 
travel to VA medical centers.
    This bill also establishes centers for excellence to 
research waste, to improve care for rural veterans. These 
centers would be based at VA medical centers with strong 
academic connections. The outcome of these centers would be the 
development of specific models to be used by VA in providing 
health services to vets in rural areas.
    The Rural Veterans Health Care Improvement Act of 2007 also 
tasks the office of Rural Health with following their studies 
own advice. It develops demonstration projects that would 
examine the feasibility of expanding care to rural areas 
through partnerships. Partnerships between the VA centers for 
Medicare and Medicaid services, the Department of Health and 
Human Services through critical access hospitals and community 
based centers.
    Demonstration projects would also be carried out in 
partnership with Indian Health Services to improve healthcare 
for Native American veterans. In 2003, the VA entered into a 
memorandum of understanding with the departments to encourage 
partnerships like these. However, 4 years have passed without 
accomplishments and our vets have suffered.
    Mr. Chairman, we must explore every option to ensure that 
healthcare services we promised to our veterans were delivered. 
The Rural Veterans Health Care Improvement Act of 2007 aims to 
improve one of the greatest problems that plagues the VA 
system. I am proud of this bipartisan work. We have--we 
currently have over we are close to 40 co-sponsors. Very 
bipartisan legislation.
    And I want to thank the Chairman and the Ranking Member and 
members of this Subcommittee for allowing us to testify in 
front of this Committee.
    [The prepared statement of Congressman Salazar appears on p.
 57.]
    Mr. Michaud. Thank you very much, Mr. Salazar. Ms. Lowey?

                STATEMENT OF HON. NITA M. LOWEY

    Ms. Lowey. Thank you very much, Mr. Chairman. Mr. Ranking 
Member, members of the Subcommittee. I really do appreciate, 
number one, your holding this hearing and for considering the 
VA Hospital Quality Report Card Act of 2007.
    I introduced this legislation in an effort to provide 
increased disclosure and accountability in the VA hospital 
system, and ultimately increase the quality of care for the men 
and women who have served in the armed forces.
    The treatment provided to our veterans is not a partisan, a 
political issue, and I am pleased that this legislation is 
cosponsored by some of my republican colleagues as well. I do 
believe that we can all agree that quality care initiatives and 
public disclosure should not end when an individual leaves 
active military service. In fact the quality of care for those 
who have bravely served our Nation should be of the highest 
standard possible.
    To achieve that goal, we must have a clear picture of the 
quality of care provided by the Department of Veterans Affairs, 
and this information must be continually assessed and updated. 
As we learned, unfortunately, with Walter Reed Army Medical 
Center, a facility that once defined excellence may not do so 
the next time without constant internal assessments. My 
legislation would require the Department of Veterans Affairs to 
establish a formal Hospital Report Card Initiative and publish 
reports on individual hospitals level, and quality of care.
    The resulting report cards would provide clear outcomes 
data to be used for peer review and quality improvement, 
galvanize hospitals to make changes by creating public 
accountability, and provide our veterans with the information 
they need to make sound healthcare decisions. Several States, 
including Pennsylvania, New York, California, Florida, and 
Illinois have already implemented Hospital Report Card 
Initiatives.
    March 2007 Veterans Administrative report exposed major 
deficiency in the physical condition in many veteran's 
facilities. In this report, the VA Hudson Valley Health Care 
System, which serves over 25,000 veterans throughout my 
district and the surrounding areas, was cited for ceiling 
molds, suicide hazards in the psychiatric ward, and cosmetic 
deficiencies.
    I am going to repeat one part of that because I think it 
underscores the level of neglect seen throughout the VA 
healthcare system. Suicide hazards in a psychiatric ward in 
area in hospitals that most certainly should limit the ability 
of an individual to harm him or herself.
    Dr. Michael Kussman, Under Secretary for Health at the VA 
previously stated, ``VA hospitals are inspected more frequently 
than any other healthcare facilities in the Nation.'' If this 
is true, then the Department should have no problem complying 
with the requirements of this legislation.
    If we are serious about ensuring a seamless transition 
between the U.S. Department of Defense (DoD) provided 
healthcare and VA provided healthcare, we must have an accurate 
assessment of the VA system and the VA Hospital Quality Report 
Card Act of 2007 would provide just that.
    So, I thank you very much. Thank you for your work. And I 
would be delighted, as I know my colleagues are, to respond to 
any questions.
    [The prepared statement of Congresswoman Lowey appears on p.
 61.]
    Mr. Michaud. Okay. The last member of the panel is also the 
Ranking Member of this Subcommittee, Mr. Miller?

                 STATEMENT OF HON. JEFF MILLER

    Mr. Miller. Thank you very much, Mr. Chairman. I have two 
bills for the hearing today. The first one I would like to 
discuss is H.R. 2623. This bill is designed to prohibit the 
collection of copayments for all hospice care furnished by the 
Department of Veterans Affairs.
    Currently VA offers a compliment of hospice and palliative 
care options as part of the comprehensive healthcare benefit 
provided to all enrolled veterans. Hospice and palliative care 
are a continuum of comfort oriented supportive services 
provided across settings including a hospital, extended care 
facilities, outpatient clinics, and private residences.
    Under current law a veteran receiving hospice care in a 
nursing home is exempt from any applicable copayments. However, 
if hospice care is provided in any other setting such as an 
acute care hospital or even in the veteran's home, the veteran 
may be subject to an inpatient or outpatient primary care 
copayment. Essentially, VA's current policy penalizes a veteran 
who chooses to remain at home for their hospice care or out of 
medical necessity receives that hospice care in an acute care 
setting.
    Mr. Chairman, this legislation would correct this inequity 
by exempting all hospice care provided through VA from 
copayment requirements. This bill is important to ensuring that 
every veteran preference for end of life care is provided for 
in an equitable and compassionate manner.
    I thank you for the opportunity to present this bill and I 
would be available to answer questions.
    If I could move to H.R. 1925, a bill to direct the 
Secretary of Veterans Affairs to establish a separate Veterans 
Integrated Service Network (VISN) for the Gulf Coast region of 
the United States. I have a couple of charts. We will go--we 
will flip back and forth. This will give you an idea of the 
work loads at the different VISNs. I apologize for the people 
in the audience not having an available one for you to see as 
well.
    [Chart.]
    Mr. Miller. Twelve years ago most of you know that the VA 
instituted the VISN. The plan was put in motion as a way for 
the large VA network that healthcare that VA provides would be 
more attuned to the needs of its patients.
    You can see where it basically is today and graphically 
it's there are 22 VISN's although there is a number 23 on there 
some time ago, there were two VISN's that were combined into a 
single VISN, but that gives you the idea. The gray is the 
enrollees, the red is the actual patient load.
    The VISN's were implemented as a way to maintain the high 
quality of care while allowing more regional management so that 
the central office in DC was not unnecessarily micro managing 
the day-to-day aspects of the delivery of the healthcare. The 
network has enjoyed its successes in providing better access 
and more patient centered care. However, as always, there is 
room for improvement and I think that the Gulf Coast region of 
this Nation is an area where such improvement is needed.
    Having already seen, as I said earlier, the consolidation 
of two VISN's since it's creation, it is clear that flexibility 
within the healthcare system is necessary. This bill creates a 
VISN specifically targeted to improving the delivery of 
healthcare to a large and ever increasing number of veterans 
living in the Gulf Coast. In other words, a Gulf Coast VISN.
    It would create a better healthcare network that can better 
respond to veterans and the unique needs and problems facing 
veterans in the area. The area involved would, if you would 
flip it over, give you an idea. Everything the gray shaded 
areas are not part of VISN 16, but the teal and the purple and 
the peach color that is VISN. There is also a little green down 
at the very bottom, that is VISN 16. So basically it goes from 
the center of the Florida panhandle all the way to the Oklahoma 
panhandle geographically. It is the largest geographic VISN, 
but that is not necessarily the point. The point is the 
workload that is in there now.
    Obviously, my district, district one is on the southeast 
corner of the panhandle, so that gives you an idea of how large 
the VISN is. If you would, there are some and I don't know if 
staff going to handout, smaller charts for you to look at. VISN 
16 is actually the second largest in patient enrollment and 
patients as well.
    This creates again, as I said, the ability for VA to 
deliver to the unique needs and problems facing veterans in the 
area. It does stretch all the way from the Florida panhandle 
over to the State of Louisiana and up into Alabama. The Capital 
Asset Realignment for Enhanced Services (CARES) Program did 
identify this area as under served, and its unique geographical 
location is no doubt part of the reason that it was so 
designated. Most of the region would be in VISN 8. It would be 
where VISN 16 meets VISN 8. By the way, VISN 8 as Ms. Brown 
knows is also the number one VISN in the country. It happens to 
be the peninsula part of the State of Florida.
    You can see that the veteran population continues to grow 
in those regions. Looking back and looking at the map you can 
see how diverse and how largely rural. As we have talked about 
with other testimony today, regions can be over looked because 
of major metropolitan areas that are being served. We don't 
think, and I am sure that most people would agree that the 
300,000 veterans that are currently being served in that region 
there are many, many more veterans, but these are enrolled 
veterans. They certainly don't want their healthcare overlooked 
either.
    Several reasons why I see this bill as important and 
successful. Again, a new Gulf Coast VISN director could take 
great advantage of the sharing opportunities that are there 
between DoD and VA. The Gulf Coast is home to multiple defense 
installations and while a few DoD/VA facilities exist now, 
there is tremendous opportunity for expanding this relationship 
to deliver a wider range of healthcare service.
    I would say that all of our veterans across the Nation 
deserve more timely access to VA healthcare. The intent of my 
bill, albeit there could be other geographic areas that are as 
under served as ours, is to get a first step toward creating 
that access. Again going all the way back to it's original 
creation, obviously the demographics have shifted and time for 
a re-look is upon us.
    Mr. Chairman, thank you for letting me testify on this 
bill, and I can and am ready to answer questions on this or the 
other bill as well.
    [The prepared statement of Congressman Miller, and the 
charts attached to Congressman Miller's statement, which he 
referred to, appears on p. 58.]
    Mr. Michaud. Thank you very much, Mr. Miller. A few 
questions: The first one for Mr. Hodes. If I understand 
correctly, what you want to do is look at all of these programs 
and work toward having one access point for veterans to be able 
to access these programs.
    Have you given any thought about also trying to streamline 
the process? And for those who can use a computer, to ask just 
a few basic questions on a computer-based system that will tell 
them where to go?
    The reason why I mention that is when we had a couple of 
mills shut down and healthcare was a big issue, drug companies 
offered programs for individuals. There are 329 different 
programs that drug companies offered with applications for each 
one of those programs. And if you are laid off trying to find a 
job and healthcare, you are not going to do it.
    However, what they did was take all of these programs, 
narrowed it down to four basic questions, established an 800 
number and that will show an individual applying for one of 
these programs where to go.
    Is that something that you would envision under your 
legislation as well?
    Mr. Hodes. That would certainly be part of a good way for 
the Ombudsman Office to accomplish it's work, because I guess 
if I had to use a word I see the Ombudsman Office as providing 
the hub to which people go. And it--the Ombudsman Office would 
then help route people through the system. They could then 
return to the Ombudsman Office as they are working their way 
through the system for other questions.
    So your suggestion would certainly be a good part of 
implementing the Office of the Ombudsman. Thank you, Mr. 
Chairman.
    Mr. Michaud. Ms. Lowey, I have read the testimony from the 
Department and they talk about the Joint Commission previously 
known as the Joint Commission Accreditation of Health Care 
Organizations (JCAHO). They have a website that provides a lot 
of the data that you were talking about. Have you looked at 
that website and is it inclusive of what you are including in 
your legislation?
    Ms. Lowey. Well, I thank you for bringing up that question, 
because the Joint Commission does reviews. We have been told it 
is about every two, 3 years and it is not as--it is not as 
comprehensive as the kind of review we propose.
    And again the basic idea here is to do it frequently at 
least twice a year, provide up-to-date information, 
transparency so that VA's veteran's can access this information 
and actually make some decisions based upon the information 
provided.
    Mr. Michaud. Great. And my last question actually deals 
with one of Mr. Miller's bills, the hospice bill. If I read and 
heard your testimony correctly, veterans will not have to pay 
the copayment if they go through VA for services. Now does that 
include contract services? I am just thinking of someone in a 
rural area that needs hospice care, how do you envision that?
    Mr. Miller. It would cover them. Absolutely.
    Mr. Michaud. It would cover them. Okay. Good. Thank you. 
Mr. Miller do you have any questions?
    Mr. Miller. Ms. Lowey, I am interested in and we all can 
appreciate the desire to set some type of standard. Do you 
envision measuring VA hospitals against private facilities in 
some way where or is this just within the VA healthcare system 
where you are saying this one is an ``A,'' ``B,'' ``C.'' Are we 
going to measure them against other facilities?
    Ms. Lowey. That is an important question. And it has been 
suggested to me and I certainly would be flexible about it, 
that we might call it VA Medical Center because it would 
encompass a more extensive group of hospitals that would be 
included in this review.
    I was thinking about the VA system, but I would certainly 
be open if the Committee would suggest it to making it more 
expansive.
    Mr. Miller. The reason I ask the question is the Joint 
Commission on Accreditation of Healthcare Organizations (JCAHO) 
standards that you know all hospitals go through accreditation, 
how would this be more in depth? How would it compare to those 
standards, and if you are not sure right now you can report 
back.
    Ms. Lowey. I am not sure about the JCAHO standards.
    Mr. Miller. No, I would like to know in regards to 
standards that are out there that VA currently has to abide by 
how far we are looking at going forward.
    Ms. Lowey. You know I am very interested in the idea of 
providing facilities that specialize, for example, in traumatic 
brain injury (TBI) to veterans making them inclusive and 
expanding opportunities for veterans getting these services.
    So, although I was talking about the VA system, I am hoping 
that we can bring in hospitals such as the Helen Hays Hospital 
in part of my district in Rockland County which has expertise 
in traumatic brain injuries.
    So it is another issue that I know some people are thinking 
about, because the numbers of people that are coming out of the 
hospital. Just recently I was talking to a group called the 
``Wounded Warrior Project.'' And they are providing the role of 
the intermediary. I was interested in what my colleague was 
talking about in the ombudsman position, because many of these 
veterans come out so lost and need additional guidance and 
additional help.
    So with this bill, I was talking about an assessment of the 
VA hospital system to provide the transparency and to provide 
the information to the veterans. But I certainly would be happy 
to work with you, Mr. Miller, to see if you believe that it 
should be more expansive and more inclusive.
    Mr. Miller. Thank you very much. The other question, Mr. 
Salazar is in regards to the mileage reimbursement, would you 
envision it paying for service and non-service connected visits 
or just service connected visits?
    Mr. Salazar. Basically just service-connected visits and it 
would just be similar to what we get. I mean, as members of 
Congress we get 40 or we are allowed to get 48 cents a mile. 
The current reimbursement rate of course is only 11 cents.
    And I get the story, I represent a district that is larger 
than half of the State of Colorado. And many of my veterans 
have to drive 5 hours to one center or another and some even 
have to go to Albuquerque. And many of them will tell me that 
their wives cannot go with them because gas is so expensive 
they can't afford the hotel to stay in over night. So for that 
reason I think it is only fair that we look at this. You know 
gas was only 63 cents a gallon in 1978 and that is when the 
last raise was or the last, I guess, increase was made. So 
thank you.
    Mr. Michaud. Mr. Hare?
    Mr. Hare. I don't have any questions, Mr. Chairman.
    Mr. Michaud. Dr. Snyder?
    Mr. Snyder. Thank you. I wanted to ask our Ranking Member, 
Mr. Miller, just a couple questions. I notice that the bill 
regarding the hospice co-pay is not on the list that Dr. 
Kussman discusses. Was that a late add on or do you know what 
the VA position is on that bill?
    Mr. Miller. VA supports it.
    Mr. Snyder. Supports it. Okay. And then the second with 
regard to the VISN lines. Were all the VISN boundaries have 
they been set by statute in the past or were those set 
administratively?
    Mr. Miller. I believe they have been set administratively.
    Mr. Snyder. Administratively. Thank you.
    Mr. Michaud. Ms. Brown.
    Ms. Brown of Florida. I don't have any questions at this 
time.
    Mr. Michaud. Thank you. Once again, I would like to thank 
the panelists for your testimony this morning. I look forward 
to working with you as we move forward with these pieces of 
legislation. Thank you very much.
    Mr. Hodes. Thank you very much.
    Ms. Lowey. Thank you.
    Mr. Michaud. I would like to ask the third panel to come 
up. We have Shannon Middleton, American Legion; Kimo 
Hollingsworth, AMVETS; Adrian Atizado, Disabled American 
Veterans; Carl Blake, Paralyzed Veterans of America; Dennis 
Cullinan, Veterans of Foreign War; and Barry Hagge, Vietnam 
Veterans of American.
    I would like to welcome all the panelists here today and I 
look forward to hearing your testimony.
    We will start with Ms. Middleton and just work down the 
table.

 STATEMENTS OF SHANNON MIDDLETON, DEPUTY DIRECTOR FOR HEALTH, 
 AMERICAN LEGION; KIMO S. HOLLINGSWORTH, NATIONAL LEGISLATIVE 
   DIRECTOR, AMERICAN VETERANS (AMVETS); ADRIAN M. ATIZADO, 
  ASSISTANT NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN 
VETERANS; CARL BLAKE, NATIONAL LEGISLATIVE DIRECTOR, PARALYZED 
  VETERANS OF AMERICA; DENNIS M. CULLINAN, DIRECTOR, NATIONAL 
  LEGISLATIVE SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED 
 STATES; AND BARRY HAGGE, NATIONAL SECRETARY, VIETNAM VETERANS 
                           OF AMERICA

                 STATEMENT OF SHANNON MIDDLETON

    Ms. Middleton. Mr. Chairman and members of the 
Subcommittee, thank you for this opportunity to present the 
American Legion's views on the several pieces of legislation 
being considered by the Subcommittee today.
    The American Legion commends the Subcommittee for holding 
the hearing to discuss these very important issues. And I will 
limit my comments to just a few of the bills being considered.
    Mr. Michaud. Could you pull the microphone up a little bit 
closer please?
    Ms. Middleton. This better?
    Mr. Michaud. Much better.
    Ms. Middleton. Much better. H.R. 2005, the ``Rural Veterans 
Health Care Improvement Act of 2007,'' addresses many issues 
affecting veterans who reside in rural areas. It seeks to 
increase the beneficiary travel rate to make it equivalent to 
the rate provided to Federal employees; establish centers for 
rural healthcare--rural health research, education, and 
clinical activities; offer transportation grants for service 
organizations to assist rural veterans; and explore 
alternatives to improve transportation to medical facilities 
for rural veterans. The American Legion fully supports this the 
provisions in this bill.
    Beneficiary travel pay has not been increased from its 
current rate since 1978. The price of gasoline has steadily 
increased since the 11 cent per mile rate was established, 
creating a financial hardship for veterans who have to travel 
long distances for care, or those who have limited financial 
resources.
    Since service-connected veterans and other veterans 
authorized beneficiary travel only receive 11 cent per mile and 
are subjected to a six dollar per trip deductible, this amount 
does very little to defer the cost of travel.
    There are no provisions in law that VA must increase the 
per mile travel authorization on a regular basis. The 
beneficiary travel program is discretionary and the Secretary 
of Veterans Affairs has determined that it is necessary to 
maintain the current reimbursement rate in order to allow the 
VA healthcare system to accommodate the increasing patient 
workload.
    The lack of a consistent and reliable mechanism to 
periodically adjust the rate authorized for beneficiary travel 
creates an injustice and an unfair economic burden for many 
veterans. The American Legion believes that mandatory funding 
for VA healthcare would allow the Secretary to provide adequate 
healthcare without inversely affecting programs designed to 
mitigate the cost of accessing that care.
    Establishing centers for rural health research, education, 
and clinical activities would afford VA the opportunity to 
build strategies to improve it's system of care for rural 
veterans, as well as educate and train healthcare professionals 
on health issues prevalent in specific rural veteran 
populations.
    And offering transportation grants for organizations that 
can assist rural veterans and exploring alternatives to improve 
transportation to medical facilities for rural veterans would 
make accessing care easier for those who are not financially 
able to travel to facilities, especially those who, due to 
their financial--sorry--their physical condition are not able 
to make extremely long trips in 1 day. If more transportation 
options became available it may also improve coordination of 
care for those who have to travel distances for special 
services, especially in the unavailability of a family care 
giver.
    H.R. 2173 seeks to amend title 38, U.S. Code, to authorize 
additional funding for the Department of Veterans Affairs to 
increase capacity for provision of mental health services 
through contracts with community mental health centers, and for 
other purposes.
    The American Legion believes that VA should contract with 
community providers only when it is unable to provide needed 
services to the veteran, if travel for the veteran would be a 
danger to his or her health, or the veteran resides in a rural 
area. As long as VA healthcare remains discretionary, VA will 
always struggle to maintain sufficient funding to provide 
access to quality care for eligible veterans seeking care in VA 
facilities. Mandated funding would provide a method to provide 
dependable stability, stable and sustained funding for veterans 
healthcare.
    H.R. 2378, Services to Prevent Veterans Homelessness Act. 
This bill aims to establish a financial assistance program to 
facilitate supportive services for very low income veteran 
families to assist them in ending their chronic homelessness 
state and to prevent chronic homelessness.
    Enactment of this legislation will enable funding to 
provide much needed supportive services to veterans and their 
dependants. It takes into account that the VA Grant and Per 
Diem Program can only provide services to veterans and fill a 
much needed gap of caring for their dependents.
    Veterans require a coordinated effort that provides secure 
housing and nutritious meals; essential physical healthcare, 
substance abuse aftercare, mental health counseling; as well as 
personal development and empowerment. They also need job 
assessment training and placement assistance.
    The American Legion fully supports this bill in it's 
efforts to assist homeless veterans. And we applaud that the 
bill recognizes that families also suffer alongside the 
veterans struggling with homelessness.
    Again, thank you Mr. Chairman for giving the American 
Legion this opportunity to present it's views on such important 
issues and we look forward to working with the Subcommittee to 
address these and other issues affecting veterans.
    [The prepared statement of Ms. Middleton appears on p. 62.]

               STATEMENT OF KIMO S. HOLLINGSWORTH

    Mr. Hollingsworth. Mr. Chairman, members of the 
Subcommittee, I am pleased to offer testimony on behalf of 
AMVETS regarding the health legislation for this Subcommittee.
    Regarding the Hospital Quality Report Card Initiative, 
AMVETS would like to note that the Government Performance and 
Results Act requires that agencies develop measurable 
performance goals and report these results against these goals.
    In addition, the Department has tracked and monitored the 
quality of care at VA facilities since the early seventies 
through comprehensive quality management programs. In addition, 
there are some Federal laws that require VA Office of Inspector 
General to oversee VA Quality Management (QM) Programs at every 
level. And a large part of the VA Inspector General's Office 
performs the Combined Assessment Program (CAP). These reports 
review focus on quality safety and timeliness of VA healthcare.
    Overall AMVETS supports efforts to improve VA healthcare 
and supports the intent of H.R. 1448. However, we believe the 
bill would mandate a duplicative effort as many of the items to 
be reported in the report card are already reviewed and 
reported through either the VA QM and CAP programs.
    Regarding the training of police officers to interact with 
visitors and patients at medical facilities who are suffering 
from mental illnesses, AMVETS supports this bill.
    Regarding the creation of a new VISN, AMVETS has testified 
previously that CARES was supposed to be system-wide process to 
prepare the VA for meeting the current and future healthcare 
needs of veterans. Overall, AMVETS supported the CARES process, 
and we believe that Congress should consider the CARES 
recommendations in deliberations about VA infrastructure to 
include deliberations about the current VISN model.
    I would like to note that there has been some considerable 
time has elapsed since implementation of the VISN model, and 
there clearly have been some demographic changes within the 
general population that would most likely include changes to 
the veteran population as a whole.
    Regarding the Rural Health Care bill, AMVETS continues to 
support an increase to the mileage reimbursement rate. 
Regarding the overall Centers of Excellence, AMVETS would like 
to note that Congress did set up the Office of Rural Health 
Care and we urge Congress to fully fund and require the VA to 
conduct that assessment.
    With regards to the establishment of the Ombudsman within 
the Department of Veterans Affairs, AMVETS supports this bill. 
H.R. 2219 would direct the Secretary to award a grant to a 
private non-profit entity to establish and publicize a toll 
free suicide prevention.
    Overall, Mr. Chairman, AMVETS would oppose efforts by 
Congress to mandate the Secretary enter in to contracts with a 
private entity for these services. And we believe that the 
Secretary must continue to have the flexibility in how he 
implements these services.
    Lastly, H.R. 2378 regarding a financial assistance program 
to facilitate the provision of supported services for very low 
income veteran families in permanent housings. We support the 
intent. A large part of this bills, many of these services are 
already available to veterans. However, we do have concerns 
with the provision that specifically targets payments to 
veterans. And we would urge Congress instead to consider 
priority assistance at one of the other agencies that deals 
with housing.
    This concludes my testimony. I would be happy to answer any 
questions.
    [The prepared statement of Mr. Hollingsworth appears on p. 
65.]

                 STATEMENT OF ADRIAN M. ATIZADO

    Mr. Atizado. Mr. Chairman, Ranking Member Miller, members 
of the Subcommittee, thank you for inviting the DAV to testify 
at this important legislative hearing. For the sake of brevity, 
I will cover a number of bills or provisions relevant to the 
DAV and would request the Subcommittee refer to my written 
testimony for more details regarding all the measures under 
consideration with exception to the two draft bills that we 
were unable to provide comments due to time constraints.
    While we support sections two and four of H.R. 2005, the 
``Rural Veterans Health Care Improvement Act of 2007,'' we 
consider these provisions a good first step to ensure sick and 
disabled veterans are able to access the medical care they 
need.
    As funding for both provisions will most likely come from 
VA's medical services account, we urge first and foremost that 
Congress and VA correct inequity in the VA beneficiary travel 
program. This program unlike the Transportation Grant Proposal 
affects access for all veterans residing in rural, urban, and 
medically under served areas.
    Second, for good stewardship of taxpayer dollars and for 
the most effective use of such precious medical care funds, we 
urge that this Transportation Grant Program not be duplicative 
of current services, particularly those provided by the DAV 
Transportation Network or other transportation networks in 
existence.
    Further, the implementation of this proposed program should 
be coordinated through the Office of Rural Health to assure 
that unmet needs of rural veterans are addressed. As you may be 
aware, the DAV knows first hand the benefits of a 
Transportation Program. The DAV, in coordination with VA's 
Voluntary Service Program, began buying and donating vans to 
the VA facilities. To date, we have donated nearly 2,000 vans 
at a cost exceeding $39 million.
    Since inception, these vans, the dedicated VA volunteer 
drivers and volunteer transportation coordinators have 
transported more than 10 million veterans over 397 million 
miles to and from VA medical appointments.
    Having said that, we must not forget one of the reasons our 
transportation program began in 1987. Regulations amended by 
the VA, effective April 13, 1987, severely curtailed and 
restricted the eligibility and method by which beneficiary 
travel was paid. Many veterans in need of VA medical care found 
themselves effectively precluded from receiving such care.
    In addition to our transportation program, DAV has a 
longstanding resolution to repeal the beneficiary travel pay 
deductible to create a line item budget for this program and to 
increase travel reimbursement rate, which remains unchanged 
since 1977 at 11 cents a mile.
    We urge this Subcommittee to approve and enact legislation 
this year to reform the VA beneficiary travel program.
    H.R. 2173 would allow the VA to provide mental health 
services through contracts with community mental health 
centers. The DAV believes that VA-purchased care is an 
essential tool in providing timely access to quality medical 
care.
    However, as VA's contract workloads have grown 
significantly at a cost of about $3 billion this year, we are 
concerned that this bill does not provide any consideration for 
the judicious use of purchased care. Nor does it address our 
concerns regarding the lack of a systematic process to improve 
VA contract care services.
    H.R. 2219, the ``Veterans Suicide Prevention Hotline Act of 
2007,'' would require the VA to award a grant to a private, 
nonprofit entity to establish and operate a national toll-free 
suicide prevention hotline.
    The DAV notes that there is already in existence a 
Federally funded 24-hour, toll-free suicide prevention service 
comprised of over 120 individual crisis centers across the 
country. From the toll-free number, a caller is seamlessly 
routed to a certified provider of mental health and suicide 
prevention services nearest to the call of origination.
    If applied to service veterans, a veteran could be 
transferred similarly, but to a VA mental health provider if 
the individual wants the services and support of the VHA.
    We would like to thank Ranking Member Miller for 
introducing H.R. 2623 and Chairman Michaud for including it in 
today's hearing. This bill seeks to prohibit the collection of 
copayments for all hospice care furnished by the VA.
    The DAV has previously testified before this Subcommittee 
on this important issue, and we support the intent of this 
measure. We would just like to ensure that its scope is broad 
enough to include exemption of veterans from copayments for 
hospice care provided in any treatment setting.
    This concludes my testimony. I'd be happy to answer any 
questions you may have.
    [The prepared statement of Mr. Atizado appears on p. 68.]

                    STATEMENT OF CARL BLAKE

    Mr. Blake. Mr. Chairman, Ranking Member Miller, and members 
of the Subcommittee, on behalf of Paralyzed Veterans of 
America, I would like to thank you for the opportunity to 
testify today.
    Given the broad spectrum of bills on the agenda, I will 
limit my comments to only a few items.
    Although PVA has no objection to the requirements for a 
Hospital Quality Report Card Initiative, as outlined in H.R. 
1448, we remain concerned that this wealth of information will 
go unused.
    Collecting this information and assessing it without acting 
on any findings from that information, would serve no real 
purpose. We would hope that the congressional Committees will 
use this information published in these reports each year to 
affect positive change within the VA.
    PVA generally supports H.R. 2005, the ``Rural Veterans 
Health Veterans Health Care Improvement Act.'' However, we have 
concerns about the demonstration projects that will establish 
partnerships between the VA and the Centers for Medicare and 
Medicaid Services to seek care in critical access hospitals or 
community health centers.
    Principally we believe that this legislation is ``jumping 
the gun'' by getting ahead of the Office of Rural Health, which 
is responsible for determining if solutions, such as this 
proposed demonstration project, are feasible.
    We think that this new office in the VA should be given 
time to do its job before Congress begins legislating solutions 
to the problems that rural veterans face. However, this 
certainly does not say that Congress should not pressure the VA 
into implementing this office expeditiously as we believe they 
have not done so.
    PVA has serious concerns about the provisions of H.R. 2172. 
PVA strongly opposes the provisions of H.R. 2172. PVA strongly 
opposes the provision of section 2 of the bill that would allow 
the VA to contract for service and repair of prosthetic 
devices.
    We interpret this legislation to mean that the VA can 
contract with a single entity to provide these services and 
repairs. This is absolutely a bad idea. By using a single 
entity, the pool of devices and services available will be 
severely limited.
    A one-size-fits-all approach to prosthetics cannot be 
applied. As an example, prosthetics departments that serve PVA 
members needing wheelchairs often, if not always, contract with 
multiple different vendors to provide those wheelchairs.
    Because every PVA member, and every disabled veteran for 
that matter, is different, the equipment they need varies. 
Although an Invacare power chair may be suitable for one spinal 
cord injured veteran, another spinal cord injured veteran might 
be better served by a Jazzy wheelchair.
    Two uniquely different veterans cannot be expected to use 
the same equipment simply because it might streamline processes 
for the VA.
    PVA has no objection to the provision of the legislation 
that would require certification of VA orthotic-prosthetic 
laboratories with the ABC in Orthotics and Prosthetics or the 
Board of Orthotics and Prosthetic Certification.
    However, we believe that the VA already meets these 
requirements, but if this provision will reinforce that action, 
then we have no problem with it.
    The incidence of suicide among veterans, particularly OEF 
and OIF veterans, is a serious concern that needs to be 
addressed. PVA principally supports H.R. 2219. Any measure that 
will reduce the incidence of suicide among veterans is 
certainly a good thing.
    However, we must emphasize a couple of important points. 
First and foremost, there need to be absolute standards 
established that ensure that the individuals staffing this 
hotline are adequately trained to handle the complex issues 
associated with individuals contemplating suicide.
    We certainly support the idea that this service should be 
staffed by veterans, but they must have the proper training to 
deal with these cases. Simply having the shared experience of 
military service is not enough.
    Secondly, clear steps for referral into VA mental health 
clinics and other VA facilities with related services must be 
outlined. The private entities responsible for the operation of 
the suicide prevention hotline must understand how to refer 
veterans dealing with these problems into programs that will 
provide the services that they actually need.
    These services are essential to helping the veteran 
overcome the suicidal feelings he or she may be dealing with.
    Mr. Chairman, Mr. Miller, and members of the Subcommittee, 
we look forward to working with this Subcommittee to develop 
workable solutions that will allow all veterans to get the best 
quality care available.
    I would like to thank you again for allowing us to testify, 
and I would be happy to answer any questions that you might 
have.
    [The prepared statement of Mr. Blake appears on p. 72.]

                STATEMENT OF DENNIS M. CULLINAN

    Mr. Cullinan. Mr. Chairman, distinguished members of the 
Subcommittee, On behalf of the men and women of the Veterans of 
Foreign Wars, I want to thank you for inviting us to 
participate in today's most important legislative hearing.
    The VFW is pleased to support H.R. 1488, the ``VA Hospital 
Quality Report Card Act.'' Resulting data would allow veterans 
to compare quality of services the VA provides, letting them 
make more important judgments about their healthcare.
    It would allow VA to identify areas of improvement, and it 
would provide essential data for Congress to better use its 
essential oversight.
    We only urge that this action not conflict with the 
reporting requirements that VA is already undergoing and 
attempting to implement.
    The VFW supports H.R. 1853, the ``Jose Medina Veterans 
Affairs Police Training Act.'' Given the large numbers of 
returning veterans who are suffering from mental illnesses of 
various degrees, extra training for VA employees on how to deal 
with these patients is entirely appropriate. This is especially 
true for those patients who are vulnerable and suffering the 
most. The extra training will ensure that wounded warriors are 
treated with dignity and respect.
    The VFW has no objection to H.R. 1925, legislation that 
would establish a new VISN in the Gulf Coast Region.
    The VFW is pleased to support H.R. 2005, the ``Rural 
Veterans Health Care Improvement Act.'' The legislation is 
aimed to solve one of the greatest problems facing the large 
number of veterans who live in remote areas: access to care. It 
aims to improve services including transportation for disabled 
vets, research and partnerships with small communities.
    We are strongly supportive of section 2, which would 
increase the mileage reimbursement rate veterans receive for 
their travel expenses related to VA healthcare to the rate 
provided to all Federal employees.
    The VFW is supportive of H.R. 2172. However, the VFW is not 
sure if changing the rules of VA's prosthetic programs is 
needed, and we have concerns that the certification 
requirements that would affect all service and repair programs 
for prosthetics and orthotics is necessary.
    We are also concerned that some efforts to create a 
certification process could lead toward excessive 
standardization that aims for one-size-fits-all solution.
    The VFW supports H.R. 2173 that would allow the Secretary 
to enter into contracts with service for community mental 
healthcare.
    With the number of returning servicemembers who are 
suffering from mental health conditions, it is clear that VA 
can and must do more.
    However, an over reliance on contract care, especially the 
mental health area, could lead to some extensive continuity of 
care problems.
    Among other things, VA would have to determine some way to 
ensure that no veteran falls through the cracks when going from 
the department to a local provider.
    Further, it would be absolutely critical that patient 
records be transferable among all providers so that all 
information is provided to all involved healthcare givers. With 
respect to H.R. 2192, ``Providing for VA Ombudsman,'' the VFW 
is supportive of the intent of this act. We only question 
whether it's feasible for a single office or entity to gather 
together and properly coordinate so much information.
    Be that as it may, there is definite need for additional 
assistance for veterans in this complex system.
    The VFW supports H.R. 2219, the ``Veterans Suicide 
Prevention Hotline Act.'' We understand, however, that the VA 
is in the process of establishing a similar hotline. So it may 
be necessary to determine how much overlap there is between the 
programs. It is clear, however, that the program would be 
beneficial.
    The VFW supports H.R. 2378, which would establish a program 
of financial assistance to help veterans and their families 
from slipping back into homelessness.
    The VFW offers our strong support for H.R. 2623 that would 
exempt patients seeking hospice care from paying copayments. 
This is a compassionate idea that relieves a burden on the 
veteran and their loved ones at a most critical time.
    Thank you, Mr. Chairman, for my testimony.
    [The prepared statement of Mr. Cullinan appears on p. 76.]

                    STATEMENT OF BARRY HAGGE

    Mr. Hagge. Good morning Mr. Chairman, Ranking Member 
Miller, and Members of this Subcommittee. Thank you for giving 
Vietnam Veterans of America the opportunity to offer our 
comments on several veterans' health-related bills that are up 
for discussion here today.
    All of these bills, with the possible exception of H.R. 
1853, are extremely important. And with a few reservations, 
they are worthy of your consideration and certainly our 
support.
    I note that while we have not adopted an official position 
on H.R. 1925, we do not object to it.
    The topic of accessibility to VA medical services for 
veterans who live in rural areas has been percolating of late. 
We believe that H.R. 2005 offers pragmatic solutions to address 
the problems of access to healthcare experienced by too many 
rural veterans.
    The bill would increase travel reimbursement for veterans 
who travel to VHA facilities to the rates paid to Federal 
employees.
    The current reimbursement rate was established decades ago 
and does not adequately compensate for the costs of gasoline, 
``wear and tear'' on the vehicle and increased insurance that 
may be necessary in order to travel to distant medical centers.
    In the same vein, the grant program for rural veterans' 
service organizations to develop transportation programs could 
be an innovative way to strengthen community resources that may 
already assist with veterans' travel needs.
    The establishment of centers of excellence for rural health 
research, education, and clinical activities, another component 
of this bill, should fill a gap in VA healthcare and should 
lead to innovation in long-distance medical and telehealthcare.
    These centers have brought the synergies of clinical, 
educational, and research experts to bear in one site. Such 
centers have allowed VA to make significant contributions to 
the field of geriatric medicine and mental illnesses.
    It would require demonstrations of rural treatment models. 
Demonstrations on treating rural veterans' populations would be 
extremely useful in assessing effective ways to offer 
healthcare to individuals who are generally poorer, more likely 
to be chronically ill, and almost, by definition, more likely 
to have challenges in access to regular healthcare.
    And establishing partnerships with the Indian Health 
Service and with the Department of Health and Human Services 
should also add to greater cooperation and collaboration in 
meeting the needs of rural veterans.
    We would caution, however, that we would not like to see 
these demonstration projects exploring more opportunities to do 
widespread contracting out of veterans health services. 
Demonstration models should be assessed according to a number 
of outcomes such as quality of care, cost, and patient 
satisfaction and the results reported back to Congress.
    H.R. 1448, the ``VA Hospital Quality Report Card Act of 
2007,'' is a quality control measure that would help with 
accountability and issues regarding follow-up care and timely 
visits.
    It would require the VA to provide grades for its medical 
centers on measures such as effectiveness, safety, timeliness, 
efficiency, patient``centeredness,'' and equity. Health-care 
quality researchers have long thrived trying to objectively 
define some of these measures.
    As members of this Subcommittee are aware, the VA has a 
number of performance measures it regularly assesses in order 
to reward its medical centers and network directors among 
others. Some of these outcomes, such as immunizations for flu, 
foot care and eye care for diabetics, set the benchmark for 
care in the community.
    In addition to these internal performance measures, VHA 
voluntarily submits to Joint Commission on Accreditation of 
Healthcare Organization, Commission on Accreditation of 
Rehabilitation Facilities, and managed care quality review 
standards.
    VVA understands the importance of quality measurement. 
There is an expression with which we agree, and it's called 
``What's measured, matters.''
    We also agree that VA officials should be held to the 
highest degree of accountability, and whatever measures are 
available to allow this to better occur, we wholeheartedly 
endorse.
    However, before enacting this clearly well-intended 
legislation, we could require significant retooling of quality 
measurement systems in the VA. The Committee should hold a 
hearing to identify the gaps and deficiencies in current 
performance and quality measurement systems.
    It would also be useful to understand how report cards 
would be used and reported to improve VHA processes and 
performance rewards. Would poor grades be dealt with by changes 
in management? By withholding bonuses to senior executives? 
With more funding? How would good grades be rewarded?
    Such questions should be addressed before requiring a 
significant new quality measurement program to be installed.
    Again, VVA appreciates the opportunity to testify before 
this Subcommittee, and we thank the Chairman for the 
opportunity.
    [The prepared statement of Mr. Hagge appears on p. 77.]
    Mr. Michaud. I would like to thank all the panelists once 
again for your testimony, and we appreciate all the work that 
you are doing and have done as it relates to fighting for 
healthcare services for our veterans. We really appreciate it. 
You represent your organizations very well.
    I only have a couple of questions. The first one to Mr. 
Blake. You were talking about Mr. Salazar's bill. You mentioned 
that we ought to wait and see what happens with the Office of 
Rural Health, which was enacted in the 109th Congress. How long 
should we wait for that office to get up before we start, you 
know, taking steps?
    A lot of bills that we have heard today, a lot of bills 
that we heard earlier, dealt with access issues. If the VA 
would move forward, whether it is the Office of Rural Health, 
whether it is the CARES process, we would not see a lot of 
these bills if they were doing the job that they should be 
doing.
    And quite frankly I have a problem with this Congress, 
because of the funding issues, but hopefully we will be 
addressing that later on today. Mr. Blake?
    Mr. Blake. Mr. Chairman, I would say that I guess on some 
level you kind of answered the question for me. I would say 
that they--it should have been done in January. When the bill 
was enacted in December, they should have gotten it up and 
going right away, and we haven't seen any sign. I mean, maybe 
they have, but we haven't seen any real sign that they have 
done anything with that office yet. And maybe the VA will be 
able to testify to the--what the office is doing now when they 
have the opportunity.
    Short of that, I mean, I couldn't give you a timeframe to 
say, well, let us give them six more months and act. I 
understand all of the members frustration, and given that you 
created an office that doesn't seem to be doing anything, I 
don't necessarily blame you for taking action.
    But we don't want to jump over that hurdle without giving 
an office that is directed with this responsibility the chance 
to come up with something.
    Mr. Michaud. Thank you very much.
    My next question goes to Mr. Atizado, and it relates to, 
once again, Mr. Salazar's bill dealing with the increase in 
mileage reimbursement.
    I know the DAV has vans that help veterans with getting to 
VA services and facilities. My question is where are you on 
your vans? Is there a need for more vans? Do you think that 
this might be a way to help hold down costs by getting more 
veterans to utilize the vans?
    Mr. Atizado. Well, thank you for the question, Chairman 
Michaud. The DAV transportation network obviously cannot 
provide its services to all veterans who need it. Every year we 
have requests from our local chapters requesting additional 
vans for the network, and the way that it is structured, it is 
actually structured for services in--basically in concentric 
circles outside the facility. And when we map that out across 
the Nation, there are some gaps out there.
    What we would like to see is that, as I had mentioned in my 
testimony, the moneys, the funds that are going to go into this 
program, are going to come from the medical care services 
account, which as we have noted earlier, has experienced some 
shortages, and we have always advocated for additional funding 
in those accounts.
    In fact, our resolution speaks to that about the 
beneficiary travel pay. That is these funds are to be used out 
of that--out of that account for which--for either one of these 
programs, that it be done efficiently, effectively, and without 
duplication of services.
    Mr. Michaud. Could you provide for the Subcommittee what 
these are as it relates to the gaps that you have talked about 
as far as getting vans?
    Mr. Atizado. Sure. We would most certainly love to work 
with the Subcommittee on that. We will give you that answer for 
the record.
    Mr. Michaud. Great. Thank you very much. Mr. Salazar?
    Mr. Salazar. Thank you, Mr. Chairman.
    I believe that most of you understand that what we are 
trying to do here is to create a quality--some kind of 
semblance of the fact that 40-some percent of most veterans are 
coming from rural communities, and we need to address the needs 
and the shortfalls.
    You know, the study that I related to, it talked about how 
healthcare or basically veterans health was in poor shape in 
rural communities, and that is basically what our intent is 
with this legislation.
    In reference to the reimbursement rate, this is only 
relative to those traveling 100-mile radius, over 100-mile 
radius. In my district, many veterans have traveled 250 to 300 
miles to get access to healthcare.
    So I understand the situation, but I also hope that you can 
understand that we have to continue fighting for rural 
veterans, because I think they are the ones that lack access. 
Thank you, Mr. Chairman.
    Mr. Michaud. Mr. Hare?
    Mr. Hare. Thank you, Mr. Chairman. Just a comment to you, 
Mr. Blake, and then a couple of questions.
    I do share with you this concern of the contract out of the 
one-size-fits-all for folks, and I would like to say I want to 
get--I want us to be very careful that we do not hurt our 
veterans while we are trying to help. So I share with you that 
concern, and I think that is something that we need to be 
taking a look at.
    I would like to ask you, Mr. Hollingsworth, with regard to 
H.R. 2378. In your testimony you urged Congress to provide 
priority assistance to the Department of Health and Human 
Services, as opposed to creating a new program.
    Now, I was wondering why you think that would address the 
problem better?
    Mr. Hollingsworth. Well, I think it is a good--it is a fair 
question. We struggled with this bill internally, and I think 
our overall concerns are clearly we want to help those at risk. 
Clearly we want to help homeless veterans not become homeless.
    But I think we are dealing with the reality of limited 
financial resources for a lot of things. We want to maintain 
true to the mission of VA with regards to providing priority 
service healthcare to those injured in the line of duty and 
service.
    And I think our overall fear, quite frankly, is what we 
didn't want to see happen is to create a voucher program within 
the Department of Veterans Affairs for low-income veterans.
    Mr. Hare. Thank you. I appreciate that. Just one other 
question for--that I have.
    Mr. Atizado, regarding H.R. 2173, to increase the funding 
for the VA, can you tell me a little bit more about the 
concerns that you have for the bill and how you think it would 
affect the VA and the current VA system?
    Mr. Atizado. I'm sorry, Congressman.
    Mr. Hare. That is okay.
    Mr. Atizado. If you could repeat the question.
    Mr. Hare. Sure.
    Mr. Atizado. Because I had to look up what the bill was.
    Mr. Hare. I was just wondering if you could tell me on H.R. 
2173, the bill to increase the funding for the VA for mental 
health services, could you tell me a little bit more about the 
concerns that you had with the bill and how it would affect the 
current VA system?
    Mr. Atizado. I thank you for that question it actually 
deals with the issue--it is a two-prong issue. Right now VA has 
the authority to contract services.
    Our concern isn't what the quality of care providing 
community mental health clinics. Our concern is how this 
legislation implements services to be provides through 
community mental health clinics.
    The two-prong issue is how it requires VA to contract these 
services, as opposed to using its current statutory authority 
to make discriminate use of limited resources to contract care.
    The second concern we have is how VA actually provides 
contract care. There are some issues such as care--coordination 
of care, getting veterans out to seek care in the private 
sector and then back into the healthcare--the VA healthcare 
system, to ensure that VA's holistic care of a disabled veteran 
is, in fact, intact.
    When a Veteran leaves the VA healthcare system to seek care 
outside, it is subject to issues that VA has addressed and is 
considered high quality such as patient satisfaction, medical 
and medication errors, patient safety issues.
    So we would like to make sure that these veterans who 
receive care outside the VA healthcare system, come back in to 
enjoy what has been called the best healthcare system at least 
in the Nation.
    Mr. Hare. I just want to conclude, Mr. Chairman, by saying 
that--to all the panelists, I have only been here for going on 
6 months now that the great thing is to see that the pieces of 
legislation, the numbers of this legislation coming out for 
veterans, I think that is a wonderful thing.
    And I appreciate all of you and what you do. And I look 
forward to working with you, because I certainly have no quorum 
of wisdom on all these bills. And it is good to hear from the 
people that you represent with what you think is right about 
these bills, what you think is wrong about them. I think it 
helps us to put together a better bill.
    And I just want to compliment all of you for--and thank you 
for taking the time, but also compliment you on what you do 
to--for representing the people that you do each and every day.
    So I was look very much forward to working with you on 
that. Not just these bills, but other bills, the assured 
funding and some other things as we go down the path.
    So with that, Mr. Chairman, I give it back.
    Mr. Michaud. Dr. Snyder?
    Mr. Snyder. I don't have any questions. Thank you all for 
being here.
    Mr. Michaud. Ms. Brown?
    Ms. Brown of Florida. Yes. I just have a couple of 
questions, Mr. Chairman, thank you.
    Mr. Hollingsworth, can you expound a little bit more about 
the report card? You say a lot of the information is available, 
but it seems to be scattered, and difficult to use. Can you 
expound upon that a little bit more?
    Mr. Hollingsworth. As I indicated in my testimony, the VA 
does track and report on quite a few statistics and quality of 
care initiatives.
    I can speak very specifically to the combined assessment 
program, because I have actually had some personal dealings in 
that area. And it is a very thorough review. The assessment 
team will go into the facility. It is generally supposed to be, 
to the best of my knowledge, unannounced, and they do kind of 
the top-to-bottom review. And it looks at everything from 
patient care to patient safety issues.
    And they issue a report, and generally within that report, 
not only are there discrepancies listed, but they recommend 
courses of action to fix those discrepancies. And they provide 
a period of time for the VA to come back and fix those.
    So I guess the only thing I am saying is that we would 
encourage--you know, there are numerous programs in place, and 
we would encourage Congress to continue to hold VA accountable 
for those programs in those reports.
    You know, last but not least, and I forget the exact 
numbers and the statistics, but I would encourage this 
Committee to possibly take a look at formally.
    There are a lot of reports the VA puts together. Okay? And 
it costs a lot of time, money, and resources, and many of these 
reports their time may have come and gone.
    So we are leery about mandating the fact that you are going 
to formally institute something for VA to do something when 
they are going to take manpower, resources to put together 
these things and provide it to Congress when, in fact, it just 
may become another program that is there.
    Ms. Brown of Florida. Thank you.. Mr. Blake, you mentioned 
the hotline. You had some concerns about that. Could you 
expound on that a little bit?
    Mr. Blake. Well, after listening to some of the discussion 
this morning about what the VA is doing with their own internal 
hotline versus this outside entity, I thought the discussion 
was interesting in that Mr. Moran suggested that these are 
different types of people providing, you know, an outside 
service.
    And the VA, as I understand it, is going to staff their 
hotline, and maybe I am incorrect, with clinical professionals 
and individuals who work in the mental health field. And not to 
suggest that those aren't the right people, but this secondary 
hotline maybe provides a different perspective.
    Now, I have to reiterate our point that we made that you 
can't just stick anyone behind--on the other end of the 
receiver and have them answering phone calls, particularly for 
this population of veterans.
    But the shared perspective of a veteran, I think, is 
important. Understanding that they have to have some kind of--I 
don't want to say expertise maybe, but some kind of formal 
training in understanding how to handle these types of 
individuals.
    I mean, most of the hotlines for special needs like that 
are volunteers that don't necessary--aren't necessarily 
clinical professionals as well. And it provides some 
perspective that might provide balance to what the VA is doing 
internally.
    Ms. Brown of Florida. My last question concerns not the 
reimbursement, the cost, but about moving forward and 
permitting another program.
    I am thinking that we need to be considering how we can 
pool resources and other ways to get people to the different 
facilities, as opposed to what is wrong here. Everybody wants 
to drive their own car. I understand that, but that is part of 
our problem.
    With gasoline being $3.00-plus a gallon, we have got to 
come up with some alternative ways to move people. And it seems 
to me it could be scheduling, working together, and more vans, 
more car pools. What are your ideas?
    Mr. Hollingsworth. Well, from AMVETS perspective, we have 
testified in the past and will continue--rural healthcare and 
in under served areas, it is a real issue. And it is a problem. 
I think all of the veteran organizations know that.
    You know, the Secretary of Veterans Affairs does have the 
authority in some cases to contract out. You know, we walk a 
fine line, because, you know, from an AMVETS perspective, we 
want to maintain the integrity of the Veterans' Affair system. 
But at the same time, we want to provide rural veterans in 
underserved areas healthcare.
    So we would encourage the Secretary to continue to contract 
out. However, we, obviously, hope he uses that authority 
judiciously where applicable.
    Ms. Brown of Florida. Mr. Chairman, I have a couple more. I 
want to see if he can answer my question.
    Mr. Blake. I just wanted to kind of reiterate our point 
about the travel reimbursement rate. I think most of the 
organizations here, if not all of them, principally believe 
that if you had a reasonable travel reimbursement rate, you 
might do away with some of the complaining that veterans have 
about access in rural areas. That is not to say it solves the 
problem entirely. That certainly doesn't.
    But a lot of the problem that veterans have that live in 
rural areas is they have to foot a large part of the bill out 
of their own pocket just to get the care from a VA facility. 
Yes, some veterans have to drive 250 miles. Well, that is 
expensive, because it is a tank of gas.
    But in a lot of cases they foot the bill for a hotel, 
because they probably have to stay somewhere overnight if they 
have to travel that far, eating, and all those types of things. 
And 11 cents to the mile just doesn't get it done when 
addressing that concern.
    So we think that some of those concerns would be offset if 
they knew that they weren't going to have to foot the bill out 
of their own pocket. Now again, some rural access issues are 
broader than that. Some of them are just--but an area that are 
clearly under served as a whole.
    That is not just the VA. I mean, there are a lot of areas 
across the country that are under served for healthcare in 
general. So--and I think that is another issue that falls in 
line with that as well.
    Ms. Brown of Florida. Thank you, Mr. Chairman.
    Mr. Michaud. Maybe we could get railroad access to some.
    Ms. Brown of Florida. We will work it out.
    Mr. Michaud. The Chairwoman chairs the Railroad 
Subcommittee on Transportation. Mr. Miller?
    Mr. Miller. No questions.
    Mr. Michaud. Once again, I thank the panel for your 
testimony this morning, and we look forward to continue to work 
with you as we deal with veteran issues. Thank you.
    And the last panel that we have this afternoon is Dr. 
Michael Kussman who is the Under Secretary for Veterans Health 
Administration, who is accompanied by Walter Hall who is the 
Assistant General Counsel for the Department of Veterans 
Affairs.
    I want to thank both of the gentlemen for coming today, and 
I turn it over to you, Dr. Kussman. I want to congratulate you 
for no longer acting as the Under Secretary of Health, and now 
that you are no longer acting, hopefully we will see good, 
strong results, particularly as it relates to the Rural 
Healthcare Office.

  STATEMENT OF HON. MICHAEL J. KUSSMAN, M.D., MS, MACP, UNDER 
  SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. 
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY WALTER A. HALL, 
 ASSISTANT GENERAL COUNSEL, U.S. DEPARTMENT OF VETERANS AFFAIRS

    Dr. Kussman. Thank you Mr. Chairman and Mr. Ranking Member, 
and other Members of the Subcommittee.
    When you were talking about no longer being acting, I want 
to assure you that I am now going to pretend to be the Under 
Secretary of Health.
    Thank you for inviting me here today to present the 
Administration's views on the nine bills affecting the 
Department of Veterans Affairs health programs.
    As you mentioned, sir, with me today is Walter A. Hall, 
Assistant General Counsel.
    As you already did, Mr. Chairman, I don't have to request 
that the written statement be submitted for the record, because 
you all did that.
    Mr. Chairman, I am going to focus on my remarks on five of 
the bills, but I would like to state from the beginning, VA 
does not oppose the intent of any of the bills under 
consideration.
    In some cases, the VA's current efforts meet or exceed the 
requirements of the bill and in others, some additional work is 
needed to allow the Congress and the VA to best serve our 
Nation's veterans.
    And our request would be that we could continue to partner 
with you and the staff to get the best bills possible.
    Mr. Chairman, H.R. 1925 would require the Secretary to 
establish a separate ``Veterans Integrated Services Network'' 
for the Gulf Coast region.
    While VA certainly desires to serve all our veterans, we 
find at this point, on the basis of information that we have, 
no justification for establishing a separate VISN for a service 
area driven by the workload needed to make such a significant 
organizational change cost-effective.
    Current facilities and referral patterns provide the best 
access for the veterans on the Coast using the combined efforts 
of VISNs 7, 8 and 16 who--which are--work very well together to 
provide the care for veterans living in the area.
    H.R. 2005 is intended to improve the VA's ability to meet 
the healthcare needs of rural veterans. The VA recently 
established the Office of Rural Health, which is charged with 
determining how we can best continue to expand access to care.
    And the Office of Rural Health is developing a strategic 
plan for operations that there is consideration for a proposal 
to create new research centers.
    We would request that the Congress wait until these 
assessments are complete before requiring further action 
Moreover, while we recognize the significant increase in fuel 
prices, beneficiary travel payments are paid to a limited 
category of eligible veterans out of funds appropriated for 
healthcare for all the veterans.
    Our initial estimates project that the bill would cost 
potentially and approximately up to $7 billion over the next 
ten years. At present, that cost would have to come out of 
medical care services.
    H.R. 2173 would amend VA's authority readjustment 
counseling while permitting the Secretary to enter into 
contracts with community mental health centers for the 
provision of mental health services.
    I have to admit that I have been a little bit confused by 
the discussion, because the bill talks about veterans health 
centers, not the VA in general contracting for care. The Vet 
Centers currently have authority to contract with community 
mental health agencies for the provision of readjustment 
counseling services.
    For veterans with more complex mental health needs, the 
veterans--Vet Centers routinely refer them to the VA medical 
facilities.
    This provision, if it really was intended for the Vet 
Centers to contract out for the full services of mental health, 
would blur the distinction between the VA's readjustment 
counseling and more sophisticated mental health services.
    Readjustment counseling is a special, more than medical 
community based counseling service that creates--that treats 
veterans and family members under the bereavement counseling to 
help them make a successful readjustment from combat to 
civilian life.
    VA mental health is a medical care service provided by VA 
mental--medical centers for enrolled veterans. We already have 
the authority to outsource and contract if for care, and it is 
very clear that my guidance is that there are only two ways 
that you can do this. Let me make it three, but one is 
unacceptable.
    One is that you--we have an obligation to provide whatever 
services are necessary for the veterans consistent with out 
benefit package. That we can either do it in-house, and if we 
can't have the resources, you don't have the infrastructure, 
then we are obligated to buy it. In other words, contract with 
it.
    The third thing is not to do it, and that is totally 
unacceptable.
    H.R. 2219 would require the Secretary to establish a 
national toll-free hotline for suicide prevention, staffed by 
peer-to-peer counselors.
    Mr. Chairman, as you already know and has been mentioned 
already, VA's already developing a comprehensive program for 
suicide prevention, including a national 24-hour toll-free 
hotline.
    The VA plans to staff the hotline with VA mental health 
professionals who may access the electronic health record of 
the callers and can work with local facility suicide prevention 
coordinators to provide immediate and provide more 
comprehensive care.
    H.R. 2378 intends to prevent low-income veterans in 
permanent housing from falling back into their former homeless 
condition.
    The VA generally supports H.R. 2378, but we strongly 
recommend the bill be modified to allow VA to establish 
additional criteria to ensure that this program reaches veteran 
families requiring additional support to end their 
homelessness.
    There was one bill, the 2623, the ``Hospice Care Bill'' 
that I don't know exactly what happened in the process. I did 
not provide comments on that either in written or verbal, but I 
would be happy to answer any questions about it. But we didn't 
develop a formal response to that bill.
    [Comments for H.R. 2378 and H.R. 2623 were provided by the 
U.S. Department of Veterans Affairs on August 19, 2007, and 
appear on p. 91.]
    I am pleased to answer any questions you or any of the 
other members may have, Mr. Chair.
    [The prepared statement of Hon. Kussman appears on p. 80.]
    Mr. Michaud. I have a few questions. What have you provided 
to the Subcommittee dealing with Ms. Watson's bill as far as 
training. Looking at PVA's testimony, they had mentioned that 
they had talked to one of the VA chiefs and were told that the 
officers received training primarily on how to handle veterans 
aged 60 to 70 years old. I want to know if you could provide to 
the Subcommittee what other requirements for the officers as 
far as training goes.
    [The FY 2007 Basic Police Officer Training Course Syllabus 
and Training Schedule from the U.S. Department of Veterans 
Affairs Law Enforcement Training Center, North Little Rock, 
Arkansas, is being retained in the Committee files.]
    Mr. Michaud. Another issue talked about--a report on the 
reports. I think it is important that we have reports. But, I 
am concerned about the redundancy and how we can streamline 
that process.
    Regarding testimony the VA does a good job on a lot of its 
programs, but I can see the frustration that people might have 
in trying to access the system.
    It is my hope that the VA will look at how it can improve 
access to programs, such as through a computer and telephone 
system. Did you want to comment on that?
    Dr. Kussman. Yes, sir. I would be happy if I could, if I 
could remember all the questions you had.
    But first and foremost, as was mentioned, all our VA police 
are VA employees by statute. They are not contracted. There may 
be some confusion. I think that there is some contracting for 
guards, but not for the police themselves.
    If I may just take a minute. Clearly, the description of 
what happened to Jose Medina is unacceptable, and all I can say 
as the leader of the VHA, that is unacceptable. And we 
apologize for whatever happened or anything veteran who is 
inappropriately treated by any employee in our system, much 
less the police.
    Now, we--in the hiring our VA police, there is an extensive 
training program done even before they get to the ability to 
work. There is an 80-hour basic injury level of training course 
at whatever medical center they are going to be employed on. 
And then a 200-hour residential basic police office training 
course at our law enforcement training center, I think, that is 
in Little Rock, Arkansas. And we have been lauded by much of 
this training.
    Title 38, U.S. Code, section 902, requires VA to create 
regulations with respect to training department police 
officers, with particular emphasis on situations involving 
patients.
    The specific question that you had, it was alluded to that 
the training was only for people over 60. I have to go back and 
look at that, but clearly our job is to take care of the full 
depth and breadth of veterans, with specific emphasis on 
adjustment reactions in mental health and people who may or may 
not be acting in a way that is not normal the way they act 
because they are ill. And that is something that all medical 
employees have to do.
    Whether it is a policeman or anybody else is that people 
don't necessarily act the way they might in the department 
store versus--or a bank versus when they come into mental--for 
medical services, because that is the problem. They are coming 
for medical services.
    Much of the training, there is a 17.5 hour block of 
training in behavioral science, which includes training on 
mental illness----
    Mr. Michaud. Instead of going through that whole thing----
    Dr. Kussman. Okay.
    Mr. Michaud [continuing]. Could you provide that for the 
Subcommittee?
    [The following was subsequently received:]

    By statute, the Secretary is required to provide VA Police Officers 
with training that emphasizes effective management of situations 
involving patients. To carry out that mandate, VA provides specialized 
training to VA Police Officers in dealing with disruptive and other 
unusual behaviors, key portions of which are taught by VA 
psychologists. VA officers must successfully complete:

      An 80-hour basic entry level training course at their 
Medical Center;
      A 200-hour residential basic police officer training 
course at the VA Law Enforcement Training Center in Little Rock, 
Arkansas;
      A 17.5-hour block during their residential basic officer 
training in Behavioral Science (including topics such as mental 
illness, communications/conflict management, verbal judo, crisis 
intervention/conflict resolution, and the dynamics of the suicidal 
individual); and
      A biannual refresher training program.

    Dr. Kussman. Sure.
    Mr. Michaud. I know my time is up.
    Dr. Kussman. Okay. I am sorry. Just--okay.
    Mr. Michaud. But the other issue you could look at that we 
are dealing with today is the budget. It is a very robust 
budget for the VA system, and our problem, when you look at the 
bills that you mentioned earlier, a lot of these issues could 
have been dealt with if the VA had the budget and moved 
forward, whether it is the CARES program or other access 
issues.
    I am also looking at how we can help save costs. A good 
example, is the dental area.
    For example when you go to the VA for dentures or you need 
amalgam fillings, it depends on whether the VA gets it. If you 
go to the dentist, the dentures tend to cost twice as much, as 
much as $600.00 or more if you went--than if you went to a 
denturist. Likewise, if you go to a dentist and they decide to 
fill a filling with a white filling versus an amalgam filling. 
The white tends to be a lot more expensive and it doesn't last 
as long.
    So hopefully the VA is looking at ways where they might be 
able to save money, and it might make the system more 
effective. I will ask other members to ask that question, and 
we will go a second round if we have time.
    Mr. Miller?
    Dr. Kussman. So you--there was one--on the last part of 
your question about the ombudsman?
    Mr. Michaud. Yes
    Dr. Kussman. Yes.
    Mr. Michaud. Excuse me.
    Dr. Kussman. And, obviously, in intent, that is a great 
idea, and it really depends on what type of veteran you are 
talking about. Whether it is the more routine veteran that is 
getting out, using the Benefits Delivery at Discharge (BDD) 
process, the Transition Assistance Program (TAP) process, and 
all those things. That is where a lot of that counseling goes.
    But we realize that people who are injured in service, 
particularly with TBI and more severe injuries, needed a lot 
more care. And as you know, we have had our benefits counselors 
and case managers get deeply involved with these VA facility. 
They wrap themselves around, try to communicate with them, make 
sure everybody knows that their benefits are. Military people 
who are in our four Polytrauma Centers to help on the reverse 
way of making sure that people get help if they are worried 
about the Medical Evacuation Proponency Directorate (MEPD) 
process.
    We also, as you know, just put in place a program of 
transition patient advocates that are going to glom themselves 
on, on a one-on-one basis with people who are in the Walter 
Reeds of Bethesda and Brooks, and help them longitudinally as 
they go through the process but not give up on them. They are 
going to have cell phone contact. They are going to picked by 
where the patient would generally want to go and will keep in 
contact with them over a period of years.
    Mr. Michaud. Thank you. Mr. Miller?
    Mr. Miller. Thank you very much, Mr. Chairman. Doctor, good 
to see you.
    Dr. Kussman. Nice to see you, sir. Thank you.
    Mr. Miller. I look forward to working with you. I did put 
the chart back up so you could refer to the VISN in the Gulf 
Coast Region.
    You stated in your testimony that there was not sufficient 
workload to make an organization change, create a new Gulf 
Coast VISN. Could you give me some type of idea of what you 
consider as sufficient workload?
    Dr. Kussman. The information that I have, and, sir, I would 
have to go back and validate it and discuss with you further, 
but the information that I have is that in 2005, there were 
88,000 enrollees in the area that you are describing, with 
281,000 veterans of which 88,000 were enrolled with us.
    Mr. Miller. So you are saying--my question is not----
    Mr. Snyder. I was not sure of his answer. Is the number he 
is giving in the new area that he wanted----
    Mr. Miller. You can't--I mean, you--I mean----
    Dr. Kussman. Okay.
    Mr. Snyder. Yeah, that is what I figured.
    Mr. Miller. My first question is what do you consider an 
adequate workload, a sufficient workload? Looking at this 
chart, it is very clear that there are two VISNs that are 
absolutely covered up. One is 16; one is eight.
    Obviously, a lot has changed since the inception of the 
VISN, and I think the Gulf Region is the concept works, and, 
obviously, because we took two and we fold them into one, there 
is flexibility in doing what needs to be done.
    Clearly, you can look and see that VISN 16 has three times 
the number of Gulf veterans as VISN two, five, or 19. My 
question is at what time would the enrollment be too high that 
you would look at splitting? Splitting, not combining, but 
splitting this?
    Dr. Kussman. That actually is a very good question, and I 
don't think we have a criteria for that. And we certainly 
should look at it.
    [The following was subsequently received:]

    Question: For the record, ``the opportunity for VA to look closer 
at the numbers'' of VISN 16, particularly how many veterans it has 
relative to other VISNs and whether that should be reconfigured.
    Response: Currently, we have no data to support an additional VISN 
in the Gulf Coast Region. The size of the area proposed for a VISN does 
not have the workload needed to be cost effective, nor to require that 
level of management. This area has only 88,583 enrollees and 281,476 
veteran population in 2005, with the 2025 projections at 94,779 
enrollees (a 7% increase) and 223,598 veteran population (a 21% 
decrease). The smallest VISN currently has at least 200,000 enrollees 
and over 500,000 veteran population.
    This area has one hospital, the Gulf Coast Veterans Healthcare 
System in Biloxi, Mississippi, and no tertiary care facility. The Gulf 
Coast area has four operational Community Based Outpatient Clinics 
(CBOCs) in Panama City, Pensacola, Dothan, and Mobile, and one approved 
to open in the next year in Jackson County, Florida. In addition, there 
are sharing agreements in place at three major military installations 
in Pensacola, Ft. Walton, and Panama City for inpatient and other 
healthcare services as needed.
    Each of the other 22 VISNs has at least four hospitals, with at 
least one providing tertiary care, and at least 15 CBOCs to manage the 
services and healthcare for veterans. With only one facility in the 
Gulf Coast, there is no need for Network Management. In addition, 
balancing the budget, opening new programs, and making large capital 
investments, among others, will be difficult at best. The Gulf Coast 
area does not have a tertiary care facility and as is the current 
practice, patients would still be referred to the closest tertiary care 
facility--Birmingham, Alabama; Jackson, Mississippi; or Gainesville, 
Florida.
    The current facilities and referral practices in this area provide 
access for veterans. VISNs were originally created around referral 
patterns and geographic boundaries. In addition, VISNs work together 
along their borders to ensure access to healthcare for veterans in 
those areas. The Gulf Coasts region is one area where VISNs seven, 
eight, and 16 have worked together to manage care for veterans in the 
area. VA has no plans at this time to add an additional Network for 
this region.
    Mr. Miller. What catches me by surprise with a visual such 
as this, that is it is very, very clear that there are some 
areas I would say are underserved or under worked.
    Now, they won't say that, and I would never impute that or 
imply that, because they are all overworked. However, if the 
folks in VISN two, five, and 19 are overworked, then eight and 
16 are really overworked.
    I would like for the record the opportunity for VA to look 
closer at the numbers, and if it is time to realign the whole 
network, fine. I am looking obviously at the veterans in the 
Gulf Coast Region, but it may be other regions as well.
    Another thing, on a personal note if I may, Public Law 109-
461 required a report not later than 180 days after enactment 
on the option of construction of a VA medical center in 
Okaloosa County. We are upon that date. In fact, it may even be 
next week. My question is are we going to meet that deadline, 
and when can we see a copy of the report?
    Dr. Kussman. Sir, we working on it, and let me get back to 
you exactly when we will get that report to you.
    [The ``Report to Congress on Options for the Construction 
of Department of Veterans Affairs Medical Center in Okaloosa 
County, Florida,'' dated June 26, 2007, is being retained in 
the Committee files.]
    Mr. Miller. Okay. Thank you.
    Mr. Michaud. Mr. Salazar?
    Mr. Salazar. Thank you, Mr. Chairman. And, Dr. Kussman, 
thank you for being here, and I understand the issues that you 
face with VA funding. And I can assure you that this Congress 
is trying to do everything they can to provide these funds that 
are badly needed for veterans.
    Can you tell me what model you use to estimate the $7 
billion that you talked about that it would cost VA for mileage 
reimbursement?
    Dr. Kussman. I would have to go back to policy and planning 
and resource managers, and I will get you an answer. I don't 
have it at the tip of my tongue about how they develop the 
estimation.
    [The following was subsequently received:]

    Question: What was the methodology used to determine the $7 billion 
cost for beneficiary travel in Section 2 of HR 2005, the Rural Veterans 
Health Care Improvement Act of 2007?
    Response: (16, 10A5, 17) Beneficiary travel is a discretionary 
program with funding coming directly from the annual VA healthcare 
appropriation. Funds expended for beneficiary travel decreases those 
available for direct medical care. The Secretary is required to 
undertake a yearly evaluation of the program in order to determine 
whether VA has sufficient funds to continue to provide veteran 
transportation benefits and whether any rate changes should occur. 
Given the unprecedented rise in veteran patient workload and the 
associated demand for limited VA medical care resources, the current 
reimbursement rates of .11 mile for travel relating to medical care and 
.17 mile when a veteran is recalled to redo a portion of a C&P 
examination that were established in 1979 have been maintained. Note: 
Under current law, when the beneficiary travel rate is adjusted, the 
deductible is adjusted proportionately to the adjustment.
    The proposed legislation requires VA to reimburse veteran mileage 
at the same rate as that of federal employees. It would also pay a 
subsistence amount (e.g. meals, lodging) at the same rate as a federal 
employee for that locality. Cost determination data is presented below.
    Cost Analysis: H.R. 2005, Section 2, changes the method of 
determining the mileage reimbursement rate of the VA Beneficiary Travel 
Program by equating it to that received by Federal employees as well as 
provides for a subsistence rate equal to that of a federal employee. 
The following provides a 5-year and 10-year estimate of the cost that 
would result from enactment of the proposed bill.


----------------------------------------------------------------------------------------------------------------
                                                 Estimated Reimburseable                        Increased Cost
                  Fiscal Year                           Mileage*            Payment Rate**        (Millions)
----------------------------------------------------------------------------------------------------------------
2008                                                        675,363,636                .375                $253
----------------------------------------------------------------------------------------------------------------
2009                                                        776,668,181                 .40                $311
----------------------------------------------------------------------------------------------------------------
2010                                                        893,168,408                .425                $380
----------------------------------------------------------------------------------------------------------------
2011                                                      1,027,143,669                 .45                $462
----------------------------------------------------------------------------------------------------------------
2012                                                      1,181,215,219                .475                $561
----------------------------------------------------------------------------------------------------------------
5-Year Total                                                                                             $1,967
----------------------------------------------------------------------------------------------------------------
2013                                                      1,358,397,502                 .50                $679
----------------------------------------------------------------------------------------------------------------
2014                                                      1,562,157,127                .525                $820
----------------------------------------------------------------------------------------------------------------
2015                                                      1,796,480,696                 .55                $988
----------------------------------------------------------------------------------------------------------------
2016                                                      2,065,952,800                .575              $1,188
----------------------------------------------------------------------------------------------------------------
2017                                                      2,375,845,720                 .60              $1,426
----------------------------------------------------------------------------------------------------------------
10-Year Total                                                                                            $7,068
----------------------------------------------------------------------------------------------------------------


    May not add up due to rounding

    *Estimated 15% increase in mileage per year
    **Federal Rate minus current .11 mileage rate

    Methodology: Number of miles for FY 2008 is based upon projected 
expenditures for Budget Object Code (BOC) 2120, ``Beneficiary Travel-
Mileage'' from the first half of FY 2007. Note: While VA does pay 17 
cents per mile for recalls due to the need to redo a portion of a C&P 
exam this is considered to be relatively rare, therefore the 11 cents 
per mile rate is used to determine base miles).
    Projected expenditures for FY 2007 are a 15% increase over FY 2006, 
and based upon continued increase in the number of veterans accessing 
VA healthcare it is estimated that this mileage rate increase will 
continue. Base Federal employee rate of 48.5 cents per mile is current 
rate. For the past 10 years there has been an annual average 2.5 cents 
per mile increase to the Federal employee rate, thus the rate changes 
noted.
    A subsistence rate adjustment has not been included since meals and 
lodging is estimated to have minimal impact due to current operations 
of only paying when hotel or other VA lodging is not available and the 
trip requires an overnight stay. VA usually pays actual charges in this 
event for lodging and meals.

    Mr. Salazar. I would appreciate that very, very much. And 
as far as the office that was established in January, the 
Office of Rural Health Care, could you also provide to this 
Committee an assessment as to what you have done to date in the 
last 6 months?
    Dr. Kussman. Yes, sir. Thank you for the question. As you 
know, we owe you a response in September of 2007, a written 
response about what progress has been made in the Office of 
Rural Health.
    Right now it has been stood up under the auspices of the 
Office of Policy and Planning under the direction of the 
Assistant Deputy Under Secretary for Health, Pat Vandenberg. 
This is a good place for this office, because it is involved 
with the office that does projections on workload, access, 
CARES, and the Milliman Model.
    Right now, Peter Sellick is in charge of that office, and 
they are looking at some strategic recommendations. At the same 
time, they are in the process of hiring a full-time director 
and establishing the necessary staff. So we will have a report 
for you.
    Mr. Salazar. So we still do not have a director, and we 
still are not fully staffed?
    Dr. Kussman. Right. That is correct.
    [The U.S. Department of Veterans Affairs, Veterans Health 
Administration, submitted the following report on January 10, 
2008,``Plan to Increase Access to Quality Long-Term Care and 
Mental Health Care for Enrolled Veterans Residing in Rural 
Areas,'' which appears on p. 96.]
    Mr. Salazar. One other question, Doctor. You talked a 
little bit about the Centers of Excellent and your objection to 
us directing you to establish the Centers of Excellence; is 
that correct?
    Dr. Kussman. I----
    Mr. Salazar. Could you tell us what your objection is to 
this?
    Dr. Kussman. Yes, sir. I will try. By the way, I was 
accused last year when I was here as being ``Dr. No.'' I 
don't--I would like to be ``Dr. Yes.''
    But to answer your specific question, we are not--I am 
not--I don't think anybody is against the Centers. The question 
is is there five, or four, or three that would be needed, and I 
think that is what we would hope that the Office of Rural 
Health, approaching the appropriate experts and everything, 
would recommend of how many or whatever that we need of these 
centers, because I think they are valuable centers.
    Mr. Salazar. But would you also agree that it is really up 
to members of Congress to request from you that these offices 
wouldn't just be established on one coast or the other and 
forget about middle America?
    And, you know, I think that is one of our reasons for 
trying to move this legislation forward so that we can 
basically make these Centers of Excellence, you know, located 
in--so that they address the needs of middle America as well, 
like Colorado, or Montana, or South Dakota.
    Dr. Kussman. Yes, sir. I wouldn't take exception. I don't 
recall that the legislation prescribed where they would be, but 
I don't disagree with you. It ought to be in areas that have 
the most need for the research and development of things 
related to rural health.
    Mr. Salazar. Thank you. I yield back.
    Mr. Michaud. Mr. Hare?
    Mr. Hare. Thank you, Mr. Chairman. Thank you for coming 
today, Dr. Kussman. Just three questions, I guess. One on H.R. 
2623, the--which prohibits the collection of copayments for the 
hospice care.
    I was wondering if the VA has a position on that or----
    Dr. Kussman. Well, as I mentioned earlier, I apologize. For 
some reason we didn't get that bill to put together an official 
policy. But in the past, and as we have done already with 
certain segments, we understand the need for that.
    And I don't want to prejudice the ability to look at the 
legislation, but it is clearly something that we need to look 
at.
    Mr. Hare. Thank you. The other one is on H.R. 2219, the 
``Veterans Suicide Prevention Hotline.'' I was wondering if you 
could just maybe update me on the status of the--of this 
project that you have.
    Specifically, when you expect it to be up and running, the 
qualifications of the people who are staffing the hotline, and 
does the VA plan on advertising this resource, so that the 
veterans have an understanding that it is there or their 
families have an understanding that it is there to be used? And 
if so, how are you going to do that?
    Dr. Kussman. Well, yes, sir. Obviously, any suicide is one 
too many, and our goal is to be as aggressive as we can. And we 
put together a very aggressive suicide prevention program, 
including having suicide coordinators at every facility, and 
this is another aspect of that, training all our people to know 
about how to look for and treat, even non-mental health people.
    The intent here, this will be established fully by the end 
of September of this year, and that we believe, after much 
discussions and everything--and by the way, the Joshua Omvig 
bill actually drove saying--we were doing this before that, but 
it was consistent with the bill, that said that they would be 
mental health professionals.
    And so our intent is to have the most sophisticated 
responses available to people when they call in, especially 
that they have access to the medical records if they weren't a 
veteran that we had never seen, so that they would be able to 
know about the veteran and assess the patient, because they 
would have the information. And then be able to coordinate 
directly with the suicide coordinators and the clinical people 
who are actually taking care of this person.
    Mr. Moran's point is well taken, and I think that it is 
something that we want to look at in balancing this, because 
there are veterans who don't like to use the system. That is 
what the Vet Centers, the readjustment counseling centers, are 
so valuable for.
    So I think that this is just another thing that we need to 
work together to decide what was the best way to do this. But 
having two hotlines, I am not sure how productive that would 
be.
    Mr. Hare. How do you plan on advertising this so the 
veterans can call in? The other question I had was for those 
who are staffing the hotline, what qualifications they had to 
have in order to be there?
    Dr. Kussman. With all our communication efforts with our 
newspapers and information papers at the facilities, we will do 
everything we can to make sure that people and their families 
know.
    Clearly when people transition out of the military, they 
will know as well as all the other veterans. Our intent is to 
have fully trained psychiatrists or psychologists available to 
provide that service.
    Mr. Hare. Do you have--just one last question. Is there a 
guesstimate, if you will, on how many veterans or families who 
would utilize this hotline during the course of the year? I am 
thinking several thousand.
    Dr. Kussman. Well, I am sorry. I don't know. We can look at 
per capita things that have happened in other hotlines, and 
presume that that would be----
    Mr. Hare. Would you--would you expect the numbers would be 
significant or your thought maybe even?
    Dr. Kussman. I don't know if they would be higher than we 
thought, but I think that we need to do it even if it is small 
numbers.
    Mr. Hare. I agree. All right. Thank you. I yield back, Mr. 
Chairman.
    Mr. Michaud. Dr. Snyder?
    Mr. Snyder. Thank you, Mr. Chairman. Dr. Kussman, I--is it 
Kussman or Kussman?
    Dr. Kussman. I think my father who is deceased would say it 
was Kussman, but everybody says Kussman. So I have been called 
worse.
    Mr. Snyder. There was a San Diego Padre ballplayer named 
Kussman. I don't know if you----
    Dr. Kussman. It is K-O-O-S.
    Mr. Snyder. If I call you Koosman, I will harass you for 
your batting average.
    Dr. Kussman. I don't see well enough.
    Mr. Snyder. Regarding--Mr. Miller had to leave, but in 
regard to this VISN issue, you know, part of VISN 16 includes 
Arkansas. And I have not heard much. You try to reach out a 
little bit on Mr. Miller's bill, and I have heard many 
complaints either way about how the lines have been drawn.
    I do have some concerns though that if we were to start 
drawing these lines by statute, and regarding seeing some 
benefit to doing that, and we changed the lines. And so I would 
hope that you would take into consideration Mr. Miller's 
concerns about those areas and waiting on the veterans. And I 
think it has been growing. And I hope we take a very formal 
look at this.
    And it may well be that in Arkansas we should also be 
concerned. Maybe there is an additional benefit to our veterans 
to have a smaller number of them under that administrative 
umbrella. I don't know what is magic, but I don't think Moses 
had golden tablets that said, what the most efficient number of 
enrollment is, this number versus a smaller number.
    It doesn't follow beyond that because you have a larger 
number. You can be more efficient. I would assume that the 
staffing would reflect the numbers of veterans, and those kinds 
of issues.
    But I hope you will formally look at that, and get that 
evaluation back to us, because----
    Dr. Kussman. Yes, sir.
    Mr. Snyder [continuing]. It has been a while since we took 
a look at it administratively.
    The second question I want to ask, but I share your 
concerns about the dental hotlines. So many years ago was that 
before I ever got into medicine and practiced medicine, 
staffing hotlines, you really do get a lot of kinds of calls 
that come into the different hotlines.
    But there are--every once in a while, there is one that 
really is a major problem and how that call is handled can make 
a huge difference in that person's life for better or worse. 
And I share your concern about who we would have on the 
hotline, and then like the real hotline. I think there could be 
some real confusion.
    I think, ultimately what everyone wants is that there be a 
place that people can go when they really are having a problem. 
If everything else is broken down, hopefully they are calling 
their health professionals or before they reach the hotline, 
but I share your concern.
    The issue of contracting out service in rural areas, about 
half my district is--would be considered rural, if not a little 
bit more. A great expanse of Arkansas are considered rural. We 
are very pleased with our VA system, the healthcare system in 
Arkansas.
    One of the things I like about it is if something goes 
wrong, I can pick up the phone or my staff can pick up the 
phone and go straight to a VA employee and say, ``Fix this.'' 
When things are contracted out, that is not so easy to do. You 
have people who have contractual responsibilities, which is 
different than having responsibilities to a member of Congress. 
I remember my office sent you a letter. We faxed it yesterday 
afternoon. If you haven't seen it, we have an issue going on 
now with regard to the seat back business in my district. I 
know we are hearing about veterans.
    But my specific question is, if they can provide the best 
care, more power to them. The problem is, I also noticed 
reports--especially reports out of Eureka, California, that 
they were rejected for a contract out there. We have had some 
indication that one of the VA's out there said they were real 
concerned about the company. That they decided to reject that 
contractor.
    But now we have got them in another VISN. That people may 
have a different set of information. How much information is 
shared when you have these kinds of--when you use this kind of 
contractor? How much information is shared amongst the 
decisionmakers, so that we are sure that the experience is good 
or bad and the contractors in one area that they reach out to 
other areas? How is that information shared so we know that 
they work on the same basis, and don't have to rediscover?
    Dr. Kussman. Thank you for the question. I have not seen 
the facts, so I apologize. But I think that the point is very 
well taken. Obviously is what do we learn from one place to 
another.
    You know, the old adage, you have seen one VA, you have 
seen one VA, is not what I believe. We have to have standards 
and consistency in the deliver.
    I have no idea why that Eureka, California, contractor was 
rejected. There could be a lot of reasons. If it was truly the 
quality of care, then we certainly should be able to track 
that, because what brought in all the other sea box that they 
may be contracted around the country.
    So I think we certainly have to look at that, and see if 
how we transmit information related to good contracts or bad 
contracts.
    Mr. Snyder. The number of contracts contracted is certainly 
going down. Thank you, Mr. Chairman.
    Mr. Michaud. Thank you. Ms. Brown.
    Ms. Brown of Florida. Thank you. Mr. Chairman, I don't have 
all of the details right before me, but in the last couple of 
days there was a news report. It indicated that veterans, over 
the last, I think it said 10 years, were twice as likely to 
commit suicide than people who were non-veterans.
    And I guess in response to that and other issues, the 
Department has indicated that they are going to hire 153 
prevention counselors at all of the veteran centers.
    My question lies--and I am not one for contracting out, but 
perhaps in a situation like this, it would be better, because I 
don't know what the cost is to hire 153. But how would those 
people who can't be available 24 hours help all the veterans. 
This would be the opportunity to work with some organizations 
and other groups to have people available and training in 
coordination.
    I just don't know how it is going to work. Can you expound 
upon that?
    Dr. Kussman. Yes, ma'am. We are constantly looking at our 
mental health processes, suicide, PTSD, whatever it is.
    Ms. Brown of Florida. Are you familiar with the study that 
I am talking about?
    Dr. Kussman. I am aware of it. I haven't read the study 
specifically. The subject matter experts are looking at that to 
determine, because a lot of times the small numbers, and it is 
hard to know for sure what was in the report. I am not 
debunking the report at all.
    I mean, I--but the ones--the counselors we were talking 
about are suicide coordinators to make sure that the facilities 
have all the programs and processes in place. That the staff is 
educated in things of that sort.
    I have put in place a new policy related to mental health. 
That when somebody surfaces, that they need to be evaluated 
within 24 hours of what it is. Now, obviously, if a suicide, 
you can't even wait 24 hours, but we have people on call 24 
hours a day. And we will make that the standard in our 
facilities.
    So if somebody calls, again, and they call the hotline, 
that hotline has the way of getting to wherever the geography 
if the person will tell us. Sometimes they call and won't tell 
you where they are, and you have got to look at the call--
caller ID and see the area code.
    But if somebody comes to the emergency room or somebody 
knows about it, we have people on call 24/7 to come in and 
assess that person, because you have to take every person who 
says, ``I think I am going to do something bad to myself,'' 
seriously.
    Thank God most of them don't do it. But there are enough 
that do that we have an obligation to try to intervene to the 
maximum extend possible.
    Ms. Brown of Florida. One follow up. You indicated in your 
written testimony you generally support most of the bills, but 
under the area of permanent housing for the homeless vets, why 
would clinical indicators be a reason to deny permanent 
housing?
    I felt that if we are looking at veterans, there is going 
to be a big increase in funds to deny a program to staffing 
issues is kind of--is very unacceptable to me. And I would like 
for you to be ``Dr. Yes.''
    Dr. Kussman. Or ``Maybe Could Be.'' I don't know. But in 
truth, I don't think we are against the permanent housing. I 
think what we were saying is that we support the bill. It would 
be a better bill for us if we could add some of these clinical 
services that are there.
    For instance, we would want to know what--if there was a 
history of mental illness, whether there was a history of 
substance abuse, demonstrated significant impediments to 
holding a job, whether there was social dysfunction in the 
family. All those things would make it better for us to be able 
to provide services.
    Ms. Brown of Florida. Well, would you work with us as we 
move forward----
    Dr. Kussman. Yes.
    Ms. Brown of Florida [continuing]. With the bill and my 
staff to make sure that we include those areas that you think 
would make it better?
    Dr. Kussman. Yes, sir. And I think as the Chairman knows, I 
would like to do that in all the different bills, because I 
think we agree in principle as I said. We just want to 
maximally affect what we can do, and not, perhaps, get 
someplace where we are duplicating what we are doing.
    But our effort is to take care of veterans.
    Ms. Brown of Florida. I know you know that there is a lot 
of frustration----
    Dr. Kussman. Right.
    Ms. Brown of Florida [continuing]. With us, because we all 
care about the veterans, and it is just--it seemed to be not 
working for them.
    Dr. Kussman. Right. It----
    Ms. Brown of Florida. And they are very frustrated, and 
they get on us. And then we have to get on you.
    Dr. Kussman. Yes, ma'am, I understand that. I have been 
sworn in since the 30th of May.
    Ms. Brown of Florida. All right, ``Dr. Yes.''
    Mr. Michaud. Just a follow up. I think it was Mr. Hare's 
question and others about hospice. I believe that was actually 
requested from the VA back in the 2006 budget.
    Just one last question, and we'll take questions in 
writing. It gets to questions asked earlier about the Office of 
Rural Health. You had mentioned you had not hired a director or 
anyone in that office.
    Dr. Kussman. I have to go ask Matt about that. I think that 
they have, but I don't want to give you the wrong information. 
Let me get back to you on that, whether they have actually 
hired any specific--they have a lot of detailed work out to 
hire the people. I don't know if anybody has actually been 
brought on.
    As you know, there some challenges sometimes when we want 
to go hire somebody. It has got to go through all the process 
that can take months.
    Mr. Michaud. Again, it would be interesting to know, and 
particularly for the director of Rural Health, who that 
individual might be and what you are looking for in that 
individual. I would hate to have someone from Boston or Los 
Angeles or Chicago. But I would like to have somebody who 
really understands and has a mindset of problems that people 
are facing in rural areas.
    Dr. Kussman. Yes, sir. And there is a job description that 
is established. I would be happy to try to get it to you.
    [The job description for the Program Analysis Officer, 
Office of the Assistant Deputy Under Secretary for Policy and 
Planning, Veterans Health Administration, U.S. Department of 
Veterans Affairs, appears on p. 103.]
    Mr. Michaud. Great. Once again, I want to thank the panel 
for your testimony today and we look forward to continue 
working with the VA as we move forward in this upcoming 
Congress. Thank you very much.
    Dr. Kussman. Thank you, Mr. Chairman.
    The hearing is adjourned.
    [Whereupon, at 12:41 p.m., the Subcommittee was adjourned.]


                            A P P E N D I X

                              ----------                              

        Prepared Statement of the Honorable Michael H. Michaud,
                    Chairman, Subcommittee on Health
    Today's legislative hearing will provide Members of Congress, 
veterans, the VA and other interested parties with the opportunity to 
discuss legislation within the Subcommittee's jurisdiction in a clear 
and orderly process.
    While I may not necessarily agree or disagree with the bills before 
us today, I do believe that this is an important process that will 
encourage frank discussions and new ideas.
    We have ten bills before us that seek to improve healthcare for the 
nation's veterans, and I look forward to hearing the views of our 
witnesses.
    I also look forward to working with everyone here to continue to 
improve the quality of care available to our veterans.
    There are two draft discussions that are not before us today. There 
is a discussion draft on homelessness, and a discussion draft on mental 
health services. Congressman Patrick Murphy of Pennsylvania has also 
introduced H.R. 2699. I ask that the members of the third panel, the 
VSOs, and the fourth panel, VA, provide comments and views on these 
three items for the record once they are made available. We would like 
your written comments submitted to the Committee by June 21st, 2007.

                                 
  Prepared Statement of the Honorable Jeff Miller, Ranking Republican
                     Member, Subcommittee on Health
    Thank you, Mr. Chairman.
    I appreciate your holding this legislative hearing and welcome the 
opportunity to discuss the ten different legislative proposals before 
us today. I would like to offer brief introductory remarks, and note 
that I have introduced two of the bills and will expand on these bills, 
H.R. 1925 and H.R. 2623, at the appropriate time.
    As we evaluate this legislation, it is important to consider that 
the demand for veterans' healthcare is increasing and will continue to 
grow. While there may be some areas that will see a decrease in the 
veteran population, other areas, including my own Florida district, are 
experiencing a large increase in the veteran population. In fact, in 
the past 10 years, the number of veterans living in FL CD 1 has grown 
more than 30% and is among the top 10 districts in the United States 
for growth of veterans since 2000.
    I'd like to thank my colleagues, Dr. Kussman and all of the veteran 
service organization representatives for their commitment to join us 
today to discuss these very pertinent issues affecting our Nation's 
veterans.
    Thank you, Mr. Chairman, I yield back.

                                 
     Prepared Statement of the Honorable Stephanie Herseth Sandlin,
      a Representative in Congress from the State of South Dakota
    Chairman Michaud and Ranking Member Miller, thank you for allowing 
me to be here to discuss the Services to Prevent Homelessness Act, a 
bill which I introduced on May 17, 2007, to provide supportive services 
for very low-income veterans.
    The U.S. Census Bureau estimates that 1.5 million of our nation's 
veterans live in poverty, including 702,000 veterans with disabilities 
and 404,000 veterans in-households with children. 634,000 of the 1.5 
million poor veterans live in extreme poverty. These poor veterans face 
residential insecurity due to their low-income levels or their past 
episodes of homelessness. They also face health and vocational 
challenges and access barriers to supportive services, which limit 
their ability to sustain housing and maintain independence from more-
costly public institutional care and support. These poor veterans may 
benefit from flexible and individualized support services provided in 
home-based settings.
    The Services to Prevent Veterans Homelessness Act would authorize 
the Secretary of Veterans Affairs to provide financial assistance to 
nonprofit organizations and consumer cooperatives to provide and 
coordinate the provision of supportive services that addresses the 
needs of very low-income veterans occupying permanent housing. The 
financial assistance shall consist of per diem payments for each 
household provided supportive services.
    Supportive services that may be offered include physical and mental 
health, case management, daily living, personal financial planning, 
transportation, vocational counseling, employment and training, 
education, assistance in obtaining veterans benefits and public 
benefits, child care, and housing counseling.
    Veteran subpopulations expected to benefit from the program include 
veterans transitioning from homelessness to permanent housing, poor 
disabled and older veterans requesting supportive services in home-
based settings, and poor veterans in rural areas with distance barriers 
to centrally located services.
    While federal programs exist to help create veterans homeownership, 
there is no national housing assistance program targeted to low-income 
veterans. Permanent housing opportunities for veterans ready for 
independent living are limited. In addition, the VA currently is not 
permitted to provide grants to create affordable permanent housing, and 
the resources that are available for providers are inadequate and 
highly sought after by competing housing projects.
    Thank you again for allowing me to be here. I look forward to 
continuing to work with the Chairman and Ranking Member to support 
efforts to meet the housing assistance needs of our Nation's low-income 
veterans through the establishment of a permanent housing assistance 
program for low income veterans.
    I would be happy to answer any questions you may have.

                                 
   Statement of the Honorable Ciro D. Rodriguez, a Representative in 
                    Congress from the State of Texas
    Chairman Michaud, Ranking Member Miller, and distinguished Members 
of the Subcommittee. Thank you for the opportunity to speak before you 
in support for an issue near and dear to my heart. H.R. 2173, a bill I 
introduced with my friend and colleague Congresswoman Napolitano, 
provides for the increase in capacity for mental health services 
through contracts with qualified community mental health centers.
    Recent surveys show that one in eight returning Iraqi war veterans 
report symptoms of post traumatic stress disorder (PTSD). The same 
studies also report high incidence of major depression and anxiety 
disorders among returning members of Army and Marine combat units. As a 
Member of this Committee, we have long identified mental health 
services as a major issue facing returning soldiers as well as at the 
Veterans Administration (VA).
    Experts note that the manifestation of clinical symptoms of PTSD 
and other mental health disorders often occurs over several years. With 
the increase of active duty, guardsmen and reservists returning from 
combat, the necessary capacity to provide mental health services is 
relatively unknown. It is difficult to know if our large number of 
returning veterans will need mental health services beyond what the VA 
is capable of providing.
    My bill, H.R. 2173, authorizes the VA to contract with community 
mental health centers to increase their capacity. In my opinion the 
need has outpaced the capacity for the VA to provide mental health 
services in outpatient clinics. Contracting out to community mental 
health centers is already been done successfully in some states and 
could serve as a model for VA-wide implementation.
    Mr. Chairman, in my previous career, I worked in the mental health 
field as a social worker. I am fully aware of the great service 
provided by community mental health centers. If there is any doubt of 
the quality of care they provide, I can tell you of the hundreds of 
families whose lives have been changes by the treatments received 
during my professional career in the field. But don't take my word for 
it. Each year, community health centers give nearly 6 million children, 
adults, and families in communities across the country the chance to 
recover and lead productive lives. Our returning soldiers deserve the 
same opportunity.
    As I mentioned before, it is clear that our soldiers are returning 
with an increased need for mental health services, but after this long 
war, it is unclear what the VA's capacity to fulfill this need will be. 
It is my hope that H.R. 2173 can provide the VA with the tools to 
continue to provide top notch mental health services to veterans in 
their own communities.
    Mr. Chairman, I would like to again thank you and the Members of 
this Subcommittee for the opportunity to speak on this bill. I urge the 
Members to support this important legislation. Thank you and I would 
gladly answer any questions you may have.

                                 
               Statement of the Honorable James P. Moran,
        a Representative in Congress from the State of Virginia
    Mr. Chairman, members of this Subcommittee, I want to thank you for 
holding this important hearing today and commend the Subcommittee for 
the work that it has already undertaken on behalf of our Nation's 
veterans.
    The problem of suicide among our veterans is one of the most 
serious issues that we have to address as we care for our older 
veterans and prepare for a new generation of returning soldiers.
    The Centers for Disease Control recently released a troubling 
statistic: Each year, approximately 115,000 veterans attempt suicide. 
This accounts for nearly 20% of all suicide attempts, yet, the veteran 
population only accounts for 11% of the entire population.
    The disproportionate prevalence of suicide among veterans suggests 
that, in addition to our overall national strategy on suicide 
prevention, particular attention must be paid to preventing suicide 
among this special population.
    Unfortunately, I expect this trend to continue as more of our brave 
men and women return from multiple deployments with the symptoms of 
post-traumatic stress disorder, or PTSD. As we have learned, a 
staggering 20% of soldiers returning from Iraq are experiencing 
depression, sleep deprivation, anxiety and other symptoms of PTSD.
    I am proud that this Congress has already acknowledged the growing 
problem of PTSD and dedicated substantial resources to it. Still, I 
believe, as scientific evidence suggests, that as our returning 
soldiers are increasingly susceptible to PTSD, they are at an elevated 
risk for suicide attempts.
    My bill, the ``Veterans Suicide Prevention Hotline Act of 2007'', 
would create a 24-hour national toll-free hotline to assist our 
Nation's veterans in crisis. It would be staffed predominantly by 
veterans, trained to appropriately and responsibly answer calls from 
other veterans. This hotline would follow the models of the National 
Suicide, Sexual Assault and Domestic Violence hotlines, where 
volunteers trained in active listening and crisis de-escalation respond 
to a variety of crisis calls.
    I believe that this cultural competency--the ability to connect to 
another veteran who understands best what the caller may be 
experiencing--can make a real difference in crisis counseling. It is 
difficult to connect on this level with anyone else, even trained 
doctors or other professionals.
    To build this capacity nationwide, my bill calls for a 3-year, 
competitively awarded grant for $2.5 million in the next three fiscal 
years. The funding will be made available to a qualified non-profit 
crisis center to establish, publicize, and operate the hotline, 
including developing curricula to train and certify volunteers.
    We have reached out the Department of Veterans' Affairs and are 
encouraged that the VHA is undertaking new efforts to establish a 
suicide hotline and address mental health needs. Their plan is to 
divert callers from the National Suicide Prevention Hotline to a VA 
facility, staffed by doctors, psychologists and other certified 
counseling professionals.
    On the surface the VHA's effort may appear duplicative of my 
proposal, but there are some very important differences that I feel 
need to be highlighted.
    First, my legislation requires that the people answering the 
phones, those dealing directly with the veterans, are veterans 
themselves. There are times when speaking with someone who has the 
cultural competence and empathy to really understand the experiences of 
veterans in crisis can help make the difference between successful 
integration into mental health treatment and failure to reach a veteran 
in dire need of services.
    Second, The VHA has many responsibilities for providing the highest 
quality of healthcare for our veterans. However, they have experienced 
stretched budgets and staffing shortages in recent years. Because the 
demands placed on any veterans' hotline may be great as our Nation 
redeploys from Iraq in the future, I have concern that the VHA may not 
have the capability and commitment to the hotline that a non-profit 
organization dedicated to suicide prevention as its sole purpose might 
be able to provide.
    Third, there are times when a person in crisis doesn't want to talk 
to a doctor--they want to talk to a volunteer. Mentally ill individuals 
all face societal stigma associated with seeking care. Research from 
the Air Force's suicide prevention efforts suggests that this is 
perceived to be even more profound in the military and veteran 
communities. Fear of ``the system'', of an unfriendly mental health 
establishment, and of potential job-related consequences keep many from 
seeking care.
    One of the motivations behind the National Suicide hotline and this 
bill is to give people in crisis another option--an anonymous hotline 
that can respond to their immediate crisis.
    To conclude, our vets deserve as much support when they return from 
combat as they receive while in battle. Too many of our veterans are 
struggling to make the difficult adjustment back to society and need 
someone they can talk to, someone who's walked a mile in their shoes.
    This legislation will offer a caring voice at the end of the line 
when it feels like there's no where else to turn.

                                 
              Statement of the Honorable Diane E. Watson,
       a Representative in Congress from the State of California
    Thank you Mr. Chairman for holding today's hearing, and letting me 
speak about my bill, H.R. 1853--The Jose Medina Veterans Affairs Police 
Training Act. I believe this legislation is vital to protect our heroes 
who have sacrificed their minds and bodies to protect our freedoms.
    Mr. Chairman, too many veterans are suffering from mental health 
problems after returning from combat, and they are not receiving the 
proper treatment they deserve. Congress has a responsibility to provide 
quality healthcare for our veterans. We must analyze every aspect of 
services associated with the treatment of Post Traumatic Stress 
Disorder, or PTSD, for our vets.
    I have introduced H.R. 1853--The Jose Medina Veterans Affairs 
Police Training Act, a bill that would force the Department of Veterans 
Affairs to better prepare its police force to interact with patients 
and visitors at VA medical facilities who suffer from mental illnesses.
    Jose Medina is a constituent of mine. He is a Vietnam veteran who 
suffers from PTSD. In January 2006, Mr. Medina was assaulted by two 
West Los Angeles VA police officers who kicked him and forced him to 
the ground after he isolated himself and fell asleep in a hallway at a 
VA Medical Center in Los Angeles.
    After a physical altercation ensued, this fifty-six year old 
veteran was forced to lay face down on a hospital floor. The officers 
injured Mr. Medina, and after the altercation they did not allow him to 
use the hospital's emergency room. Instead, the officers handcuffed him 
and detained him for an hour, before sending him home with a loitering 
ticket. This is not the way we should be treating veterans who have 
served and protected this country.
    What bothers me the most is that when you see someone sitting on a 
hospital floor, one would think law enforcement and hospital staff 
would ask the individual if they were all right, or in need of 
assistance. Instead, in this case, Mr. Medina was mistreated. This is 
happening to too many of our brave veterans.
    As we look to the future, thousands of veterans will be entering 
the VA healthcare system. We must ensure that the VA has the ability to 
administer quality healthcare services to veterans that suffer from 
mental illnesses. With over 20% of the one and a half million veterans 
that served in Iraq or Afghanistan showing signs of PTSD, we do not 
want any of them to endure what Mr. Medina had to endure.
    Mr. Chairman, the Veterans Administration believes this legislation 
is unnecessary, but the story of Jose Medina and other veterans from 
around the country who have contacted my office with similar problems 
has proven to me that this training is indeed necessary. As Congress 
debates funding strategies and timelines for our military missions, we 
must not forget that not only do we need our vets to have the resources 
for the battlefield; they must also be treated with dignity and respect 
once they resume their lives after combat. We must ensure that this 
happens!
    Mr. Chairman, I thank you for the opportunity to address your 
committee, and I urge the members of the committee to support H.R. 
1853.

                                 
              Statement of the Honorable John T. Salazar,
        a Representative in Congress from the State of Colorado
    Thank you Mr. Chairman.
    Mr. Chairman, I'm pleased to bring H.R. 2005 to the Subcommittee 
this morning, and I look forward to the discussion on this important 
legislation.
    The Rural Veterans Healthcare Improvement Act seeks to improve 
healthcare services to veterans living in rural areas.
    A study of more than 767,000 veterans by researchers working for 
the Department of Veterans Affairs shows vets in rural areas are in 
poorer health than vets living closer to cities.
    The VA found that the health of rural veterans still persisted, 
even after researchers adjusted for socioeconomic factors such as race, 
education or employment status.
    It was identified in the study, that access to care is a key 
factor.
    The study suggested, that in addition to establishing more clinics 
in rural areas, VA should consider coordinating services with Medicare 
or other healthcare services based in rural areas.
    As a way to begin addressing some of these issues, the Veterans 
Benefits, Health Care, and Information Technology Act of 2006, which 
passed at the end of the 109th Congress, created the Office of Rural 
Health within the VA.
    Dr. Kussman's testimony will tell you that the VA is opposed to 
this legislation because the Office of Rural Health is charged with 
these tasks. . . .
    I would like to make the point that even though Congress directed 
VA to establish this office, it has yet to be implemented.
    This new office, when the VA does decide to set it up, needs 
support, direction, and resources in order to fulfill its mission of 
coordinating care to this vital constituency.
    The Rural Veterans Healthcare Improvement Act of 2007 would task 
the Director of the Office of Rural Health with developing:

      demonstration projects
      centers of excellence
      a transportation grant program

    and the bill would also more fairly reimburse veterans in rural 
areas for the traveling expenses they incur when driving long distances 
to VA medical facilities.
    Mr. Chairman . . . with both an ailing veteran population to care 
for, and a new generation of veterans returning from service in Iraq 
and Afghanistan, we immediately need to address access to care issues 
for our rural vets.
    It is estimated, that nearly 45% of all new recruits are coming 
from Rural America, and with a large percentage of this war burdened by 
our national Guard, that number is only going to increase.
    Many vets must travel hundreds of miles to access the medical care 
we've promised and they do so almost entirely at their own expense.
    Currently, we reimburse veterans at a rate of $0.11 cents per mile, 
a rate that has not increased since 1978.
    In 1978 . . . the average price of gasoline was $0.63 cents. I 
don't have to remind the Committee of the price of gasoline today.
    This legislation would increase the reimbursement rate to $0.48 
cents per mile, the same rate paid to federal employees.
    This legislation also establishes a transportation grant program 
called VetsRide.
    VetsRide encourages Veterans Service Organizations to develop 
innovative transportation options to vets in rural areas.
    With a grant up to $50,000, a VSO could purchase a van, or find 
other ways to assists veterans with travel to VA medical centers.
    This bill also establishes Centers of Excellence to research ways 
to improve care for rural veterans. These centers would be based at VA 
Medical Centers with strong academic connections.
    The outcome of these Centers would be the development of specific 
models to be used by VA in providing health services to vets in rural 
areas.
    The Rural Veterans Healthcare Improvement Act also tasks the Office 
of Rural Health with following their studies own advice.
    It develops demonstration projects that would examine the 
feasibility of expanding care in rural areas through partnerships.
    Partnerships between the VA; Centers for Medicare and Medicaid 
Services; and the Department of Health and Human Services through 
critical access hospitals and community health centers.
    Demonstration projects would also be carried out in partnership 
with the Indian Health Service to improve healthcare for Native 
American veterans.
    In 2003, the VA entered into a Memorandum of Understanding with 
these departments to encourage partnerships just like these, however 4 
years have passed without accomplishment and our vets have suffered.
    Mr. Chairman . . . We must explore every option, to ensure that the 
healthcare services we promised to our veterans are delivered.
    The Rural Veterans Healthcare Improvement Act of 2007 aims to 
improve one of the greatest problems that plague the VA system.
    I am proud of the bipartisan work that has gone into this bill and 
the forty cosponsors that share these goals.
    Thank you Mr. Chairman. I'm happy to answer any questions the 
Committee might have.

                                 
                Statement of the Honorable Jeff Miller,
         a Representative in Congress from the State of Florida
    Mr. Chairman, thank you for considering H.R. 2623. This bill would 
prohibit the collection of co-payments for all hospice care furnished 
by the Department of Veterans Affairs (VA).
    VA offers a complement of hospice and palliative care options as 
part of the comprehensive heath care benefit provided to all enrolled 
veterans. Hospice and palliative care is a continuum of comfort-
oriented and supportive services provided across settings, including 
hospital, extended care facility, outpatient clinic and private 
residence.
    Under current law, a veteran receiving hospice care in a nursing 
home is exempt from any applicable copayments. However, if the hospice 
care is provided in any another setting, such as in an acute-care 
hospital or at home, the veteran may be subject to an inpatient or 
outpatient primary care copayment.
    Essentially, VA's current policy penalizes a veteran who chooses to 
remain at home for their hospice care or out of medical necessity 
receives hospice care in an acute care setting.
    Mr. Chairman, this legislation would correct this inequity by 
exempting all hospice care provided through VA from copayment 
requirements.
    This bill is important to ensuring that every veteran's preference 
for end-of-life care is provided in an equitable and compassionate 
manner.
    I appreciate the opportunity to testify on H.R. 2623, and will be 
happy to answer any questions on the bill.

                               H.R. 1925

    Thank you, Mr. Chairman.
    Nearly 12 year ago, the VA's Veterans Integrated Service Network, 
or ``VISN,'' plan was set in motion as a way to make the large VA 
healthcare network more attuned to the needs of its patients. For 
certain, VA provides some of the best care in this nation. The VISNs 
were implemented as a way to maintain the high quality of care while 
allowing more regional management so that the central office in 
Washington did not unnecessarily micromanage the day-to-day aspects of 
healthcare delivery.
    The VISN network has enjoyed its successes in providing better 
access and more patient-centered care. However, there is room for 
improvement, and the Gulf Coast region of our nation is an area where 
such improvement is needed. Having already seen a consolidation of two 
VISNs since their creation, it is clear that flexibility within the VA 
healthcare system is necessary. My bill, H.R. 1925, would create a VISN 
specifically targeted to improving the delivery of healthcare to the 
large and ever-increasing population of veterans living in the Gulf 
Coast--a ``Gulf Coast VISN.''
    A new Gulf Coast VISN would create a healthcare network that could 
better respond to the unique needs and problems facing veterans in the 
area. The area involved covers the coastal counties just west of 
Tallahassee, Florida over to the Louisiana state line, an area home to 
few VA clinics and lacking hospitals providing inpatient care. It is an 
area identified by the CARES report as underserved, and its unique 
geographical location is no doubt part of that reason. Most of the area 
that would make up the Gulf Coast VISA is in the region where VISN 
eight meets VISN 16. VISN eight encompasses the rest of the state of 
Florida. VISN 16, the largest single VISN in the country, reaches all 
the way west past Houston, Texas, and all the way up through Oklahoma.
    Looking at the map, you can see how this largely rural region can 
get overlooked in such a huge VISN with major metropolitan areas. The 
more than 300,000 veterans that would be directly served within this 
VISN do not want their access to care overlooked--and that has happened 
for far too long. With even basic outpatient care being difficult for 
many to obtain, it is time to ensure that the Gulf Coast's veterans are 
provided the full range of services they have earned.
    There are several reasons why I see this bill as being successful. 
With an increased focus on the unique, shared needs for veterans in the 
area, the Gulf Coast VISN director could take great advantage of the 
sharing opportunities with the Department of Defense (DoD) that are 
available in that region. The Gulf Coast is home to multiple DoD 
installations, and while a few joint VA/DoD facilities exist now, there 
is a tremendous opportunity for expanding this relationships to deliver 
a wider range of healthcare services.
    The VISN system was founded on good principles to improve access 
and quality of care by eliminating the inefficiencies of a centralized 
bureaucracy and promoting a local, patient-focused system of healthcare 
delivery. However, it is not perfect, and with the findings of the 
CARES Commission as well as the simple fact that veterans in the Gulf 
Coast area have to drive upward of three hours in many instances to 
receive inpatient care, it is abundantly clear that improvements are 
still needed. I feel the creation of a Gulf Coast VISN can do just 
that. Its implementation would be neither costly nor particularly 
difficult. In addition, the bill would give VA the authority to decide 
on the location of the VISN headquarters.
    The GulfCoast's veteran population clearly deserves more timely 
access to VA healthcare. Creating a Gulf Coast VISN would be a 
significant step toward providing that access.
    Thank you, Mr. Chairman, for considering this important legislation 
and I am pleased to answer any questions on the bill.
[GRAPHIC] [TIFF OMITTED] 37465A.001

[GRAPHIC] [TIFF OMITTED] 37465A.002


                                 
               Statement of the Honorable Paul W. Hodes,
      a Representative in Congress from the State of New Hampshire
    Thank you Chairman Michaud and Ranking Member Miller for holding 
this important hearing today. I appreciate the opportunity to testify 
today about H.R. 2192, the bipartisan bill I introduced establishing an 
Office of the Ombudsman in the Department of Veterans' Affairs. I would 
also like to thank Chairman Filner for his support of the bill.
    I recently visited Walter Reed Army Medical Center with the 
Oversight and Government Reform Committee. I talked with soldier after 
soldier about the problems they experienced transitioning out of active 
duty and into the VA. Veterans in my district have repeatedly told me 
their compelling stories of the great difficulties and challenges they 
have faced in understanding and receiving all the benefits and services 
to which they are entitled.
    The Ombudsman's Office should serve as the outreach master office--
a coordinating and coordinated center for benefits and health 
information services available both within and outside of the VA.
    I am not interested in creating another meaningless layer of 
bureaucracy. Instead, I would like the Ombudsman's Office to become a 
one stop shop for veterans, a CENTCOM for veterans' benefits 
information.
    I applaud the VA for their hard work in providing information that 
veterans need. The VA has numerous hotlines and support services 
available to veterans. I've counted 10 different 1-800 numbers on the 
VA's website to help with different types of benefits--one for 
disability pension, another for healthcare benefits, another for life 
insurance, etc.
    While the VA provides veterans benefits and service information, 
the veterans may not know where they put their informational pamphlets 
6 months or 1 year down the road when they have a question or a 
problem.
    Veterans are falling through the cracks and do not know where to 
turn.
    The Office of the Ombudsman would provide a focal point of 
information within the VA. The Ombudsman's Office should be a one stop 
shop of information and resources. The Office should head up the 
advocacy and information campaigns that the VA already has in place, 
and consolidate the information services with one 1-800 number to 
address all the veterans' needs and complaints.
    For a veteran who has just returned from active duty in OIF 
(Operation Iraqi Freedom) or OEF (Operation for Enduring Freedom) with 
Traumatic Brain Injury, it would be a whole lot simpler and easier to 
have only one office to call to receive the information he or she 
needs. The VA has a patient advocacy program for healthcare, but a lot 
brave men and women need help with loans for their homes and schooling 
too. They should not have to run around asking the same ten questions 
to ten different offices. The Ombudsman's Office can help the veteran 
figure out the all the services in the benefits system, not just 
healthcare, and not just disability ratings.
    I have reviewed the testimony of the esteemed panelists, the VA and 
VSOs. Just in the six testimonies that specifically discussed the 
Ombudsman's Office, the panelists referred to fourteen different 
programs both within and outside of the VA that veterans could turn to 
for help with benefits coordination. These fourteen programs are 
extremely important to our veterans and providing specialized services. 
But, as a healthy Member of Congress and not a PTSD patient or an 
ailing elderly veteran, I am even confused about which programs to use 
and under which circumstances.
    Mr. Chairman, I am not trying to make redundant services. The 
Veterans Administration provides advocacy and resources, VSOs provide 
advocacy and resources.
    I would, however, like to work with the Honorable Members of the 
Committee to mold the Office of the Ombudsman into a viable, helpful 
resource for veterans. I believe that this consolidation of various 
information sources into a coordinated center of information will help 
make sure the veterans receive the care they need and cut through the 
seemingly endless amounts of bureaucratic red tape.
    Thank you again for giving me the opportunity to testify before the 
Subcommittee on Health today. I look forward to working with the 
Committee to help veterans understand and access the benefits they 
deserve.

                                 
               Statement of the Honorable Nita M. Lowey,
        a Representative in Congress from the State of New York
    I want to thank the Committee for holding this hearing today and 
for considering the VA Hospital Quality Report Card Act of 2007. I 
introduced this legislation in an effort to provide increased 
disclosure and accountability in the VA hospital system, and ultimately 
increase the quality of care for the men and women who have served in 
the Armed Forces.
    The treatment provided to our veterans is not a partisan or 
political issue, and I am pleased that this legislation is cosponsored 
by some of my Republican colleagues.
    I believe we can all agree that quality care initiatives and public 
disclosure should not end when an individual leaves active military 
service. In fact, the quality of care for those who have bravely served 
our Nation should be of the highest standard possible.
    To achieve that goal we must have a clear picture of the quality of 
care provided by the Veterans Administration, and this information must 
be continually assessed and updated. As we learned with Walter Reed 
Army Medical Center, a facility that once defined excellence may not do 
so in the future without constant internal assessments.
    My legislation would require the Department of Veterans Affairs to 
establish a formal Hospital Report Card Initiative and publish reports 
on individual hospitals' level and quality of care. The resulting 
report cards would: provide clear outcomes data to be used for peer 
review and quality improvement; galvanize hospitals to make changes by 
creating public accountability; and provide our veterans with the 
information they need to make sound healthcare decisions. Several 
states, including Pennsylvania, New York, California, Florida and 
Illinois, have already implemented Hospital Report Card Initiatives.
    A March 2007 Veterans Administration report exposed major 
deficiencies in the physical conditions in many veterans' facilities.
    In this report, the VA Hudson Valley Health Care System, which 
serves over 25,000 veterans throughout my district and the surrounding 
areas, was cited for ceiling mold, suicide hazards in the psychiatric 
ward and cosmetic deficiencies. I'm going to repeat one part of that 
because I think it underscores the level of neglect seen throughout the 
VA healthcare system--suicide hazards in a psychiatric ward, an area in 
hospitals that most certainly should limit the ability of an individual 
to harm him or her self.
    Dr. Michael Kussman, Under Secretary for Health at the VA, 
previously stated, ``VA facilities are inspected more frequently than 
any other healthcare facilities in the nation.'' If this is true, the 
Department should have no problem complying with the requirements of 
this legislation.
    If we are serious about ensuring a seamless transition between DOD-
provided healthcare and VA-provided healthcare, we must have an 
accurate assessment of the VA system, and the VA Hospital Quality 
Report Card Act of 2007 would provide just that.
    I thank the Members of the Subcommittee once again for this hearing 
and I look forward to working with each of you to provide our veterans 
with the level of healthcare worthy of their service and dedication to 
our country.

                                 
      Statement of Shannon Middleton, Deputy Director for Health,
    Veterans Affairs and Rehabilitation Commission, American Legion
Mr. Chairman and Members of the Subcommittee:

    Thank you for this opportunity to present The American Legion's 
view on the several pieces of legislation being considered by the 
Subcommittee today. The American Legion commends the Subcommittee for 
holding a hearing to discuss these very important and timely issues.
    H.R. 1448, VA Hospital Quality Report Card Act of 2007, seeks to 
establish the Hospital Quality Report Card to ensure quality measures 
data on the Department of Veterans Affairs (VA) hospitals are readily 
available and accessible.
    The state of VA healthcare/medical facilities are an important 
issue for The American Legion. Each year the organization is mandated 
by resolution to conduct a series of site visits to various VA medical 
facilities and submit a report to the President, Congress and VA.
    The bill is similar in scope to our report--A System Worth Saving. 
Periodic assessments would enable VA to get a clearer picture of its 
system-wide needs and assist lawmakers in determining adequate funding 
for the VA healthcare system.
    H.R. 1853, Jose Medina Veterans Affairs Police Training Act of 
2007, seeks to ensure that VA police officers receive training on 
interacting with visitors and patients suffering from mental illness at 
VA medical facilities. The American Legion has no official position on 
this issue, but hopes that VA is training all of its employees to 
interact with veterans and their families in the dignified, respectable 
manner in which they deserve.
    H.R. 1925, A Bill to Direct the Secretary of Veterans Affairs to 
Establish a Seprate Veterans Intergrated Service Network (VISN) for the 
Gulf Coast Region of the United States, would mandate that the 
Secretary create a VISN that would encompass several counties in the 
states of Florida, Alabama and Mississippi. The American Legion has no 
position on this issue.
    H.R. 2005, Rural Veterans Health Care Improvement Act of 2007, 
addresses many issues affecting veterans who reside in rural areas. It 
seeks to increase the beneficiary travel rate to make it equivalent to 
the rate provided to federal employees; establish centers for rural 
health research, education, and clinical activities; offer 
transportation grants for service organizations that assist rural 
veterans; and explore alternatives to improve transportation to medical 
facilities for rural veterans. The American Legion fully supports the 
provisions in this bill.
    Beneficiary travel pay has not been increased from its current rate 
since 1978. The price of gasoline has steadily increased since the 
$0.11 per mile rate was established, creating a financial hardship for 
veterans who have to travel long distances for care, or those who have 
limited financial resources.
    Since service-connected veterans and other veterans authorized 
beneficiary travel only receive $0.11 per mile are subjected to a $6 
per trip deductible not to exceed $18 per month--this amount does very 
little to defray the cost of travel. Eligible veterans are not 
reimbursed at a reasonable level for costs incurred to visit a VA 
medical facility for service-connected or other authorized care and 
treatment.
    There are no provisions in law that VA must increase the per mile 
travel authorization on a regular basis. The beneficiary travel program 
is discretionary and the Secretary of Veterans Affairs is required to 
review the program annually to determine the Department's ability to 
maintain the program and its ability to increase the reimbursement rate 
for eligible veterans. The Secretary has determined that it is 
necessary to maintain the current reimbursement rate in order to allow 
the VA healthcare system to accommodate the increasing patient 
workload.
    The lack of a consistent and reliable mechanism to periodically 
adjust the rate authorized for beneficiary travel creates an injustice 
and an unfair economic burden for many veterans. The American Legion 
believes that mandatory funding for VA healthcare would allow the 
Secretary to provide adequate healthcare without inversely affecting 
programs designed to mitigate the cost of accessing that care.
    Establishing centers for rural health research, education, and 
clinical activities would afford VA the opportunity to build strategies 
to improve its system of care for rural veterans, as well as educate 
and train healthcare professionals on health issues prevalent in 
specific rural veteran populations.
    Offering transportation grants for veterans' service organizations 
that assist rural veterans and exploring alternatives to improve 
transportation to medical facilities for rural veterans would make 
accessing care easier for those who are not financially able to travel 
to facilities, especially those who, due to their physical condition, 
are not able to make extremely long trips in 1 day. If more 
transportation options became available, it may also improve 
coordination of care for those who have to travel distances for special 
services, especially in the unavailability of a family care giver.
    H.R. 2172, Amputee Veteran Assistance Act, would require that VA's 
orthotic-prosthetic laboratories, clinics, and prosthetists are 
certified by either the American Board for Certification in Orthotics 
and Prosthetics or the Board of Orthotics and Prosthetic Certification. 
It is The American Legion's understanding that VA's ortho-prosthetic 
labs/clinics are accredited and each has at least one orthotist that 
has certification which is how the labs were able to gain 
accreditation. The orthotists and prosthetists are being trained on 
latest prosthesis at Walter Reed, so they can be knowledgeable about 
the prosthetics being given to returning soldiers. They also 
participate in focus groups with veterans' service organizations, and 
OIF veterans. Furthermore, VA already contracts with non-Department 
entities when the medical facility is not capable of providing the 
service or the veteran lives too far away and patients are given 
information about their prosthetic choices.
    H.R. 2173, Seeks to Amend Title 38, United States Code, to 
Authorize Additional Funding for the Department of Veterans Affairs to 
Increase Capacity for Provision of Mental Health Services Through 
Contracts with Community Mental Health Centers, and for Other purposes. 
The American Legion believes that VA should contract with community 
providers only when it is unable to provide needed services to the 
veteran, if travel for the veteran would be a danger to his or her 
health, or if the veteran resides in a rural area. As long as VA 
healthcare remains discretionary, VA will always struggle to obtain 
sufficient funding to provide access to quality care for eligible 
veterans seeking care in VA facilities. Assured (mandated) funding 
would provide a method to provide dependable, stable and sustained 
funding for veterans' healthcare. The American Legion believes that 
Congress should designate assured funding for VA medical care; continue 
to provide discretionary funding, as required, to fully operate other 
programs within the Veterans Health Administration's budgetary 
jurisdiction; and provide, if necessary, supplemental appropriations 
for budgetary shortfalls in VHA's mandated and discretionary 
appropriations to meet the healthcare needs of America's veterans.
    H.R. 2192, A Bill to amend Title 38 USC, to establish an Ombudsman 
within the Department of Veterans Affairs, would designate an Ombudsman 
to serve as a liaison for veterans and their families to guarantee the 
receipt of VA healthcare and benefits. The American Legion supports the 
provisions of this bill. Establishing a point of contact to work with 
families to ensure that veterans receive all benefits, to which he or 
she is entitled, based on his or her unique situation, would reduce the 
stress and frustration associated with navigating the complex VA 
healthcare and benefits system.
    H.R. 2219, Veterans Suicide Prevention Hotline Act of 2007. The 
American Legion has no position on this issue.
    H.R. 2378, Services to Prevent Veterans Homelessness Act. This bill 
aims to establish a financial assistance program to facilitate 
supportive services for very-low income veteran families to assist them 
in ending their chronic homeless state and to prevent chronic 
homelessness.
    Enactment of this legislation will enable funding to provide much 
needed supportive services to veterans and their dependents. It takes 
into account that the VA Grant and Per Diem (GPD) program can only 
provide services to veterans and fills a much-needed gap of caring for 
their dependents..
    The American Legion fully supports this bill in its effort to 
assist homeless veterans. We applaud that the bill recognizes that 
families also suffer alongside the veteran struggling with 
homelessness.
    The American Legion supports the efforts of public and private 
sector agencies and organizations with the resources necessary to aid 
homeless veterans and their families. The American Legion supports 
proposals that will provide medical, rehabilitative and employment 
assistance to homeless veterans and their families.
    Currently, the VA has no authority to provide grant funding to 
create affordable permanent housing units for low-income veterans and 
those who have completed their transition programs. Veteran service 
providers must compete with other housing projects for limited HUD 
funding, and constantly search for additional funding sources to 
provide this housing option.
    This legislation will be in addition to the VA Grant and Per Diem 
program, but will enable the mechanism of funding supportive services 
to become more streamlined.
    Homeless veteran programs should be granted full appropriations to 
provide supportive services such as, but not limited to outreach, 
healthcare, habilitation and rehabilitation, case management, daily 
living, personal financial planning, transportation, vocational 
counseling, employment and training, and education.
    Veterans need a coordinated effort that provides secure housing and 
nutritious meals; essential physical healthcare, substance abuse 
aftercare and mental health counseling; as well as personal development 
and empowerment.
    Veterans also need job assessment, training and placement 
assistance. The American Legion believes all programs to assist 
homeless veterans must focus on helping veterans reach their highest 
level of self-management.
    The most effective programs for homeless and at-risk veterans are 
community-based, nonprofit, veteran-staffed groups. It is critical that 
community groups continue to reach out and help to provide the support, 
resources and opportunities most Americans take for granted.
    Homelessness impacts every community in the nation. Approximately 
200 community-based veterans' service organizations across the country 
have successfully reached homeless veterans through specialized 
programs. Veterans who participate in these programs have a higher 
chance of becoming productive citizens again.
    A full continuum of care--housing, employment training and 
placement, healthcare, substance abuse treatment, legal aid, and 
follow-up case management--depends on many organizations working 
together to provide services and adequate funding. The availability of 
homeless veteran services, and continued community and government 
support for them, depends on vigilant advocacy and public education 
efforts on the local, state and federal levels.
    The FY 2006 Department of Veterans Affairs Community Homelessness 
Assessment, Local Education and Networking Groups (CHALENG) report 
estimates that nearly 200,000 veterans are homeless at any point in 
time. Prior reports state that one out of every three homeless men 
sleeping in a doorway, alley or box in our cities and rural communities 
has put on a uniform and served this country. According to the February 
2007 Homeless Assessment Report to Congress (U.S. Department of Housing 
and Urban Development 2007) veterans account for 19% of all homeless 
people in America.
    For FY 2006, The VA Health Care for Homeless Veterans (HCHV) 
reports that 101,182 homeless veterans are enrolled in their programs. 
Community-based organizations are attempting to assist the overwhelming 
remainder of veterans who are homeless.
    In addition to the complex set of factors affecting all 
homelessness (the extreme shortage of affordable housing, livable 
income, and access to healthcare), a large number of displaced and at-
risk veterans live with lingering effects of Post Traumatic Stress 
Disorder (PTSD), substance abuse, and a lack of family and social 
support networks. Many times these veterans have mental health 
disorders related to their honorable service to their country, are 
unable to compensate for their condition. They unfortunately 
deteriorate to unrecognizable individuals compared to their pre-
military experience.
    Operation Iraq Freedom and Operation Enduring Freedom (OIF/OEF) 
veterans are at high risk of becoming homeless. Combat veterans of OIF/
OEF and the Global War on Terror who need help--from mental health 
programs to housing, employment training and job placement assistance--
are beginning to trickle into the nation's community-based homeless 
veterans' service organizations. Already stressed by an increasing need 
for assistance by post-Vietnam Era veterans and strained budgets, 
homeless services providers are deeply concerned about the inevitable 
rising tide of combat veterans who will soon be requesting their 
support.
    Since 9/11, nearly 800,000 American men and women have served or 
are serving in a war zone. Rotations of troops returning home from Iraq 
are now a common occurrence. Military analysts and government sources 
say the deployments and repatriation of combat veterans is unlike 
anything the nation has experienced since the end of the Vietnam War.
    The signs of an impending crisis are clearly seen in VA's own 
numbers. Under considerable pressure to stretch dollars, VA estimates 
it can provide assistance to about 100,000 homeless veterans each year, 
only 20% of the more than 500,000 who will need supportive services. 
Hundreds of community-based organizations nationwide struggle to 
provide assistance to as many of the other 80% as possible, but the 
need far exceeds available resources.
    VA's HCHV reports 1,049 OIF/OEF era homeless veterans with an 
average age of 33 years young. HCHV further reports that nearly 65% of 
these homeless veterans experienced combat. Now receiving combat 
veterans from Iraq and Afghanistan daily, the VA is reporting that a 
high percentage of those casualties need treatment for mental health 
problems. That is consistent with studies conducted by VA and other 
agencies that conclude anywhere from 15 to more than 35% of combat 
veterans will experience some clinical degree of PTSD, depression or 
other psychosocial problems.
    Homeless veteran service providers' clients have historically been 
almost exclusively male. That is changing as more women veterans and 
women veterans with young children have sought help. Additionally, the 
approximately 200,000 female Iraq veterans are isolated during and 
after deployment making it difficult to find gender-specific peer-based 
support. Access to gender-appropriate care for these veterans is 
essential.
    More women are engaging in combat roles in Iraq where there are no 
traditional frontlines. In the past 10 years, the number of homeless 
women veteran has tripled. In 2002,the VA began a study of women and 
PTSD. The study includes subjects whose PTSD resulted from stressors 
that were both military and non-military in nature. Preliminary 
research shows that women currently serving have much higher exposure 
to traumatic experiences, rape and assault prior to joining the 
military. Other reports show extremely high rates of sexual trauma 
while women are in the service (20-40%). Repeated exposure to traumatic 
stressors increases the likelihood of PTSD. Researchers also suspect 
that many women join the military, at least in part, to get away from 
abusive environments. Like the young veterans, these women may have no 
safe supportive environment to return to, adding yet more risk of 
homeless outcomes.
    ``Homeless providers continue to report increases in the number of 
homeless veterans with families (i.e., dependent children) being served 
at their programs. Ninety-four sites (68 percent of all sites) reported 
a total of 989 homeless veteran families seen with Los Angeles seeing 
the most families (156). This was a 10-percent increase over the 
previous year of 896 reported families. Homeless veterans with 
dependents present a challenge to VA homeless programs. Many VA housing 
programs are veteran-specific. VA homeless workers must often find 
other community housing resources to place the entire family--or the 
dependent children separately. Separating family members can create 
hardship.'' (FY 2006 VA CHALENG report)
    Homeless veteran service providers recognize that they will have to 
accommodate the needs of the changing homeless veteran population, 
including increasing numbers of women and veterans with dependents. In 
conclusion, The American Legion supports the provisions in H.R. 2378 
which will be helpful in addressing the issues of homeless veterans.
    H.R. 2623, Seeks to amend title 38, United States Code, to prohibit 
the collection of copayments for all hospice care furnished by the 
Department of Veterans Affairs. The American Legion is continuing to 
study the bill and will provide an addendum to this testimony to the 
Committee.
    Again, thank you Mr. Chairman for giving The American Legion this 
opportunity to present its views on such important issues. We look 
forward to working with the Subcommittee to address these and other 
issues affecting veterans.

                                 
                  Statement of Kimo S. Hollingsworth,
       National Legislative Director, American Veterans (AMVETS)
    Mr. Chairman and Members of the Subcommittee:
    I am pleased to offer testimony on behalf of American Veterans 
(AMVETS) regarding pending health legislation before this Subcommittee. 
AMVETS appreciates the Subcommittee's work to ensure the Department of 
Veterans Affairs can fulfill its obligation to provide healthcare and 
other health related services to veterans.
    Mr. Chairman, some of the issues relevant to today's hearing are 
extremely important to returning veterans from Operations Iraqi Freedom 
and Enduring Freedom. Specifically, suicide prevention, mental health 
funding, and access to healthcare in rural or underserved areas. These 
issues were identified and highlighted at the AMVETS sponsored 
``National Symposium for the Needs of Young Veterans'' in Chicago, 
Illinois last year. More than 500 veterans, active duty and National 
Guard and reserve personnel, family members and others who care for 
veterans examined the growing needs of our returning veterans. With 
regards to today's legislative agenda, AMVETS would like to offer the 
following observations.
    H.R. 1448 would establish a Hospital Quality Report Card Initiative 
in order to report on healthcare quality in the Department of Veterans 
Affairs Hospitals. The Government Performance and Results Act, Public 
Law 103-62, requires that agencies develop measurable performance goals 
and report results against these goals. In the President's Fiscal Year 
2008 budget request, VA focuses on the Secretary of Veterans Affairs 
priority of providing timely and accessible healthcare that sets a 
national standard of excellence for the healthcare industry. VA 
generally tracks the timeliness of care in two broad areas--primary and 
specialty clinic appointments. Over the next year, the percent of 
appointments scheduled within 30 days of the desired date is expected 
to reach 96% for primary care appointments and 95% for specialty care 
appointments.
    In July 2005, the VA Office of Inspector General (OIG) reported 
that VHA's scheduling procedures needed to be improved and issued eight 
recommendations. As of September 2006, five of the eight 
recommendations for improvement remained open and AMVETS encourages the 
Department to implement the remaining recommendations. The Department 
has tracked and monitored the quality of care at VA facilities since 
the early seventies through comprehensive quality management (QM) 
programs. Furthermore, Public Laws 99-166 and 100-322 require the VA 
OIG to oversee VA QM programs at every level and a large part of the VA 
Office of Inspector General Combined Assessment Program (CAP) reviews 
focus on quality, safety and timeliness of VA healthcare. Mr. Chairman, 
AMVETS supports efforts to improve VA healthcare and supports the 
intent of H.R. 1448. However, we believe this legislation would mandate 
a duplicative effort as many of the items to be reported in a report 
card are already reviewed and reported through the VA QM and CAP 
programs.
    H.R. 1853 would direct the Secretary to ensure the Department of 
Veterans Affairs police officers receive training to interact with 
visitors and patients at medical facilities who are suffering from 
mental illness. VA police officers already receive some degree of 
training in interacting with individuals with potential mental 
illnesses and mandating this training will codify an existing practice. 
AMVETS supports the intent of the bill.
    H.R. 1925 would direct the Secretary of Veterans Affairs to 
establish a separate Veterans Integrated Service Network (VISN) for the 
Gulf Coast Region of the United States. Mr. Chairman, Public Law 104-
204 directed VA to implement a more equitable resource allocation 
system that was to reflect, to the maximum extent possible, the 
Veterans Integrated Services Network developed by the Department to 
account for forecasts in expected workload and to ensure fairness to 
facilities that provide cost-efficient healthcare; and . . . ways to 
improve the allocation of resources so as to promote efficient use of 
resources and provisions of quality healthcare . . . Obviously the 
Veterans Equitable Resource Allocation (VERA) model is designed to 
bring consistency, fairness and stability to the VA funding process. 
This in turn is dependent upon the VISN model.
    The Capital Asset Realignment for Enhanced Services (CARES) was 
supposed to be a system-wide process to prepare the VA for meeting the 
current and future healthcare needs of veterans. CARES addressed the 
appropriate clinical role of small facilities, vacant space, the 
potential for enhanced use leases and the consolidation of services and 
campuses. To date, it is the most comprehensive analysis of VA's 
healthcare infrastructure conducted. The CARES made some very specific 
recommendations with regards to healthcare infrastructure, to include 
areas of the Florida Panhandle and the Gulf Coast.
    Overall, AMVETS supported the CARES process and we believe Congress 
should consider the CARES recommendations in deliberations about VA 
infrastructure to include deliberations about the current VISN model. 
AMVETS would like to note that VA adopted the VISN model in 1995. 
Considerable time has elapsed since implementation of the VISN model 
and there clearly have been demographic changes within the general 
population that would most likely include changes to the veteran 
population.
    H.R. 2005 would seek to improve healthcare for veterans living in 
rural areas, to include providing an increase in the travel 
reimbursement and establishing centers of excellence for rural health 
research, education and clinical activities. AMVETS continues to 
support an increase to the travel reimbursement rate for our veterans. 
The VA beneficiary travel program was intended by Congress to assist 
veterans when trying to access VA healthcare. The mileage reimbursement 
rate is currently fixed at 11 cents per mile; however, current law 
limits the actual reimbursement with a $3.00 per trip deductible capped 
at $18.00 per month. The Secretary of Veterans Affairs has the 
authority to make rate changes to these rates, but changes have not 
been adopted in more than 30 years. Obviously the price of owning and 
operating a vehicle has risen dramatically during this time period. 
AMVETS believes it is now time for Congress to act by mandating a 
realistic reimbursement rate for the VA beneficiary travel program.
    Regarding the delivery of rural healthcare, an important issue 
brought forth at the ``National Symposium for the Needs of Young 
Veterans'', Sections 212 and 213 of Public Law 109-461 are specifically 
targeted at advancing the healthcare needs of veterans in rural areas. 
VA is mandated to establish an Office of Rural Health within the 
Veterans Health Administration (VHA). The office is charged with 
improving VA healthcare for veterans living in rural and remote areas. 
Among other provisions, the law requires an extensive assessment of the 
existing VA fee-basis system of private healthcare, and eventual 
development of a VA plan to improve access and quality of care for 
enrolled veterans who live in rural areas. AMVETS would encourage 
Congress to fully fund the Office of Rural Health and allow VA to 
conduct the mandated assessment.
    H.R. 2172 would require VA orthotic-prosthetic laboratories, 
clinics and prosthesists to be certified by either the American Board 
for Certification in Orthotics and Prosthetics or the Board of 
Orthotics and Prosthetic Certification. Mr. Chairman, the VA already 
receives certification from these agencies and we support the 
certification process. AMVETS does have concern with the section of the 
bill that would require the VA to enter into contracts for service and 
repair of prosthetic devices with non-department entities. This 
provision would create a ``sole-source'' contract, and AMVETS would 
oppose this provision.
    H.R. 2173 would authorize additional funding to allow VA to enter 
into contracts with local or community health centers. Mr. Chairman, as 
we are all aware, there is a large number of National Guard and reserve 
units that have deployed or will be deployed into a theater of combat 
operations. Many of these units and personnel are from areas of the 
country that do not have VA healthcare or VA healthcare services 
readily available. AMVETS continues to support the Secretary of 
Veterans Affairs in his authority to contract out for medical and 
healthcare services when/where applicable and also supports additional 
funding for these services.
    H.R. 2192 would establish an Ombudsman within the Department of 
Veterans Affairs to act as a liaison for veterans and their families 
with respect to the receipt of healthcare and benefits administration. 
The VA has a long history of special efforts to bring information on VA 
benefits and services to active duty military personnel. These efforts 
include counseling about VA benefits through the Transition Assistance 
Program (TAP), a nationally coordinated federal effort to assist 
military men and women to ease the transition to civilian life through 
employment and job training assistance. A second component of the 
program, the Disabled Transition Assistance Program (DTAP), helps 
separating servicemembers with disabilities.
    VA also has launched special efforts to provide a ``seamless 
transition'' for those returning from service in Operations Iraqi 
Freedom and Enduring Freedom. Internal coordination was improved and 
efforts currently focus on reducing red tape and streamlining access to 
all VA benefits. Each VA medical facility and benefits regional office 
has identified a point of contact to coordinate activities locally to 
help meet the needs of these returning combat servicemembers and 
veterans. In addition, VA increased the staffing of benefits counselors 
at key military hospitals where severely wounded servicemembers from 
Iraq and Afghanistan are frequently sent. AMVETS does not oppose 
legislation to establish an Ombudsman within the VA.
    H.R. 2219 would direct the Secretary to award a grant to a private, 
nonprofit entity to establish, publicize and operate a national toll-
free suicide prevention telephone hotline targeted to and staffed by 
veterans of the Armed Forces. Mr. Chairman, the Department of Veterans 
Affairs Office of Inspector General recently reported that veterans 
returning from Iraq and Afghanistan are at increased risk of suicide 
because Veterans Administration health clinics do not have 24-hour 
mental healthcare available. Many facilities lack 24-hour staff, 
adequate screening for mental problems, or personnel who were properly 
trained.
    The report also concluded that VA clinics and military hospitals 
must improve their sharing of health information, particularly for 
patients who might return to active-duty status and that VA should 
loosen criteria for inpatient PTSD care. Currently only veterans with 
``sustained sobriety'' get treatment. It is AVMETS' understanding that 
the VA Undersecretary for Health, concurs with findings and 
recommendations, and that VA has recently installed suicide prevention 
coordinators in each medical center to better develop prevention 
strategies. AMVETS supports the Undersecretary in this endeavor; 
however, AMVETS would oppose efforts by Congress to mandate the 
Secretary of VA to enter into contracts with a private entity for these 
services and believes that the Secretary must continue to have 
flexibility in how he implements these services.
    H.R. 2378 would establish a financial assistance program to 
facilitate the provision of supportive services for very low-income 
veteran families in permanent housing. We continue to urge Congress to 
provide resources and oversight on homeless veterans programs and 
veterans who may be at risk. With regards to the establishment of a 
financial assistance program for very low-income veterans, AVMETS would 
urge Congress to provide veterans priority assistance through the 
Department of Health and Human Services as opposed to creating a new 
program within the Department of Veterans Affairs.
    Mr. Chairman, this concludes my testimony.

                                 
                    Statement of Adrian M. Atizado,
  Assistant National Legislative Director, Disabled American Veterans
    Mr. Chairman, Ranking Member Miller and other Members of the 
Subcommittee:
    Thank you for inviting the Disabled American Veterans (DAV) to 
testify at this important legislative hearing of the Subcommittee on 
Health of the Committee on Veterans' Affairs. DAV is an organization of 
1.4 million service-disabled veterans, and along with its auxiliary, 
devotes its energies to rebuilding the lives of disabled veterans and 
their families.
    You have requested testimony today on ten bills primarily focused 
on healthcare services for veterans under the jurisdiction of the 
Veterans Health Administration (VHA), Department of Veterans Affairs 
(VA). Your staff indicated two additional draft bills would be 
considered but we did not receive those two bills in time to include 
them in this testimony. With exception to the aforementioned draft 
legislation, this statement outlines our positions on all of the 
proposals before you today. The comments are expressed in numerical 
sequence of the bills, and we offer them for your consideration.
H.R. 1448--The VA Hospital Quality Report Card Act of 2007
    H.R. 1448 would establish a ``hospital report card'' covering a 
variety of activities of inpatient hospital care occurring in the 
medical centers of the Department. We support this bill, because it is 
consistent with trends occurring in private sector healthcare. We 
believe that veterans under VA care have the same rights as private 
sector patients to review the quality and safety of the care they 
receive while hospitalized. We do note, however, that the purposes of 
this bill do not cover the grand majority of overall patient care 
workload in VA healthcare, namely primary (outpatient) care and 
extended care services provided in VA's nursing home care units and its 
various contracted programs. Nevertheless, this is a good bill and one 
that is supported by DAV. We do note for the Committee's purposes, that 
the term ``VA hospital'' was supplanted by the term ``VA medical 
center'' in prior legislation. You may wish to consider conforming this 
bill accordingly, should the Committee decide to approve and report it.
H.R. 1853--The Jose Medina Veterans Affairs Police Training Act of 2007
    H.R. 1853 would require the Secretary of Veterans Affairs to ensure 
that officers of the VA police service be trained with respect to 
officers' interactions with veterans possibly suffering from mental 
illnesses. While DAV does not have a resolution dealing with this 
issue, we consulted with the National Alliance for Mental Illness 
(NAMI) and its NAMI Veterans Council, an advocacy group that, like DAV, 
is deeply concerned about VA mental health programs and veterans who 
benefit from them. NAMI fully supports the concept of adequate training 
being provided to VA police, who are sworn federal police officers 
charged with providing physical and personal security at all VA 
healthcare facilities. We concur with NAMI's views on this issue. We 
would suggest that the bill be amended, however, to ensure that 
properly credentialed mental health practitioners (principally those 
whom VA employs within the VHA to care for veterans with mental 
illnesses) be designated as training resources for the purposes of this 
bill.
H.R. 1925--To direct the Secretary of Veterans Affairs to establish a 
        separate Veterans Integrated Service Network for the Gulf Coast 
        region of the United States
    H.R. 1925 would establish a 22nd Veterans Integrated Service 
Network (VISN) in the western Panhandle of Florida, far south Alabama, 
and eastern Mississippi, within 1 year of date of enactment.
    DAV does not have a resolution from our membership addressing this 
issue. It should be noted however, that the bill raises valid questions 
on the relevance and effectiveness of current VISN boundary alignments. 
These VA jurisdictional lines have been in place with only one 
adjustment for the past 12 years. These boundaries were generally 
formed based on veteran patient care referral patterns established in 
the eighties, and it should be recalled that VA has revolutionized its 
patient care system over the past dozen years.
    It is unclear if VA has reviewed whether the current alignment is 
optimal or may need adjustment. Also, it should be noted that some 
parts of the geographic area encompassed by the bill's intent is still 
in transition in terms of VA physical assets, with no major affiliated 
VA medical centers and only one significant VA facility in Florida, the 
Pensacola Outpatient Clinic, one in Alabama, the Mobile Outpatient 
Clinic and one Mississippi VA medical center, in Jackson. Distances and 
access to these facilities is challenging for the veterans of the 
region, especially for specialized VA services that had generally been 
provided by the New Orleans, Louisiana VA facility until Hurricane 
Katrina destroyed it in 2005. It is also important to note that the 
Florida Panhandle area is not a part of VISN eight, constituting the 
remainder of the State of Florida excepting a few counties along its 
northern border. With most of this area now embedded within VISN 16, 
the VA system's largest VISN (encompassing parts of eight States), the 
proponent of this bill makes a valid argument that perhaps a new 
alignment is in order.
H.R. 2005--Rural Veterans Health Care Improvement Act of 2007
    Section 2 of this bill would improve reimbursement rates for 
veterans for their travel expenses related to VA medical care. It would 
reimburse veterans at the same rate paid to federal employees, by 
increasing it from 11 cents per mile to 48.5 cents per mile.
    For several years, we have urged VA to correct the inequity in its 
travel reimbursement program and include a line item in the budget to 
make a fair adjustment in travel pay while retaining sufficient funding 
for direct medical care. Given the cost of transportation in 2007, 
including record-setting gasoline prices, a reimbursement rate 
unchanged since 1977 pales in comparison to the actual cost of travel. 
Adequate travel expense reimbursement is directly tied to access to 
care for many veterans and not a luxury.
    The VA beneficiary travel program is intended by Congress to assist 
veterans in need of VA healthcare to gain access to that care. While 
the mileage reimbursement rate is currently fixed, actual reimbursement 
is limited by law with a $3.00 per trip deductible capped at $18.00 per 
month. The mileage reimbursement rate has not been changed in almost 30 
years, even though the VA Secretary is delegated authority by Congress 
to make rate changes when warranted. The law also requires the 
Secretary to make periodic assessments of the need to authorize changes 
to that rate. Unfortunately, no Secretary has acted to make those 
changes, despite the obvious need to update the rate of reimbursement 
to reflect rises in travel and transportation costs.
     DAV Resolution No. 212 is a longstanding resolution supporting 
repeal of the beneficiary travel pay deductible for service-connected 
veterans and to increase travel reimbursement rates for all veterans 
who are eligible for reimbursement. Additionally, we support 
legislation that has been introduced in Congress to repeal the 
mandatory deductible and increase the rate veterans are reimbursed for 
their authorized travel to and from VA services. We believe the House 
and Senate bills titled the ``Veterans Travel Fairness Act,'' offer a 
fair and equitable resolution to this situation which we have been 
concerned for many years. We urge this Subcommittee to approve and 
enact legislation this year to reform the VA beneficiary travel 
program.
    Section 4 of this measure would establish a grant program to 
provide innovative transportation options to veterans in remote rural 
areas. The bill tasks the Director of VA's Office of Rural Health to 
create a program that would provide grants of up to $50,000 to 
veterans' service organizations and State veterans' service officers to 
assist veterans with travel to VA medical centers and to improve 
healthcare access in remote rural areas. The bill authorizes $3 million 
per year for the grant program through 2010.
    In 1987, the DAV, in coordination with VA's Voluntary Service 
program, began buying and donating vans to VA for the purpose of 
transporting veterans to receive VA medical care. Since that time, the 
DAV National Transportation Network has become a very significant and 
successful partnership between VA and DAV. We have donated 1,959 vans 
to VA facilities at a cost exceeding $39 million. Since its inception, 
these vans, their DAV volunteer drivers and medical center volunteer 
transportation coordinators have transported more than 10 million 
veterans over 397 million miles. We plan to continue and enhance this 
program, not only because the VA beneficiary travel rate is so low, but 
also we have found our transportation network serves as a truly vital 
link between rural veterans and crucial VA healthcare. Its absence 
would equate to the actual denial of care for eligible veterans because 
many of them have no means to substitute. Although as an organization, 
the DAV does not accept federal funds such as the grant program; 
however, knowing first hand the value and effectiveness of such a 
program, we would not oppose this section of the bill.
    Section 3 of this bill would establish at least one and no more 
than five Centers of Excellence to research ways to improve care for 
rural veterans. The centers would be based at VA medical centers with 
strong academic connections. The Office of Rural Health would establish 
between one and five centers across the country with the advice of an 
advisory panel.
    Existing VA research, education clinical centers, and various 
centers of excellence have proven to be a valuable resource to educate 
sick and disabled veterans as well as VA healthcare providers on new 
and effective treatment regimes. We are hopeful the proposed Rural 
Health Research, Education and Clinical Care Centers will strive to 
strike the balance we seek when providing better outreach and high 
quality VA medical care to veterans residing in rural and remote areas.
    To examine alternatives for expanding care for rural veterans, 
section 5 of this measure would require the VA to conduct demonstration 
projects through the recently created VA Office of Rural Health to 
establish partnerships between the VA, Centers for Medicare and 
Medicaid Services, and the Department of Health and Human Services to 
coordinate care in critical access hospitals and community health 
centers. In addition, VA would be required to expand coordination with 
Indian Health Service for Native American veterans, and a report to 
Congress on these test projects would be due in 2 years.
    While these initiatives are laudable, we recommend the VA office of 
Rural Health be given ample opportunity to discharge the 
responsibilities specified by Congress in Public Law 109-461 which 
would include developing, refining, and promulgating policies, best 
practices, lessons learned, and innovative and successful programs to 
improve care and services for veterans who reside in rural areas of the 
United States. In addition, we urge this Subcommittee to provide 
oversight and urge the Department of proceed with expeditious 
implementation by the Department.
H.R. 2172--The Amputee Veteran Assistance Act
    This measure seeks to improve VA's prosthetics programs by 
requiring all VA orthotic/prosthetic laboratories and clinics to be 
certified by either of the two leading boards in these fields, the 
American Board for Certification in Orthotics and Prosthetics or the 
Board of Orthotics and Prosthetic Certification, within 5 years of the 
enactment of this bill, and allow disabled veterans to obtain new 
devices and seek care for the repair and servicing of their existing 
prosthetic devices from outside the VA system when VA facilities are 
unable to perform the required service or repairs due to a lack of 
technology or capability or when a suitable VA facility is not within a 
55 mile radius.
    The bill would also require a complete review and a report to 
Congress by VA of its prosthetic laboratories and clinics to determine 
the need to modernize such facilities to ensure that the VA is capable 
of servicing and repairing the most technologically advanced prosthetic 
devices. Also, VA would be required to complete a review and a report 
to Congress on VA prosthesists to determine what kinds of training and 
education will be needed to ensure that its prosthesists have the 
required knowledge to service and repair the latest prosthetic devices.
    The DAV agrees that the Department's prosthetics program should be 
able to provide all necessary prosthetic services, devices, and 
supplies for the proper treatment of service-connected disabled 
veterans. We believe much of the bill's requirements are already being 
addressed and implemented by VA. We are concerned however, with the 
bill's requirement for VA to enter into one contract with one non-VA 
entity to repair and service prosthetic devices in certain 
circumstances. In addition to the arbitrary nature of a 55-mile radius 
as a requirement to contract for the service and repair of prosthetic 
devices, VA currently utilizes numerous service and repair contractors 
to allow a more personalized and convenient care to veteran in need of 
prosthetic and orthotic devices.
H.R. 2173--To amend title 38, United States Code, to authorize 
        additional funding for the Department of Veterans Affairs to 
        increase the capacity for provision of mental health services 
        through contracts with community mental health centers, and for 
        other purposes
    This measure would allow the VA to provide mental health services 
through contracts with community mental health centers, and authorizes 
appropriations of $150 million from fiscal years 2008 through 2010 for 
such contracts.
    First and foremost, DAV's position on contracted or fee-based care 
is well known. We believe that VA purchased care is an essential tool 
in providing timely access to quality medical care. Current law limits 
the indiscriminant use of VA purchased care to specific instances so as 
not to endanger VA facilities' ability to maintain a full range of 
specialized inpatient services for all enrolled veterans and to promote 
effective, high quality care for veterans, especially those disabled in 
military service and those with highly sophisticated health problems 
such as blindness, amputations, spinal cord injury or chronic mental 
health problems.
    Second, as VA's contract workloads have grown significantly at a 
cost of about $3 billion each year, it has not been able to monitor 
this care, consider its relative costs, analyze patient care outcomes, 
or even establish patient satisfaction measures for most contract 
providers. This measure does not include provisions to address our 
concerns that VA has no systematic process for contracted care services 
to ensure that:

      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.

    Any bill seeking to contract for care outside VA without addressing 
these concerns would essentially shift medical resources and veterans 
from VA to the private sector to the detriment of the VA healthcare 
system and eventually sick and disabled veterans themselves. VA 
operates under constant pressure to do more with less and we believe 
the expansion of the current form of VA contracted care would benefit 
some veterans at the cost of eroding VHA's patient resource base, 
undermine the Department's ability to maintain its specialized service 
programs, and endanger the well-being of veteran patients under care 
within the system.
    We are concerned that this bill does not provide any consideration 
for judicious use of contract care nor does it address our concerns 
regarding the lack of a systematic process for contract care. Such a 
measure could place at risk VA's well recognized qualities as a 
renowned and comprehensive direct provider of healthcare.
H.R. 2192--To amend title 38, United States Code, to establish an 
        Ombudsman within the Department of Veterans Affairs
    This measure would require VA to assign an Ombudsman to act as a 
liaison for veterans and their family members to navigate the VA 
healthcare and benefits system. We appreciate the intent of this bill; 
however, we believe VA has taken actions to address these issues by 
providing assistance and outreach to newly returning veterans through a 
cadre of case managers, transition patient advocates, patient 
representatives, peer counselors, suicide prevention coordinators, and 
other special purpose assistance to guide veterans through the VA 
healthcare benefit systems.
    VA's actions noted above raise questions concerning the purposes of 
the proposed Office of the Ombudsman, given the fact that some of these 
positions have only recently been filled or that VA is in the midst of 
recruiting or training personnel to fill these positions. We urge the 
Subcommittee to provide oversight on the effectiveness of these new 
programs before authorizing the additional Office as proposed by this 
legislation.
H.R. 2219--Veterans Suicide Prevention Hotline Act of 2007
    This measure would require the VA to award a grant to a private, 
nonprofit entity to establish and operate a national toll-free suicide 
prevention hotline. It would establish a 3-year authority for this 
program, at a cost of $7.5 million, to be paid from VA's Medial 
Services Appropriation.
    There is already in existence a federally funded 24-hour, toll-free 
suicide prevention service comprised of over 120 individual crisis 
centers across the country. This service is available to all persons in 
need or in suicidal crisis. Individuals seeking help can call the 
National Suicide Prevention Lifeline (NSPL) at 1-800-273-TALK (8255). 
From the toll free number, they will be seamlessly routed to the 
certified provider of mental health and suicide prevention services 
nearest to the call of origination.
    We agree with testimony provided by Mr. Jerry Reed, Executive 
Director of Suicide Prevention Action Network USA (SPAN USA), before 
the Senate Committee on Veterans' Affairs on May 23, 2007, that we 
could build upon what Congress has already funded with the NSPL.
    As it was pointed out during that hearing, once a veteran in need 
calls the number, an option could be provided for that veteran to be 
transferred to a VA call center if the individual wants the services 
and support of the VHA. We also agree that the VA should be providing 
up-to-date information to non-VA crisis centers on all VA suicide 
prevention counselors, hospitals, medical centers, outpatient clinics, 
and peer support groups and, where appropriate, this national network 
of crisis centers should reliably transfer cases to the VHA call 
center. It is our understanding that VHA's mental health program office 
is discussing the possibility of joining the existing system rather 
than mounting an independent VA suicide prevention service. We concur 
with that concept and urge VA to move forward in lieu of Congress 
passing this bill.
H.R. 2378--Services to Prevent Veterans Homelessness Act
    This bill would direct the VA to provide financial assistance for 
supportive services for very low-income veterans' families in permanent 
housing. Under the bill VA would provide grants to certain eligible 
entities such as private nonprofit organizations or consumer 
cooperatives to provide various supportive services.
    The DAV supports the intent of the bill to better address homeless 
veterans' needs, and to help them move toward independent living. 
Furthermore, unlike the companion bill in the Senate, this measure 
authorizes appropriation and does not divert resources from VA's 
medical care account. However, as well-intentioned as this measure may 
be, we are concerned that a grant under which healthcare and counseling 
services would be provided by private providers versus VA providers 
raises questions about cost, quality, continuity and safety similar to 
our views on other proposals with these goals.
H.R. 2623--To amend title 38, United States Code, to prohibit the 
        collection of copayments for all hospice care funished by the 
        Department of Veterans Affairs
    VA is the only public healthcare system that charges copayments to 
hospice patients, and the DAV is greatly concerned particularly as the 
number of veteran deaths has been increasing to a current average of 
1,800 per day. Congress initially addressed this issue, but only to a 
limited extent. section 204 of Public Law 108-422, the Veterans Health 
Programs Improvement Act of 2004, exempted veterans who receive hospice 
care from the requirement to pay copayments, but only if the hospice 
care were being provided at a nursing home.
    The DAV recommends the fulfillment of Congress's original intent in 
Public Law 108-422 by exempting veterans from paying copayments when 
they receive VA hospice care in any authorized setting. We thank 
Ranking Member Miller for introducing this measure and Chairman Michaud 
for including it in today's hearing, which seeks to prohibit the 
collection of copayments for all hospice care furnished by the VA.
    Veterans are subject to inpatient copayments if they seek inpatient 
hospice care at facilities without nursing home beds, or if the hospice 
care must be provided in an acute care setting as a result of clinical 
complexity. Moreover, veterans choosing to remain at home for their 
hospice care are subject to outpatient primary care copayments. While 
the DAV supports H.R. 2623, we recommend that its scope be broadened to 
include exempting veterans from copayments for hospice care provided in 
any treatment setting by amending section 1710 of Title 38 United 
States Code.
    Mr. Chairman, again, the members and auxiliary of DAV appreciate 
being represented at this hearing today, and I appreciate being asked 
to testify on these bills. Mr. Chairman, this concludes my testimony. I 
and other members of the DAV Legislative Staff will be pleased to make 
ourselves available to you and your staffs for further discussion of 
our positions on any of these issues, in hopes of working toward 
compromise on measures that we can eventually support. I will be 
pleased to respond to any of your or other Committee Members' 
questions.

                                 
             Statement of Carl Blake, National Legislative
                Director, Paralyzed Veterans of America
    Mr. Chairman and members of the Subcommittee, on behalf of 
Paralyzed Veterans of America (PVA), I would like to thank you for the 
opportunity to testify today regarding the proposed legislation. We 
appreciate the fact that you continue to address the broadest range of 
healthcare issues possible to best benefit veterans. We particularly 
support any focus placed on meeting the complex needs of the newest 
generation of veterans, even as we continue to improve services for 
those who have served in the past.

         H.R. 1448, THE ``VA HOSPITAL QUALITY REPORT CARD ACT''

    Although PVA has no objection to the requirements for a Hospital 
Quality Report Card Initiative outlined in this legislation, we remain 
concerned that this wealth of information will go unused. Collecting 
this information and assessing it without acting on any findings from 
that information would serve no real purpose. We would hope that the 
congressional committees will use this information published in these 
reports each year to affect positive change within the VA. However, we 
must emphasize that additional resources should be provided to allow 
the VA to properly compile this information as we believe that this 
could be a major undertaking.

  H.R. 1853, THE ``JOSE MEDINA VETERANS AFFAIRS POLICE TRAINING ACT''

    PVA supports H.R. 1853, the ``Jose Medina Veterans Affairs Police 
Training Act of 2007.'' H.R. 1853 will compliment the training that is 
currently in place for VA police officers. Some of the current 
personnel in the VA police force nationwide may have little or no 
specific training to work with emotionally distressed veterans. A 
majority of VA officers must deal with veterans with various degrees of 
emotional problems. In conversations with some of the VA officers at 
the VA Headquarters here in Washington, D.C., they have informed us 
that they have been told to be ready to deal with the large number of 
new veterans returning from the Iraq and Afghanistan war who may have 
significant mental health problems.
    The current style of conduct as a VA officer is considered 
``situational enforcement''. While regular law enforcement officers 
take action upon a violation of the law, VA police officers evaluate a 
given situation to determine if the situation presents a danger to 
veterans, medical staff, other individuals, or the officer. If the 
situation is or could become harmful to individuals who are present, or 
to government property, the VA officer then takes action.
    All new officers receive initial training at the VA police officers 
training academy. After that training any future training is at the 
discretion of the Chief of Police at each VA location. The Chief will 
decide what training is required and how much training each officer 
receives. One VA Chief we spoke with told us that his officers receive 
training primarily on how to handle veterans age 60 to 70, as that is 
the age group of most veterans that they see at the VA medical center.
    PVA believes that VA police officers across the system should have 
mandatory, standardized, training to help them address the new 
challenge of dealing with the newest generation of veterans, along with 
the older veteran population. This bill would certainly support this 
idea ensuring that specific training to help VA police officers 
understand how to best handle the new Iraq and Afghanistan veterans and 
how to accommodate them as they come to the VA for services.

             H.R. 1925 (New VISN in the Gulf Coast Region)

    PVA opposes H.R. 1925, a bill that would establish a new Veterans 
Integrated Service Network (VISN) in the Gulf Coast region. This would 
encompass counties in Florida, Alabama, and Mississippi. PVA has 
serious concerns about the precedent that this legislation would set. 
The VA currently uses the VISN structure as a management tool for the 
entire VA healthcare system. It makes no sense for the Congress to 
legislate how the VA should manage its system. Furthermore, this sets a 
dangerous precedent whereby any member could decide that a VISN, or 
some similar network structure, should be redrawn in such a way to 
support his or her own district.
    However, we certainly believe that the current network alignment 
could be reassessed and possibly realigned. There is certainly nothing 
that suggests that 21 service networks is the optimal structure. But 
where does the VA draw the line when establishing its healthcare system 
structure? With the current 21 VISN's, the VA seems to do a good job of 
managing a massive healthcare system.

     H.R. 2005, THE ``RURAL VETERANS HEALTH CARE IMPROVEMENT ACT''

    PVA generally supports H.R. 2005, the ``Rural Veterans Health Care 
Improvement Act.'' This bill would enhance the implementation of the 
rural health requirements of P.L 109-461 enacted last year. However, we 
still have some concerns about how best to address the needs of 
veterans who live in rural areas. PVA recognizes that there is no easy 
solution to meeting the needs of veterans who live in rural areas. 
These 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.
    PVA fully supports the provisions of this legislation which would 
align the mileage reimbursement rate afforded to eligible veterans with 
the rate that all federal employees get when they are on travel. It is 
wholly unacceptable that veterans have to live with the 11 cents per 
mile reimbursement rate that the VA currently provides when all federal 
employees receive 48 cents per mile. In fact, PVA believes that some of 
the difficulty in providing care to veterans in limited access areas, 
specifically rural areas, might be eliminated with a sensible 
reimbursement rate. We believe that veterans would be less likely to 
complain about access issues as a result of their geographic location 
if they know that they will not have to foot the majority of the travel 
expense out of their own pocket. This is a change that has been long 
overdue, and we urge the Subcommittee and all of Congress to take 
immediate action to correct this inequity.
    We also support the creation of rural health research, education, 
and clinical care centers. These centers would essentially serve as 
centers-of-excellence for rural healthcare. This could allow the VA to 
address the needs of rural veterans through broad application of the 
``hub-and-spoke'' principle. This is the same structure utilized in the 
spinal cord injury service. A veteran can get his or her basic care at 
a community-based outpatient clinic (spoke). However, if the veteran 
requires more intensive care or a special procedure, he or she can then 
be referred to the larger rural research, education, and clinical care 
center (hub). This would ensure that the veteran continues to get the 
best quality care provided directly by the VA, thereby maintaining the 
viability of the system. It will also allow the VA to develop 
excellence within the actual VA healthcare system, instead of farming 
out these services to the private sector. Likewise, PVA supports the 
provisions to allow for transportation grants to veterans service 
organizations to assist veterans access the VA healthcare system. We 
are all familiar with the success of the Disabled American Veterans' 
(DAV) van program that provides transportation to medical facilities 
for disabled veterans who have appointments. This provision would 
further support similar programs and allow other organizations to play 
an equally useful role.
    PVA has concerns about the demonstration projects that will 
establish partnerships between the VA and the Centers for Medicare and 
Medicaid Services to seek care in critical access hospitals or at 
community health centers. Principally, we believe that this legislation 
is ``jumping the gun'' by getting ahead of the Office of Rural Health, 
which is responsible for determining if solutions, such as this 
proposed demonstration project, are feasible. We think that this new 
office in the VA should be given time to do its job before Congress 
begins legislating solutions to the problems with rural healthcare for 
veterans. This is certainly not to say that Congress should not 
pressure the VA to get the office operating expeditiously.
    Although we do not necessarily have a problem with the reporting 
requirements contained in the legislation, they seem to be redundant. 
PVA believes that similar requirements were placed on the VA with the 
creation of the Office of Rural Health in legislation enacted during 
the 109th Congress. We do not see the need for this requirement if the 
new office at VA will be fulfilling this task once it gets up to speed 
anyway.

           H.R. 2172, THE ``AMPUTEE VETERAN ASSISTANCE ACT''

    PVA has serious concerns about the provisions of this proposed 
legislation. PVA strongly opposes the provision of Section 2 of H.R. 
2172 that would allow the VA to contract for service and repair of 
prosthetic devices. We interpret this legislation to mean that the VA 
can contract with a single entity to provide these services and 
repairs. This is absolutely a bad idea. By using a single entity, the 
pool of devices and services available will be severely limited.
    A one-size-fits-all approach to prosthetics cannot be applied. As 
an example, prosthetics departments that serve PVA members needing 
wheelchairs often, if not always, contract with several different 
vendors to provide those wheelchairs. Because every PVA member, and 
every disabled veteran for that matter, is different, the equipment 
they need varies. Although an Invacare power chair may be suitable for 
one spinal cord injured veteran, a different spinal cord injured 
veteran might be better served by a Jazzy chair. Two uniquely different 
veterans cannot be expected to use the same equipment simply because it 
might streamline processes for the VA. We believe that giving the VA 
the authority outlined in this provision would have a significant 
negative impact on the severely disabled veterans who are the highest 
users of VA prosthetics services.
    PVA has no objection to the provision of the legislation that would 
require certification of VA orthotic-prosthetic laboratories with the 
American Board for Certification in Orthotics and Prosthetics or the 
Board of Orthotics and Prosthetic Certification. However, we believe 
that the VA already meets these requirements, but if this provision 
will reinforce this action, then we have no problem with it.

                   H.R. 2173 (Mental Health Services)

    PVA opposes H.R. 2173 which would authorize VA to contract with 
community mental health centers to meet the needs of veterans dealing 
with mental illnesses. As we testified earlier this year, we oppose any 
effort to allow the VA to contract out care when it can do a better and 
more cost effective job in its own system. Furthermore, by allowing the 
VA to send these veterans out of the system to receive their care, it 
effectively relieves itself of the obligation it has to these men and 
women. The VA must be appropriated adequate funding (steps that are 
finally beginning to take place) and it must be provided in a timely 
manner if it is going to have any chance of meeting these veterans 
needs.
    Moreover, Congress must continue to conduct aggressive oversight to 
ensure that funding specifically allocated for mental health 
initiatives is properly spent. As explained in the Government 
Accountability Office (GAO) report of November 2006, the VA did not 
allocate all of the funding it planned to commit in FY 2005 for new 
mental health initiatives, nor did it spend all of the funds planned 
for FY 2006. VA must be held accountable to ensure that it lives up to 
the goals established in its National Mental Health Strategic Plan. 
Until such time as the VA meets these goals, the burden for mental 
healthcare should not be shifted to the community.

                        H.R. 2192 (VA Ombudsman)

    PVA supports H.R. 2192, a bill that would establish an Office of 
the Ombudsman in the VA. We believe that this office could certainly 
improve the transition of service members and their families from the 
Department of Defense to the VA. The office can be an important 
information tool for the VA. We do find it unfortunate, however, that 
such an office would be necessary as the VA as whole should be 
responsible for fulfilling this role through outreach.

       H.R. 2219, THE ``VETERANS SUICIDE PREVENTION HOTLINE ACT''

    The incidence of suicide among veterans, particularly Operation 
Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans, is a 
serious concern that needs to be addressed. PVA principally supports 
this legislation. Any measure that will reduce the incidence of suicide 
among veterans is certainly a good thing.
    However, we must emphasize a couple of important points. First and 
foremost, there need to be absolute standards established that ensure 
that the individuals staffing this hotline are adequately trained to 
handle the complex issues associated with individuals contemplating 
suicide. We certainly support the idea that this service should be 
staffed by veterans, but they must have the proper training to deal 
with these cases. Simply having the shared experience of military 
service is not enough. This legislation seems to address this concern, 
but the VA cannot be let off the hook for ensuring that this is handled 
properly.
    Secondly, clear steps for referral into VA mental health clinics 
and other VA facilities with related services must be outlined. The 
private entities responsible for the operation of the suicide 
prevention hotline must understand how to refer veterans dealing with 
these problems into programs that will provide the services they need. 
These services are essential to helping the veteran overcome the 
suicidal feelings he or she may be dealing with.

    H.R. 2378, THE ``SERVICES TO PREVENT VETERANS HOMELESSNESS ACT''

    PVA has no objection to the provisions contained in the proposed 
legislation. Clearly, the most important factor in combating the 
problem of homelessness among veterans is preventing homelessness in 
the first place. This legislation would seem to accomplish that task by 
offering financial assistance to organizations or entities that provide 
permanent housing and support services to very low income veteran 
families. In the mean time, we believe that additional resources should 
be invested in programs that actually target veterans and their 
families who are experiencing homelessness as well. With more than 
200,000 veterans on the street on any given night, it is time to make 
real, meaningful efforts to end this problem.

                               H.R. 2623

    PVA fully supports H.R. 2623, a bill which would prohibit the VA 
from collecting copayments from veterans receiving hospice care whether 
in an inpatient or outpatient setting. As we recall, the VA actually 
supported similar legislation during the 109th Congress. This 
legislation only makes sense as it will align with current statute that 
prevents VA from collecting copayments from veterans receiving hospice 
care in a nursing home setting.
    We look forward to working with the Subcommittee to develop 
workable solutions that will allow veterans to get the best quality 
care available. I would like to thank you again for allowing us to 
testify on these important measures. I would be happy to answer any 
questions that you might have.

                                 
               Statement of Dennis M. Cullinan, Director,
 National Legislative Service, Veterans of Foreign Wars of the United 
                                 States
MR. CHAIRMAN AND MEMBERS OF THIS COMMITTEE:
    On behalf of the 2.4 million men and women of the Veterans of 
Foreign Wars of the U.S. (VFW) and our Auxiliaries, I would like to 
thank you for the opportunity to testify before you today on a wide 
range of important veterans healthcare bills.

           H.R. 1488, the VA Hospital Quality Report Card Act

    The VFW is pleased to support the VA Hospital Quality Report Card 
Act, legislation that would require VA to develop and implement a 
system to measure data about its healthcare facilities.
    This data would be of great service. It would allow veterans to 
compare the quality of service VA provides, letting them make informed 
judgments about their healthcare. It would allow VA to identify areas 
of improvement, and it would provide essential data for Congress to 
better use its essential oversight authority.

    H.R. 1853, the Jose Medina Veterans Affairs Police Training Act

    The VFW supports this legislation which would require VA police 
officers to undergo training on how to deal with patients and visitors 
who are suffering from mental illnesses.
    Given the large numbers of returning veterans who are suffering 
from mental illnesses of various degrees, extra training for VA 
employees on how to deal with these patients is entirely appropriate. 
This is especially true for those patients who are vulnerable and 
suffering the most. The extra training will ensure that wounded 
warriors are treated with dignity and respect.

                               H.R. 1925

    The VFW has no objection to H.R. 1925, legislation that would 
establish a new Veterans Integrated Service Network (VISN) in the Gulf 
Coast Region. The regions in this area share many similar geographic 
things in common and, perhaps, aligning them all in one vision will 
allow them to better serve the veterans' population.

         H.R. 2005, Rural Veterans Health Care Improvement Act

    The VFW is pleased to support the Rural Veterans Health Care 
Improvement Act, legislation that aims to solve one of the greatest 
problems facing the large number of veterans who live in remote 
locations: access to care. It aims to improve services including 
transportation for disabled vets, research and partnerships with small 
communities.
    It would require VA to create centers of excellence for rural 
healthcare veterans and to establish a grant program for groups that 
help transport veterans from rural areas. It also includes a provision 
that would create demonstration projects for potential partnerships 
with local hospitals and community health centers, as well as for 
Native American veterans.
    We are strongly supportive of section 2, which would increase the 
mileage reimbursement rate veterans receive for their travel expenses 
related to VA healthcare to the rate provided to all federal employees. 
The current deductible for travel expenses is so limiting that most 
veterans receive little, if any, compensation for their travels. With 
so many veterans facing drives of hundreds of miles for even basic 
care, this is clearly the right thing to do.

               H.R. 2172, Amputee Veteran Assistance Act

    The VFW is supportive of H.R. 2172, a bill to require that all 
Department of Veterans Affairs orthotic-prosthetic laboratories, 
clinics, and prosthesists are certified by either the American Board 
for Certification in Orthotics and Prosthetics or the Board of 
Orthotics and Prosthetic Certification. However, the VFW is not sure if 
changing the rules of VA's prosthetic program is needed, and we have 
concerns that the certification requirements that would affect all 
service and repair programs for prosthetics and orthotics is necessary.
    VA continues to be on the forefront of advancement in this most 
important area, allowing hundreds of our wounded warriors the ability 
to regain their mobility or to become whole.
    We are also concerned that some efforts to create a certification 
process could lead toward a standardization process that aims for one-
size-fits-all solutions, instead of a personalized approach necessary 
to deal with each veteran's particular disability. Medical decisions 
must be made on the individualized needs of a veteran and what works 
best.

                               H.R. 2173

    We support the intent of this legislation, which would allow the VA 
secretary to enter into contracts for service with community mental 
healthcare centers, but we do have some concerns.
    With the number of returning service members who are suffering from 
mental health conditions, it is clear that VA can and must do more. VA 
has made great strides from where they were a few years ago in 
providing care, but the system is far from perfect. This legislation 
aims to fill in the gaps, by allowing VA to utilize local resources, 
presumably in places where there are gaps in the availability of care--
whether through a high demand or a dearth of providers.
    We remain concerned, however, with an over-reliance on contract 
care. Especially in the mental health area contract care could lead to 
some extensive continuity of care problems. Among other things, VA 
would have to determine some way to ensure that no veteran falls 
through the cracks when going from the department to a local provider. 
Further, it would be absolutely critical that patient records be 
transferable among all providers so that all information is provided to 
all involved healthcare givers. We have concerns, given VA's state-of-
the-art medical records, that this is feasible in dealing with the 
private sector.
    We need to do more for these wounded warriors, but we need to make 
sure that what we're doing really is in their best interest.

           H.R. 2219, Veterans Suicide Prevention Hotline Act

    The VFW supports this legislation which would establish a grant 
program to an organization to staff and run a suicide prevention 
hotline targeted and staffed by veterans and armed forces personnel.
    We understand that VA is in the process of establishing a similar 
hotline, so it may be necessary to determine how much overlap is 
between the programs. It is clear, however, that the program would be 
beneficial.
    This is a critical issue, especially with the difficulties so many 
of our men and women who have worn the uniform are facing. Anything we 
can do to extend a helping hand, especially when they are suffering and 
in a time of such need, is essential.

                               H.R. 2623

    The VFW offers our support for this legislation, which would exempt 
patients seeking hospice care from paying copayments. This is a 
compassionate idea that relieves a burden on the veteran and their 
loved ones at a critical time.
    This concludes my testimony and I will be happy to respond to any 
questions you may have.

                                 
             Statement of Barry Hagge, National Secretary,
                      Vietnam Veterans of America
    Good morning, Chairman Michaud, Ranking Member Miller, and members 
of this Subcommittee. Thank you for giving Vietnam Veterans of America 
(VVA) the opportunity to offer our comments on several veterans' 
health-related bills up for discussion here today.
    All of these bills, with the possible exception of H.R. 1853, are 
extremely important. With a few reservations, they are worthy of your 
consideration and our support.
    The topic of accessibility to VA medical services for veterans who 
live in rural areas has been percolating of late. We believe that H.R. 
2005, the ``Rural Veterans Health Care Improvement Act of 2007,'' 
offers pragmatic solutions to address the problems of access to 
healthcare experienced by too many rural veterans. The bill would 
increase travel reimbursement for veterans who travel to VHA facilities 
to the rates paid to federal employees. The current reimbursement rate 
was established decades ago and does not adequately compensate for the 
costs of gasoline, ``wear and tear'' on the vehicle or increased 
insurance that might be necessary in order to travel to distant medical 
centers. In the same vein, the grant program for rural veterans' 
service organizations to develop transportation programs could be an 
innovative way to strengthen community resources that may already 
assist with veterans' travel needs.
    The establishment of centers of excellence for rural health 
research, education, and clinical activities, another component of this 
bill, should fill a gap in VA healthcare and should lead to innovation 
in long-distance medical and telehealthcare. These centers have brought 
the synergies of clinical, educational and research experts to bear in 
one site. Such centers have allowed VA to make significant 
contributions to the fields of geriatric medicine and mental illness. 
It would require demonstrations of rural treatment models. 
Demonstrations on treating rural veteran populations would be extremely 
useful in assessing effective ways to offer healthcare to individuals 
who are generally poorer, more likely to be chronically ill, and 
almost, by definition, more likely to have challenges in access to 
regular healthcare.
    And establishing partnerships--with the Indian Health Service and 
with the Department of Health and Human Services--also should add to 
greater cooperation and collaboration in meeting the needs of rural 
veterans.
    We would caution, however, that we would not like to see these 
demonstration projects exploring more opportunities to do widespread 
contracting out of veterans' healthcare services. Demonstration models 
should be assessed according to a number of outcomes such as quality of 
care, cost, and patient satisfaction and the results reported to 
Congress.
    H.R. 1448, the ``VA Hospital Quality Report Card Act of 2007,'' is 
a quality control measure that would help with accountability and 
issues regarding follow-up care and timely visits. It would require the 
VA to provide grades for its medical centers on measures such as 
effectiveness, safety, timeliness, efficiency, patient-
``centeredness,'' and equity. Health-care quality researchers have long 
thrived trying to objectively define some of these measures.
    As members of this Subcommittee are aware, the VA has a number of 
performance measures it regularly assesses in order to reward its 
medical center and network directors, among others. Some of these 
outcomes, such as immunizations for flu, foot care and eye care for 
diabetics, set the ``benchmark'' for care in the community. In addition 
to these internal performance measures, VHA voluntarily submits to 
Joint Commission on Accreditation of Healthcare Organization, 
Commission on Accreditation of Rehabilitation Facilities, and managed 
care quality review standards.
    VVA understands the importance of quality measurement; there is an 
expression with which we agree: ``What's measured, matters.'' We also 
agree that VA officials should be held to the highest degree of 
accountability, and whatever measures are available to allow this to 
better occur we wholeheartedly endorse. However, before enacting this 
clearly well-intended legislation, which could require significant 
retooling of quality measurement systems in the VA, the Committee 
should hold a hearing to identify gaps and deficiencies in current 
performance and quality measurement systems. It would also be useful to 
understand how report cards would be used and reported to improve VHA 
processes and performance rewards. Would poor grades be dealt with by 
changes in management? By withholding bonuses to senior executives? 
With more funding? How would good grades be rewarded? Such questions 
should be addressed before requiring a significant new quality 
measurement program to be installed.
    H.R. 1853, the ``Jose Medina Veterans Affairs Police Training 
Act,'' would require VA police to receive training in interacting with 
patients and visitors with severe mental illness. Most VA police are in 
daily contact with veterans with mental illness, often dealing with 
stressful situations that are liable to exacerbate symptoms. 
Sensitivity training in confronting any individuals in crisis could 
potentially assist officers in peacefully de-escalating or defusing 
volatile situations, thus avoiding the use of force.
    VVA does not have a position on H.R. 1925, which would establish a 
Gulf Coast Veterans Integrated Service Network.
    H.R. 2172, the ``Amputee Veterans Assistance Act,'' would require 
that all VA orthotic-prosthetic laboratories, clinics, and prosthesists 
are certified by either the American Board for Certification in 
Orthotics and Prosthetics or the Board of Orthotics and Prosthetic 
Certification. We endorse this bill because, very simply, as more and 
more catastrophically wounded veterans are returning home minus arms 
and legs, it is incumbent on us to ensure that they are receiving 
quality prosthetics and orthotics.
    The VA already has the authority to contract with community mental 
health providers; however, under the strain of thousands of returning 
troops in need of mental health services, the VA is struggling to 
implement provisions of its mental health strategic plan, including 
providing ``round-the-clock'' access to care. The funding authorized in 
H.R. 2173 for the provision of mental healthcare from community 
providers--$50 million--would greatly assist the VA in filling the 
programmatic gaps it recognized in both its strategic plan and in its 
budget submission for FY 2008.
    Community mental health providers should be selected based on 
quality of care indicators such as compliance with standards for either 
the facility or its clinical personnel (what credentials/training are 
required for the clinical personnel?) Standards for community providers 
should be no less rigorous than those required for similar VA 
facilities. And the VA must provide vigorous oversight of the care 
these community facilities provide veterans.
    We should also note that mental health providers across the country 
are eager to assist returning veterans in dealing with their demons. 
Passage of 2173 should help give them the opportunity.
    VVA endorses H.R. 2192, which would establish an Office of the 
Ombudsman within the Department of Veterans Affairs. Although most of 
the duties of an ombudsman are the responsibility of program managers 
and assistant secretaries, veterans and their families who are 
sometimes frustrated by bureaucratic runarounds or non-answers often 
encountered at VA medical centers or regional offices will have a 
champion--if H.R. 2192 is enacted and sufficiently funded.
    VVA very much supports H.R. 2219, the ``Veterans Suicide Prevention 
Hotline Act of 2007,'' which would authorize and fund the establishment 
of a national toll-free suicide prevention hotline. As many of those in 
this room are aware, up to one-third of the thousands of veterans of 
the fighting in Iraq and Afghanistan have screened positive for mental 
illness. As more of these veterans return home from ongoing deployments 
in Southwest Asia, the acute symptoms of these illnesses, including 
post-traumatic stress disorder, depression and anxiety, are likely to 
manifest resulting in more preventable losses of life.
    In a report published last month (May 10, 2007), the VA's Office of 
Inspector General recommended that VA provide such a hotline (VA OIG 
Report No. 06-03706-126). The VA's response indicated that the Veterans 
Health Administration's Office of Mental Health Services was developing 
a hotline that would be rolled out November 30, 2007 and fully 
implemented by January 30, 2008. Enacting this legislation will better 
ensure that the VA meets these goals.
    The provision should assure that contracted services for the 
hotline call for a minimum percent of vets hired--including veterans 
who have recently returned from deployments abroad--over and above the 
3% required for government contracts.
    VVA supports, too, H.R. 2378, the ``Services to Prevent Veterans 
Homelessness Act.'' If veterans at risk of becoming homeless can be 
identified and assisted before they are turned out of their apartment, 
if they can be given the modest assistance they need to maintain their 
independence, if they have access to the supportive services they need 
to maintain their dignity, it is entirely possible that hundreds will 
be saved from having to live with no permanent address, and no roof 
over their head.
    That some 200,000 military veterans, including growing numbers of 
men and women who served in Iraq and on the ``Global War of Terror'' 
are homeless is a national scandal. It should shock you into action. 
And indeed, Congress has responded, but often with too little in the 
way of resources that can make a real difference.
    VVA supports the provisions in H.R. 2623 that would prohibit the 
collection of copayments for all hospice care furnished by the VA. 
Hospice care is a service that allows individuals with terminal illness 
to reject extraordinary measures for prolonging life and, instead, 
accept ``comfort care.'' The last year of life is known to be far more 
expensive than those that precede it. It is unfortunate, then, to 
penalize veterans and their families by charging co-payments for 
hospice care when those same veterans might have elected to receive, 
free-of-charge, acute, in-patient care that was far more expensive and 
ultimately fruitless. The VA should be encouraging its patients to 
prepare living wills and advanced directives that specify their choices 
for end-of-life care and educate veterans with terminal illness about 
hospice. Relieving veterans of copayments for hospice care seems one 
means to better ensure that they are able to choose hospice for their 
end-of-life care.
    Members of this Subcommittee, VVA welcomes your comments and your 
questions.

                                 
      Statement of the Honorable Michael Kussman, M.D., MS, MACP,
      Under Secretary for Health, 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 nine bills that would affect Department of 
Veterans Affairs (VA) programs that provide veteran healthcare benefits 
and services. With me today is Walter A. Hall, Assistant General 
Counsel. Mr. Chairman, with the exception of section 2 of H.R. 2005, VA 
has not had sufficient time to prepare cost estimates for the bills on 
today's agenda. As soon as these become available, we will supply them 
for the record. In addition, with the short time available to prepare 
for this hearing, we were not able to provide views on all of the bills 
reflected on the agenda. We can provide those views for the record.
H.R. 1448--VA Hospital Quality Report Card Act of 2007
    Mr. Chairman, I will begin by addressing H.R. 1448. This bill would 
require VA to establish a Hospital Quality Report Card Initiative 
(``Initiative'') to, among other things, help inform patients and 
consumers about the quality of care in VA hospitals. Under the 
Initiative, the Secretary would be required to publish, at least bi-
annually, reports on the quality of VA's hospitals that include 
quality-measures data that allow for an assessment of healthcare 
effectiveness, safety, timeliness, efficiency, patient-centeredness; 
and equity.
    In collecting and reporting this data, the Secretary would have to 
include very extensive and detailed information (i.e., staffing levels 
of nurses and other healthcare professionals; rates of nosocomial 
infections; volume of various procedures performed, hospital sanctions 
and other violations; quality of care for specified patient 
populations; the availability of emergency rooms, intensive care units, 
maternity care, and specialty services; the quality of care in various 
hospital settings, including inpatient, outpatient, emergency, 
maternity, and intensive care unit settings; ongoing patient safety 
initiatives; and, other measures determined appropriate by the 
Secretary). VA would be allowed to make statistical adjustments to the 
data to account for differences relating to characteristics of the 
reporting hospital (e.g., size, geography, and teaching status) and 
patient characteristics (e.g., health status, severity of illness, and 
socioeconomic status). In the event VA makes such adjustments, there 
would be a concomitant obligation to establish procedures for making 
that data available to the public.
    The bill would require the Secretary to disclose the entire 
methodology (for the reporting of the data) to all organizations and VA 
hospitals that are the subject of any information prior to making such 
information available to the public. Each report submitted under the 
Initiative would have to be available in electronic format, presented 
in an understandable manner to specified populations, and presented in 
a manner that allows for a comparison of VA's hospital quality with 
local hospitals or regional hospitals. The Department would also need 
to establish procedures to make these reports available to the public, 
upon request, in a non-electronic format (such as through a toll-free 
telephone number).
    In addition, H.R. 1448 would require the Secretary to identify and 
acknowledge the analytic methodologies and limitations on the data 
sources used to develop and disseminate the comparative data and to 
identify the appropriate and inappropriate uses of such data. The bill 
would further mandate the Secretary, on at least an annual basis, 
compare quality measures data submitted by each VA hospital with data 
submitted in the prior year or years by the same hospital to identify 
and report actions that would lead to false or artificial improvements 
in the hospital's quality measurements.
    This measure would further require the Secretary to develop and 
implement effective safeguards to: protect against the unauthorized use 
or disclosure of VA hospital data reported under this measure; protect 
against the dissemination of inconsistent, incomplete, invalid, 
inaccurate, or subjective VA hospital data; and ensure that 
identifiable patient data is not released to the public. In addition, 
the Secretary would need to evaluate and periodically report to 
Congress on the effectiveness of this initiative and its effectiveness 
in meeting the purposes of this Act. And such reports would have to be 
made available to the public. Finally, this legislation would direct 
the Secretary to use the results of the evaluations to increase the 
usefulness of this initiative.
    H.R. 1448 would authorize to be appropriated to carry out this 
section such sums as may be necessary for each of Fiscal Years (FY) 
2008 through 2017. The effective date for this bill and its 
requirements would be 18 months after the date of the bill's enactment.
    Mr. Chairman, VA supports the intent of this bill but opposes the 
bill as written. H.R. 1448 is too prescriptive in its requirements, and 
much of the information that would be required by H.R. 1448 is already 
available through other avenues, such as The Joint Commission's 
(previously known as the Joint Commission on Accreditation for 
Healthcare Organizations) website that provides standardized 
comparative data in a form that has been tested for consumer 
understandability and usefulness. Moreover, VA is in the process of 
compliance with Executive Order 13410, which requires transparency of 
quality measures in Federal healthcare programs. We would welcome the 
opportunity to meet with the Committee members to help them understand 
what is available already, how the members might better access the 
information, and how we can help veterans and the public better access 
that information.
H.R. 1853--Jose Medina Veterans Affairs Police Training Act of 2007
    H.R. 1853 would require the Secretary to ensure, not later than 8 
months after the date of enactment, all VA police officers receive 
training on how to interact with visitors and patients at VA medical 
facilities who have, or who exhibit symptoms of, mental illness. The 
purpose for this mandate is the bill's express finding that there has 
been, and will continue to be, an increase in the incidence of post-
traumatic stress disorder (PTSD) among veterans who served in past and 
present combat theaters and thus in their concomitant need for VA 
mental health treatment and services.
    We do not support H.R. 1853 because it is unnecessary. By statute, 
the Secretary is already required to provide VA Police Officers with 
training that emphasizes effective management of situations involving 
patients. To carry out that mandate, VA provides specialized training 
to VA Police Officers in dealing with disruptive and other unusual 
behaviors. VA officers also must successfully complete an 80 hour basic 
entry level training course at their medical centers as well as a 200 
hour residential basic police officer training course at the VA Law 
Enforcement Training Center. Included in the residential course is a 
17.5 hour block of training in Behavioral Science that includes such 
topics as introduction to mental illness, communications/conflict 
management, verbal judo, crisis intervention/conflict resolution and 
the dynamics of the suicidal individual. Much of this training is 
taught by VA psychologists. Moreover, VA officers must also complete a 
biannual refresher training program.
H.R. 1925--VISN for Gulf Coast Region
    H.R. 1925 would require the Secretary to establish, not later than 
1 year after enactment, a separate ``Veterans Integrated Services 
Network (``VISN'') for the Gulf Coast region of the United States. This 
new VISN would be comprised of specified counties located in Florida, 
Alabama, and Mississippi.
    VA does not support H.R. 1925. We find no justification for 
establishing a separate VISN for a service area that does not have the 
workload needed to make that organizational change cost-effective or to 
require that level of management. The current facilities and referral 
patterns in this area provide the best access for the veterans. VISNs 
were originally created around referral patterns and geographic 
boundaries. In addition, VISNs work together along their borders to 
ensure access to healthcare for veterans in those areas. The Gulf Coast 
region is one area where VISNs seven, eight and 16 have worked very 
well together in managing care for veterans in the area. Therefore, VA 
sees no reason to add an additional Network for this region.
H.R. 2005--Rural Veterans Health Care Improvement Act of 2007
    H.R. 2005 is intended to improve VA's ability to meet the 
healthcare needs of rural veterans. section 2 of this bill would amend 
VA's beneficiary travel program by requiring VA to pay or reimburse 
eligible veterans at the same per diem rates and mileage rates that 
apply to Federal employees using privately owned vehicles for official 
travel.
    Section 3 would require the Secretary, through the Director of the 
Office of Rural Health, to establish up to five Rural Health Research, 
Education, and Clinical Centers of Excellence (``Centers''). The bill 
sets forth detailed requirements that would govern the Secretary's 
designation and placement of such Centers. It also would limit 
designation of Centers to those facilities found by a peer review panel 
to meet the highest competitive standards of scientific and clinical 
merit and also found by the Secretary to have met the requirements 
specified in the legislation.
    Section 4 would require the Secretary to establish a grant program 
for State Veterans' Service Agencies and Veterans' Service 
Organizations for purposes of providing veterans living in remote rural 
areas with innovative means of travel to VA medical centers (and to 
assist them with their other medical care needs). A grant awarded under 
this section could not exceed $50,000. Grant recipients would not be 
required to provide matching funds as a condition for receiving a 
grant. This section would require the Secretary to prescribe 
regulations to implement this program and also authorize to be 
appropriated $3 million for each of FYs 2008 through 2012 to carry out 
this program.
    Section 5 would require the Secretary, through the Director of the 
Office of Rural Health, to carry out demonstration projects to examine 
alternatives for expanding care to veterans in rural areas. In so 
doing, the Secretary would be required to establish partnerships with 
the Department of Health and Human Services (HHS) to coordinate care 
for veterans in rural areas at both critical access hospitals and 
community health centers. VA would also be obliged to coordinate with 
HHS' Indian Health Service to expand care for Native American veterans.
    The bill would institute annual reporting requirements, the first 
of which would have to include the results of the statutorily mandated 
assessment of VA's fee-basis program on the delivery of care to 
veterans residing in rural areas, along with the results of VA's 
extensive outreach program to OEF/OIF veterans living in rural 
veterans.
    Mr. Chairman, while we appreciate the impetus for H.R. 2005, we do 
not support the bill. In accordance with Congress' mandate in the 
``Veterans Benefits, Health Care, and Information Technology Act of 
2006,'' VA recently established the Office of Rural Health (ORH) within 
the Veterans Health Administration. Part of that office's charge is to 
determine how we can best continue to expand access to care for rural 
veterans. Presently, ORH is developing a strategic plan for operations 
and is considering a proposal to create new research centers. We would 
request the Congress wait until these assessments are complete before 
requiring action in this area. We will keep the Committee abreast of 
ORH's activities and findings as available.
    VA is working closely with other organizations in a variety of 
areas, including outreach, clinical care, education, expanded services, 
care coordination, and telemedicine, to improve the quality of 
healthcare available to those living in rural areas. The Department of 
Health and Human Services (HHS) and the Department of Veterans Affairs 
(VA) signed a Memorandum of Understanding (MOU) in February 2003 to 
encourage cooperation and resource sharing between the Indian Health 
Service (IHS) and the Veterans Health Administration (VHA) to deliver 
quality healthcare services and enhance the health status of American 
Indian and Alaska Native (AI/AN) veterans. VHA's Office of Rural Health 
(ORH) has also established a working relationship with and sought 
consultation from HHS's Office of Rural Health. As the office matures, 
VHA's plan is to work closely with HHS to maximize the opportunities in 
a range of areas including education, training, research, and access. 
Therefore, a Congressional mandate to encourage cooperation with HHS 
and IHS is not necessary.
    Moreover, while we acknowledge there has been a significant 
increase in fuel prices, beneficiary travel payments are paid out of 
funds appropriated for healthcare treatment and services. In our view, 
VA should use medical care funds for furnishing direct patient care in 
the manner that best serves the most veterans. It is also important to 
note that increasing the beneficiary travel payment and reimbursement 
rates would benefit only the limited categories of veterans who are 
eligible for those benefits e.g., veterans whose travel is in 
connection with treatment for a service-connected disability. For that 
reason, the amendments to the beneficiary travel program that are set 
forth in H.R. 2005 may not advance the Congress' general objective of 
improving access to care for rural veterans.
    We further note that the travel benefits program for Federal 
employees is distinct and on the whole inapposite to VA's beneficiary 
travel benefits program. It is unclear, based upon the text of the 
bill, if the limitations and conditions on Federal employee eligibility 
for travel pay would be applied to veterans. Federal employees do not 
automatically qualify for reimbursement of expenses they incur while on 
official travel. They must meet certain criteria to be eligible for 
such reimbursement, particularly in connection with the use of a 
privately owned vehicle. The criteria and conditions for reimbursement 
that apply to Federal employees (e.g., travel order) would not be 
appropriate to patients traveling to VA facilities for care and 
treatment, and transposing such a system would prove to be very complex 
and difficult to manage. VA estimates the cost of section 2 of H.R. 
2005 to be $253 million for FY 2008 and $7 billion over a 10-year 
period.
H.R. 2172--Amputee Veteran Assistance Act
    Mr. Chairman, the next bill on today's agenda is H.R. 2172. This 
bill would require the Secretary to ensure, not later than 5 years 
after enactment, that all VA orthotic-prosthetic laboratories and 
clinics are certified by either the American Board for Certification in 
Orthotics and Prosthetics or the Board of Orthotics and Prosthetic 
Certification.
    This bill would also require the Secretary to seek to enter into a 
contract with a non-VA entity for the service and repair of a 
prosthetic device for a veteran in the following situations:

      If the Secretary determines that VA facilities are unable 
to perform the necessary service or repair due to a lack of technology 
or for any other reason that the Secretary determines prevents such 
service or repair in a timely manner; or
      The veteran in need of such service or repair resides at 
a distance greater than 55 miles from the nearest suitable VA facility 
capable of furnishing the service or repair.

    The bill would further require the Secretary to develop and carry 
out a plan to inform disabled veterans at least twice a year of the 
technological advances made in the field of prosthetics. The above-
discussed contracting and information related requirements would both 
have to be implemented not later than 6 months after the date of the 
bill's enactment.
    Additionally, H.R. 2172 would require the Secretary to conduct and 
complete a review of all VA orthotic-prosthetic laboratories and 
clinics to ensure that the Department is capable of serving and 
repairing the most technologically advanced prosthetic devices. Such 
review would need to be conducted and completed not later than one year 
after the bill's enactment. No later than 6 months after completion of 
that review, the Secretary would need to submit a report to Congress on 
the Secretary's findings and any recommendations to address 
deficiencies in capability that were identified during the mandated 
review.
    Finally, no later than 1 year after the bill's enactment, this bill 
would require the Secretary to conduct and complete a review of VA's 
prosthetists and orthotists to determine what level and kinds of 
training and education will be needed to ensure they are qualified to 
service and repair the most technologically advanced prosthetic 
devices. No later than 6 months after that review is completed, the 
Secretary would be required to submit a report to Congress on the 
Department's findings and any recommendations to address identified 
deficiencies in education, training, or qualification.
    VA does not support H.R. 2172 because it is unnecessary. VA's 
policies already meet or exceed the requirements in the bill. In 2003 
VA mandated all prosthetic and orthotic laboratories be accredited by 
the American Board for Certification in Orthotics and Prosthetics or 
the Board of Orthotics and Prosthetic Certification. Today, all 58 of 
our laboratories are accredited and we require all contractors be 
accredited by these organizations as well. As a prerequisite of 
attaining accreditation, each facility had to employ at least one 
certified Prosthetist/Orthotist to oversee all work. Today, 131 out of 
our 186 prosthetists/orthotists are certified and we are actively 
encouraging all staff to attain this certification. Both ABC and BOC 
require all certified practitioners maintain certification through 5-
year cycles of continuing education units, including education in new 
and emerging technology. VA will continue to conduct site visits to all 
prosthetic and orthotic laboratories to ensure they meet quality 
standards and maintain their accreditation.
    VA uses over 600 non-department entities for fabrication, service 
and repair of prosthetic devices. Veterans will continue to have their 
choice of contracted providers, including the VA. VA is informing 
veterans of new developments with Open Forums, routine newsletters and 
press releases, and a dedicated web link devoted to the care and 
treatment of amputees.
    As a technical matter we point out that H.R. 2172 would amend 
chapter 31 of title 38, United States Code, which governs vocational 
rehabilitation benefits administered by the Veterans Benefits 
Administration, not chapter 17 of the same title, which governs the 
provision of healthcare benefits, including prosthetic care and 
services.
H.R. 2173--Authorization for Vet Centers to contract for Mental Health 
        Services
    will now discuss H.R. 2173. This bill would amend VA's readjustment 
counseling authority in 38 U.S.C. Sec. 1712A to permit the Secretary to 
enter into contracts with community mental health centers (deemed 
qualified by the Secretary) for the provision of mental health services 
as part of VA's readjustment counseling program.
    VA does not support H.R. 2173. Currently, VA's authority to provide 
mental health services to veterans receiving readjustment counseling 
services under section 1712A of title 38, United States Code, is 
limited to mental health services that are necessary to facilitate the 
successful readjustment of a veteran to civilian life and limited to 
the provision of counseling, training and mental health services 
described in 38 U.S.C. Sec. Sec. 1782 and 1783 (bereavement counseling) 
for the veteran's immediate family members. It is not clear if the 
bill, in creating a new subsection wholly unrelated to the existing 
provisions governing VA's contracting authority under section 1712A, 
means to encompass mental health services beyond those currently 
authorized and those which have traditionally been provided under VA's 
readjustment counseling mission (in contrast to VA's clinical mission).
    As already alluded to, Vet Centers currently have authority to 
contract with private sector community mental health agencies for the 
provision of readjustment counseling services and related mental health 
services. For more complex mental health needs, Vet Centers readily 
refer patients to VA medical facilities. Furthermore, H.R. 2173 would 
obfuscate and blur the special service mission of the Vet Centers as 
defined by law. These services are deliberatively set apart from 
medical facilities to promote more than medical readjustment services 
for combat veterans in an easy to access, community-based setting.
H.R. 2192--Establishement of Office of Ombudsman within the Department
    H.R. 2192 would establish an Office of the Ombudsman (herein 
referred to as the ``Office'') within the Department and require the 
Secretary to designate an Ombudsman to carry out the duties of the 
Office. The Ombudsman would act as a liaison for veterans and their 
family members with respect to the receipt of healthcare and benefits 
administered by VA.
    This measure would also require the Secretary to ensure the 
services of the Office are available to all veterans and their family 
members and would further direct the Secretary to make available to 
each veteran, and to the family members of all veterans, information on 
contacting and using the services of the Office. Lastly, H.R. 2192 
would authorize the disclosure of information provided by veterans or 
their family members only to the extent necessary to carry out the 
duties of the Office.
    VA does not support H.R. 2192. Of particular concern is the 
provision that would authorize the Ombudsman to act as a liaison for 
veterans and their family members with respect to the receipt of 
healthcare. VHA has instituted a variety of measures to support our 
patients and their families, including appointing patient advocates in 
our Medical Centers, benefits counselors, OEF/OIF Coordinators, and 
Transition Patient Advocates for those seriously injured in combat. Vet 
Center counselors also contribute to resolving situations on behalf of 
veterans. VSO representatives, likewise, serve ably as counselors and 
mentors and many State Departments of Veterans Affairs contribute in 
this area. VBA has also has extensive initiatives and programs aimed at 
assisting claimants with respect to receipt of benefits, including the 
Transition Assistance Program (TAP), the Benefits Delivery at Discharge 
(BDD) Program, and expanded outreach to veterans, dependents, and 
survivors. Adding another layer of oversight and involvement could 
create a confusing situation for patients and families, who might 
become unsure whom to consult. A new Office of the Ombudsman could also 
produce confusion within VA in terms of assignments and 
responsibilities, since the bill, as written, does not delineate 
between the role the new Office would fill vis-a-vis other offices 
within VA.
H.R. 2219--Veterans Suicide Prevention otline Act of 2007
    Mr. Chairman, H.R. 2219 would require the Secretary to award one 
grant for a period of not more than 3 years to an eligible entity to 
establish, publicize, and operate a national toll-free telephone number 
to serve as a suicide prevention hotline targeted to, and staffed 
predominately by, veterans of the Armed Forces.
    Under H.R. 2219, the grantee would be required to perform the 
following functions:

      enter into a contract with a telecommunication carrier 
for the use of such a national toll-free number;
      select; train; and supervise personnel to answer incoming 
calls and to provide counseling and referral services to callers;
      ensure that sufficient staffing is provided so that the 
hotline services are available to callers at all times;
      assemble and maintain a current database of information 
to be used to refer callers to local service providers and of 
information about the availability of shelters for homeless callers;
      publicize the hotline to potential callers; and
      certify the capacity of, and provide supplemental 
training for, any local crisis center operating as a subcontractor of 
the grantee.

    H.R. 2219 would further provide that to be eligible to receive the 
grant under this section, a private, nonprofit entity would have to 
prepare and submit a detailed application to the Secretary addressing a 
number of specified areas. The selected grant recipient would, in turn, 
be required to submit an annual report to the Secretary, in the form 
and with such information as the Secretary may require. The grantee 
would have to include in that report the volume of calls to the 
hotline, the demand for specific types of referrals, and the number of 
trained volunteers answering the hotline. Finally, payments awarded to 
the grantee would be subject to annual approval by the Secretary and to 
the availability of appropriations for each FY.
    For purposes of the grant award, H.R. 2219 would authorize to be 
appropriated $2,500,000 each year for FYs 2008, 2009, and 2010.
    VA does not support H.R. 2219. VA is already developing a 
comprehensive program for suicide prevention including a national 24 
hour toll-free hotline. The services under development in VA are more 
comprehensive that those proposed in H.R. 2219. VA is proposing to 
administer the services with VA mental health professional staff, not 
outside contractors, to provide mechanisms for accessing the electronic 
health records of veteran-callers as part of the response to crisis 
calls, and to establish strong interactions between the national 
hotline and the suicide prevention coordinators in each medical center 
to provide for continuity of care. While we respect the idea of peer-
to-peer counseling, which is employed with great effectiveness in our 
Vet Centers, VA believes it is more appropriate from a clinical 
standpoint to staff VA's national hotline with trained healthcare 
professionals.
H.R. 2378--Services to Prevent veterans Homelessness Act
    H.R. 2378 is a measure intended to prevent low income veterans 
transitioning to, or residing in, permanent housing from falling back 
into their former homeless condition. Subject to the availability of 
appropriations provided for the bill's purpose, H.R. 2378 would require 
the Secretary to provide financial assistance to eligible entities to 
provide and coordinate the provision of supportive services for very 
low-income veteran-families occupying permanent housing or 
transitioning from homelessness to permanent housing. The bill would 
further require the Secretary to establish a formula for determining 
the rate of payments to be made to eligible entities providing 
supportive services under this section. The rate would have to be 
adjusted at least annually to reflect changes in the cost of living. In 
calculating the rate payment formula, the Secretary would be authorized 
to consider geographic cost of living variances, family size, and the 
cost of services provided.
    To be eligible to receive funding, H.R. 2378 would require eligible 
entities to submit a detailed application to the Secretary. This bill 
would also authorize the Secretary to give preference to an entity 
providing or coordinating the provision of supportive services for very 
low-income veteran families who are transitioning from homelessness to 
permanent housing.
    This measure would require the Secretary to provide training and 
technical assistance to entities receiving payments under this program 
on the planning, development, and provision of supportive services to 
the targeted families. Such assistance could be provided either 
directly, or through grants or contracts with appropriate public or 
nonprofit private entities.
    As to funding, H.R. 2378 would make available out of the amounts 
appropriated for medical care $25 million for each of FYs 2008, 2009, 
and 2010, of which not more than $750,000 could be used to provide 
technical assistance.
    VA generally supports H.R. 2378 but we strongly recommend that the 
bill be modified to allow VA to establish additional criteria, 
specifically clinical indicators, to ensure this program reaches 
veteran families requiring additional support to end their 
homelessness. H.R. 2378 would require additional staffing resources for 
VHA's Homeless Program Office in the Office of Mental Health Services.
    This concludes my prepared statement. I would be pleased to answer 
any questions you or any of the members of the Subcommittee may have.

                                 
      Statement of Andy Behrman, Chair, Rural Health Policy Board,
                   National Rural Health Association
    It is my distinct pleasure to submit my comments for the record in 
regard to H.R. 2005, the Rural Veterans Health Care Improvement Act of 
2007. As the Rural Health Policy Board Chair for the National Rural 
Health Association (NRHA), and as a veteran, I have long been an 
advocate for appropriate change and improvement to our VA healthcare 
delivery system. It is a priority for me and a priority for the NRHA.
    The NRHA is a national nonprofit, non partisan, membership 
organization whose mission is to improve the health of rural Americans 
and to provide leadership on rural health issues. The members of the 
NRHA have long maintained concern for the health and mental healthcare 
needs of rural veterans.
    The members of the National Rural Health Association (NRHA) have 
maintained a special concern for the health and mental healthcare needs 
of rural veterans for many years. NRHA was one of the first non-veteran 
service organizations to develop a policy statement on rural veterans 
and this policy work is evidence of our memberships' concern for rural 
veterans.
    Since our Nation's founding, rural Americans have always responded 
when our Nation has gone to war. Whether motivated by their values, 
patriotism, or economic concerns, the picture has not changed much in 
230 years. Simply put, rural Americans serve at rates higher than their 
proportion of the population. Though only 19% of the nation lives in 
rural areas, 44% of U.S. Military recruits are from rural America. And 
nearly one-third of those who died in Iraq are from small towns and 
communities across the nation.
    There is a national misconception that all veterans have access to 
comprehensive care. Unfortunately, this is simply not true. Access to 
the most basic primary care is often difficult in rural America. Combat 
veterans returning to their rural homes in need of specialized care due 
to war injuries (both physical and mental) likely will find access to 
that care extremely limited. What this means, is that because there is 
a disproportionate number of rural Americans serving in the military, 
there is a disproportionate need for veteran's care in rural areas.
    Additionally, we must all be mindful of long-term needs. While the 
NRHA is pleased that both the House and Senate FY 2008 budgets call for 
greater increases in VA medical care spending than in past years, long-
term healthcare planning is critical. The wounded veterans who return 
today won't need care for just the next few fiscal years, they will 
need care for the next half century.
    In my testimony to the Committee on April 18, 2007, I presented 
recommendations that NRHA believes to be prudent in terms of developing 
a new approach to serving our rural veterans. These recommendations 
include:
1. Increasing Access by Building on Current Successes
    Community Based Outreach Centers (CBOCs) open the door for many 
veterans to obtain primary care services within their home community. 
Additionally, Outreach Health Centers meet the needs of many rural 
veterans. NRHA applauds the success of these programs and supports 
their expansion.
2. Increasing Access By Collaborating with Non-VHA Facilities
    Many rural veterans cannot access VHA care simply because VHA 
facilities are too far away. Linking the quality of VA services with 
rural civilian services can vastly improve access to healthcare for 
rural veterans. As long as quality standards of care and evidence-based 
medicine guide treatment for rural veterans, the NRHA supports 
collaboration with:

      Federally Qualified Community Health Centers. These 
centers serve millions of rural Americans and provide community-
oriented, primary and preventive healthcare. And, most importantly, are 
located where rural veterans live. A limited number of collaborations 
between the VHA and Community Health Clinics already exist and have 
proven to be prudent and cost-effective solutions to serving eligible 
veterans in remote areas. These successful models should be expanded to 
reach all of rural America.
      Critical Access Hospitals. These facilities provide 
comprehensive and essential services to rural communities and are 
specific to rural states. If these facilities are linked with VA 
services and models of quality, access to care would be greatly 
enhanced for thousands of rural veterans.
      Rural Health Clinics. These clinics serve populations in 
rural, medically underserved areas. In many rural and frontier 
communities, these clinics are the only source of primary care 
available.

3. Increasing Traumatic Brain Injury Care
    Currently, it appears that Traumatic Brain Injury (TBI) will most 
likely become the signature wound of the Afghanistan and Iraqi wars. 
Such wounds require highly specialized care. The current VHA TBI Case 
Managers Network is vital, but access to it is extremely limited for 
rural veterans--expansion is needed.
4. Targeting Care to Rural Veterans
  A.  Needs of the Rural Family. Rural veterans have an especially 
strong bond with their families. Returning veterans adjusting to 
disabilities and the stresses of combat need the security and support 
of their families in making their transitions back into civilian life. 
The Vet Centers do a tremendous job in assisting veterans, but their 
resources are limited. The NRHA supports increases in funding for 
counseling services for veterans' and their families.
  B.  Needs of Rural Women Veterans. More women serve in active duty 
than at any other time in our Nation's history. And more women are 
wounded or are war casualties than ever before in our nation's history.

    Targeted and culturally competent care for today's women veterans 
is needed. Rural providers should also be trained to meet the unique 
needs of rural, minority, and female veterans.
5. Improving Office of Rural Veterans
    The NRHA calls on Congress and the Veterans Administration to fully 
implement the functions of the newly created Office of Rural Veterans 
to develop and support an on-going mechanism to study and articulate 
the needs of rural veterans their families.
    We are grateful to Mr. Salazar for introducing HR 2005 and are 
grateful for the Committee's consideration of the bill. This 
legislation provides important relief for rural veterans and clearly 
addresses our second and fifth recommendations. We hope the Committee 
will consider this as a strong and positive step toward addressing the 
many challenges--especially access challenges--faced by rural veterans.
    To that end, we hope that this Committee will also address other 
ways to improve access to healthcare for our rural veterans. While the 
VA has provided outstanding service to our veterans over the years (and 
I have been one of those recipients), the need to increase access to 
services has become a major concern to the VA, and a critical concern 
to veterans living in rural communities throughout the United States.
    Efforts to increase service points for rural veterans have, in 
large part, been hindered by the VA Administration itself. The VA has 
thwarted attempts to collaborate with organizations that are located 
where rural veterans reside (such as community health centers, critical 
access hospitals, and rural health clinics) because of a false 
assumption that quality of care standards in rural communities are 
inferior. To the contrary, the standards of healthcare in rural America 
are high. In fact, community health centers, for example, have been 
rated as the number one most efficient and effective program in all of 
HHS. CHS must meet the highest standards of care, and in many cases, 
they musts also be Joint Commission accredited. All facilitates must 
meet federal standards of care.
    We must never forget that many veterans forgo care entirely because 
of access difficulties to VA facilities. Often, however, local quality 
care is available within a veteran's own community. In many cases, 
these rural centers, as well as critical access hospitals and rural 
health clinics, are the only providers in a large geographic area. Our 
goal is not to mandate care to our veterans, but to provide them a 
choice, a local choice. We applaud Congressman Salazar and this 
Committee for taking steps toward providing our honored veterans with 
such a choice.
    Thank you again for this opportunity. The NRHA looks forward to 
working with you and this Committee to improve rural healthcare access 
for the millions of veterans who live in rural America.

                                 
              Statement of the Honorable Silvestre Reyes,
          a Representative in Congress from the State of Texas
    Chairman Michaud, Ranking Member Miller, and distinguished members 
of the Subcommittee, I would like to thank you for the opportunity to 
testify before you in support of my bill HR 2172 the Amputee Veteran 
Assistance Act. As a veteran and former member of this Committee, many 
of you know me well and are aware of my commitment to Veteran issues. 
Today as Chairman of the Intelligence Committee and a member of the 
Armed Services Committee much of my time is devoted to ensuring that 
our troops have the necessary equipment and timely intelligence they 
need to fight the wars in Iraq and Afghanistan and to return home 
safely. However, I believe it is also critically important that our 
troops have confidence that if they are wounded in battle that they 
will be cared for in a manner that reflects the great sacrifices they 
have made for our country.
    The wars in Iraq and Afghanistan are placing great strain not only 
on our armed forces but on the Veterans Administration (VA) as well. 
The VA has not experienced this level of casualties since the Vietnam 
War. Despite the committed work of many healthcare professionals within 
the VA, the system is having a tough time dealing with this new influx 
of wounded veterans, while addressing the needs of our others veterans 
who honorably served in previous conflicts.
    As you know, since the beginning of the wars in Iraq and 
Afghanistan, more than 500 of our brave men and women in the armed 
forces have suffered major amputations resulting from wounds and 
injuries received in combat. Many of them have suffered multiple 
amputations. Our wounded servicemen and woman are now receiving world-
renowned care and access to some of the most modern prosthetic 
technology available under the Department of Defense (DOD) healthcare 
system. Some of our amputee soldiers have even been able to return to 
duty. However, others, because of their own unique situations, are 
transitioning to the VA, a system they will be part of for the rest of 
their lives. I want to assure that the VA is well prepared to provide 
service and care for their advanced prosthetic devices. Some recent 
amputee veterans and veteran support groups have expressed reservations 
that the VA is currently too focused on convalescent care and does not 
have the resources and training to help these wounded men and women 
return to the active lives they led before their wounds.
    During her testimony before the Senate Committee on Veteran Affairs 
last March, Major Tammy Duckworth, an Iraq war amputee and Director of 
the Illinois Department of Veteran Affairs, spoke about her 
difficulties transferring from the DOD healthcare system to the VA. She 
noted that the care she received as an inpatient at Walter Read Army 
Medical Center was exceptional, but her experiences with her local VA 
prosthetic facility were less positive. She pointed out that the VA 
prosthetics departments were ``many decades behind'' in technology and 
that VA staff, while eager to be helpful, lacked the knowledge and 
training to treat amputees at high tech levels set at Walter Reed and 
other major DOD healthcare facilities.
    The Amputee Veteran Assistance Act is an important step toward 
addressing some of these shortcomings in the VA system. I would like to 
emphasize that this bill is not an indictment of the VA. The VA has 
played an important role in research and development in the field of 
prosthetics for many decades and should be commended for its efforts. 
Instead, it is a step toward giving VA personnel the training and 
resources they need to do their jobs better, while addressing the 
immediate concerns of our amputee veterans. It is my hope that this 
bill will help create a more personalized approach for our veterans. 
The field of prosthetics is as much of an art as it is a science. Each 
amputee veteran is a unique case with his or her own specific needs. My 
bill is not an attempt to create a ``one size fits all'' solution but 
to better prepare the VA to address a wide range of demands and give 
our amputee veterans greater options in the mean time.
    This legislation will require that all VA prosthetic facilities and 
prosthesists be certified within 5 years by either the American Board 
for Certification in Orthotics and Prosthetics or the Board of 
Orthotics and Prosthetic Certification. Many of the VA facilities and 
prosthesists are already board certified but some are still lagging 
behind. It also allows amputee veterans to seek care for the repair and 
servicing of prosthetic devices from outside the VA system when VA 
facilities are unable to perform the required service or repairs or 
when a suitable VA facility is not available within a 55 mile radius. 
The VA will also be required to conduct a study to provide 
recommendations on modernizing its facilities and training its 
prosthesists so that it will be able to address the high tech needs of 
these amputee veterans. This report will allow us to get a better 
handle on what kind of resources the VA will need to address these 
problems. It also requires the VA to implement a plan to inform amputee 
veterans twice a year about the latest innovations in the field of 
prosthetics. Advances in the field of prosthetics continue rapidly and 
many amputee veterans may not be aware of some of the new options out 
there for them.
    I know you will all agree that providing for our brave men and 
women in uniform who have sacrificed so much for our great nation is 
imperative. Today we have an opportunity to demonstrate to our disabled 
veterans our firm commitment to providing them with all possible means 
for living a full and rewarding life. Thank you for giving me the 
opportunity to testify before the committee. I will be pleased to 
answer any questions you might have.

                                 

                                United States Ombudsman Association
                                            Des Moines, Iowa, 50325
                                                      June 13, 2007
Hon. Michael H. Michaud
Chairman, Subcommittee on Health
U.S. House of Representatives
Committee on Veterans' Affairs
335 Cannon House Office Building
Washington, DC 20515

Dear Representative Michaud:

    On behalf of the United States Ombudsman Association (USOA), thank 
you for your invitation to comment on H.R. 2192, proposed legislation 
to establish an ombudsman within the Department of Veterans' Affairs.
    I have served as President of the USOA for 2 years and am the 
Deputy Ombudsman in the State of Iowa--Office of Citizens' Aide/
Ombudsman. My short curriculum vitae is appended.
    The USOA, a non-profit association, does not receive any federal 
funds and does not participate in any federal contract or grant, nor 
has it done so for the previous two fiscal years.
    Founded in 1977, the USOA is our Nation's oldest and largest 
organization of ombudsmen working in government to address citizen 
complaints. The membership of the USOA includes practicing ombudsmen at 
all levels of government, some of whom have general jurisdiction over 
multiple agencies and subject matters, and others who have jurisdiction 
over a specified subject matter or agency. (Detailed information 
regarding the USOA can be found at the Association's website: http://
www.usombudsman.org/.)
    As a matter of good public policy, the USOA supports the 
establishment of independent ombudsman offices for the investigation 
and resolution of complaints involving administrative agencies in 
government at all levels. An ombudsman can serve as an independent 
office not only to address individual concerns, but also to identify 
systemic problems and recommend improvements in policies, practices, 
and procedures. An ombudsman can also help in the important effort to 
provide public and, indeed, legislative oversight of administrative 
agencies in government.
    From this perspective we have reviewed the proposed legislation and 
offer these comments.
    Key to the ability of an ombudsman to function effectively is 
independence. An ombudsman whose position, budget, staff, and 
investigations can be controlled or supervised by persons who (or whose 
actions or decisions) may be the subject of an investigation is not 
independent and will not be perceived as being independent. To the 
extent possible, an ombudsman should be structurally separated from the 
entities that are subject to the ombudsman's review or investigations. 
An ombudsman should be free to hire and fire staff, within the larger 
employment structure, manage the budget, select and prioritize the 
issues to be investigated and determine how they should be 
investigated. This independence allows the ombudsman to act and to be 
viewed by the public as acting as an impartial official who reports 
findings and recommendations based on objective review of the facts and 
the applicable law.
Structural Location
    H.R. 2192 establishes the ombudsman within the Department of 
Veterans' Affairs. The USOA believes that the best way to make an 
ombudsman independent is by situating the ombudsman's office in the 
legislative branch of government. If that arrangement is not feasible, 
then we believe that everything reasonably possible should be done to 
maximize an ombudsman's independence within the branch of government or 
agency where the office is situated.
Appointment, Supervision, Term, and Removal
    H.R. 2192 provides for the Secretary of the Department to designate 
the ombudsman. It does not specifically state to whom the Ombudsman 
reports for supervision or direction on job duties. Assuming that the 
ombudsman reports to the Secretary, the USOA believes that can 
compromise the independence of the ombudsman because the Secretary sets 
policies and makes decision relevant to the Department's programs and 
is the person ultimately accountable for decisions made by departmental 
staff. The ombudsman needs to be able to function without fear or 
concern that shat he/she says in regards to supervisory officials might 
affect his/her job.
    For this reason, the USOA believes it would be best for the 
ombudsman to be appointed by Congressional action. If that is not 
feasible, an alternative is for the ombudsman to be appointed by the 
President, with the advice and consent of the Senate (like an Inspector 
General) or a Congressional Committee.
    Furthermore, the term of the office should be set in such a manner 
that it does not coincide with administrative terms of office. In 
addition, removal or dismissal from office within the term should be 
limited to ``just cause,'' with relevant definitions specified in the 
legislation.
    We urge inclusion of these provisions under subsection (a) to 
reinforce the independence of the ombudsman.
Ombudsman's Staff
    Based on the experience of USOA members, we recommend a provision 
for the ombudsman to appoint at least a deputy or assistant ombudsman, 
to maintain consistent functioning of the office, in the event the 
ombudsman is absent or the position is vacant.
Authority to Investigate
    Subsection (b), pertaining to duties of the office, states only 
that the ombudsman ``shall act as a liaison for veterans and their 
family members.'' One of the hallmarks of an ombudsman function is the 
authority to investigate the agency which it oversees. The proposed 
legislation is silent in this regard. The USOA recommends that specific 
language be included in the legislation granting the ombudsman the 
authority to investigate complaints related to the healthcare program 
and benefits administered by the Department.
Authority to Access Information
    H.R. 2192 is also silent regarding the ombudsman's ability to 
gather relevant information, including information which may be 
confidential by law. The duty to investigate ought to include the 
authority to have access to information and to issue subpoenas when 
necessary. While usually an ombudsman will be able to obtain 
information from an agency on an informal basis, there may be instances 
when the agency may resist or deny information. Therefore, we recommend 
adding such a provision regarding this authority. In addition, the 
provision may require the ombudsman to keep confidential any 
information which is confidential by law.
Authority to Issue Public Reports
    Another important function that is also missing from H.R. 2192 is 
the authority to report the investigative findings and recommendations 
for improvements. Since ombudsmen do not have enforcement authority 
they rely on the ability to persuade an agency to take corrective 
action. The option to publicly criticize an agency enhances that 
ability. In addition, public reports can educate and inform those 
interested in or affected by the issues involved. An ombudsman cannot 
be effective without the duty to investigate and report. In addition, 
the ombudsman should submit an annual report to Congressional members 
and other officials with policy and operational oversight over the 
Department of Veterans' Affairs.
    We recommend adding these duties to subsection (b) of the proposed 
legislation.
Confidentiality and Immunity
    Subsection (d) provides for information provided to the ombudsman 
by veterans or their family members to be disclosed only as necessary 
to carry out the duties of the office. We recommend expanding this 
provision to grant the ombudsman immunity from being compelled to 
testify or produce complaint and investigative records in any legal 
proceedings, except as necessary to enforce or defend the authority of 
the office.
Closing
    Thank you for allowing the USOA this opportunity to comment on the 
proposed legislation. We applaud your consideration of creating the 
ombudsman function, in the interest of improving the delivery of 
necessary services to our veterans and their families.
            Sincerely,
                                                   Ruth Cooperrider
                                                          President
                           United States Ombudsman Association, and
                                                   Deputy Ombudsman
                  State of Iowa--Office of Citizens' Aide/Ombudsman

                                 

                                U.S. Department of Veterans Affairs
                                                    Washington, DC.
                                                    August 19, 2007
The Hon. Bob Filner
Chairman
Committee on Veterans' Affairs
U.S. House of Representatives
Washington, DC 20515

Dear Mr. Chairman:

    This letter is in response to your invitation to submit for the 
record the Department's views on two discussion drafts and H.R. 2623 
and H.R. 2699. We received these legislative items too late to address 
them in the statement we submitted to the Subcommittee in connection 
with the June 14, 2007, legislative hearing.
Discussion Draft on Readjustment Counseling Services and Mental Health
    Section 1 of this discussion draft would require the Secretary to 
establish a program to provide readjustment counseling and mental 
health services to eligible veterans through contracts with community 
mental health centers. Eligible veterans would include combat-theater 
veterans who seek VA care within the 2-year period after their 
discharge or release from service, who served in Operational Enduring 
Freedom or Operation Iraqi Freedom, and who reside in an area where the 
Secretary has determined the Department is incapable of providing 
readjustment and mental health services.
    This provision would cover community mental health centers which: 
(1) meet qualification standards determined by the Secretary; (2) 
require appropriate staff to complete a VA clinical and cultural 
training program; and (3) employ a qualified veteran for the duration 
of the contract. These centers would also be required to submit 
information relating to the program's workload to the Secretary on an 
annual basis.
    Section 1 would further require the Secretary to establish a 
program to provide support and assistance to the immediate family 
members of eligible veterans. Such assistance would include the 
provision of education materials and classes on mental health issues 
(including signs and symptoms of post traumatic stress disorder). This 
provision would also require the Secretary to provide individual 
counseling and mental health services (up to 2 years) to immediate 
family members, if requested.
    Section 1 would also require the Secretary to establish a 5-year 
pilot program in at least four Veterans Integrated Service Networks 
(VISNs) to provide confidential readjustment counseling and mental 
health services to combat theater veterans at non-VA facilities. Under 
the pilot program, veterans would receive a voucher, coupon, or card 
that could be used to receive five visits with any provider on a 
Department-approved list.
    For the reasons discussed below, the Department opposes section 1. 
First, it would blur the distinction between VA's readjustment 
counseling services and mental health services and work at cross-
purposes with the existing programs. Additionally, these services are 
authorized by separate authorities and employ different eligibility 
criteria. These benefits should not be coupled because they are 
conceptually and operationally very distinct areas of treatment.
    VA's authority to furnish readjustment counseling services includes 
authority to furnish limited mental health services necessary for 
effective treatment of the veteran's readjustment problems. Vet Centers 
provide professional treatment for combat-related Post Traumatic Stress 
Disorder (PTSD), depression, and substance abuse and, if necessary, 
refer the veteran to VA facilities for treatment of additional or more 
complex mental health needs. VA's readjustment counseling services 
encompass many other unique social and psychological readjustment 
services separate from mental health services. Readjustment counseling 
is considered to be a special, ``more-than-medical,'' community-based 
counseling service providing an array of services to combat theater 
veterans to facilitate a successful readjustment from combat to 
civilian life. Vet Centers also have authority to furnish limited 
counseling, education, and training services to the veteran's immediate 
family members when such services are needed for the effective 
treatment and readjustment of the veteran. Family readjustment services 
include outreach, early intervention educational services, and family 
counseling. Family counseling is provided through the Vet Centers to 
treat any psychological, social or other military-related readjustment 
problems of the veteran whether those problems are service connected or 
not. We note that family services currently provided through Vet 
Centers are available throughout the life of the veteran. section 1 
would provide individualized counseling and mental health services for 
immediate family members for no more than 2 years, a significant 
reduction of the current benefit.
    Comprehensive mental health services are furnished as medically 
needed to all enrolled veterans, regardless of combat-status, as part 
of VA's standard medical benefits package. VA already has authority to 
furnish certain family members with counseling, training, and education 
services. However that authority is extremely limited by statute and 
extends only to those family members of veterans receiving treatment 
for a service-connected condition. That authority also requires a nexus 
between the services furnished to the family members and the effective 
treatment of the veteran.
    While we certainly appreciate that a veteran's family member may 
have his or her own mental health needs apart from the veteran's, we 
believe it is beyond the Department's statutory mission to furnish 
treatment or services to family members whose individual mental health 
needs are unrelated to the Department's ability to effectively treat 
the veteran.
    Second, VA already has authority to contract for both readjustment 
counseling services and mental health services. Currently, VA contracts 
for readjustment counseling and related readjustment services with 
private sector community mental health agencies and other professional 
entities. We see no justification for limiting the entities with which 
VA may contract for these services, as the bill would do. Of note, most 
of our contract providers are located in rural areas. In providing 
mental health services, VA collaborates with publicly supported clinics 
in furtherance of VA's Mental Health Strategic Plan. Several existing 
contracting related authorities can be used to ensure a veteran 
receives needed mental health services if VA cannot timely provide the 
needed services in a timely manner. In this regard, section 1 is 
duplicative of VA's existing contract authorities and on-going 
activities.
    Third, section 1 is not necessary because Vet Centers already 
provide veteran-peer outreach and counseling. In 2004, VA began an 
aggressive outreach effort, which included the hiring of combat-theater 
veterans of Operation Enduring Freedom (OEF) and Operation Iraqi 
Freedom (OIF) to provide outreach services and peer-counseling to their 
fellow veterans. To date, the Vet Center program has hired 100 OEF and 
OIF outreach workers.
    The Vet Center program is also undergoing the largest expansion in 
its history. The planned expansion complements the efforts of the Vet 
Center outreach initiative, discussed above, by ensuring sufficient 
staff resources are available to provide the professional readjustment 
services needed by the new veterans as they return home. In fiscal year 
(FY) 2006, VA announced plans for establishing two new Vet Centers in 
Atlanta, Georgia, and Phoenix, Arizona, and augmenting staff at 11 
existing Vet Centers, bringing the current number of Vet Centers to 
209. In February 2007, VA announced plans to increase the number of Vet 
Centers to 232 and augment the staff at 61 existing Vet Centers. The 
following communities will be receiving new Vet Centers: Montgomery, 
Alabama; Fayetteville, Arkansas; Modesto, California; Grand Junction, 
Colorado; Orlando, Fort Meyers, and Gainesville, Florida; Macon, 
Georgia; Manhattan, Kansas; Baton Rouge, Louisiana; Cape Cod, 
Massachusetts; Saginaw and Iron Mountain, Michigan; Berlin, New 
Hampshire; Las Cruces, New Mexico; Binghamton, Middletown, Nassau 
County and Watertown, New York; Toledo, Ohio; Du Bois, Pennsylvania; 
Killeen, Texas; and Everett, Washington.
    In May 2007, VA announced a plan to add 100 new staff positions to 
the Vet Center program in FY 2008. Together with the 100 OEF and OIF 
outreach specialists hired in FY 2004 and 2005, these program 
expansions represent an increase in Vet Center staffing by 369 
positions since 2004, a 39% increase.
    Fourth, while well-intended, the pilot program required by section 
1 could result in harm to a participating veteran. In most cases, five 
sessions is too few to ensure an adequate course of evidence-based 
treatment is delivered safely and effectively. A participating veteran 
may believe, in error, that upon completing the fifth visit that he or 
she has received a full course of treatment and no longer requires 
further assistance from the Department. The draft bill's arbitrary 
limit of five visits could create an unreasonable expectation on the 
part of the patient that he or she should be able to resolve their 
readjustment or mental health problems in that timeframe.
    Moreover, the pilot program would fragment care and impede VA's 
ability to ensure veterans in the program receive the benefits of 
continuity of care. In sharp contrast, VA-furnished readjustment 
services and mental health services are delivered in a manner promoting 
the veteran's continuity of care. Under the readjustment counseling 
program, VA conducts site-visits to contract providers to verify the 
quality of readjustment counseling services being rendered to veterans. 
With respect to mental health services currently provided through 
Department medical facilities, these services are fully integrated. Of 
utmost importance, the patient's medical data are maintained in the 
VA's electronic health record system, which further helps prevent 
fragmentation and ensure continuous high-quality care.
    Finally, the Vet Center program reports the highest level of 
veteran satisfaction recorded for any VA program. For the last several 
years, over 99% of veterans consistently using the Vet Centers reported 
satisfaction with services received and indicated they would recommend 
the Vet Center program to other veterans. In view of the Vet Center's 
authorities and accomplishments, we oppose section 1 because it would 
amend the Vet Center program in a way that adds no value and results in 
substantial confusion between these benefits and those separately 
furnished under VA's mental health programs.
    Section 2 of this discussion draft would authorize the Secretary to 
make a grant to a qualified entity to conduct workshop programs in the 
performing arts, public speaking, writing, and culinary arts to further 
the readjustment of veterans. Qualified entities would include a 
nonprofit private entity with expertise in conducting workshop programs 
or one that the Secretary determines has a program that is likely to 
improve the readjustment of veterans. A grant under this section could 
not exceed $100,000 for any calendar year and would need to be used 
exclusively for the benefit of veterans. section 2 would also authorize 
$2 million to be appropriated to carry out this section each fiscal 
year.
    VA does not support section 2. It is not clear what appropriation 
it is intended that VA use for this authority. We would oppose using 
medical care funds for services that would not constitute medical care.
Second Discussion Draft on Programs for Homeless Veterans
Homeless Providers Grant and Per Diem Program
    Section 1 would amend the Department's Homeless Providers Grant and 
Per Diem Program (the ``Program'') by requiring the Secretary to 
furnish funding assistance to grantees on an annual basis; currently 
the grantees receive per diem payments based on the provider's daily 
cost of care. It would also require the Secretary to annually increase 
the annual rate of payment to reflect anticipated changes in the 
grantee's cost of furnishing services and to take into account the cost 
of providing services in a particular geographic area. section 1 would 
further authorize the Secretary to establish a maximum annual amount 
that could be paid to a provider under the Program. Currently, the 
statutory cap on the per diem amount is the same that applies to per 
diem payments made to State homes.
    Section 1 would also eliminate the current requirement that VA 
adjust the per diem rate to exclude other sources of income a provider 
receives for the purpose of furnishing services to homeless veterans. 
However, section 1 would permit the Secretary to continue collecting 
such information as needed to determine the provider's cost of care. 
section 1 would also allow grantees to use VA payments to match, or in 
combination with, other payments or grants for which the grantee is 
eligible.
    The Department does not support section 1 in its entirety. Although 
payment on an annual basis would appear to ease the administrative 
burden of calculating daily per diem rates, it would not offer any 
incentive to providers for maintaining the census and level of services 
throughout the year for which the funding amount is awarded. Providing 
the grantee with an annual lump-sum payment would lessen a provider's 
accountability concerning the use of VA grant funds. This concerns us 
greatly. Also, this measure is unnecessary because the Department 
recently modified its system for determining per diem rates under the 
Program. This should make it much easier to determine the per diem 
rates and alleviate the administrative workload for both VA and the 
grantee.
    However, VA supports the provision in section 1 that would 
establish a maximum rate that could be paid to grantees, VA's grant 
program for State homes and the grant program for homeless providers 
are too dissimilar to justify linking the maximum payment level as is 
currently done by statute. And VA has no objection to eliminating the 
requirement to adjust a grantee's per diem payment by excluding other 
sources of income from the provider's estimated daily cost of care. We 
note, however, that this provision would not prohibit a provider from 
receiving payments from VA and other sources that together exceed the 
grantee's actual cost of providing care or services to homeless 
veterans. We would therefore recommend that section 1 be modified to 
prevent a grantee from being able to receive more than 100 per cent of 
its actual daily cost of care.
    The Department estimates the total cost of section 1 to be 
$88,388,137 for fiscal year 2008 and $1,479,329,118 over a 10-year 
period.
Dental Benefit for Homeless Veterans
    Section 2 would eliminate the current requirement that in order to 
receive one course of dental services an eligible veteran must also be 
receiving care or services for a period of 60 consecutive days in one 
of the specified treatment settings (domiciliary care, care in a 
therapeutic residence, community residential care, care from a grantee 
under the Program).
    VA strongly opposes section 2. Without the 60-day treatment 
requirement, there is no means to ensure the homeless veteran gets his 
or her other medical needs addressed. The availability of the dental 
benefit often provides the only opportunity to connect a homeless 
veteran to other VA programs that can provide the veteran with more 
vital care. Also, a single course of dental care in the absence of 
other medical services does little to help homeless veterans lift 
themselves from their plight. Most homeless veterans suffer from 
substance or alcohol abuse problems and/or serious mental health 
conditions. These conditions make it difficult, if not impossible, for 
them to find and keep permanent housing and to secure gainful 
employment. If these veterans receive not only the one-course of dental 
care services but also medical services to help them rise above their 
homelessness, everyone's interests are served. VA data support this 
position: homeless veterans have a better rate of treatment success and 
experience longer stays in permanent housing if they complete their 
residential treatment programs. We therefore find no justification for 
changing the current program eligibility criteria,
    The Department estimates the cost of section 2 to be $8.1 million 
for fiscal year 2008 and $98.1 million over a 1 a-year period.
VISN Staffing
    Section 3 would require the Secretary to ensure that each VISN 
office assigns at least one full-time employee of the Veterans Health 
Administration (VHA) to oversee and coordinate VA's programs for 
homeless veterans. VA regards section 3 as unnecessary. VHA has already 
assigned a full-time employee to coordinate homeless veterans programs 
in every VISN and has fully funded those positions.
Grants to Repair and Replace Homeless Providers' Facilities
    Section 4 would authorize the Secretary to make emergency grants, 
pursuant to criteria and requirements prescribed by the Secretary, to 
entities receiving grants under the Homeless Providers Grant and Per 
Diem Program for the purpose of repairing or replacing a grantee's 
facility that is damaged or destroyed by a major disaster.
    VA supports section 4. Grantees receiving VA grants and per diem 
for furnishing care to homeless veterans under the Program lost their 
capacity to continue providing care and services (including 
transitional beds) in the aftermath of Hurricane Katrina. Desperately 
trying to find beds for their displaced veterans, the grantees whose 
facilities were damaged turned to VA for additional assistance. To 
assist them, VA had to rely on other departments which administer 
Federal laws and regulations managing the Federal response to disasters 
and national emergencies. This situation resulted in delays, which in 
turn lengthened the time displaced homeless veterans had to survive 
without services previously furnished by the grantee. All-but foremost 
the displaced homeless veterans previously served by the grantee--would 
benefit if VA were able to provide financial assistance to grantees in 
these types of catastrophic situations more quickly. However, we note 
that if a grantee's facility cannot be replaced or repaired, VA would 
still not have authority to award grants out-of-cycle to maintain 
capacity in the area(s) affected. We note that the costs for emergency 
activities of this nature are not typically available within existing 
funding levels.
Pilot Program for Permanent Housing
    Section 5 would require the Secretary to conduct a 5-year pilot 
program to award grants to public or nonprofit entities with 
established single-room occupancy facilities for the purpose of (1) 
acquiring and operating single-room occupancy housing solely for the 
benefit of homeless veterans and (2) providing rental assistance on 
behalf of homeless veterans. Section 5 would also establish detailed 
reporting requirements and authorize $10 million for fiscal year 2008 
and each subsequent fiscal year to carry out this pilot program.
    VA does not support section 5. As a general matter, VA's statutory 
mission appropriately does not encompass permanent housing for homeless 
veterans. In our view, section 5 is a measure far better suited to the 
expertise, capacity, and mission of the Department of Housing and Urban 
Development. If enacted, VA estimates the cost of section 5 to be $5 
million in fiscal year 2008 and $93 million over a 10-year period.
H.R.2623 Elimination of Co-payments for Hospice Care
    H.R. 2623, as ordered reported, would exempt a veteran who is 
receiving inpatient or outpatient hospice care from all copayment 
requirements that would otherwise apply.
    We support this measure.
H.R. 2699 amendments to VA's Homeless Providers Grant and Per Diem 
        Program
Elimination of Adjustments to Per Diem Rate
    Section 1 would repeal the requirement that the Secretary adjust 
the amount of per diem payable to a grantee under the Homeless 
Providers Grant and Per Diem Program by excluding income the grantee 
receives from other sources to provide services to homeless veterans. 
We refer the Committee to our comments on the discussion draft bill 
that included a similar provision and our concern that a grantee could 
receive more than 100% of its cost of care.
Demonstration Program for Members of the Armed Forces
    Section 2 would require the Secretary to conduct, through September 
3D, 2011, a demonstration program (at a minimum of three sites) for the 
purpose of identifying active duty members who are at risk of becoming 
homeless after they are discharged or released from service. The 
Secretary would also be required to provide (directly or by contract) 
referral, counseling, and supportive services to service members 
participating in the demonstration program. section 2 would also 
require the Secretary of Veterans Affairs to consult with the Secretary 
of Defense (and other appropriate officials) in developing the criteria 
for inclusion in the demonstration program. Finally, section 2 would 
authorize $2 million to be appropriated to carry out this demonstration 
project.
    VA does not support section 2. There exist no reliable criteria for 
identifying which active duty members are at risk of becoming homeless 
once they leave the military, nor is there any reliable means for 
developing such criteria. VA could not carry out such a program.
Referral and Counseling Demonstration Program
    Section 3 would expand. from 6 to 12, the number of sites 
participating in the Department of Labor's on-going demonstration 
program of furnishing referral and counseling services to veterans at 
risk of becoming homeless upon their release from certain institutions 
(e.g., penal institutions and long-term mental health facilities). 
section 3 would also eliminate this program's demonstration status and 
authorize it through September 30, 2011.
    We defer to the views of the Secretary of Labor, who administers 
this program. We are aware, however, that this demonstration program 
has been very successful at reducing recidivism rates among the 
participating veterans and we therefore applaud Labor's success with 
this program.
    Grants for Staffing Service Centers
    Section 4 would permit service centers receiving grants under the 
Homeless Providers Grant and Per Diem Program to use those funds to 
meet mandated staffing levels. VA has no objection to section 4.
Domiciliary Care
    Section 5 would require the Secretary to take appropriate actions 
to ensure that the domiciliary care programs of the Department are 
adequate to meet the capacity and safety needs of women veterans. VA 
does not support section 5 because it is unnecessary. The Department 
has on-going efforts to ensure the domiciliaries are able to meet the 
unique needs of women veterans and to ensure their privacy and safety 
while in that setting. Finally we note that the measure would also 
eliminate the authorization for appropriations for fiscal years 2003 
and 2004 currently found in law. That authorization does not expire as 
may be suggested by the caption for section 5.
    The Office of Management and Budget advises that there is no 
objection to the transmittal of this letter in regard to the program of 
the President.
            Sincerely yours,
                                                 R. James Nicholson
                                                          Secretary

                                 

                                U.S. Department of Veterans Affairs
                                                    Washington, DC.
                                                   January 10, 2008
The Hon. Michael H. Michaud
Chairman
Subcommittee on Health
Committee on Veterans' Affairs
U.S. House of Representatives
Washington, DC 20515

Dear Mr. Chairman:

    In accordance with the requirements of section 212(c) of Public Law 
109461, enclosed is the Department of Veterans Affairs' (VA) plan to 
improve access to quality long term care and mental health services for 
veterans residing in rural areas.
    Similar letters have been sent to other leaders on the House and 
Senate Committees on Veterans' Affairs.
            Sincerely yours,
                                               James B. Peake, M.D.
                                                          Enclosure

                              ----------                              


                     Department of Veterans Affairs
                     Veterans Health Administration
         Plan to Increase Access to Quality Long-Term Care and
    Mental Healthcare for Enrolled Veterans Residing in Rural Areas
                              January 2008

Table of Contents

I.

INTRODUCTION

II.

BACKGROUND

A.

The Office of Rural Health

B.

Definition of Urban/Rural/Highly Rural

C.

Demographics

D.

Current Services

III.

PLAN

A.

Goal

B.

Long-Term Care Initiatives

C.

Mental Health Initiatives

IV.

BARRIERS TO RURAL HEALTH CARE

A.

Long-Term Care

B.

Mental Health

V.

CONTINUOUS IMPROVEMENT

ATTACHMENTS

Attachment A

Veteran Enrollee and Patients by Urban/Rural/Highly Rural Designations

Attachment B

Veteran Enrollee Drive Time Access Standards

Attachment C

Acronyms

I.

INTRODUCTION

    On December 22, 2006, the Information Technology Act of 2006, 
Public Law 109-461, was signed into law. Section 212 of this law 
established the Office of Rural Health (ORH) and, among other things, 
requires the Director of the Office of Rural Health to develop a plan 
to improve the access and quality of care for enrolled veterans in 
rural areas.
    Specifically, section 212(c) states the plan shall include:

(l)

Measures for meeting the long-term care needs of rural veterans; and

(2)

Measures for meeting the mental health needs of veterans residing in rural 
areas

    This plan addresses the specific actions underway in regards to 
mental health (MH) and long-term care (LTC). The plan includes a 
systematic evaluation of the current state of MH and LTC service 
provided by the Veterans Health Administration (VHA) and presents a 
strategy to increase access, either by enhancing existing services or 
developing new initiatives, to further advance access to quality MH and 
LTC services for veterans residing in rural areas.

II.

BACKGROUND

A.

The Office of Rural Health (ORH)

    VA's Office of Rural Health was established in March 2006, in 
compliance with P.L 109-461 section 212 Sec. 7308(c) under the VHA 
Office of the Assistant Deputy Under Secretary for Health (ADUSH) for 
Policy and Planning.
    The mission of the office is to promulgate policies, best practices 
and innovations to improve services to veterans who reside in rural 
areas of the United States. The office is accomplishing this by 
assessing the delivery of services with a range of VHA program offices 
to ensure the needs of rural veterans are being considered as program 
development and implementation takes place. As a program office, the 
role of the ORH is to provide policy, guidance, and oversight within 
VHA to enhance the delivery of care by creating greater access, 
engaging in research, promulgating best practices and developing sound 
and effective policies to support the unique needs of enrolled veterans 
residing in geographically rural areas.
    As specified in the Public Law, one of the key responsibilities of 
ORH is to conduct, coordinate, promote, and disseminate research into 
issues affecting veterans who reside in rural areas. With a strong 
collaboration between ORH and internal VHA program offices, ORH is also 
responsible to develop, refine, and promulgate policies, best practices 
and innovations to improve services. ORH will translate lessons learned 
into policy and facilitate broader execution through Patient Care 
Services (PCS).

B.

Definition of Urban/Rural/Highly Rural

    There is no single, universally preferred definition of rural that 
is used across either government or private sector agencies.\1\ 
Currently, more than 15 definitions of rural are used by Federal 
programs. The two most commonly used classification systems are from 
the U.S. Census Bureau and the Office of Management and Budget. In 
order to be consistent with most commonly used definitions, VHA adopted 
a census bureau based classification system, where our definitions are:
---------------------------------------------------------------------------
    \1\ Choosing Rural Definitions. March 2007. Rural Policy Research 
Institute Issue Brief. Mueller, et. al.

        Urban: A veteran (or clinic) located in a Census defined 
---------------------------------------------------------------------------
        urbanized area.

        Rural: A veteran (or clinics) not designated as urban.

        Highly Rural: A veteran (or clinic) that is defined as rural 
        and located in counties with less than 7 civilians per square 
        mile.

    For this plan, the term rural will refer to both rural and highly 
rural populations.

C.

Demographics

    The Census Bureau estimates approximately eight percent of the 
general population are veterans. In FY 2006, the Veterans Health 
Administration (VHA) had almost 7.9 million enrollees and served about 
4.8 million unique patients. In fiscal year 2006, VHA identified 
approximately 39% (1,878,624) of the veteran patients served resided in 
rural areas and another one and six tenths percent (79,464) resided in 
highly rural areas. Of our enrollee population, approximately 36% 
(2,850,173) resided in rural areas and 1.5 percent (118,685) resided in 
highly rural areas (Attachment A).

D.

Current Services

Long-Term Care (LTC)
    Health care services, both within and outside VA, exist along a 
continuum consisting of: (1) ambulatory care, which is predominantly 
offered as primary care (through Geriatric Primary Care or Geriatric 
Evaluation and Management programs when available) with use of urgent 
care and referrals for specialty services; (2) acute care which 
encompasses hospital-based acute and intensive/critical care; and (3) 
long-term care. Long-term care is a spectrum of medical and non-medical 
services provided for a prolonged period of time, to eligible persons 
with chronic, disabling conditions, delivered in institutional and non-
institutional settings and can be either provided, purchased, or 
coordinated by VA. VHA provides long-term care through programs managed 
by the Office of Geriatric and Extended Care (GEC) and the Office of 
Care Coordination (GCC).
    The GEC provides oversight for the majority of VHA's LTC programs. 
While LTC services are provided to veterans of all ages, the elderly 
comprise a major proportion of those needing LTC (two-thirds of the 
population using VHA LTC are over the age of 75). These LTC programs 
provide a continuum of increasingly resource-intensive services ranging 
from outpatient Geriatric Primary Care to institutionalized nursing 
home care. Veterans can receive services in one or more of VHA's LTC 
care programs concurrently based on need.
    Veterans whose care needs exceed the resources for continued 
support in the home may require placement in settings where 
professional staff on site can support necessary self-care and health 
needs: VA operated nursing home care units, VA contracted community 
nursing homes, and the State Veterans Homes provide this form of long-
term care. A final form of long-term care is offered to those whose 
disease process is anticipated to result in death. Palliative care 
focuses on the comfort-physical, mental, and spiritual-of-patients. The 
most well known form of palliative care is hospice, which is palliative 
care provided when death is expected in 6 months or sooner. VA provides 
hospice and palliative care in a continuum of environments, both 
institutionally and in-home care, as well as linking with community 
services through participation in Hospice-Veteran Partnerships to 
improve veterans' access to community hospice care in rural areas.
    VHA's strategic direction since the enactment of the Veterans 
Millennium Health Care and Benefits Act, P.L. 106-117 (Nov. 30, 1999), 
has been to develop and offer community and home-based alternatives to 
nursing home care. When veterans are unable or limited in their ability 
to come to a VA facility for care, this strategic direction is to bring 
care closer to the veterans and to enhance the veteran's ability to 
remain in his or her customary place of residence. To meet this need, 
VA has several non-institutional programs, including Home Based Primary 
Care (HBPC), which provides comprehensive longitudinal care by an 
interdisciplinary team in the homes of veterans with complex chronic 
disabling disease. Additional initiatives to increase rural veterans' 
access to care include establishing satellite HBPC programs at remote 
sites such as Community Based Outpatient Clinics (CBOC) and an 
expansion of the Office of Care Coordination's Care Coordination Home 
Telehealth (CCHT) program into 155 VA facilities and clinics 
nationwide. CCHT uses home telehealth technologies to enhance and 
extend care and case management in the home for veteran patients with 
chronic diseases. These veterans are monitored at home using telehealth 
technology that transmits vital sign measurements and symptoms to a VA 
care coordinator. CCHT reduces clinical complications, increases access 
to care when it is needed, and prevents or delays elderly veterans from 
being admitted into long-term institutional care.
    Other non-institutional LTC services that are available include, 
but are not limited to, Community Residential Care (including Medical 
Foster Home), Adult Day Health Care, Homemaker/Home Health Aide, 
outpatient respite services, and purchased skilled home care. To 
develop future opportunities for greater access to care for veterans, 
collaborations with other Federal entities such as the Administration 
on Aging, Indian Health Service, and the Health Resource Services 
Administration have been established.
Mental Health
    Comprehensive and effective mental healthcare is a top priority for 
VA. VA is making changes to address veterans' needs and is investing 
significantly to improve access to mental health services for veterans 
residing in rural areas and throughout the country. Mental health 
services are available at all VHA outpatient clinics either from 
primary care staff, who are trained to manage many common mental health 
problems, or from mental health specialists, who can manage a full 
range of mental healthcare needs. VA also provides readjustment 
services through the Vet Center program, which is designed to provide 
quality readjustment counseling and some related mental health 
services, for combat veterans and family members (to the extent 
necessary for successful readjustment for the veteran).
    The advancement of technology has increased the range of specialty 
mental health services that can be provided in rural areas, creating 
greater access for these veterans. VA's Office of Care Coordination 
(OCC), in collaboration with the Office of Mental Health Services 
(OMHS), has developed telemental health programs, which involve the use 
of health information and telecommunications systems to enable delivery 
of care when veteran patients and clinicians are separated by 
geographical distance. Telemedicine equipment has been deployed to VA 
facilities and their corresponding CBOCs, thus building an 
infrastructure to provide expert telemental healthcare where direct 
access to mental health specialists is unavailable. The advantages of 
telemental health are that it improves access to mental health 
services, reduces the need for travel by patients and is associated 
with preliminary evidence that it reduces the ``no show'' rate in 
clinics.
    Additionally, VHA has implemented care coordination home telehealth 
(CCHT) to support the care of veteran patients with chronic mental 
health conditions in their homes and local communities. Another example 
of VA telemental health programs is the collaboration with the Indian 
Health Service where VA provides services on several reservations.
    VA OMHS is also meeting the needs of rural veterans through the 
pilot implementation of the Mental Heath Intensive Case Management--
Rural Access Network for Grouth Enhancement (MHICM-RANGE) program, 
where VA provides community based support for veterans with severe 
mental illness. Other programs include the use of referrals for fee-
based mental health services in Community Mental Health Centers and a 
program that sends VA mental health providers to Community Mental 
Health Centers where they can use laptop computers for Computerized 
Patient Record System (CPRS) access. Still other efforts include 
integrating psychologists into the Home Based Primary Care program and 
adding mental health professionals to the staffs of CBOCs.

III.

PLAN

    The Office of Rural Health (ORH) has collaborated with an array of 
subject matter experts within VHA program offices to develop a plan to 
improve access to quality mental health and long-term care for veterans 
residing in rural areas. This plan takes the results from an internal 
programmatic assessment and either expands current services to increase 
focus on rural veterans or identifies new initiatives to meet the long-
term care and mental health needs of rural veterans. The performance 
period is FY 2008.

A.

Goal: To increase access to quality mental health and long-term care 
services for veterans residing in rural areas.

B.

Long-Term Care Initiatives

1.

Expand access to VA's innovative non-institutional LTC services for 
veterans residing in rural areas by supporting the Office of Geriatrics and 
Extended Care (GEC) and the Office of Care Coordination (OCC) in 
implementing additional programs that serve rural veterans. Programs 
include:

a.

Home Based Primary Care (HBPC)

b.

Care Coordination Home Telehealth (CCHT)

c.

Medical Foster Home program

Milestone: During FY 2008 establish CCHT programs in all 21 Networks and at 
most facilities

2.

Conduct a baseline assessment of the average daily census (ADC) in non-
institutionalized settings for veterans residing in rural areas for the 
following programs:

a.

Home Based Primary Care (HBPC)

b.

Care Coordination Home Telehealth (CCHT)

c.

Medical Foster Home program

Milestone: Completion of baseline by 4th Quarter, FY 08 and completion of 
plan by 1st Quarter FY 09

3.

Fund at least two studies or demonstration projects that address issues of 
long-term care, institutional or non-institutional, access or quality for 
veterans residing in rural areas.

Milestone: Develop a Request for Proposals (RFP) and select projects by 4th 
Quarter, FY 08

4.

Create an Office of Rural Health Web site to give veterans greater access 
to information and research.

Milestone: 4th Quarter, FY 08

5.

Establish a Rural Health National Advisory Committee (RHNAC) to examine 
ways to improve and enhance VA services for enrolled veterans residing in 
rural areas through evaluation of current program investment, policy, and 
barriers to providing services as well as the development of strategies to 
improve services. The RHNAC will be comprised of experts within the 
federal, non-federal, academic, and veteran community.

Milestone: Charter developed by 3rd Quarter, FY 08

6.

Develop strategies and incentives to support recruitment and retention of 
staff to provide geriatric care in rural settings, including those 
stationed on a full-time basis within rural settings, those who rotate 
between facilities, and those utilizing telehealth services for care 
delivery.

 Milestone: Ongoing activity in FY 08

C.

Mental Health Initiatives

1.

Expand the Mental Health Intensive Case Management-Rural Access Network 
Growth Enhancement (MHICM-RANGE) pilot program into additional rural areas 
where need is identified.

Milestone: 3rd Quarter, FY 09

2.

Increase the capacity to provide telemental health services from VA 
facilities over the FY 07 baseline.

Milestone: Ongoing initiative, FY 08

3.

Evaluate strategies and the feasibility of implementing VA collaborations 
with non-VA entities to expand telemental health linkages between VA 
providers and patients in community settings.

Milestone: Assessment by 4th Quarter, FY 08

4.

Through VHA's Strategic Planning process, assess rural geographic areas 
identified as underserved markets based on VHA's drive time access 
standards to primary care (which includes access to mental health services) 
and develop plans for addressing gaps in care.

Milestone: 4th Quarter, FY 08

5.

Require each VA medical center or clinic to develop plans for the delivery 
of VA mental health services by using on-site providers, telemental health, 
referral to other facilities, or referral to community providers as 
appropriate.

Milestone: Implementation of plans by 4th Quarter FY 08

6.

Assess the degree to which CBOCs defined as rural or small (<1500 unique 
veterans) provide timely delivery of mental health services completing an 
initial evaluation within 24 hours of veteran referral and for a full 
diagnostic and treatment planning evaluation for non-urgent cases within 14 
days.

Milestone: 4th Quarter FY 08

7.

Develop metrics to serve as quality monitors for the delivery of mental 
health services in rural areas, in collaboration with mental health 
services.

Milestone: Development of metrics by 4th Quarter FY 2008

8.

Fund at least two studies or demonstration projects that address issues of 
mental healthcare, access or quality for veterans residing in rural areas.

Milestone: Develop a Request for Proposals (RFP) by 4th Quarter, FY 08. 
Select and begin initiatives by 4th Quarter, FY 08

9.

Create an Office of Rural Health Web site to give veterans greater access 
to information and research.

Milestone: 4th Quarter, FY 08

10.

Develop strategies and incentives to support recruitment and retention of 
staff to provide mental healthcare in rural settings, including those 
stationed on a full-time basis within rural settings, those who rotate 
between facilities, and those utilizing telemental health services for care 
delivery.

Milestone: Ongoing activity in FY 08

11.

Develop a Rural Health National Advisory Committee (RHNAC) to examine ways 
to improve and enhance VA services (including mental health services) for 
enrolled veterans residing in rural areas through evaluation of current 
program investment, regulatory policy, and barriers to providing services 
as well as the development of strategies to improve services. The RHNAC 
will be comprised of experts within the federal, non-federal, academic, and 
veteran community.

Milestone: Charter developed by 3rd Quarter, FY 08

IV.

BARRIERS TO RURAL HEALTH CARE

    The ORH has systematically identified barriers to delivery of 
accessible high quality care in rural America. Initial findings 
include:

A.

Long-Term Care

    Meeting access and quality standards in rural areas is a challenge 
for both VA and non-VA healthcare systems. This is because rural 
veterans live farther from Veterans Administration Medical Center-
based, tertiary care options (which are largely in urban areas in order 
to meet the needs of the larger concentrations of veterans), greater 
delay and disease exacerbation before care is accessed, less local 
availability to specialty and geriatrics expertise, and greater 
likelihood referrals to tertiary care centers will be unfulfilled. The 
intrinsic challenges of providing LTC in less populous areas and over 
wider geographic distances are exacerbated by the worsening undersupply 
of trained professionals that characterizes rural settings.
    Additional challenges to rural, elderly veterans include: limited 
transportation services; frail, elderly primary care givers with few 
resources; preferential relocation to urban areas of younger family 
members who might otherwise provide non-professional support services 
and care giving; higher poverty rate; a lower level of awareness of 
those services that may be available, and more constricted financial 
resources.

B.

Mental Health

    The provision of mental healthcare in rural settings has 
historically been a challenge for all health systems and providers, 
including VA. While Community Based Outpatient Clinics (CBOCs) have 
been the anchor for VHA's efforts to expand access to veterans in rural 
areas, there are notable challenges in providing mental health services 
in rural communities, such as:

      Availability of qualified mental health professionals in 
small rural communities is often limited.
      Very small rural CBOCs may require mental health 
specialists too infrequently to justify even part-time on-site mental 
health staff. However, telemental health at remote clinics, where 
feasible, has proven to be convenient and is generally well accepted by 
veterans.
      VA salaries at times are not competitive in specific 
locations, both rural and urban.
      Transportation to and from CBOCs is problematic for many 
veterans living in sparse population areas. However, telemental health 
at remote clinics, where feasible, has proven to be convenient and is 
generally well accepted by veterans.
      VHA's CBOCs are complemented by contracts in the 
community for specialty services. The range of specialty care services 
is highly dependent on the services available in the local community.
      Constraints on the expansion of telehealth in VHA, as in 
all organizations, include clinical (e.g. clinician buy-in and training 
of clinicians), technical (e.g. interoperability of technologies, 
telecommunications bandwidth availability, a national video-
telecommunications, and adequate scheduling systems) and business 
processes (e.g. clinical coding and reimbursement systems).

    While these barriers exist, the ORH will leverage VA's capabilities 
and develop partnerships with governmental and non-governmental 
entities to provide the best solutions to the challenges that rural 
veterans face. Areas of focus include: technology expansion, 
transportation, research and evaluation, workforce recruitment and 
retention, and education and training. By using a data-driven 
decisionmaking and collaborative approach to develop policies and 
practices that expand and adapt current initiatives, as well as 
developing new models of care delivery, the ORH will improve access to 
high quality healthcare care for rural veterans.

V.

CONTINUOUS IMPROVEMENT

    VA's plan to increase access and quality mental health and long-
term care services to veterans residing in rural areas will be 
implemented, evaluated, and undergo continuous improvement. Prior to 
implementation of initiatives outlined in the plan, the Office of Rural 
Health will consult with the Office of Geriatric and Extended Care, the 
Office of Care Coordination, and the Office of Mental Health Services 
within the Office of Patient Care Services, and other VA offices as 
appropriate, to assess feasibility and identify barriers that could 
affect the successful implementation of the initiatives.

                              ----------                              


                              Attachment A
    Veteran Enrollee and Patients by Urban/Rural/Highly Rural 
Designations

----------------------------------------------------------------------------------------------------------------
                                                                                                       Rural &
                     Total Enrollees                          Urban         Rural     Highly Rural  Highly Rural
                                                            Enrollers     Enrollees     Enrollees     Enrollees
----------------------------------------------------------------------------------------------------------------
7,848,282                                                   4,879,424     2,850,173       118,685     2,968,858
----------------------------------------------------------------------------------------------------------------
100.0%                                                          62.2%         36.3%          1.5%         37.8%
----------------------------------------------------------------------------------------------------------------



----------------------------------------------------------------------------------------------------------------
                                                                                                       Rural &
                     Total Patients                           Urban         Rural     Highly Rural  Highly Rural
                                                            Patients      Patients      Patients      Patients
----------------------------------------------------------------------------------------------------------------
4,877,733                                                   2,919,645     1,878,624        79,464     1,958,088
----------------------------------------------------------------------------------------------------------------
100.0%                                                          59.9%         38.5%          1.6%         40.1%
----------------------------------------------------------------------------------------------------------------


                              ----------                              


                              Attachment B
              Veteran Enrollee Drive Time Access Standards
        Access standard for Primary Care (includes mental health).
        Seventy percent of enrollees within a market meet the following 
        drive time standards:
        30 Min.--Urban
        30 Min.--Rural
        60 Min.--Highly Rural

                              ----------                              


                              Attachment C
                                Acronyms

    ADC--Average Daily Census
    CBOC--Community Based Outpatient Clinics
    CCHT--Care Coordination Home Telehealth
    CPRS--Computerized Patient Record System
    GEC--Office of Geriatric and Extended Care
    HBPC--Horne Based Primary Care
    LTC--Long-Term Care
    MH--Mental Health
    MHICM-RANGE--Mental Health Intensive Case Management--Rural Access 
Network Growth Enhancement
    NHC--VA Nursing Home Care
    OCC--Office of Care Coordination
    OMHS--Office of Mental Health Services
    ORH--Office of Rural Health
    PCS--Patient Care Services
    RFP--Request for Proposals
    RHNAC--Rural Health National Advisory Committee
    VA--Department of Veterans Affairs
    VHA--Veterans Health Administration

                                 
                        Program Analysis Officer
                               GS-340-15
 Office of the Assistant Deputy Under Secretary for Health for Policy 
                              and Planning
                     Veterans Health Administration
                     Department of Veterans Affairs

    Under the general guidance of the Assistant Deputy Under Secretary 
for Health (ADUSH) for Policy and Planning, incumbent provides 
leadership, advice and subject-matter expertise in tasks, projects and 
assignments related to rural health policy development, analysis, 
decision making, and implementation activities affecting the entire VA 
healthcare system. Incumbent serves as Director, Office of Rural 
Health.
    Incumbent functions in a supervisory capacity in contributing to 
attainment of Department of Veterans Affairs (VA) and Veterans Health 
Administration (VHA) goals and objectives with regard to rural health. 
In this capacity, the incumbent works very closely with other key 
Departmental Officials on cross-cutting programs and issues and is 
responsible for the for the planning, direction, coordination, 
development, and implementation of rural health programs and projects.
DUTIES AND RESPONSIBILITIES
    Directs and leads the development and implementation of the 
Veterans Health Administration Office of Rural Health to address 
healthcare needs of veterans in the rural and highly rural areas.
    Researches, plans, develops, implements, and evaluates policy and 
programs to improve the access and delivery of healthcare services in 
rural and highly rural areas for the planning and implementation of 
appropriate healthcare to improve access and improve the quality of 
healthcare services and enhance the access and delivery of healthcare 
in rural and highly rural areas for veterans.

    Addresses key issues, such as,

      improves communication and coordination among key VA 
health providers and medical administrators within and across the VHA 
and other government healthcare providers, such as, the DHHS in the 
rural and highly rural areas;
      enhances access to select services, (e.g., prescription 
drugs, non-emergency medical transportation, chronic disease management 
programs, mental health and long term healthcare);
      improves travel times and evaluates transportation needs;
      provides quality health assessment data to promote 
information-based health policy and planning; and
      Investigates and improves the capacity of VA rural and 
highly rural healthcare from infrastructure to staffing needs.

    As the focal point within VHA and the Department for monitoring 
rural health issues and coordinating Department-wide efforts to 
strengthen and improve the delivery of veterans health services to 
populations in rural areas, the Director

      coordinates rural health activities within the 
Department;
      oversees the collection and analysis of information 
regarding the special problems and needs of rural healthcare providers;
      maintains a clearinghouse for the collection and 
dissemination of information and research related to veterans rural 
health services;
      manages rural health services outreach projects and 
network development, and support;
      conducts or provides contracts for the conduct of 
specific rural health studies and activities directed toward specific 
rural issues; and
      responds to inquiries on rural health matters from the 
Congress and the public and private sectors.

    Directs the conduct of complex qualitative and/or quantitative 
analysis to assess patient care trends and anomalies in rural and 
highly rural settings.
    Leads and coordinates technical, professional and administrative ad 
hoc teams established to conduct comprehensive studies on patient care 
in rural and highly rural settings; the conclusions of which are 
recommended to management for decisions, relative to the design and 
development of new, or the curtailment or modification of existing 
patient care delivery.
    Serves as the primary link between the Assistant Deputy Under 
Secretary for Health (ADUSH) for Policy and Planning and other 
executive staff and key offices within the Veterans Health 
Administration (VHA), the Office of the Under Secretary for Health and 
other appropriate offices, congressional offices and Committees, and 
other Federal agencies, and a wide variety of external groups and 
organizations with regard to rural and highly rural health issues.
    Counsels the ADUSH for Policy and Planning and key management in 
the development and implementation of policies, plans, guidelines, and 
proposals for patient care in rural and highly rural settings. He/she 
develops written documents for a wide range of matters, including the 
development or the implementation of policies, practices, or other 
operational and management activities. Conclusions, findings, 
recommendations and reports are in many instances used by top VA 
management to make management decisions and to develop policy.
    Acts as a representative of the ADUSH for Policy and Planning on 
interpretation of policy, in public relations issues, and in 
reconciling conflicting interpretations and differences among the Rural 
and Highly Rural staff nation-wide.
    Serves as a member of various Committees as designated by the ADUSH 
for Policy and Planning with Administrative and other key officials, 
other government agencies, and organizations outside the Federal 
Government and represents the ADUSH for Policy and Planning.
    The incumbent plans, organizes, and carries through to completion 
program plans, program/policy analyses, data collection, legislative 
interpretation, and analytical studies involving Federal and VA 
programs and policies on patient care in rural and highly rural 
settings.
    Coordinates special studies and projects with other agencies within 
the Department to ensure involvement of the appropriate Departmental 
officials, as well as involvement by outside groups. Provides technical 
and policy advice on healthcare financing and rural healthcare 
proposals reflecting the Administration's objectives and priorities.
    Promotes effective communication and coordination of departmental 
activities with other Federal agencies and outside organizations. 
Communicates the policies and positions of the Department to 
governmental and private organizations concerned with the provision of 
veterans' healthcare in rural areas.
    Explains a variety of policies and/or procedures to VA officials 
and resolves problems of a highly complex nature. May resolve issues 
independently or make recommendations for resolution. Coordinates 
critical and sensitive office correspondence with top management of the 
Department.
    Directs comprehensive studies from which to analyze and evaluate 
the needs, strategic plans, and goals of the Office of Rural Health, 
and makes recommendations for new directions, initiatives, policies and 
procedures. S/he participates in senior management decisions regarding 
strategic planning and priority-setting for these activities.
    Ensures coordination of reports, evaluations and follow up actions. 
Identifies deficiencies or problems and consults with the ADUSH for 
Policy and Planning for problem resolution
    Supervises the staff of the Office of Rural Health. Plans and 
assigns work to be accomplished. Evaluates performance; gives 
instructions on work and administrative matters; interviews and selects 
candidates for subordinate positions; hears and resolves employee 
problems; and takes disciplinary measures and recognizes noteworthy 
contributions as warranted.
    Identifies and makes provisions for the training of staff as 
needed. Assures that staff in the Office of Rural Health maintain state 
of the art knowledge in this program area. Assures and oversees that 
staff are remaining current with the availability of relevant 
literature, and also with applicable regulations, manual, and other 
related policies. Maintains competency of self and existing staff and 
encourages use of resources and continuing education courses.
    Performs other duties, as assigned.
SCOPE
    The incumbent is a national level resource, responsible for 
directing and supervising the conduct of complex analysis, design, 
development, technical support work; providing assistance to VA Central 
Office and Field units throughout the VHA system; and utilizes existing 
tools and/or recommends the development of new processes and 
applications to troubleshoot problems and meet specified business 
needs, having a cross organizational affect on Department-wide 
administrative policies and programs, as they relate to providing 
medical services in an effective environment to veterans nationwide.
    The incumbent will have expert knowledge of analytical and 
evaluative methods plus a thorough understanding of how regulatory or 
enforcement programs are administered to select and apply appropriate 
program evaluation and measurement techniques in determining the extent 
of compliance with rules and regulations issued by the agency, or in 
measuring and evaluating program accomplishments. This may include 
evaluating the content of new or modified legislation for projected 
impact upon the Agency's programs and resources.
EFFECT
    The incumbent directs the completion of significantly complex 
administrative, technical and analytical projects such as qualitative 
and quantitative studies of patient care delivery in rural and highly 
rural settings; data analysis to determine customer satisfaction with 
care provided in rural and highly rural settings; development of tools 
and metrics to monitor the outcomes of newly established or implemented 
policies and procedures to enhance patient care in rural and highly 
rural settings. The work significantly affects Department-wide VHA 
business requirements, veterans using VHA medical facilities, 
stakeholders and end user customer satisfaction.
    This incumbent will be skilled in planning, organizing, and 
directing team study work and in negotiating effectively with 
management to accept and implement recommendations, where the proposals 
involve substantial agency resources or may require change in 
procedures.
    The incumbent will have a mastery of advanced management and 
organizational principles and practices along with a comprehensive 
knowledge of planning, program and budget regulations, guidelines and 
process, and thorough knowledge of the Agency's planning, acquisition, 
and management process to prepare long-range and short-range planning 
guidance in accordance with broad agency program policies and 
objectives.
ORGANIZATIONAL SETTING
    The incumbent reports directly to the Director of Policy Analysis 
and Forecasting, an SES position and is accountable to the VHA 
Assistant Deputy Under Secretary for Health for Policy and Planning, 
who encumbers a SES Position.
SUPERVISORY & MANAGERIAL AUTHORITY EXERCISED
    The incumbent directs and supervises a staff of highly analytical 
and technically skilled specialist, and professionals, which may 
include contract staff. Decides methodologies to use in achieving 
program objectives or to determine which goals and objectives to 
emphasize. In addition, he/she serves as an active team member for 
projects encompassing the development, maintenance and improvement of 
patient care in rural and highly rural settings.
    The incumbent plans work to be accomplished by subordinates, sets 
and adjusts short-term priorities, and prepares schedules for 
completion of work; assigns work to subordinates based on priorities, 
selective consideration of the difficulty and requirements of 
assignments, and the capabilities of employees; gives advice, counselor 
instruction to employees on both work and administrative matters; 
evaluates subordinate performance and identifies developmental and 
training needs for employees, providing or arranging for needed 
development and training; finds ways to improve production or increase 
the quality of the work of subordinates and develops performance 
standards for supervised staff'; hears and resolves minor complaints 
from employees, referring group grievances and more serious unresolved 
complaints to a higher-level management; Prepares and updates position 
descriptions and performance plans for subordinate employees; 
interviews applicants, develops criteria for selection of best 
candidate and recommends or makes selection; and approves/disapproves 
leave, makes work assignments, resolves work conflicts and implements 
established or management approved policies, as it relates to customer 
service and support.
PERSONAL CONTACTS
    Nature of contacts: Contacts include VA program officials 
representing VACO VHA, Staff Offices, OI&T, VHA field offices, VA 
Medical Centers, VISN Offices, Congressional Offices, etc. Contacts 
also include communication media, consultants, affiliated universities, 
professional organizations and associations. Contacts take place in 
planned or unscheduled meetings, including presentations, conferences, 
hearings, etc. As requested, the incumbent prepares reports or 
responses for Congress, executive branch agencies such as the Office of 
Management and Budget, Agency for Health Care Policy and Research and 
foundations such as Academy Health, or media audiences, working through 
appropriate VA offices. Meets and addresses constituency, advocacy and 
national and local veterans groups, as well as Congressional staff and 
professional associations
    Purpose of Contacts: Contacts are designed to meet several 
objectives, including: developing appropriate collaborative 
relationships for sharing information among colleagues and agencies 
with similar interests; communicating information about the Office of 
Rural Health's programs, plans, and strategies; obtaining information 
from well-known rural health experts; to influence managers or other 
officials to accept and implement findings and recommendations on 
organizational improvement or program effectiveness; and to effectively 
provide advice and counsel to management on the resolution of patient 
care in rural and highly rural settings problem issues. The incumbent 
may encounter resistance due to such issues as organizational conflict, 
competing objectives, or resource problems. He/she must be familiar 
with congressional and legislative activities bearing upon VHA Rural 
Health Care program activities.
DIFFICULTY OF TYPICAL WORK DIRECTED
    The highest graded non-supervisor work directed, which requires at 
least 25% of this position's duty time, is GS-14 or higher, or 
equivalent.
    The incumbent directs and supervises the work of approximately two 
subordinate employee's performing highly analytical, specialized, 
technical and administrative work.
    This position manages through subordinate supervisors and/or 
contractors who each direct workloads comparable to GS-12 or higher.
    Identifying the nature of issues or problems in planning, 
organizing, and determining the scope and depth of rural health 
studies, and discerning the intent of legislation and policy statement 
and how to translate the intent into program actions is extremely 
complex.
    The incumbent provides high-level operational and program 
management leadership. The work is highly varied, visible, and subject 
to an exceptional level of scrutiny by stakeholders and advocacy groups 
within and outside the system.
TRAVEL
    Position requires 25% overnight travel.
OTHER CONDITIONS
    The attention paid to the Office of Rural Health is very 
significant. The incumbent must carefully coordinate the myriad efforts 
of the Office's diverse portfolio, ensuring attention to all these 
politically sensitive issues. All this must be accomplished in an 
environment of extraordinary oversight of activities by advocates 
within and outside the Department. The incumbent must deal with 
demands, expectations, and oversight at a very high level.
    This work requires familiarity with a broad range of topics and 
current issues related to the provision and outcomes of rural 
healthcare, and to the conduct of research on those issues. This 
includes general knowledge of concepts and methods drawn from 
healthcare administration, scientific review and evaluation, public 
health, and other health organizations. The incumbent must be a 
critical thinker with excellent writing and organizational skills.
    Requires expert level knowledge of the principles and practices of 
the following disciplines as they relate to rural health: healthcare 
management, resource management, and policy development, in order to 
provide consultation/advice to the ADUSH for Policy and Planning in 
healthcare administration and organizational management matters.
    The incumbent is responsible for extensive coordination and 
integration of work efforts related to rural health policy development 
associated with a national healthcare delivery system. The incumbent 
makes major recommendations that have a direct and substantial impact 
on current and future rural healthcare initiatives. The incumbent must 
be thoroughly familiar with the Department's programs, objectives, 
operations, and the interrelationships among these as well as those of 
other federal agencies, Congress, etc.
    Mastery of program and organizational analysis principles, methods, 
practices and techniques; analytical methods; and interpersonal 
relations practices. Skill to apply this mastery in developing new 
methods and approaches in planning, integrating and evaluating rural 
health programs for the agency. Knowledge and skill to advise other 
specialists in and outside the agency, as well as top managers and 
decisionmakers, on issues of developing, communicating, or enhancing 
program matters involving interaction with all of the agency's publics, 
both nationally and internationally.
    Because of the sensitivity inherent in analyses and recommendations 
made by the VHA Office of Rural Health, the incumbent is expected to 
elicit a high and sustained level of collaboration and trust with VA 
program managers. The incumbent must also demonstrate marked qualities 
of diplomacy, patience, and persistence, professional deportment, and 
discretion suited to all levels of VA management. The incumbent 
develops and implements systems and processes to gather and analyze the 
information needed to make strategic and tactical decisions.
OTHER SIGNIFICANT FACTS
    Customer Service: Incumbent meets the needs of customers while 
supporting VA missions. Consistently communicates and treats customers 
(veterans, their representatives, visitors, and all VA staff) in a 
courteous, tactful, and respectful manner. Employee provides the 
customer with consistent information according to established policies 
and procedures. Handles conflict and problems in dealing with the 
customer constructively and appropriately.
    ADP Security: Incumbent protects printed and electronic files 
containing sensitive data in accordance with the provisions of the 
Privacy Act 1974 and other applicable laws, federal regulations, VA 
statutes and policy, and VHA policy. Employee protects the data from 
unauthorized release or from loss, alteration, or unauthorized 
deletion. Follows applicable regulations and instructions regarding 
access to computerized files, release of access codes, etc., as set out 
in the computer access agreement that the employee signs.