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





                 FINDINGS OF THE PRESIDENT'S COMMISSION
                    ON CARE FOR AMERICA'S RETURNING
                            WOUNDED WARRIORS

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

                                HEARING

                               before the

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

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                           SEPTEMBER 19, 2007

                               __________

                           Serial No. 110-43

                               __________

       Printed for the use of the Committee on Veterans' Affairs







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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

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

                               __________

                           September 19, 2007

                                                                   Page

Findings of the President's Commission on Care for America's 
  Returning Wounded Warriors.....................................     1

                           OPENING STATEMENTS

Chairman Bob Filner..............................................     1
    Prepared statement of Chairman Filner........................    32
Hon. Steve Buyer, Ranking Republican Member......................     3
Hon. Harry E. Mitchell, prepared statement of....................    33
Hon. Jerry Moran, prepared statement of..........................    33
Hon. Ginny Brown-Waite, prepared statement of....................    34

                               WITNESSES

President's Commission on Care for America's Returning Wounded 
    Warriors:
    Hon. Donna E. Shalala, Co-Chair (former Secretary of Health 
      and Human Services)........................................     4
        Prepared statement of Secretary Shalala..................    34
    Hon. Bob Dole, Co-Chair (former United States Senator from 
      the State of Kansas).......................................     8
        Prepared statement of Senator Dole.......................    36

                       SUBMISSIONS FOR THE RECORD

Disabled American Veterans, Joseph A. Violante, National 
  Legislative Director, statement................................    38
Miller, Hon. Jeff, a Representative in Congress from the State of 
  Florida, statement.............................................    40

                   MATERIAL SUBMITTED FOR THE RECORD

Post-Hearing Questions and Responses for the Record:
    Hon. Bob Filner, Chairman, Committee on Veterans' Affairs, to 
      Hon. Donna E. Shalala, Co-Chair, President's Commission on 
      Care for America's Returning Wounded Warriors, and 
      President, University of Miami, and Hon. Bob Dole, 
      President's Commission on Care for America's Returning 
      Wounded Warriors, letter dated October 18, 2007, also 
      transmitting additional questions from Hon. Joe Donnelly...    42

Reports:
    ``Serve, Support, Simplify: Report of the President's 
      Commission on Care for America's Returning Wounded 
      Warriors,'' July 2007......................................    45
    ``Serve, Support, Simplify: Report of the President's 
      Commission on Care for America's Returning Wounded 
      Warriors,'' Subcommittee Report and Survey Findings, July 
      2007.......................................................    82



















 
                 FINDINGS OF THE PRESIDENT'S COMMISSION
                    ON CARE FOR AMERICA'S RETURNING
                            WOUNDED WARRIORS

                              ----------                              


                     WEDNESDAY, SEPTEMBER 19, 2007

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

    The Committee met, pursuant to notice, at 10:02 a.m., in 
Room 334, Cannon House Office Building, Hon. Bob Filner 
[Chairman of the Committee] presiding.

    Present: Representatives Filner, Snyder, Herseth Sandlin, 
Mitchell, Hall, Hare, Berkley, Salazar, Rodriguez, Donnelly, 
McNerney, Space, Walz, Buyer, Moran, Brown of South Carolina, 
Boozman, Brown-Waite, Turner, Bilbray, Lamborn, Bilirakis, 
Buchanan.

              OPENING STATEMENT OF CHAIRMAN FILNER

    The Chairman. This meeting of the House Committee on 
Veterans' Affairs is called to order and we have a 
distinguished panel to address us this morning.
    As we all know, in March the President signed an Executive 
Order to establish the President's Commission on Care for 
America's Returning Wounded Warriors. That came in the wake of 
the Walter Reed scandal and I must say there were a couple of 
silver linings in that cloud we call Walter Reed. One was the 
Commission that was formed and your report, for which we are 
grateful. The other, of course, was, we were able to add in the 
various budget bills that went by over $13 billion of resources 
for veterans' healthcare for this year over last year, because 
all of America understood that we are not caring for the 
veterans who came back from Iraq and Afghanistan the way they 
thought that we were doing and we should be doing.
    The Commission was charged with the task of examining the 
effectiveness of returning wounded servicemembers' transition 
from deployment in support of the Global War on Terror to 
returning to productive military service or civilian society, 
and recommend needed improvements.
    That report, of course, was recently released and we will 
be hearing from the Co-Chairs of that Commission, Secretary 
Donna Shalala and Senator Bob Dole. I look forward to a frank 
discussion of your recommendations.
    Of course, we are all focused on how to serve our troops 
when they transition from the Pentagon to the U.S. Department 
of Veterans Affairs (VA) for their healthcare. In order for our 
troops to experience the seamless transition that they deserve, 
the bureaucratic problems that prevent many from getting the 
care they need must be fixed. And while both VA and the U.S. 
Department of Defense (DoD) have made adjustments and changes 
over the last few years in an attempt to address these issues, 
many obstacles, as you point out, still remain.
    As Chairman of the Committee on Veterans' Affairs, I am 
sensitive to the difficulties involved in coordinating the 
activities of the Department of Defense and the Department of 
Veterans Affairs. They have different missions. But we no 
longer have the luxury of time and we, as a country, must act.
    Right now, while we prepare to discuss this issue, our 
servicemembers are in harm's way. Some of these brave men and 
women will be killed or seriously wounded. We have talked about 
the necessity of providing a seamless transition for a long, 
long time. But now we have a test as a Nation and this is a 
test that, with your help, we will pass.
    I want to welcome our two distinguished panelists. Donna 
Shalala was appointed by President Bill Clinton as Secretary of 
the U.S. Department of Health and Human Services (HHS) in 1993 
where she served for 8 years, becoming the longest serving 
Secretary of HHS in our Nation's history. She directed the 
welfare reform process, made health insurance available to an 
estimated three and a half million children, raised child 
immunization rates to the highest levels in history, led major 
reforms of the Food and Drug Administration's drug approval 
process and food safety system, revitalized our National 
Institutes of Health and directed a major management and policy 
reform of Medicare.
    You have dealt, Secretary Shalala, with large bureaucracies 
like the VA and DoD before this, and so we welcome your 
experience in implementing programs that work for people, not 
against people.
    Senator Dole, your story is well-known. But every time I 
read it, I am just amazed by your strength and courage. You 
were twice decorated for heroism, receiving two Purple Hearts 
for injuries and the Bronze Star Medal with combat ``V'' for 
valor. You joined the United States Army's Enlisted Reserve 
Corps to fight in World War II and became a second lieutenant 
in the 10th Mountain Division. In April 1945, while engaged in 
combat in the hills of northern Italy, you were hit by German 
machine gun fire in the upper right back and badly injured, 
waiting 9 hours on the battlefield before being taken to the 
evacuation hospital before you began your recovery at a U.S. 
Army hospital in Michigan. And then, of course, a distinguished 
career in politics.
    So thank you both for your service, not only on this 
Commission, but I know your commitment to implementing the 
recommendations. You are not letting this just become something 
on people's shelves. I asked both of our panelists what they 
were going to do and they said we are going to get this done. 
And so we welcome your energy, your enthusiasm, and the 
expertise that you brought to this adventure and we look 
forward to hearing from you.
    I would yield to the Ranking Member, Mr. Buyer.
    [The prepared statement of Chairman Filner appears on p. 
32.]

             OPENING STATEMENT OF HON. STEVE BUYER

    Mr. Buyer. Thank you, Mr. Filner.
    Secretary Shalala and Senator Dole, we thank you for your 
work. Your report is before us and we appreciate your service 
to our country. Our country continues to call upon you, and you 
always step forward willingly to serve others and that is what 
separates you from so many. So on behalf of the country, I 
extend my appreciation for your contribution.
    We are involved in a long war against terrorism. For this, 
the Nation's mothers, fathers and spouses trust their sons and 
daughters and spouses to the Nation's armed forces. They must 
be confident that they will be cared for should harm come their 
way. I believe that systems are still dysfunctional. The 
question is, are the bureaucracies, organizationally and 
culturally, ill-suited to make the bold changes necessary for a 
seamless transition?
    I have my questions, because the bureaucracy will tell us 
that they are on top of it, that they are fixing it. The 
bureaucracy has had 6 years of ground combat to fix this 
problem. We have developed new combat systems in the last 6 
years, perfected new tactics, ushered in new governments. It is 
time our servicemembers and veterans have seamless transition.
    I personally have been fighting this battle over seamless 
transition since I arrived in Washington in 1992. From the year 
2004, when I was a Subcommittee Chairman and a full Committee 
Chairman, I held 19 hearings on the issue of seamless 
transition. Legislation mandating the cooperation between the 
Pentagon and VA, Senator Dole, dates back to perhaps your 
memory. Nineteen eighty-two is when the mandate came from 
Congress and the Senate.
    So it is time our servicemembers and veterans have the 
seamless transition. It is why I was equally enthused when I 
heard that President Bush hailed your work product and directed 
that the Administration prepare legislative proposals 
reflecting your recommendations. I think I can speak for all of 
us here that we look forward to seeing these proposals. We 
expect to get those proposals soon so we can act to improve the 
care and the seamless transition that our Nation's warriors are 
entitled.
    We look forward to your testimony and your candor is always 
welcomed.
    I yield back.
    The Chairman. Thank you, Mr. Buyer.
    You have as much time as you need and we will start with 
Secretary Shalala. Thank you again for your service.

  STATEMENTS OF HON. DONNA E. SHALALA, CO-CHAIR, PRESIDENT'S 
  COMMISSION ON CARE FOR AMERICA'S RETURNING WOUNDED WARRIORS 
 (FORMER SECRETARY OF THE U.S. DEPARTMENT OF HEALTH AND HUMAN 
SERVICES); AND HON. BOB DOLE, CO-CHAIR, PRESIDENT'S COMMISSION 
 ON CARE FOR AMERICA'S RETURNING WOUNDED WARRIORS (FORMER U.S. 
  SENATOR FROM THE STATE OF KANSAS); ACCOMPANIED BY EDWARD A. 
ECKENHOFF, MEMBER, PRESIDENT'S COMMISSION ON CARE FOR AMERICA'S 
 RETURNING WOUNDED WARRIORS, AND FOUNDER, PRESIDENT, AND CHIEF 
   EXECUTIVE OFFICER, NATIONAL REHABILITATION HOSPITAL, AND 
   MEMBER, BOARD OF DIRECTORS, DISTRICT OF COLUMBIA HOSPITAL 
  ASSOCIATION; MARIE E. MICHNICH, DR.PH., EXECUTIVE DIRECTOR, 
PRESIDENT'S COMMISSION ON CARE FOR AMERICA'S RETURNING WOUNDED 
 WARRIORS, AND DIRECTOR, HEALTH POLICY EDUCATION PROGRAMS AND 
 FELLOWSHIPS, INSTITUTE OF MEDICINE / THE NATIONAL ACADEMIES; 
KAREN GUICE, M.D., MSP, DEPUTY DIRECTOR, PRESIDENT'S COMMISSION 
ON CARE FOR AMERICA'S RETURNING WOUNDED WARRIORS, AND CLINICAL 
PROFESSOR OF SURGERY, MEDICAL COLLEGE OF WISCONSIN, MILWAUKEE, 
 WI; AND SUSAN D. HOSEK, CO-DIRECTOR, RAND CENTER FOR MILITARY 
   HEALTH POLICY RESEARCH, AND GROUP MANAGER, ECONOMICS AND 
                  STATISTICS, RAND CORPORATION

               STATEMENT OF HON. DONNA E. SHALALA

    Secretary Shalala. Mr. Chairman, Mr. Buyer and sitting 
Members of the Committee, thank you for giving us the 
opportunity to testify today, and in particular with Senator 
Bob Dole, about the recommendations of our Commission----
    The Chairman. Madam Secretary, can you pull the microphone 
closer to you--thank you.
    Secretary Shalala. Thank you for giving me the opportunity 
to testify today. It is truly a privilege to serve, to have 
served on the President's Commission on Care for America's 
Returning Wounded Warriors, especially with Senator Dole, whose 
shrewdness and distinction as a great public servant and whose 
knowledge of this subject and dedication was really an 
inspiration to all of us.
    We worked hard, but we had an awful lot of fun and I 
learned a lot from him in the process. We were joined by a 
stellar group of Commissioners, each of whom gave their full 
energy and attention to the critical mission we faced. One of 
them, Ed Eckenhoff, who just arrived, of course, is the head of 
the National Rehabilitation Hospital here in Washington and one 
of the great experts on rehabilitation in this country and we 
are delighted to see Commissioner Eckenhoff here with us.
    As you know, we had an extremely short timeframe to 
complete our mission, but we were propelled by a sense of 
urgency that the issues before us required. Mr. Chairman and 
Members of the Committee, we know you share this sense of 
urgency and that is why we are pleased to be with you today to 
discuss not only our recommendations, but the critical need to 
implement them.
    We have been truly heartened by the response to our report 
that we have received from Congress, from the White House and 
throughout the country. This country has rallied behind the 
need to help those who have put their lives on the line in 
service to our country and we are optimistic that the Congress 
and the Administration will move quickly to respond to this 
need by enacting all of our recommendations.
    We were reminded again in Saturday's Washington Post the 
problems facing our injured service men and women have not gone 
away. Congress and the Administration have spent a great deal 
of time these past few weeks discussing the future of the war 
in Iraq. And while this debate is one that our Nation must 
have, I implore you not to forget about those who have already 
sacrificed so much--our injured men and women. They need to be 
front and center in the congressional debate and within the 
Administration. The story of Staff Sgt. John Daniel Shannon, as 
told in the Washington Post, is a story that we heard 
throughout our time with the Commission, a story of numerous 
case managers, none of whom held responsibility for 
spearheading an integrated care system, a story of lost 
paperwork and frustration, a story of a disability system that 
was in desperate need of repair.
    It is stories like this that sparked the creation of our 
Commission and stories like this that should and must drive 
immediate congressional and White House action. This past July, 
it was the Commission's honor to present to the President, to 
Congress and the public, six groundbreaking patient and family 
centered recommendations that make sweeping changes in military 
and veterans' healthcare and services. The recommendations 
include the first major overhaul of the disability system in 
more than 50 years.
    It includes the creation of recovery plans with recovery 
coordinators; a new e-Benefits Web site; and guaranteeing care 
for post-traumatic stress disorder (PTSD) from the VA for any 
servicemember deployed to Iraq and Afghanistan. Our report, 
Serve, Support, Simplify, is a bold blueprint for action that 
will enable injured servicemembers to successfully transition, 
as quickly as possible, back to their military duties or to 
civilian life. Our report calls for, and I quote, ``fundamental 
changes in care management and the disability system.'' I 
respectfully request that this report be submitted for the 
record, Mr. Chairman.
    Specifically, our six recommendations will immediately 
create comprehensive recovery plans to provide the right care 
at the right time and in the right place. We recommend that we 
completely restructure the disability determination and 
compensation systems, aggressively prevent and treat post-
traumatic stress disorder and traumatic brain injury (TBI), 
significantly strengthen support for families, rapidly transfer 
patient information between DoD and VA, and strongly support 
Walter Reed by recruiting and retaining first rate 
professionals through 2011.
    Our 6 recommendations do not require massive new programs 
or a flurry of new legislation. We have identified 34 specific 
action steps that must be taken to implement the 6 
recommendations. Only 6 of the 34 items require legislation, 
and that is what we will focus on today. A complete list of the 
action steps for the 6 recommendations is included on the last 
page of my testimony.
    Let me summarize the first three actions that require 
legislation and then my colleague, Senator Dole, will cover the 
remaining three.
    The first is to improve access to care for servicemembers 
with post-traumatic stress disorder. We call on Congress to 
authorize the VA to provide lifetime treatment for PTSD for any 
veteran deployed to Iraq or Afghanistan in need of such 
services. This presumptive eligibility for the diagnosis and 
treatment of PTSD should occur regardless of the length of time 
that has transpired since the exposure to combat events.
    The current conflicts involve intense urban fighting, often 
against civilian combatants, and many servicemembers witness or 
experience acts of terrorism. Five hundred thousand 
servicemembers have been deployed multiple times. The longer 
servicemembers are in the field, they are more likely to 
experience events which can lead to symptoms of PTSD. The 
consequences of PTSD can be devastating. The VA is a recognized 
leader in the treatment of combat-related PTSD, with an 
extensive network of specialized inpatient, outpatient, day 
hospital, and residential treatment programs. Therefore, we ask 
that any veteran of the Iraq or Afghanistan conflicts be able 
to obtain prompt access to the VA's extensive resources for 
diagnosis and treatment.
    Next, we ask Congress to strengthen the support for our 
military families. In our travels across the country, it has 
become abundantly clear that we not only need to help the 
severely injured, we need to help their loved ones as well. 
These loved ones are often on the frontlines of care and they 
are in desperate need of support. Therefore, we call upon 
Congress to make servicemembers with combat-related injuries 
eligible for respite care and aide and personal attendant 
benefits. These benefits are provided in the current Extended 
Care Health Option program under TRICARE.
    Presently, DoD provides no other benefit for caregiving. 
Yet we know that many families are caring for their injured 
servicemember at home, and many of these servicemembers have 
complex injuries. These families, forced into stressful new 
situations, don't need more anxiety and confusion. They need 
support. Families are unprepared to provide 24/7 care. Those 
that try, wear out quickly. By providing help for the 
caregiver, families can better deal with the stress and 
problems that arise when caring for a loved one with complex 
injuries in their homes.
    We also recommended that Congress amend the Family and 
Medical Leave Act (FMLA) to extend unpaid leave from 12 weeks 
to up to 6 months for a family member of a servicemember who 
has a combat-related injury and meets the other FMLA 
eligibility requirements. According to initial findings of 
research conducted by the Commission, approximately two-thirds 
of injured servicemembers reported that their family members or 
their close friends stayed with them for an extended time while 
they were hospitalized; one in five had to give up their job to 
do so. That is simply unacceptable.
    Getting family members to the bedside of an injured 
servicemember is not a problem. The services have developed 
effective procedures to make this happen, and the private 
sector has stepped up to provide temporary housing. Because 
most injured servicemembers recover quickly and return to duty, 
a family member's stay may be short. However, for those whose 
loved one has incurred complex injuries, the stay may last much 
longer. Extending the Family and Medical Leave Act for these 
families will make a tremendous difference in the quality of 
their lives. Congress enacted the initial Family and Medical 
Leave Act in 1993, when I was Secretary of Health and Human 
Services. Since then, its provisions have provided over 60 
million workers the opportunity to care for their family 
members when they need it most. We have tremendous experience 
and evidence with that Act. All of these family members have 
been able to care for a family member without losing their 
jobs.
    We were pleased to see the Senate has already unanimously 
passed the Support for Injured Servicemembers Act which 
implements this particular recommendation. We hope that the 
House will quickly follow suit.
    Mr. Chairman, having served in government for about half of 
my adult life, I believe that government can work to improve 
the lives of its citizens. But sometimes, people of good will 
want to solve a problem and their idea is to fix a problem by 
adding a program or a new regulation. What we have done in this 
report and the reason why it is short and very focused, is 
rather than simply coming to you and recommending new 
legislation on top of existing legislation, we have rethought 
existing programs.
    And one of the things we have done that is never done on 
commissions is that we have suggested simplifying the program 
itself so it is very clear who is responsible for what. And 
Senator Dole will be speaking to the disability provision that 
we have recommended. So don't think of this as adding another 
piece of legislation that adds a program on top of programs. I 
spent years, as you well know, trying to sort out Medicare. 
Part of the problem with the most complex legislation is that 
it is almost impossible for an ordinary competent government 
worker to administer the programs, let alone the people that 
are supposed to get the services of that legislation to 
understand them, not because someone tried to create a complex 
bureaucracy, but because they kept trying to fix problems by 
adding new legislation which added to the complexity of the 
administration.
    So read this and the word ``simplify'' as attempting to 
make clear who is responsible for what and making it much 
easier for the patient and their families, as well as the 
people that have to administer the programs, to administer 
those programs in a way that is very responsive and very 
efficient for the programs.
    I believe our recommendations are doable, whether it is 
requiring congressional legislation or implementation by DoD or 
VA. We made sure what we were recommending could actually be 
acted on quickly. The advantage of having Senator Dole and me 
up here is that in many ways we are the old warriors. We know--
--
    [Laughter.]
    Me too. We have a pretty good feel for what the bureaucracy 
can administer and what can be implemented, because we have 
been through this. And I hope that you, I know that you agree 
with us that our seriously injured servicemembers must not be 
made to wait. They deserve a healthcare system that serves, 
supports and simplifies.
    So I would like to thank the Committee again on behalf of 
the Commission for the opportunity to discuss our 
recommendations. And because those of you who know me know I 
don't mince words, I leave the Committee and the Administration 
with three simple words. Just do it. Thank you very much.
    Senator Dole.
    [The prepared statement of Secretary Shalala appears on p. 
34, and the Commission reports appear on p. 45 and p. 82.]
    Senator Dole. Oh, thank you.

                   STATEMENT OF HON. BOB DOLE

    Senator Dole. Well, first let me thank the Chairman, Steve 
and others for being here. I want to thank Congressman Moran, 
Congressman Salazar, Congresswoman Berkley and others who have 
already introduced a draft of the legislation which may not be 
totally accurate, because we drafted it as we were going 
through. I know the Administration is working on a draft, and I 
know there are others on the Committee who have joined this 
bipartisan effort, which leads me to the second point.
    I know which political party my Co-Chair is in and she 
knows which party I am in. But frankly, I don't know the 
political affiliation of any of the other seven members. We 
never discussed politics. It was totally nonpartisan. We never 
discussed costs. My view was, if we spend billions and billions 
and billions of dollars of getting young women and men in 
harm's way, we will have to spend what it takes to get them 
back in as normal a life as possible, whatever it takes. And I 
think that is where we are coming from.
    So it is going to cost a little money. And Bob, we may use 
some of that which you have authorized. So----
    The Chairman. Are you sure you are not a Democrat?
    [Laughter.]
    Senator Dole. Pardon?
    The Chairman. Are you sure you are not a Democrat?
    Senator Dole. Yeah. But, you know we----
    [Laughter.]
    No. We went way back to the Commission headed by Omar 
Bradley in 1956. Now, most of you weren't around then, but I 
was. And there have been a lot of Commissions. This problem 
just didn't happen with Building 18 at Walter Reed Hospital. It 
has been out there for years and years and years. We have 25 
million, probably 26 million, veterans now. As they get older, 
especially the World War II generation, more and more need 
hospital care and VA care. One thing we found, and we had 
visits all over the country, I don't remember a single 
complaint--there may have been one--about the acute care the 
soldiers received from the battlefield until the end of their 
acute care.
    That is not the problem, as my Co-Chair Secretary Shalala 
pointed out, it is what happens after that. It is the 
bureaucracy, which is true in many civilian hospitals, too. And 
that is why we are so honored to have Ed Eckenhoff, Chairman of 
the National Rehabilitation Hospital, on our Commission. He 
understands the private sector. One thing we also underscored 
in our report is that we want the soldier to get the best 
possible care. If it is not available in a DoD or a VA 
facility, then they are authorized to go to the best private 
facility that they can find. We can do no less. And Ed was very 
helpful, not only in that area, but many others.
    We had a young man named Jose Ramos on the Commission, and 
he would have been here today but he has a test. He is back in 
school. He lost an arm in Iraq. Another young man from our 
Commission, Marc Giammatteo, is attending Harvard, which I 
won't hold against him, but--well, my wife attended Harvard. 
Marc has a very badly damaged leg. We had a young woman on the 
Commission, Tammy Edwards, whose husband had burns on 70 
percent of his body. So we had a good representative 
Commission. We had people who really understood the problem.
    And I must say, I had a Co-Chairman who must have invented 
the Energizer Bunny, because all we did was work, work, work 
and she would tell us what to do and we would all try to do it. 
We learned a lot from each other and we really think we have 
some commonsense ideas. Some have said, ``Why didn't you go way 
back and overhaul the whole system?'' Well, our charter was 
limited to Iraq and Afghanistan and people who may follow. Now, 
we hope that war ends quickly. We don't want any more injuries. 
One is too many. One death is too many.
    But one thing we discovered in trying to get down to the 
brass tacks was the group, the seriously injured group, those 
were severe TBI or spinal cord injuries or amputees or 
whatever. There are about 3,000. Now, if we can't manage the 
care of that group in the United States of America, with all 
the VA facilities and all the DoD facilities we have, we are in 
pretty bad shape. And we can. We just need to work out some of 
the wrinkles and that is where we believe our Commission can be 
helpful.
    We can't dictate anything to this Committee. I spent 35\1/
2\ years in Congress and I know how the system functions. And 
we know it takes time. We have been pushing the Executive 
Branch. I was at the White House last week and I can say very 
honestly, I am really not surprised, but I am very pleased with 
the effort they are making on the executive side and they will 
have their legislation ready in what, another 10 days?
    Secretary Shalala. Ten days.
    Senator Dole. So the veteran groups can look at it, and 
certainly Members of this Committee. We also had some 
outstanding staff, and I would just introduce our Director, 
Marie Michnich, who is here and Karen Guice who worked with the 
Veterans Service Organizations (VSOs) and Sue Hosek of RAND 
Corporation who has had about 30 years experience working with 
these same problems. So I think we have some credibility. At my 
age, I don't need this job. And you know, I told that to the 
President. Well, I guess I didn't see him. I saw him later. But 
I told that to the people at the White House and we told it to 
Bob Gates. Donna--excuse me, Secretary Shalala, she has a lot 
to do. She is busy.
    The University of Miami football team, they got off to kind 
of a bad start, but they will recover.
    [Laughter.]
    So, you know, we wanted to do something that might mean 
something to somebody. I talked to a young man from Kansas 2 
days ago. I was at Fort Sam Houston. He is a triple amputee. I 
think there are about 10 or 11 of those. His name is Sergeant 
Matt Lammers and I just was in disbelief of his attitude and 
his spirit and what an inspiration he is. He said he can get 
down with one arm. He has two legs gone above the knee and one 
arm above the elbow missing. He has two children, one 6 and a 
baby about 1 year old. And how he can get down on the floor and 
play with his children and get back in a chair by himself 
without any assistance.
    Now, if that doesn't inspire us to do what we need to do to 
make certain that young man and his family and his children are 
taken care of. If you would just write him a blank check, it 
would be all right with us. But are those young people going to 
be able to go to college? Is he going to be able to earn enough 
money? He won't be able to do it with the pension he gets. So 
these are some of the things you may want to look at and I know 
some of the things have been looked at elsewhere.
    I have been interested in veteran affairs--I will confess. 
I didn't know much about disabilities until I had one, and then 
you suddenly become interested. I served as a service officer 
of the American Legion and VFW when I was County Attorney 100 
years ago in Russell, Kansas. And I worked with veterans all my 
life and all my years in Congress and now I am working with 
World War II veterans. They have what they call an Honor Flight 
where they bring in World War II veterans from your districts, 
without any cost to them. They charter them in. They go out and 
visit the memorials--spending most of their time at the World 
War II Memorial. They have a box lunch and they go back home 
and this makes their whole life. There will be a group in from 
Cleveland this afternoon. I will be down to say hello.
    But the point I make is that we hope we have credibility. 
This is not perfect and there are changes you will want to 
make. And Secretary Shalala, I can't think of anybody with more 
experience in working with Congress than she has had and 
anybody more effective. So I just want to touch on three other 
points.
    As Secretary Shalala said, there are six areas where we 
believe Congress needs to act, and you may think of others. And 
what we would like to do, but it may not be possible, is 
somehow get some of our suggestions into a conference report 
that you may be holding later this year on the Senate passed 
bill and your bill because these veterans can't wait much 
longer. And when we talk about the wait they have to get their 
claim settled and we know that if it doesn't make it in this 
year's bill, it will be next year, and that is a long time.
    We think Saturday's story in the Washington Post would not 
have been there had Secretary Shalala's idea been adopted with 
the care coordinator. When you get out of the battlefield, and 
you walk or are carried into Walter Reed, you are assigned a 
recovery coordinator who stays with you throughout your 
treatment. Jose Ramos, who is on our Commission, had so many 
caseworkers that he couldn't remember their names. And that is 
what happened to this Sergeant Shannon.
    So Secretary Shalala had a great idea. It is the first 
recommendation. And we are not talking about adding thousands 
or another bureaucracy. We are talking about 20, 30, 40, 50 
people who have followed the seriously injured from day one 
until the time they leave the hospital or go back home or back 
to work. Secretary Shalala has already touched on that. She 
outlined three major recommendations. Let me just touch on the 
others.
    We want to get the DoD out of the disability business and 
we think they wouldn't mind doing that themselves. Veterans 
tell us that they get better ratings from the Veterans 
Administration, so we are trying to figure out some way--how do 
we work this so it is fair and we don't penalize anybody and 
still have the DoD with some. First they would have to get 
together with the VA and work out what kind of a physical it 
would be. And after the physical, when you are determined to be 
unfit for duty, then you go to the VA and they make your 
disability rating--not the DoD, but the Veterans 
Administration.
    We have also added what will be called transition payment. 
I know from personal experience, when you first get out of the 
service, whether you are in the hospital or not--it doesn't 
make any difference--you are sort of at sea for 2 or 3 months. 
And so we have these transition payments. It would be your base 
pay for 3 months, or whatever Congress decides, while you are 
getting home, getting settled, getting your kids in school, 
getting a job, whatever.
    There is another payment. It will all be in the same 
check--but something that has never really been considered 
separately and that is called quality of life. I think when you 
get your rating, I am certain if you are an amputee or you lost 
your sight, it is a consideration. But if you have lost your 
sight or if you are Sergeant Lammers who has lost three limbs, 
your quality of life has gone from a 10 to what, 1, 2 or 3? We 
think that should be compensable and that should be added to 
any other payment, whatever your rating may be, because you 
have lost that qualify of life forever.
    It has never been specifically identified. I guess some who 
examine soldiers would probably say, well, they will include 
something. But we want to make certain that happens. Then, of 
course, there is the earnings loss payment which you would 
receive based on your disability, what your earnings loss might 
have been in your lifetime.
    So we think, and we know there is another commission 
working on the disability program. I think it is fair to say 
that they have endorsed what we have done with two, is it two 
exceptions, Karen or Sue?
    Ms. Guice. They are still working on their recommendations.
    Senator Dole. In other words, we are pretty much in 
agreement and their report is due out, I think, sometime in the 
next 30 days or 45 days. But in other words, we don't want to 
wait and I know you don't want to wait. I think they would tell 
you now what they are going to do. So now there are differences 
in ratings depending on which military service or which 
regional office determines the rating. In our national survey 
of injured servicemembers, fewer than half understood the DoD's 
disability evaluation system and only 42 percent of retired or 
separated servicemembers who had filed a VA claim understood 
the process. That is about one out of two that even understood 
what was happening.
    So, as I said, we recommend that DoD do one thing. They 
retain the authority to determine the fitness to serve. Out of 
the 28,000 wounded, 60, 70 percent are back to duty in 30 days 
and then there is another 10 or 12 percent that aren't 
hospitalized very long. But there is a group, say around 3,000, 
3,200 that are very seriously injured and are going to need 
very special care for a long time. We believe that there should 
be only one physical exam, done by the DoD, and then the VA 
should resume all responsibility for establishing the 
disability and the rating.
    This new structure, I think, makes it reliable and 
transparent and accountable. Under this action item, DoD and VA 
can focus on what they do best. The DoD determines fitness and 
the VA can determine your earnings loss and what your rating 
should be and the other things that my colleague has mentioned. 
The VA can do what they should do and I think it is a much 
simpler system that better supports the needs of those who 
transition between active duty and veteran status.
    In our fifth action step, we recommend healthcare coverage 
for servicemembers who are found unfit because of conditions 
that were acquired in combat, supporting combat or preparing 
for combat. That includes about everybody, because once you 
sign up you are getting ready for combat the next day. So we 
think Congress should authorize comprehensive lifetime 
healthcare coverage and pharmacy benefits for those 
servicemembers and their families through DoD's TRICARE 
program.
    Is it fair to say what the White House maybe----
    Secretary Shalala. Well----
    Senator Dole. We think the White House is going even 
further on this.
    Secretary Shalala. We think the White House is considering 
going even further to recommend that everyone who is declared 
unfit for service for health reasons, they will cover the 
individual and their family's healthcare forever. The advantage 
of that is, obviously, it is easier to get a job if you are 
disabled, even if you can work 20 hours a week, if you don't 
have to worry about working for benefits for your family 
members. I think it will help keep families together and will 
allow people to go to work and not have to worry about getting 
their healthcare covered. It is a tremendous step forward. We 
have limited jurisdiction and the White House may recommend 
going further in that regard.
    Senator Dole. So we have given a short summary here and we 
know there are questions and other members may want to make 
statements. We know everybody on this Committee wants to do 
what we want to do, and that is to make it work, and 
particularly for those who are really going to be jammed up the 
rest of their life. We want outcomes. We put in more money, as 
the Secretary indicated, for education. To keep people in the 
program, we raised the benefit 10 percent a year if they 
stayed. There is also a stipend to keep them in school. When 
these veterans finally leave the hospital and go to school, 
they are going to be better equipped to move into the 
mainstream of American life and have a better quality of life 
and a life of dignity for themselves and their family.
    So you all know the figures. In Vietnam, five out of eight 
seriously injured survived. Now it is seven out of eight and we 
owe a debt to the people on the battlefield, the medics, the 
doctors, the nurses, therapists and all the people that take 
care of these men and women who come back. Many who come back 
are not injured or wounded. Their illnesses, the things that 
happened to them are not their fault. But they are entitled to 
the same care. You don't have to be shot to receive benefits 
under our program. If it is combat-related which, as I said, 
covers about everybody, and if you are on the way to combat or 
whatever you are doing and you have an injury that is, that 
should be covered.
    So I just say, Congressman Filner and Congressman Buyer and 
others, we are grateful for this opportunity. We did tell the 
other Commissioners that we would continue to try to help get 
this done. We are going to be around, Secretary Shalala will be 
around, for a long time. I will be around for a while at least 
and we are going to keep working on this. Hopefully, we are 
going to have your help. So thank you very much.
    [The prepared statement of Senator Dole appears on p. 36.]
    The Chairman. Thank you so much.
    [Applause.]
    Your common sense and your sense of urgency come through 
and provide a standard through which we have to meet. The 
Executive Branch will speak for itself. But we, in Congress 
here, have to act and act quickly. And we thank you for giving 
us that impetus and that charge and the background that you 
have here.
    Secretary Shalala, you have had quite an effect on the 
Senator. If you had talked to him, or if he had talked like 
this----
    Secretary Shalala. We assure you, though, he did not become 
a Democrat in the process.
    The Chairman. If he had learned this 10 years ago, you 
might not have had your last 4 years in the Cabinet, so----
    Senator Dole. I think the key, Mr. Chairman, is that I 
don't think we had any disagreements--I mean we may have--it 
doesn't mean everything was just whatever somebody wanted. But 
a lot of our Commission members had the ideas. On electronic 
transfer of records, we had this outstanding doctor from the 
Cleveland Clinic. He was a tremendous help to us because it is 
one of the problems out there. The VA has a great system. The 
DoD is trying to catch up. When you leave Walter Reed, you 
leave with a stack of paper. When you leave a VA hospital, you 
don't have anything. They can just punch a button and they can 
get your record. And there is a recommendation on information 
technology (IT), which we think makes a lot of sense and 
doesn't cost a big, big bundle of money.
    The Chairman. Again, thank you so much. Your charge was the 
current war, but when I read your recommendations and I think 
about our Vietnam vets, it seems we could easily substitute 
Vietnam for what you said and do the same things. I think we 
did not treat our returning Vietnam vets with the honor, 
respect and care that they needed and we are paying a heavy 
price for it. And we still can correct some of that, but we 
also see what we have to do to get it right. Otherwise, we are 
going to be left with the kinds of homelessness and suicide 
rates that we saw----
    Senator Dole. I don't want to--this is the last time I will 
interrupt but----
    The Chairman. I doubt it.
    Senator Dole. We are in the Senate. We never interrupt. But 
what we discussed is that it is a new kind of warfare. There 
are new kinds of injuries. There is new technology. There are 
new opportunities. We tried to update--and I know the Chairman 
would have rather gone way back and kind of overhauled the 
whole system--but we did what our charter said. We tried to 
update and make some recommendations that are forward-looking.
    Now, some people may resist change. I assume in the Bradley 
Commission report there were some who resisted change. But we 
have to bring the benefits and everything else up to date and 
we tried to do that in our report.
    The Chairman. Did you at all, as we looked at the 
disability system and recommended a major transition, we do 
have a problem that exists right now, 600,000 or more 
backlogged claims. Some of us want to just cut through that 
bureaucracy right now, for example, and if a claim has been 
well documented and had advice of a veteran service officer, 
for example, to accept in the same way the Internal Revenue 
Service accepts your tax return and sends you a check for a 
refund, subject to audit, and just move out those 600,000, you 
know, as rapidly as we can. Did you at all think about that or 
take that up at all?
    Secretary Shalala. No. We actually didn't look at the 
backlog. As you know, this country has had considerable 
experience. The backlogs in Social Security were cleaned up. 
That requires a systems approach. That was not within our 
jurisdiction. We do believe, though, that our recommendations 
will actually help to make sure we don't create new backlogs 
because it will be much more straightforward as to who is 
responsible for what, what you are going to get and the 
combination of benefits, including, I should point out, an 
annuity even if you haven't spent 20 years in the military. All 
those found medically unfit to serve and leave before 20 years, 
will get an annuity.
    I got an annuity after 14 years in the Federal service. If 
you are injured, you ought to be able to take that annuity with 
you from the DoD. So that is added to the pieces and that is 
pretty straightforward. I think that the combination of 
transition and some of these different ways of simplifying the 
system will help eliminate the backlog. So we didn't speak to 
it directly, but we just need a more modernized, 
straightforward system that is easier for everybody to 
understand.
    Senator Dole. Another thing is, I remember way back when I 
was at the retirement board and I had some pretty serious 
injuries. I couldn't use my hands and I couldn't walk at the 
time. But I got a disability based on the fact that I was a 
captain. If I were a colonel, I would have gotten a lot more 
money, even with lesser disabilities. That didn't make any 
sense to me then, and it doesn't make any sense to me now. So 
we think we have devised a system where you get this annuity 
payment, but then you also get a rating, whether you are a 
colonel or a private first class. We think we ought to make 
certain that you are being compensated for the disability.
    And your rank--if you have been in the service 10 or 20 
years, and many people dedicate their life to the service and 
we want to reward that, you will get the payment that the 
Secretary just pointed out, this so-called annuity, whether you 
have been in the service 6 years or have been in the service 25 
years.
    The Chairman. You all mentioned, on the basis of a medical 
discharge, that TRICARE should be given for life. This 
Committee has been concerned about the practice of using a 
personality disorder discharge which we think is almost a 
purposeful misdiagnosis of a preexisting condition, and 
therefore, would not obligate our government from compensating 
these servicemembers in the future. We think that is a big 
mistake and I don't know if you took that up in your report or 
not. But I mean we think we might have to put a temporary stop 
to these diagnoses because they are doing great disservice to 
these young men and women who are serving so faithfully. Did 
you look at that issue at all?
    Senator Dole. I think the Secretary is looking for the--we 
have the facts on it. I think the number discharged for 
personality disorder since 2000 has been about 6,000. I think 
there are some misleading figures out there; am I correct, or 
did you find that?
    Secretary Shalala. Right. I think--that is right. Eighty 
percent were never in combat.
    Senator Dole. We did check on that because you had raised 
the question when you testified.
    Secretary Shalala. On page 47 of our supplemental report, 
it is 6,000. And if I remember correctly, most of them were not 
in combat specifically. That obviously could use some study. 
But one of the things that we recommend is that the standard of 
care for PTSD, and a lot of the appeals are about that, must be 
widely disseminated. We need more research on that subject. But 
everyone who comes for care ought to be treated and everybody 
ought to be eligible to be treated, no matter when they served 
in combat.
    And I wish I could say that the private sector had great 
centers of excellence. The experts in the world are in our 
military and in our VA, in particular. And while there are some 
private sector rehab hospitals that have some capabilities, 
most of this is in-house. We need to disseminate the standard 
of care. There are a number of centers and we need to make that 
available to everyone.
    The Chairman. And thank you, Senator Dole, for praising the 
whole system of care, not only in the VA, but on the 
battlefield today. The Secretary, the VA and I and Congressman 
Boozman just returned from Iraq and Afghanistan and what we did 
was, we followed that trail of the wounded warrior from when 
they are wounded, to their medical evacuation, to a forward 
base hospital, to a regional hospital, to Landstuhl, Germany, 
and we followed that for very specific individuals and the 
incredible professionalism, expertise, dedication, morale. I 
mean, and these kids, I mean they are 19, 20, 21, who are doing 
all of this and we were just amazed at their professionalism 
and leading to this, you know, this incredible survival rate 
once you, if you survive a battlefield injury. So thank you for 
praising them, because they are a tremendous, tremendous asset 
to this Nation.
    Senator Dole. I think in our report there is a segment that 
tracks a veteran from injury through medical treatment.
    Secretary Shalala. We did.
    Senator Dole. We have a little chart in there.
    Secretary Shalala. We did. And the University of Miami 
actually trains those trauma teams. The soldiers and military 
personnel fly in from different parts of the country. We turn 
them into a team before they go off to Iraq and Afghanistan. 
And the medicine today is unbelievable. The disability system 
is based on a 30-year-old medical system. That is the whole 
point here. If you saw the schedules on orthopedics in the 
disability system that we have in VA, it is unbelievable. It 
doesn't reflect modern medicine. This has to be brought up to 
date. It is just unacceptable the way it is currently set. And 
in this case, we know what to do.
    Senator Dole. The one place we need help, and Steve may 
have pointed this out in his hearings, is in the mental health 
field. There are not enough professionals available in the 
private sector or in VA and military hospitals. I don't know 
where they are going to come from, but----
    The Chairman. Thank you. Thank you again. And that 
teamwork, by the way, was so vital, as we watched it in Iraq 
and Afghanistan.
    Mr. Buyer, you are recognized for 5 minutes.
    Mr. Buyer. Thank you.
    You know, it is great to see your enthusiasm. As you know, 
that can move mountains. And so not only is it your 
credibility, but your enthusiasm that has me excited. And Mr. 
Dole, they kind of poked you here a little bit when you talked 
about spending as much money as necessary. I think you espoused 
exactly how you felt all the years that I have known you on 
these issues. When I came here in 1992, we had a VA system that 
was depicted in the movie ``Born on the Fourth of July.'' And 
as a country we didn't do well.
    And Ms. Shalala, Dr. Ken Kaiser, your good friend who was 
then the Under Secretary of Health during the Clinton 
Administration, had his ideas of moving to outpatient care and 
we embraced that. And we have invested well--when you look at 
1995 as a benchmark, we have invested probably in excess of 
$300 billion.
    So I embrace exactly what you said, Senator Dole, and----
    Senator Dole. Thank you.
    Mr. Buyer [continuing]. A couple of things I wanted to 
touch on and I thank you, Secretary Shalala, for your comments. 
You made yourself narrow and then you went deep and that is why 
you have a good product. We have the Disability Commission that 
was out there, so you were respectful of them. Yet you touched 
on a few areas. So we are with great anticipation waiting on 
their testimony to us.
    I have some questions regarding the TRICARE for Life. I 
created the TRICARE for Life for the military retirees when I 
was Chairman of the Personnel Subcommittee in our Armed 
Services Committee. So when you say, Senator Dole, that you 
would like to get DoD out of the disability business, there are 
a couple of things that I need to ask. In order to get DoD out 
of this business, we still have the medical retirees, or as 
your recommendation, to even do away with medical retirees. 
That is one question.
    The other is, if we are going to say that TRICARE for Life 
is available to those who are found unfit because of conditions 
acquired in combat, supporting combat or preparing for combat, 
then DoD pays for the TRICARE for Life. So they are not going 
to be totally out of that. We are not going to be able to 
stovepipe that. So there are still going to be payors. And so I 
will be a good listener when the Disability Commission comes 
over and I will embrace your recommendations.
    My question to you is about implementation. So if we are 
going to take the TRICARE for Life program and we are now going 
to implement that, the eligibility, are we going to restrict 
that eligibility to a core constituency, meaning those, as you 
defined here, and what is the effective date?
    Senator Dole. Why don't you go first?
    Secretary Shalala. The effective date is going to be 
determined by Congress and there will be legislation that will 
be coming up. I think----
    Mr. Buyer. Do you have a recommendation?
    Secretary Shalala [continuing]. We are talking about, that 
will be part of, back to 2001. And you will see legislation. 
That, obviously, is something that can be discussed with 
Congress in terms of setting that, as well as who is to be 
covered. We are simply talking about DoD making only the fit/
unfit decision and if one is not fit for health reasons and you 
get a medical discharge, then you ought to have the 
opportunity--and then you go over and get your disability out 
of VA. You ought to have the opportunity to have your 
healthcare covered.
    The addition here is to cover your family as well, to 
encourage you to go on and get education, as well as to get 
ready to go to work, if you can. If you can't, obviously, there 
are all sorts of services that would be available for you.
    Mr. Buyer. All right. With regard to the issue on VA 
contract care, if DoD, what you are trying to do is move these 
to be patient-centric, thank you very much. I wanted to jump up 
and hug you when I heard you talk about patient-centric.
    Secretary Shalala. Oh, that would be fun.
    [Laughter.]
    The Chairman. Trust me, it is not.
    [Laughter.]
    Mr. Buyer. Well, I am hetero, Mr. Filner.
    Senator Dole. Steve, could I ask----
    Mr. Buyer. I am not sure.
    [Laughter.]
    Sure, Senator Dole.
    Senator Dole. You raised a point that I don't have an 
answer to on medical retirees.
    Sue, would you, or Karen, address that? Let's say you have 
served 25 years and you----
    Secretary Shalala. This is Sue Hosek from the RAND 
Corporation.
    Senator Dole. RAND Corporation. She has had 30 years 
working with these issues.
    How do you treat the medical retiree--I should know, but I 
don't.
    Ms. Hosek. If you are declared unfit, you get your 
discharge for medical reasons. And, obviously, if you have 
served 20 years, you are still going to get your retirement. 
What our proposal does is to provide essentially a partial 
retirement benefit in the form of an annuity payment for those 
who don't reach the 20 years. Right now they walk away with 
nothing. And so we don't want the person who has, you know, 
say, 15 years of military service to walk off without that. And 
so that is an important change that we----
    Senator Dole. But then you get your earnings loss from the 
VA.
    Ms. Hosek. Yes. Then the VA takes care of the disability 
benefits that you would be entitled to, yeah.
    Mr. Buyer. Thank you.
    Senator Dole. Well, they are a little different, Steve. I 
wanted to say just one word about Walter Reed. I think the 
initial Washington Post story was kind of a wake up call for 
all of us and everybody began to focus on a lot of things that 
should have been focused on before. But, again, having been 
treated there for a lot of--I had several operations there. It 
is a great hospital.
    Our last recommendation is that until the other place is 
totally ready, we have to keep Walter Reed in A-1 condition 
before they turn off the lights, because we hope this conflict 
is going to end soon. For about 26 percent of the patients, 
their first stop is Walter Reed Hospital. So we have to keep 
that, if we have to, and we suggest providing incentives, 
because a lot of people don't want to stay in a place that is 
about to sink. You know, you want to get overboard, get in a 
life raft or something or find another job.
    So we would recommend some incentives for the civilians who 
may be contracting there or even the military personnel--some 
kind of a bonus for staying on the job at Walter Reed, because 
this is where at least one-fourth of our casualties go. So we 
don't want anything but first-rate service there until somebody 
finally says, okay, we can turn off the lights.
    Mr. Buyer. Thank you for your contribution and viewing this 
through the eyes of a soldier.
    The Chairman. Thank you. Dr. Snyder is next. I just want to 
thank him for focusing on an issue that I know may be not as 
part of your charge, but, you know, half of our fighting forces 
are the Guard and Reserve units who we think have got to have 
access to the same benefits. And Dr. Snyder has led the way and 
we thank him. You are recognized.
    Dr. Snyder. Thank you, Mr. Chairman. Thank you all for 
being here today. We held a hearing yesterday on the 
Subcommittee on Oversight and Investigations on the Armed 
Services Committee on Military----
    Senator Dole. I have a little, I have a little trouble----
    Dr. Snyder. I am sorry. We held a hearing yesterday on our 
Subcommittee on Oversight on the Armed Services Committee on 
DoD civilian personnel and their medical care and benefits and 
incentives serving in a war zone. And I will tell you what, I 
presented a scenario to the Department of Labor guy. If I was a 
DoD civilian that worked 18 hours a day at the Baghdad airport 
and had 6 hours off and was playing basketball on the court for 
my recreation time and a mortar came in and I got injured, 
would I be covered by worker's comp?
    And we could not get a definitive answer, that for sure, 
even though it was a clear-cut combat-related injury, that a 
DoD civilian would be covered by worker's comp. My guess is 
they will come back and say well, yeah, we thought about it and 
we think we can definitely say that. But I will tell you what, 
if you were a civilian government worker working in Iraq right 
now, that kind of answer would create some uncertainty for you.
    The Disability Commission, I am told, report will be 
briefed to the Armed Services Committee staff on October 2nd 
and that their report will be made public October 3rd, which 
should be out in plenty of time, I think, to inform these 
decisions as we go forward in conference and hopefully there 
will be things that we can react to this year.
    I wanted to ask a couple of specific questions. In your 
report, you mention--well, I will just read the two sentences. 
``To make the system work, recovery coordinators need 
considerable authority and to be paid accordingly. Recruitment, 
training and oversight by a new unit of the U.S. Public Health 
Service serves as commission corps and the Department of Health 
and Human Services should be strongly considered.'' That makes 
some of us apprehensive when we consider the years that we have 
tried to bring the VA system and the DoD system together and we 
are going to throw up our hands and say well, the way to get it 
is bring in a third huge system that everybody in this room has 
had problems with also in other areas.
    Is that really something we need to do in terms of bringing 
in HHS, or is there not another way to get at that?
    Secretary Shalala. There are other ways, obviously. And our 
feeling was that the Commission corps ought to be involved 
certainly in the training and that is being considered by the 
White House in the legislation they are going to send forward. 
The most important thing is a degree of independence, that this 
recovery coordinator has to be able to cut across whatever 
benefits are available and have some authority and be there for 
the full period of time when the soldier, from the time they 
are injured until they either go back to civilian life or 
complete their disability and rehab period.
    If a police officer goes down in my community of Miami, an 
officer is assigned to that person from the time they are 
injured, right through their hospital stay, right through their 
rehabilitation. The problem now, as the Senator pointed out, is 
that there are so many care coordinators. These soldiers and 
their families can't remember all their names. So that for the 
most severely injured people, we need a highly trained 
professional. And we are not talking about that many people. 
But a number of agencies have to participate in the outline in 
that training. Where they are located, who pays their salary, 
we were, we strongly recommended that it be independent of the 
VA and the DoD. But the most important thing to us is the level 
of their training, the fact that they are going to stick with 
that soldier and their family right through the process and 
that they don't change, for particularly these very complex 
cases.
    Dr. Snyder. I agree with all----
    Secretary Shalala. We are not talking about a large number 
of people. Does that answer your question well enough?
    Dr. Snyder. It does. I think it is the function that is 
key.
    Senator Dole. I would just add that there has been some 
concern with that provision by the veterans groups, another 
layer of bureaucracy. Well, we are not trying to do that. We 
are talking about a very small number of people. And if it is 
not the Public Health Service, the Secretary has had a lot of 
experience with them because HHS is sort of the umbrella group.
    But she stated it very clearly. We want somebody with 
authority to get an appointment.
    Dr. Snyder. No. I want to ask one----
    Senator Dole. It might speed up the process and----
    Dr. Snyder. I want to ask one final question before my time 
runs out. And you talked about it, Senator Dole, when you 
talked about the combat-related injury related to training 
hazardous duty. I think we have always had a pretty strong 
feeling in the Congress that we want to treat all our veterans, 
military people, in similar situations the same. And so, I can 
come up with scenarios, you know, Little Rock Air Force Base is 
in my district. A guy is working on a water tower in the 
military, falls off the tower or gets blown off by the wind or 
crosses the street and gets hit by a car, has a terrible spinal 
cord injury, that we would, I would think that would not fit 
under the language of Ms. Berkley's bill or the kind of 
language that you outline there and we are going to treat that 
person differently and their family medical leave qualification 
differently than a person who may have landed on a carrier in 
the Gulf and had a similar kind of injury.
    I understand the importance of focusing on combat-related, 
but on the other hand, we are going to have two classes of 
people in our military. I am not sure that we want to go down 
that road. What do you think?
    Senator Dole. Right. We had a lot of discussion. We talked 
about line of duty, combat-related, other ways we can define 
it. I think what we, in essence, finally concluded was that 
unless it is some reprehensible conduct--you are drunk, 
disorderly and you are injured or something--but if you are on 
a tower and you are in the line of duty and the wind blows you 
off, in my view, you are covered.
    Dr. Snyder. Well, take the one you are crossing the street 
to the PX and you are hit in the parking lot, that would not be 
considered hazardous duty, right?
    Senator Dole. Yes.
    Dr. Snyder. We could have families living next door that 
are treated differently with similar injuries.
    Senator Dole. I am not sure we would cover everybody 
crossing the street, but our intent was to make it broad----
    Dr. Snyder. Right, I see.
    Senator Dole [continuing]. Not to limit it. You know, you 
don't have to be shot to be----
    Dr. Snyder. Severely hurt.
    Senator Dole [continuing]. To be injured in the line of 
duty serving your country, and you ought to have the same 
benefit.
    Dr. Snyder. Right. Thank you. Thank you for your service.
    Thank you, Mr. Chairman.
    The Chairman. Thank you.
    Mr. Moran.
    Mr. Moran. Mr. Chairman, thank you. Thank you to you and 
Mr. Buyer for holding this hearing today and it is a real 
privilege to be here with Secretary Shalala and Senator Dole 
and I want to thank them for their distinguished service to our 
country and especially in this latest effort in regard to their 
Commission's work.
    Senator Dole, of course, needs to make no statements to 
prove his credibility on the topic that is before us. Senator 
Dole, I was at the Dole Institute of Public Policy on Monday 
before returning to Washington, DC, where I welcomed 100 new 
U.S. citizens to our country and used you as the role model, 
the example of what one can attain in their life. With the 
recognition that in many ways, I suppose, you grew up an 
ordinary Kansan, but accomplished extraordinary things.
    And Kansans hold you in high regard, as do Americans, for 
your public service here in our Nation's capital. But I really 
do think it is your service to our country in the military, the 
injuries that you incurred and your recovery that is the 
remarkable part of your life. And I appreciate the effort that 
you make on a daily basis to care for those who have been 
injured in service to their country.
    You tell in your book One Soldier's Story that none of us 
who travel the valleys of life ever walk alone. And your 
personal story is one that is a reminder to all of us about how 
we do rely upon others. Your mother, Bina, and her day-to-day 
efforts in your recovery----
    Senator Dole. She was my coordinator, my mother, yeah. She 
was there every day. She even held my cigarette. She hated 
people who smoked, but it was a little habit I picked up 
because in World War II they gave you a little pack with four 
cigarettes in it for your dessert, so we all started smoking. 
But one of them dropped down my cast one day and we had to pour 
water down there and all that stuff, but--but again, you go out 
to Walter Reed and if you see a single soldier, I will bet you 
10 to 1, in nearly every case, the mother is going to be 
standing right there, or the father or some family member. And 
that is another area that the Secretary and I want to address.
    Mr. Moran. Well, your mother and your family, as well as 
the folks of Kansas, particularly your hometown of Russell, the 
cigar box story is one that is an inspiration, I think, to all 
of us. The community of Russell, which is a typical Kansas 
community, put the cigar box in the drug store and collected 
money for Senator Dole's rehabilitation and today there are 
those in Russell who remember their efforts on behalf of the 
Senator and how well he is----
    Senator Dole. Well, if I could add, it was only $1,800 and 
I was wounded late in the war and all the good doctors, of 
course, wanted to go home, because the war was--I was wounded 
in April and it ended in Europe in May. In fact, I was wounded 
a hill apart and a week apart from where Senator Inouye was 
wounded and we ended up in the same hospital together and then 
later ended up in the Senate.
    But that is an indication--and I wish the Committee could 
give me some guidance on, there are all these wonderful groups 
out there trying to raise money to help veterans. I don't know 
whether, Mr. Chairman, have you ever checked to be sure they 
are all bona fide? The volunteer groups are doing a great deal. 
In those days, in our little town of Russell, $1,800 was a big 
amount. In 1947, that was kind of a recession era. I remember 
one man, Mr. Wegley, brought a duck. He didn't have any money, 
but he brought a duck, which we couldn't put in the bank, but 
we ate it.
    So just the generosity of the people and it is still out 
there and we want to tap into that, too.
    Secretary Shalala. And I think that is also the point, 
Senator. We met a mother who is from Ohio whose community is 
paying her mortgage while she is down in San Antonio at Brooke 
coordinating the care. Three decades later, we are still doing 
the same thing and there are other ways to do this that are 
more supportive of family. Women are working now. They weren't 
in an earlier generation and the whole family is working.
    Mr. Moran. Well, I think you both have great credibility in 
bringing to us this idea of a support system for those who are 
leaving the military. I have one question, although I would 
like to tell you, Senator Dole, but for you, I have never seen 
any place outside Kansas. I grew up in a family where vacations 
were a very rare thing. We only went to Iowa on an almost 
annual basis on your behalf. Every time you ran for President 
we got to see the rest of the country.
    Senator Dole. Yeah, well, it still----
    Mr. Moran. It didn't work.
    Senator Dole. It is still a possibility for 2008, but I 
don't think, I don't think so.
    [Laughter.]
    Mr. Moran. Let me ask you----
    The Chairman. We have an exclusive.
    Mr. Moran. Let me ask you, Senator Dole, about contract 
care. One of the things that I worry a lot about on behalf of 
rural America, rural Kansans in particular, is the ability for 
us to have a continuum of care that exceeds just the boundaries 
of our cities. The VA traditionally has been bricks and mortar 
in large communities. I represent a congressional district, 
your congressional district. There is no VA hospital and we 
continue to push the VA to provide greater contract care where 
the veteran can access through his own, his or her own 
physician, local hospital, other providers. And I wonder if 
your Commission has looked at what we do to expand the 
opportunities across America, not just in the traditional 
places at the VA or a military hospital which can provide 
assistance.
    Senator Dole. Right. You know, I wonder if I could just ask 
Ed Eckenhoff, a member of the Commission, to respond to that, 
because one thing we emphasize in our report, if you live in 
Las Vegas, you know, you have a big, wonderful VA hospital 
there. But in some of these rural areas, you have got to drive 
300 or 400 miles to get access to good medical care if you are 
going to go to a DoD or VA facility.
    So we urge--well, we want Congress to make it possible to 
underscore that you can go to the private sector to get good 
care.
    And Ed, can we hear you? You have a good voice.
    Mr. Eckenhoff. Well, if you can hear me, I will just stay 
right here.
    Senator Dole. Yeah, Ed Eckenhoff.
    Mr. Eckenhoff. We have talked a great deal about that and 
came to the conclusion that while you are absolutely right that 
170 plus Veterans Administration hospitals, 60 plus DoD 
hospitals, we have 5,200 civilian hospitals, many of them 
practicing good acute rehabilitation. Now, within that 
population of civilian hospitals, we have roughly 1,100 that 
have acute rehabilitation units, anywhere from 10 to 50 beds. 
We have roughly 250 freestanding civilian rehabilitation 
hospitals, all of these very well-staffed, even though we do 
have our vacancy problems, understand rehabilitation 
extraordinarily well, particularly the traumatic brain injury, 
as we have discovered, is our signature injury within these two 
wars.
    Secretary Shalala. Our first recommendation was for a 
recovery plan and with the recovery coordinator. The point of 
that plan is that with an interdisciplinary team, you can 
figure out and make adjustments to it when someone can go home, 
what care is available where, and particularly for these young 
men and women that want to go home, getting access to that care 
would be part of the recovery plan. So plotting it out so that 
someone could go home as soon as possible, get access to care, 
even the use of telemedicine. We have had a lot of experiences 
in this country now with rural healthcare. My family, part of 
it lives in North Dakota and there are a lot of soldiers in 
that place. And making sure people can get home and get care, 
the quality of care that they need, using local physicians, 
local rehab hospitals, traveling when they need to, ought to be 
part of that plan and the recovery coordinator ought to be able 
to get them to the right place at the right time.
    Senator Dole. That is a good question. It is a big issue.
    Mr. Moran. Mr. Chairman, thank you. I appreciate the 
gentlemen from Colorado, Mr. Salazar. He and I have joined 
together and have introduced as legislation the recommendations 
of the Commission. We now know that the Administration also has 
a plan to do something similar, but we would welcome any of our 
colleagues to join us. Thank you, Mr. Chairman.
    Senator Dole. That may be, you know, it is subject to 
change, obviously. You may want to change it. I know the White 
House is working on a draft. They are actually liberalizing 
some of the areas. I think it is good to send a message, you 
know. We appreciate your introducing what could be modified 
later.
    The Chairman. Thank you. I now recognize Mr. Michaud, who 
chairs our Subcommittee on Health.
    Mr. Michaud. Thank you very much, Mr. Chairman, Mr. Ranking 
Member, for having this hearing and I really want to thank both 
Senator Dole and Secretary Shalala for all your work, not only 
on this, but your continued service to our country. Providing 
the best possible care for our men and women who risk their 
lives for our country should be, and is, one of our highest 
priorities.
    I believe that in general we do a good job, but there are 
also, as you realize, significant gaps in services that our men 
and women receive. I not only thank both of you, but also your 
staff for all their hard work in putting this report together. 
I really appreciate it. I believe that your recommendations as 
they relate to PTSD and TBI, as well as those regarding 
assisting families, are very good and we will continue to 
hopefully move those ideas forward and I look forward to 
working with you as we do move this bill forward.
    My question is, I appreciate recommendation number two to 
simplify the disability and compensation system, but I want to 
make sure that we do not create an unintended negative system 
at the same time. This would essentially create a rating system 
for current veterans and new veterans that will be coming into 
the system. My concern is that dual type system, but also, how 
does your, how do you envision this disability, how does that 
take into account veterans who, as you know, will manifest 
service-connected disabilities much later in life in some 
cases? How does this new disability system affect that?
    Senator Dole. I am going to let you, but I----
    Secretary Shalala. Go ahead.
    Senator Dole. One thing we do, and we do it in a positive 
way. Now, some may not like it. For the veterans with 
disabilities, we have a review every 3 years which will take 
care of anything that may arise in that 3-year period if there 
is a sickness or illness or something they discover. We think 
it is a very positive step. Particularly men don't go to 
doctors like they should and there are all kinds of studies on 
that issue. I think we really tried to simplify the system. And 
I think in every case that we tried to look at, the veteran is 
better off under our system dollar-wise.
    Even more importantly, we had our eye on what we call 
outcome. What is the outcome? What condition will this person 
be in when they are finally free of all the hospitalization and 
education? Where are they going to fit in society? We think in 
both cases we did the best we could and I think Secretary 
Shalala has an added comment, with some help. Go ahead.
    Secretary Shalala. The disability system will establish, 
the new system will establish a really good baseline. So if 
someone gets something else a little later, it will be easy to 
make that adjustment. The most important thing for people that 
have already gotten their disability determination is they will 
have a choice. They can keep the current determination or they 
can look at the new system and then make a choice of what is 
better for them. We believe that in the new system, people will 
be much better off. All of our recommendations, it will 
simplify it. If you combine the annuity, the extended 
disability payment that covers quality of life, as well as 
modernizes that actual decision, people will just be better 
off.
    If they were injured in an accident and there was liability 
and they were represented by a lawyer, they would get all these 
other payments. They would get the earnings stuff. They get the 
quality of life payment. Why is it that these young soldiers 
don't get that? Because we have a very old fashioned system. 
And yet if they got a similar kind of injury in the private 
sector, all of those other things would be taken into account 
as part of the payment.
    Mr. Michaud. Okay. My next question, actually, Senator 
Dole, you had mentioned that, I believe it was in action plan, 
your fifth action plan, that the White House is coming up with 
actually a more liberal proposal and I couldn't really figure 
out the distinction between the report versus what the White 
House might be coming up with.
    Senator Dole. Well, I can't tell you specifically. I do 
know in the TRICARE area they are going to extend it to more 
people and families. So that is a big, big step. It is probably 
a big cost. But that is already in the mix. As I said, I was 
there last week. The Secretary was there yesterday. She may 
have some later information. I was very pleased because we have 
been pushing the people in the White House and, obviously, 
haven't been pushing Members of Congress, but we have been 
letting Members of Congress know we were available. We wanted 
to follow up. We wanted something to happen. I don't know 
whether they spell out any other areas. But they like our 
report. I think they really think we did a pretty good job in 
the time we had.
    We were together with the President at the local VA 
hospital where he, in effect, endorsed the report. We know 
there is another one coming out on benefits, but again, I think 
with minor differences.
    Did the White House add anything else you learned 
yesterday?
    Secretary Shalala. No. This Presidential Commission made 
six recommendations that require congressional action. The 
White House is preparing draft legislation and has indicated 
absolute willingness to work with the Congress. From what we 
heard, and I was there yesterday, they are considering 
broadening both the definition of who is covered, extending the 
TRICARE benefit to those that are discharged for medical 
reasons and to their families further than we did.
    So I think that you will be very pleased with their 
proposal. And that, of course, is draft legislation to give you 
another touchstone to work from. So because it was a 
Presidential Commission, they will do the drafting of those 
six. All of the other recommendations are now being implemented 
by the Administration and they are marching through each one 
with, from what I could tell, because I have talked to the two 
secretaries as well as to the White House, pretty firm 
commitments. I can usually tell, since I have been there 
before, whether they are really doing it. They have pretty firm 
commitments from the agencies that need to do the 
implementation, with the expected push back and I think you can 
hear our enthusiasm because we think this is going to get done.
    I actually don't believe in long commissions. I think you 
ought to be able to go in, see where you ought to intervene to 
make it better, identify pieces of legislation that need to be 
passed and just get it done.
    Senator Dole. We have already had a report, and I assume 
that--if you don't have it, we will send it up. But what is 
happening so far with DoD and VA and their joint meetings and 
the areas of our recommendations they have focused on is that 
they are starting to implement. So there is positive movement, 
so----
    Mr. Michaud. Good. I thank you both very much.
    The Chairman. Thank you. Mr. Boozman.
    Mr. Boozman. Thank you, Mr. Chairman.
    I want to thank you all for your work. I think you are a 
great example of how you can take individuals that are very 
well respected on both sides of the aisle and really accomplish 
a great deal. I think that you are a great example for all of 
us.
    In dealing with the 3,200, that group that is severely 
injured, I think the recovery coordinator is an excellent idea. 
All of us though, having been around the bureaucracy and 
things, and there is nothing inherently wrong. It is just the 
system. I would really encourage that hopefully those people, 
those recovery coordinators, will have a general officer, 
somebody with some clout that when they run into a roadblock, 
they have somebody that can cut through the system that says 
hey, these 3,200 are individuals that were totally committed 
and have unique situations, many times, that can cut through 
the red tape. And I hope somehow we can integrate that into the 
thing.
    Secretary Shalala. I think that is exactly right for 
accountability. I think of them as torpedoes which literally 
cut through with the authority to order appointments, to get 
agencies and services to work together, but more importantly, 
to make sure that individuals with very complex problems and 
their families get every benefit they are eligible for and get 
it on time.
    Senator Dole. Our hope is, when they have that meeting when 
the patient arrives at Walter Reed and the doctors are hovering 
around there, one member of that team will be the recovery 
coordinator and he will be there from, or she or he will be 
there from whatever point. I really give full credit for that 
to Secretary Shalala, and I think it is a great idea and it is 
not a big, big layer. We are talking about 40 or 50 
specialists, right?
    Secretary Shalala. Yeah, not that many, you know, it is 
just a handful of people given the number of people that are 
involved. And I think the most important thing is they don't 
get deployed. What happens now with the care coordinators is 
they are there for a year and then they get deployed. And so 
they keep changing and you have one for each kind of service. 
You just can't do that when you have a complex situation.
    Mr. Boozman. Right. Let me ask you another thing, too, or 
maybe you can comment. I have run into another situation. I am 
an optometrist and was asked to--I have been to Walter Reed 
several times. I went over to Walter Reed, was asked by the 
ophthalmologist and optometrist there, they have a situation 
where, with traumatic brain injury and they don't really 
understand why, but many of these people have symptoms of not 
being able to read, you know, like they used to, comprehend. 
And so we are trying, we introduced a bill to provide them some 
money to go forward with that study.
    As you all know, it is very difficult and hopefully we can 
get that blended into this legislation or some other. But there 
ought to be a pool of money that as these things come up, you 
know, a small pool of money was something where they don't have 
to have an act of Congress to go forward with these little, 
very, very important things. Does that make sense? You all are 
very familiar with this issue.
    Secretary Shalala. You know, DoD has a lot of research 
money for health research, as does the National Institutes of 
Health (NIH) and there is no reason why a first class 
application for research money for a period of time on 
something specific like that ought not to be funded.
    Mr. Boozman. And, again, I think you can help by cutting 
the----
    Secretary Shalala. But it is not that the resources aren't 
available. We have just got to make sure that when those 
applications go in, that they have the priority they deserve.
    Mr. Boozman. Exactly.
    Secretary Shalala. And there is an increasing interest. I 
am happy to talk to the Director of the NIH and to the DoD 
health research people. But you have put a lot of money in DoD 
research, as well as in NIH research. I come from a place that 
has the number one ranked eye hospital, Baskin-Palmer, and I 
know that our scientists are very interested in these kinds of 
questions.
    Mr. Boozman. Well, again, that would be helpful, like I 
say, in getting some priority.
    Secretary Shalala. I would be happy to have those conversati
ons.
    Mr. Boozman. The last thing, you mentioned unfit for 
service. And what does that, what does that entail as far as 
disability? That doesn't mean 100 percent, does it, or does 
that mean the whole gambit or----
    Senator Dole. Well, DoD wants to keep as many people as 
they can. So you could have some problems, some health 
problems, some disabilities, but still be fit for service. And 
it doesn't mean you are in perfect health and everything is 
fine.
    Mr. Boozman. Sure.
    Senator Dole. But there are certain, some things you can do 
in the service that if you are 100 percent you couldn't do. So 
that is why we want to make certain that they make that finding 
and the VA does the rest.
    Secretary Shalala. You know, the two young soldiers that 
were members of our panel, both of them could have stayed in 
the military, that is, in desk jobs. They chose not to. So they 
took their discharge and got on with their education. But it 
was basically their choice. And the military is trying to keep 
some people--first of all, they are great role models and there 
obviously are stories of people jumping out of airplanes, you 
know, who have a prosthetic limb. But I think they know pretty 
well who is fit to serve, but their incentive is to try to keep 
people.
    Mr. Boozman. Thank you all very much. Senator, you 
mentioned the program, the vets coming up, you know, the World 
War II guys.
    Senator Dole. Honored Flight.
    Mr. Boozman. We had a group from Arkansas that you met and 
that was such a special thing. So we appreciate those little 
things that make such a big difference. Thank you very much.
    Senator Dole. Yeah. Well, not many World War II veterans 
around are all that active. But I am sort of the official 
greeter. I try to go out there whenever I can and greet these 
World War II veterans. And if they are not doing it in your 
district, you ought to check into it, because it is just a 
great thing to do. It may change the life of some of these 80-
year-olds, 85. I met one guy who was 92. He wanted to get a 
picture. He was in a wheelchair. I said you stay right there. 
He said no, no, I am going to stand up and he stood up straight 
and strong, but you can see the tears in their eyes and they 
probably reflected when they were young and what they were 
doing. It is a great program. You just raise the money locally. 
It is called Honor Flight. You can get information on their Web 
site. Some fellow that is not a big CEO, but some young 
businessman in Hendersonville, North Carolina, named Jeff 
Miller came up with the idea and it is really great. Every 
Saturday you can almost count on--last Saturday there were 600 
from all over the country. And I did have a good chance to 
meet, I met two Kansans in that group from Arkansas, so----
    The Chairman. Thank you. Mr. Walz.
    Mr. Walz. Well, thank you, Mr. Chairman and Ranking Member, 
and of course, a thank you to our guests, Senator Dole and 
Secretary Shalala.
    Senator Dole, you were out in Rochester, Minnesota, to our 
soldier's field which we are very proud of our memorial out 
there and my friend, Wayne Steelman, and many of our veterans 
out there recall that day with intimate detail about your 
taking time to tour the memorial and it truly does matter.
    As a veteran, when I saw that the two of you were appointed 
to this, I couldn't have been happier and the report you 
produced is one that I was hoping we would get. It is 
absolutely what we need. It comes from two distinguished voices 
on this and my regret is today that this hearing is not being 
covered with the same, the same gusto as was last week's 
hearing, because listening to Senator Dole's words, the two are 
intertwined.
    I see members out here of our veteran service 
organizations, veterans themselves, people who have worked on 
this issue for decades and we know you can't separate the two 
and I think it is very important for this Nation to understand 
that this treatment is truly critical. And I think it is 
important when we talk about the VA to recognize the amount of 
great work that happens there. I have in Minnesota, at the VA 
medical center in Minneapolis, the polytrauma center there. The 
work that they are doing--when I hear mothers with severely 
injured sons and they say the only thing getting them through 
the day are those saints that are there on that floor, those 
nurses, those doctors, that is heartwarming.
    But the Senator made the point that all of us make on this. 
This is a zero sum proposition. One Sergeant Shannon is one too 
many. And that is what we have to get to. And I think in all of 
these areas, we are trying to figure out what are the systemic 
issues here and some of us are trying to understand the 
cultural inertia that happens in this. One area that I am 
interested in, and I am glad to hear it got reported on, is 
this issue of exchanging medical records from DoD to VA. I 
represent the City of Rochester, which includes the Mayo 
Clinic. And this is an area that has been working, an 
institution that has been working on this for years. This is a 
very complex issue. It doesn't involve just getting a 
standardized database. It involves many things that go into 
what is on that record.
    And when I talk to the people at the Mayo who have been 
looking at this, they are convinced that the VA has the best in 
the world. They said this is the best system in the world. And 
their suggestion was, and this was made not, you know, this was 
a little more anecdotally when I was talking to them about it 
with their very intimate knowledge of this, that DoD needs to 
maybe adjust to that.
    Now, I had the opportunity after talking with the Mayo 
people in looking at this to mention this to some, a person in 
DoD on the Army side that would have the ability to influence 
these types of decisions. And they simply wanted to hear 
nothing about it. They didn't want to hear about it. It wasn't 
the right way to go.
    My question to both of you with vast experience in the 
bureaucracy, talking about the torpedo, Secretary, of cutting 
through, how do we get to this issue? How do we move these 
electronic medical records, this record sharing? It is so 
important for the care of our soldiers, for the efficiency and 
for everything else. And I guess I am asking you maybe to 
answer a really, really difficult question here. But it is one 
that I think--this has been around for many of these Members' 
entire tenure here and we still can't get it fixed and it is a 
critical part of that seamless transition, so, please.
    Secretary Shalala. Actually, I don't think it is that 
complex, not if you look at it from the point of view of the 
patient. I was Secretary of HHS while the VA record system was 
being put in place. That technology certainly will need 
modernization and some investments in the years ahead. It seems 
so simple, why doesn't the military just adopt it and be done 
with it. It is in part not the answer because the VA and DoD 
are doing different things. That is number one.
    But what we focused on is the soldiers now, and what can 
you do to get the interoperability of the two systems. We 
suggested, under the leadership of a member of our Commission 
who does this for the Cleveland Clinic and is an international 
expert on the subject, that there are a series of steps that 
will get us more rapidly to interoperability, which are now 
taking place. They have to do it as fast as they can to make 
sure that you have access to information necessary for both 
care and services.
    That is more important at this point in time than for us to 
suggest that you spend billions trying to get one new system 
built from the bottom up. And you can tell our pragmatism here, 
that first of all, those of us that have experienced the bottom 
up systems are a little nervous about starting that while the 
technology is changing. It is not that we would ever say we are 
opposed to it, but at the moment, what you want to do is serve 
these soldiers now and also the ones that come behind them. 
There are ways to do that.
    We have suggested a series of steps. You don't have to pass 
any legislation on it. The government can do it. The two 
agencies can do it. They are in the process of doing it. And we 
have suggested action steps that can be measured and what the 
goals are of those steps so that we can actually hold the DoD 
and the VA accountable for making sure those systems work 
together. And they are in the process of doing that. That is 
the good news here.
    The bad news is that we actually did not take a vote or 
look at, you know, adopting one system versus another, because 
they actually do have different purposes and need different 
kinds of interactions, nor did we make a recommendation on a 
bottoms up, multi-billion dollar review. We looked at the 
practical ways to get the system to work for these soldiers now 
so it is not necessary to carry paper records across the 
street.
    The Chairman. Madam Secretary, we are going to have to 
adjourn very soon. But we have time for--I apologize to the 
Members. But if Mr. McNerney, Mr. Hare and Ms. Herseth each 
have one question before we adjourn----
    Secretary Shalala. Okay. We will try to answer it quickly 
then.
    The Chairman. Do you have a question before we adjourn?
    Mr. McNerney. Thank you, Mr. Chairman. I really wanted to 
compliment you all on your can-do attitude, which is inspiring, 
and on the simplicity of the approach. Sitting here on the 
Veterans' Affairs Committee, we see problems that seem 
overwhelming and you have taken them by the horns and you have 
produced a report that makes it look like we can actually make 
significant progress. So I applaud you on that.
    One thing that was interesting was the proposal to ask for 
reevaluation on a continuing basis. And my concern is, wouldn't 
that seem like it would make the backlog even more for 
evaluation of veterans?
    Senator Dole. Well, that is one of the practical questions 
that we looked at and I don't--it would seem to me, after maybe 
a couple evaluations it would stop. You don't do this for the 
rest of your life because you are going to know, unless 
somebody has a deteriorating condition that you want to 
continue to check on. But we are just going to have to find the 
people. It is pretty much like the passport problem when we had 
this big backlog. Maybe we are going to have to bring in some 
of these people who have left and bring them back on a 
temporary basis and let them help us get rid of these backlogs. 
That could be a problem.
    The Chairman. Mr. McNerney, thank you. I----
    Secretary Shalala. But we do want to give the opportunity 
to upgrade someone's benefits, so there is a positive and a 
negative here. But people ought to be able to look at someone's 
file and make a pretty quick decision on whether you need to 
move forward on that evaluation, because in the vast majority 
of the cases it makes no sense. But we want to make sure that 
we can upgrade benefits if that is necessary.
    The Chairman. Thank you. Mr. Hare.
    Mr. Hare. Mine is just real quick. Thank you very much for 
what you both have done. The other day, the Secretary was here 
just yesterday talking about 177 days for a person as an 
average on a claim. And it seems to me, why, and I wanted to 
get your thoughts. Why can't we err on the side of the veteran? 
In other words, start the process of the claim immediately the 
same way you do when somebody files their taxes and the claim 
begins.
    If we want to audit this claim and we think that there is a 
problem with it, fine. But it would seem to me, and the 
Secretary said he supported a pilot program, but their goal is 
to get it down from 177 to 145 days and for that veteran, I 
don't think that is, I don't think that is acceptable. So I 
wonder what your thoughts are on being able to err on the side 
of the veteran and at the VA here on disability claims.
    Secretary Shalala. You know, I think we are always in favor 

of erring on the side of the patient, that this has to be 
patient-centered. We did not look at how to eliminate the 
backlog. I have had some experience in looking at that kind of 
thing, but our Commission did not actually review that specific 
issue. So I am reluctant to even comment on it, because there 
are different ways to approach it. But our point is that you 
get a patient-centered system that doesn't delay people's 
ability to get the help they need and doesn't delay their 
ability to get educational benefits and get those investments 
on the front end as quickly as possible.
    The Chairman. Thank----
    Senator Dole. And some people have a right to appeal and, 
of course, the appeal takes a long time and I think, yeah, what 
is it, 12 months or something----
    Secretary Shalala. Yeah.
    Senator Dole [continuing]. Can delay it. So there are other 
things that maybe we need to look at. We think with our new 
system we are going to streamline the process so you won't have 
that big backlog. And you also, obviously, you get paid even 
though you will have to wait for a time, but you will get paid 
when it is finally adjudicated.
    The Chairman. Thank you. Ms. Herseth.
    Ms. Herseth Sandlin. Thank you, Mr. Chairman, and thanks to 
both of you. I commend you for your great work and the 
recommendations. I, too, like many others here, appreciate and 
would support the creation of someone who would coordinate 
recovery for servicemembers. I have had a number of 
constituents who I feel have been kind of caught between DoD 
and VA, one in particular who suffered a devastating traumatic 
brain injury. His family did not feel that he was getting the 
quality of care at a polytrauma center and, after some 
intervention, had him transferred to a private rehabilitative 
facility in California.
    And so I guess just two very quick questions. One, do you 
envi- 
sion the recovery coordinator serving as the advocate for the pa
tient?
    Secretary Shalala. Yes.
    Ms. Herseth Sandlin. Okay. And then the other, in all of 
the interviews and surveys that you did over the past 4 months, 
did you find anything that would suggest that we prematurely 
moved traumatically brain injured soldiers to long-term care 
who did not receive aggressive ongoing therapy and rehab and, 
if they did, would be much better off today than if they were 
prematurely transferred to a long-term care facility?
    Secretary Shalala. Our survey did not provide answers at 
that level of detail, nor did we have a health services 
research capacity to be able to answer that question. But it 
certainly is a question that ought to be looked at.
    Ms. Herseth Sandlin. And one final thought----
    Senator Dole. I would just add that Mr. Eckenhoff, who is a 
member of our Commission and the National Rehab Hospital 
Director--they have a number of, or have had a number of active 
duty people where they couldn't get the best care. They can get 
the best care at his facility and we encourage that.
    Ms. Herseth Sandlin. Okay. Thank you. That answered the----
    The Chairman. Thank you, Madam Secretary and Senator Dole. 
This has been one of the most productive and helpful sessions 
we have ever had here. It reflects your personalities, your 
enthusiasm, your commitment and we thank you so much and we 
intend to meet your challenge of speed and urgency and being 
patient-centered. And we thank you so much. We are going to 
have the--next week the Disability Commission will be in to 
testify and--I am sorry, the 10th of October. And we look 
forward to working with you on behalf of our combat veterans. 
Thank you so much.
    This meeting is adjourned.
    [Whereupon, at 11:44 a.m., the Committee was adjourned.]



                            A P P E N D I X

                              ----------                              

                 Prepared Statement of Hon. Bob Filner,
             Chairman, Full Committee on Veterans' Affairs
    On March 6, 2007, the President signed an Executive Order to 
establish the President's Commission on Care for America's Returning 
Wounded Warriors.
    The Commission was charged with the task of examining the 
effectiveness of returning wounded servicemembers' transition from 
deployment in support of the Global War on Terror to returning to 
productive military service or civilian society, and recommend needed 
improvements.
    The Report of the Commission was recently released and today the 
Committee will be hearing from the Co-Chairs of that Commission--
Secretary Donna Shalala and Senator Bob Dole. I look forward to a frank 
and open discussion of the recommendations made by the Commission.
    According to the report, there have been 1.5 million servicemembers 
deployed to Iraq and Afghanistan. Twenty-eight thousand have been 
wounded in action, with 3,082 of those seriously injured. The nature of 
the injuries sustained on today's battlefield is very complex and 
resource-intensive. Because of the advancements in battlefield 
medicine, protective gear and technology, the rate of survival is much 
greater than that of past wars.
    My concerns are focused on how we serve our troops when they turn 
from the Pentagon to the VA for their healthcare. In order for our 
troops to experience the seamless transition they deserve, the 
bureaucratic problems that prevent many from getting the care they need 
must be fixed.
    While VA and DoD have made adjustments and changes over the last 
few years in an attempt to address the issues surrounding the treatment 
of these injuries, as well as the transitioning of severely wounded 
servicemembers, many obstacles remain.
    As Chairman of the Committee on Veterans' Affairs, I am sensitive 
to the difficulties involved in coordinating the activities of the 
Department of Defense and the Department of Veterans Affairs. These 
Departments do indeed have different missions.
    That being said, we no longer have the luxury of time, and we, as a 
country, must act.
    Right now, while we prepare to discuss this issue, our 
servicemembers are in harm's way. Some of these brave men and women 
will be killed or wounded. We have talked about the necessity of 
providing a seamless transition for many years. This is our test as a 
Nation. And this is a test we simply must pass.
    I would like to welcome our two distinguished panelists this 
morning.
    In 1993, President Bill Clinton appointed Donna Shalala as the 
Secretary of Health and Human Services (HHS) where she served for eight 
years, becoming the longest serving HHS Secretary in our history. As 
HHS Secretary, she directed the welfare reform process, made health 
insurance available to an estimated 3.3 million children, raised child 
immunization rates to the highest levels in history, led major reforms 
of the FDA's drug approval process and food safety system, revitalized 
the National Institutes of Health, and directed a major management and 
policy reform of Medicare.
    Secretary Shalala has dealt with large bureaucracies like the VA 
and DoD before and she is experienced in implementing programs that 
work for the people . . . not against the people.
    Senator Dole knows all too well the problems that our brave men and 
women face as they deal with the painful injuries of war. Senator Dole 
was twice decorated for heroism, receiving two Purple Hearts for his 
injuries, and the Bronze Star Medal with combat ``V'' for valor. In 
1942, he joined the United States Army's Enlisted Reserve Corps to 
fight in World War II and became a second lieutenant in the Army's 10th 
Mountain Division. In April 1945, while engaged in combat in the hills 
of northern Italy, he was hit by German machine gun fire in his upper 
right back and badly injured. He had to wait nine hours on the 
battlefield before being taken to the 15th Evacuation Hospital before 
he began his recovery at a U.S. Army hospital in Michigan.
    I want to take this opportunity to thank you both for your service 
to our country and your dedication to our Nation's veterans. We are all 
grateful for the work that you do.
                                 
             Prepared Statement of Hon. Harry E. Mitchell,
         a Representative in Congress from the State of Arizona
    Thank you, Mr. Chairman.
    First and foremost I want to thank Senator Dole and Secretary 
Shalala for their efforts.
    These distinguished Co-Chairs have not only provided us critical 
information . . . they have provided us a model of bipartisanship on an 
issue of great importance.
    They know that the best way for us to help our Nation's veterans is 
for all of us to work together.
    And as their report has demonstrated, we have our work cut out for 
us.
    We need to improve information-sharing between the Department of 
Defense and the Veterans Administration. This is not only inefficient, 
it poses a risk to the quality of care our veterans receive.
    We need to reduce the long wait times veterans are enduring at the 
VA, and ensure that the VA has the resources it needs to serve veterans 
in a timely manner.
    We need to do more to help the families of veterans who, in many 
cases, are forced to shoulder the burden of advocating for healthcare 
services.
    The President's Commission outlined six specific changes to the 
current veteran care organization that can be made through Congress, 
which would improve the services that our Nation's veterans receive.
    Some of these recommendations will be easy fixes requiring little 
negotiation or further investigation.
    Others, like the restructuring of disability and compensation 
systems, will require us to put our partisan differences aside and work 
creatively to arrive at the best outcome.
    The wars in Afghanistan and Iraq pose different challenges for our 
VA than previous conflicts. Many of our returning heroes are bringing 
back new and different kinds of injuries which need new and different 
kinds of treatments.
    Our challenges are great, but working together, I know we can meet 
them.
    Our veterans have served us, and they have a right to expect us to 
serve them. And that is exactly what we are going to do.
    I look forward to today's discussion, and I yield back.

                                 
                Prepared Statement of Hon. Jerry Moran,
         a Representative in Congress from the State of Kansas
    I want to first welcome our distinguished guests with us today. 
Senator Dole and Secretary Shalala have both experienced long and 
successful careers in public service. Today, we appreciate their 
willingness to use their time and talents for a most worthy goal: to 
ensure our country is providing the best care and services to our 
military men and women and veterans, especially for those wounded in 
service to our country.
    A couple years back, Senator Dole published a moving memoir titled 
``One Soldier's Story.'' In this book he chronicles his powerful story 
of growing up in Russell, Kansas, going off to war, being wounded on a 
battlefield in Italy, and his struggle to overcome the odds to recover 
and rebuild his life. What I found remarkable about the Senator's 
recovery period was not only his personal courage, but also the help 
that he received from those around him. Senator Dole wrote, ``None of 
us who travels the valleys of life ever walks alone.'' From his mother 
who was by his bedside night and day, to the gifted Army doctors, to 
the Russell community who collected donations in a cigar box to pay for 
his surgeries, the system of support for wounded servicemembers 
matters.
    Our military members and veterans today deserve a strong support 
system, one that matches the times. The Wounded Warrior Commission--
after several months of visits to DoD and VA facilities, public 
meetings, and patient surveys and interviews--recommends that 
improvements can and should be made. Change is needed to modernize the 
current system to adjust to the realities of today's wars and improve 
the quality of life of soldiers and their families. The Commission has 
put forth a set of action items to do this.
    It is now Congress's turn to take a serious look at these 
recommendations. To move things along, Congressman Salazar and I have 
introduced the Wounded Warriors Commission Implementation Act, H.R. 
3502, to enact the recommendations of the Commission requiring 
congressional action. Before the Commission's report was released, both 
the House and Senate acted to pass legislation addressing some of the 
concerns later identified by the Commission. This was a good first step 
to improving care and services, but clearly more comprehensive action 
is needed. I encourage my colleagues to move quickly to make the 
changes necessary to support those who have sacrificed so much for our 
country.

                                 
             Prepared Statement of Hon. Ginny Brown-Waite,
         a Representative in Congress from the State of Florida
    Thank you, Mr. Chairman.
    Senator Dole and Secretary Shalala, I want to thank you for 
testifying before this Committee today. I would like to commend you for 
your work on the President's Commission on Care for America's Returning 
Wounded Warriors. When we send the brave men and women of our armed 
forces into battle, we better make sure they have everything they need 
when they come home.
    Your recommendations suggest the need in some instances to make 
sweeping changes to the way the Department of Veterans Affairs conducts 
its business. I will be interested in hearing exactly how you think 
these recommendations can be implemented
    I was pleased to see the recognition you gave to the importance of 
addressing post-traumatic stress disorder and traumatic brain injuries 
in our returning soldiers. This along with strengthening the support 
for their families, will go a long way to help soldiers transition back 
to life as a civilian.
    Once again, I welcome you to the hearing and look forward to 
hearing your thoughts on the issue before us today.

                                 
         Prepared Statement of Hon. Donna E. Shalala, Co-Chair,
President's Commission on Care for America's Returning Wounded Warriors
 (Former Secretary of the U.S. Department of Health and Human Services)
    Good morning, Chairman Filner, Congressman Buyer, and distinguished 
Members of the Committee. Thank you for giving me the opportunity to 
testify today, along with my fellow Co-Chair, Senator Bob Dole, about 
the recommendations our Commission presented to the President in late 
July.
    It was a true privilege to serve on the President's Commission on 
Care for America's Returning Wounded Warriors, especially with Senator 
Dole, whose knowledge and dedication was an inspiration to us all. We 
were joined by a stellar group of Commissioners, each of whom gave 
their full energy and attention to the critical mission we faced.
    As you know, we had an extremely short timeframe to complete our 
mission--but we were propelled by a sense of urgency that the issues 
before us required. Mr. Chairman and Members of the Committee, we know 
you share this sense of urgency and that's why we are so pleased to be 
with you today to discuss not only our recommendations, but the 
critical need to implement them.
    We have been truly heartened by the response our report has 
received in the White House, the halls of Congress and throughout the 
country. The Nation has rallied behind the need to help those who have 
put their lives on the line in service to our country--and we are 
optimistic that Congress and the Administration will move quickly to 
respond to this need by enacting our recommendations.
    As we were reminded again by the article in Saturday's Washington 
Post, the problems facing our injured service men and women have not 
gone away. Congress and the Administration have spent a great deal of 
time the past few weeks discussing the future of the war in Iraq. And 
while this is a debate that our Nation must have, I implore you not to 
forget about those who have already sacrificed so much--our injured men 
and women. They need to be front and center in congressional debate and 
within the Administration.
    The story of Staff Sgt. John Daniel Shannon, as told in the 
Washington Post, is a story that we heard throughout our time with the 
Commission--a story of numerous case managers, none of whom held sole 
responsibility for spearheading an integrated care system--a story of 
lost paperwork and frustration--and a story of a disability system that 
was in desperate need of repair.
    It's stories like this that sparked the creation of our 
Commission--and stories like this that should and must drive immediate 
congressional and White House action.
    This past July, it was the Commission's honor to present to the 
President, Congress and the public, six groundbreaking patient and 
family centered recommendations that make sweeping changes in military 
and veterans' healthcare and services. The recommendations include the 
first major overhaul of the disability system in more than 50 years; 
creation of recovery plans with recovery coordinators; a new e-Benefits 
Web site; and guaranteeing care for post-traumatic stress disorder from 
the VA for any servicemember deployed to Iraq and Afghanistan. Our 
report--Serve, Support, Simplify--is a bold blueprint for action that 
will enable injured servicemembers to successfully transition, as 
quickly as possible, back to their military duties or civilian life. 
Our report calls for (and I quote) ``fundamental changes in care 
management and the disability system.'' I respectfully request that 
this report be submitted for the record.
    Specifically, our six recommendations will:

      Immediately Create Comprehensive Recovery Plans to 
Provide the Right Care and Support at the Right Time in the Right Place
      Completely Restructure the Disability Determination and 
Compensation Systems
      Aggressively Prevent and Treat Post-Traumatic Stress 
Disorder and Traumatic Brain Injury
      Significantly Strengthen Support for Families
      Rapidly Transfer Patient Information Between DoD and VA
      Strongly Support Walter Reed By Recruiting and Retaining 
First Rate Professionals Through 2011

    Our six recommendations do not require massive new programs or a 
flurry of new legislation. We identify 34 specific action steps that 
must be taken to implement the six recommendations. Only six of these 
34 items require legislation, and that's what we will focus on today. A 
complete list of the action steps for the six recommendations is 
included on the last page of my testimony.
    I will summarize the first three actions that require legislation, 
and, then, Senator Dole will cover the remaining three.
    The first is to improve access to care for servicemembers with 
Post-Traumatic Stress Disorder.
    We call on Congress to authorize the VA to provide lifetime 
treatment for PTSD for any veteran deployed to Iraq or Afghanistan in 
need of such services. This ``presumptive eligibility'' for the 
diagnosis and treatment of PTSD should occur regardless of the length 
of time that has transpired since the exposure to combat events.
    The current conflicts involve intense urban fighting, often against 
civilian combatants, and many servicemembers witness or experience acts 
of terrorism. Five hundred thousand servicemembers have been deployed 
multiple times. The longer servicemembers are in the field, the more 
likely they are to experience events which can lead to symptoms of 
PTSD. The consequences of PTSD can be devastating. The VA is a 
recognized leader in the treatment of combat-related PTSD, with an 
extensive network of specialized inpatient, outpatient, day hospital, 
and residential treatment programs. Therefore, we ask that any veteran 
of the Iraq or Afghanistan conflicts be able to obtain prompt access to 
the VA's extensive resources for diagnosis and treatment.
    Next, we ask Congress to strengthen support for our military 
families.
    In our travels across the country, it became abundantly clear that 
we not only needed to help the severely injured, we needed to help 
their loved ones too. These loved ones are often on the frontlines of 
care and they are in desperate need of support. Therefore, we call upon 
Congress to make servicemembers with combat-related injuries eligible 
for respite care and aide and personal attendant benefits. These 
benefits are provided in the current Extended Care Health Option 
program under TRICARE. Presently, DoD provides no other benefit for 
caregiving. Yet we know that many families are caring for their injured 
servicemember at home--and many of these servicemembers have complex 
injuries. These families, forced into stressful new situations, don't 
need more anxiety and confusion, they need support. Families are 
unprepared to provide 24/7 care. Those that try, wear out quickly. By 
providing help for the caregiver, families can better deal with the 
stress and problems that arise when caring for a loved one with complex 
injuries at home.
    We also recommend that Congress amend the Family and Medical Leave 
Act (FMLA) to extend unpaid leave from 12 weeks to up to six months for 
a family member of a servicemember who has a combat-related injury and 
meets other FMLA eligibility requirements. According to initial 
findings of research conducted by the Commission, approximately two-
thirds of injured servicemembers reported that their family members or 
close friends stayed with them for an extended time while they were 
hospitalized; one in five gave up a job to do so.
    Getting family members to the bedside of an injured servicemember 
is not the problem. The services have developed effective procedures to 
make this happen, and the private sector has stepped up to provide 
temporary housing. Because most injured servicemembers recover quickly 
and return to duty, the family member's stay may be short. However, for 
those whose loved one has incurred complex injuries, the stay may last 
much longer. Extending the Family and Medical Leave Act for these 
families will make a tremendous difference in the quality of their 
lives. Congress enacted the initial Family and Medical Leave Act in 
1993, when I was Secretary of Health and Human Services. Since then, 
its provisions have provided over 60 million workers the opportunity to 
care for their family members when they need it most--without putting 
their jobs on the line.
    We were pleased to see that the Senate has already unanimously 
passed the Support for Injured Servicemembers Act which implements this 
recommendation. We hope the House of Representatives will quickly 
follow suit.
    Mr. Chairman, having served in government a good deal of my life, I 
believe that government can work to improve the lives of its citizens. 
But sometimes, people of good will want to solve a problem and their 
idea of a fix is to add a program or a new regulation. What we've done 
is strip some of that away to simplify the system, to go back to basic 
principles and to make necessary programs more patient and family 
centered.
    Above all, our recommendations are doable. Whether requiring 
congressional legislation or implementation by DoD or VA, we made sure 
that what we were recommending could be acted upon quickly. Our 
seriously injured servicemembers must not be made to wait. They deserve 
a healthcare system that truly serves, supports and simplifies.
    On behalf of the Commission, I want to thank the Committee again 
for the opportunity to discuss our recommendations. And because those 
of you who know me know I don't mince words, I leave the Committee--and 
the Administration--with these three simple words--Just do it! And, Mr. 
Chairman and Members of this distinguished Committee, I know that 
through your leadership, our recommendations WILL become a reality for 
our servicemembers and their families.
    Thank you and I look forward to joining Senator Dole in answering 
your questions.
                                 
             Prepared Statement of Hon. Bob Dole, Co-Chair,
President's Commission on Care for America's Returning Wounded Warriors
        (Former United States Senator from the State of Kansas)
      Good morning, Mr. Chairman and Members of the Committee. 
It is a pleasure to appear before you today, along with my fellow Co-
Chair Donna Shalala.
      We look forward to working with you to support this 
Nation's goal of assuring that our service men and women receive the 
benefits and services they deserve.
      It has been an honor to serve on this Commission, 
especially with Secretary Shalala. I have said it before and I will say 
it here today, she's been a ``Triple A'' Co-Chair. She has boundless 
energy and kept us going as we tackled this important challenge. It has 
been a great experience to work with her and our fellow Commissioners.
      Our recommendations were guided by the Commission chaired 
by General Omar Bradley in 1956, which said: ``Our philosophy of 
veterans' benefits must be modernized and the whole structure of 
traditional veterans' programs brought up to date.''
      Problems accompany change--wars change, people change, 
techniques change, injuries change, and we need to keep our military 
and veterans healthcare system up to date. I find it remarkable that 50 
years later we are finding so much of what General Bradley had 
recommended is still relevant today.
      Secretary Shalala has outlined our recommendations and 
some of the action steps to be taken by Congress. I will now review the 
remaining three action steps that require legislation and are part of 
our call for a complete restructuring of the disability and 
compensation systems.
      In our next action step, we call on Congress to revise 
the DoD and VA disability systems. Right now each of these Departments 
assesses each injured servicemember's disability level, based on 
different objectives. Each assessment leads to a rating of the amount 
of disability. The two systems often disagree, they take way too long, 
and the process is way too confusing.
      There are differences in ratings depending on which 
military service determines the DoD rating and which VA regional office 
determines the VA rating. In our national survey of injured 
servicemembers, less than half understood the DoD's disability 
evaluation process. And, only 42 percent of retired or separated 
servicemembers who had filed a VA claim understood the VA process.
      We recommend that DoD retain authority to determine 
fitness to serve. Servicemembers whose health makes them unfit for duty 
would be separated from the military. DoD would provide them a lifetime 
annuity payment based on their rank and years of military service.
      We believe that only one physical exam should be 
performed, rather than the two required now--one by each Department--
and it should be performed by the DoD. The VA should assume all 
responsibility for establishing the disability rating based on that 
physical and for providing all disability compensation.
      This 
new structure makes timely, reliable, transparent, and accountable chang
es in both systems.
      Under this action item, DoD and VA can focus on what they 
do best--determining fitness standards and the health and readiness of 
the military workforce. The VA can focus on providing care and support 
for injured veterans, including providing education and training early 
in the rehabilitation process. It is a much simpler system that better 
supports the needs of those transitioning between active duty and 
veteran status.
      In our fifth action step, we recommend healthcare 
coverage for servicemembers who are found unfit because of conditions 
that were acquired in combat, supporting combat, or preparing for 
combat. Congress should authorize comprehensive lifetime healthcare 
coverage and pharmacy benefits for those servicemembers and their 
families through DoD's TRICARE program.
      We believe this action item would help these individuals 
find employment that fits their needs without worrying whether the job 
provides adequate family healthcare coverage.
      And, in our final action step, we would like Congress to 
clarify the objectives for the VA disability payment system by revising 
the three types of payments currently provided to many veterans. The 
primary objective should be to re- 
turn disabled veterans to normal activities, insofar as possible, and 
as quickly as possible, by focusing on education, training, and 
employment. We recommend changing the existing disability compensation 
payments for injured servicemembers to include three components: 
transition support, earnings loss, and quality of life.
      ``Transition Payments'' are temporary payments to help 
with expenses as disabled veterans integrate into civilian life. 
Veterans should receive either three months of base pay, if they are 
returning to their community and not participating in further 
rehabilitation; or an amount to cover living expenses for up to four 
years while they are participating in education or work training 
programs.
      ``Earnings Loss Payments'' make up for any lower earning 
capacity remaining after transition and after training. Initial 
evaluation of the remaining work-related disability should occur when 
training ends. Earnings loss payments should be credited as Social 
Security earnings and would end when the veteran retires and claims 
Social Security benefits.
      And ``Quality of Life Payments,'' which should be based 
on a more modern concept of disability that takes into account an 
injury's impact on an individual's total quality of life--independent 
of the ability to work.
      The disability status of veterans should be reevaluated 
every three years and compensation adjusted, as necessary.
      By overhauling the DoD and VA disability systems, 
Congress will make the systems less confusing, eliminate payment 
inequalities, and provide a solid base and incentives for injured 
veterans to return to productive life.
      I really believe, and I can say this having voted on a 
lot of military and veterans bills, having met on other commissions, 
having been a service officer in my younger years, and having worked 
hard to help veterans in the Legion and the VFW, that these are really 
bold action steps. They will do justice for our brave servicemembers 
fighting in Iraq and Afghanistan. I also believe these actions, which 
support our six recommendations, will benefit past and future 
generations of American servicemembers.
      You know, in Vietnam \5/8\ seriously injured 
servicemembers survived; today 
\7/8\ survive--many with injuries that in World War II would have been 
fatal. Over 1.5 million servicemembers have been deployed in the Global 
War on Terror. At the time of our report, 37,851 had been evacuated 
from Iraq or Afghanistan for illness or injury--23,270 of these 
individuals were treated and returned to duty within 72 hours. We 
believe that the number of seriously injured is small--on the order of 
3,000, based on the number who have received Traumatic Servicemembers' 
Group Life Insurance (TSGLI).
      Both of us are grateful that Congress is determined to 
improve the system of care for America's injured servicemembers and 
their families. We call upon you to move quickly and implement the 
actions we have discussed today. To make the significant improvements 
we recommend requires a sense of urgency and strong leadership.
      Congress plays a critical role in helping to change the 
way our military and veterans healthcare systems work. Together, we are 
truly creating a system that serves our bravest men and women who have 
made the ultimate sacrifice for our Nation.
      In closing, Mr. Chairman, let me emphasize again that our 
report is doable and necessary. We ask that you draft legislation to 
implement the six action items that Secretary Shalala and I have just 
discussed.

    Thank you.
                                 
                    Statement of Joseph A. Violante,
       National Legislative Director, Disabled American Veterans
    Mr. Chairman and Members of the Committee:
    The Disabled American Veterans (DAV), a national veterans service 
organization, was founded in 1920 and chartered by Congress in 1932 to 
represent this Nation's war-disabled veterans. DAV is dedicated to a 
single purpose: building better lives for our Nation's disabled 
veterans and their families. While representing the interests of all 
service-disabled veterans, DAV counts among its membership 1.3 million 
war veterans who were injured in service to the Nation. On behalf of 
DAV, I appreciate the opportunity to submit testimony to the Committee 
on the matter before you today.
    The President's Commission on Care for America's Returning Wounded 
Warriors (hereinafter, ``Dole-Shalala'') was ordered by President Bush 
following the public outcry earlier this year on discovery of 
substandard living conditions and confusing bureaucracy affecting 
hundreds of wounded soldiers at Walter Reed Army Medical Center. All of 
us were justifiably outraged that our Nation's newest wounded and 
disabled military servicemembers were being forced to live in 
deplorable conditions and experienced frustrating delays to get their 
disabilities adjudicated by the military service departments. But even 
today, Mr. Chairman, injured and ill veterans continue to be denied 
benefits to which they are rightfully entitled, and I will explain our 
stance on this issue further in this testimony.
    In general the report issued July 25, 2007 by Dole-Shalala strikes 
a positive chord in advocating improved support to the immediate 
families of the wounded; calling for better coordination between the 
Department of Veterans Affairs (VA) and the Department of Defense (DoD) 
across a number of separate, but overlapping responsibilities; and, 
establishing within both VA and DoD better guidance and more informed 
assistance for wounded servicemembers, veterans and their families. 
These are very good ideas and should be implemented rapidly. We support 
them and commend the Commission for making these recommendations. In 
fact DAV, in our Stand Up For Veterans initiative 
(www.standup4vets.org), is developing our own legislative 
recommendations, for consideration by Congress, covering areas very 
similar to the Dole-Shalala recommendations of better supporting family 
caregivers and improving coordination of care. We hope to have our 
recommendations from that initiative, formulated by consultants now 
working with DAV after completing significant careers in the VA 
healthcare system, in legislative form to you by the end of this 
session of Congress, and for further consideration by the Committee 
early next year.
    Over the years DAV and other veterans service organizations have 
testified before this Committee and others on numerous occasions to 
identify many existing gaps in health and benefits systems, and to urge 
they be filled by actions within either VA or DoD, or both, or by 
Congress. Congress has responded to many of these initiatives, and we 
appreciate that assistance. Nevertheless, we believe a few of the Dole-
Shalala recommendations that seek the same goals are in fact misguided 
or fail to recognize a degree of effectiveness that we at DAV 
understand and appreciate from decades of direct experience working in 
this very field, helping veterans obtain their rightful government 
benefits.
    Recalling the explosion of media reports earlier this year to 
document the Walter Reed Army Medical Center scandal, it is ironic that 
the recommendations from a well-conceived, 2-year study by the 
President's Task Force to Improve Healthcare Delivery for Our Nation's 
Veterans issued in 2003, with broad support from the entire veterans 
community, have gone nowhere. Yet the Dole-Shalala recommendations--
some of which could do harm to the very system now in place and 
intended to help veterans--are apparently being put on a fast track to 
implementation. DAV was invited with others to a White House briefing 
only a few days ago to be informed that the Administration is in the 
final stages of developing proposed legislation to carry out the Dole-
Shalala recommendations, less than two months following the report of 
the Commission. We at DAV hope this Committee--one that will have the 
major responsibility to consider the Administration's proposal--will 
very carefully evaluate the potential consequences of this bill. Its 
untoward affects in some areas that seem to help one group of disabled 
veterans may well damage the best interests of another group. DAV's 
policy is to protect the interests of all service-disabled veterans, 
not one group to the detriment of another.
    In respect to protecting the interests of all disabled veterans, a 
major strategic goal of DAV, we appreciate the Committee's interest in 
scheduling a hearing next month on the need for reform of funding of 
VA's healthcare system--a key issue ignored by the Dole-Shalala 
Commission's report. The Senate Committee on Veterans' Affairs held 
such a hearing on July 25, 2007, the same date that the Dole-Shalala 
Commission issued its report. The President's earlier Task Force in 
2003 specifically pointed out the obvious mismatch between funding made 
available through the discretionary appropriations process now in use, 
versus meeting the true financial needs of VA healthcare. This 
President's Task Force hypothesis was validated in 2005 and 2006 by 
very public and embarrassing developments in VA healthcare when, during 
both periods, the VA Secretary reluctantly admitted to Congress that VA 
needed major emergency supplemental funding to keep the system 
financially solvent. Congress eventually provided that needed extra 
funding, but we continue to believe that significant reform is 
necessary. DAV strongly supports conversion of VA healthcare funding to 
a mandatory status as our top legislative goal, and we look forward to 
further discussions of this issue at your upcoming hearing.
    Mr. Chairman, most of the six Dole-Shalala recommendations are 
already being addressed in the Department of Veterans Affairs. For 
example, early on in these wars VA established polytrauma 
rehabilitation centers to treat traumatic brain injuries and other 
polytrauma cases from the wars in Iraq and Afghanistan, and VA has been 
the pioneering force and recognized expert in the treatment and 
research on post-traumatic stress disorder (PTSD). So, in many ways, VA 
is far and away ahead of the Dole-Shalala recommendations.
    The VA has an established nationwide healthcare system that is a 
recognized leader in specialized treatment (including long-term medical 
and vocational rehabilitation) of the kinds of injuries and 
psychological wounds occurring in the wars in Iraq and Afghanistan. 
Yet, initially Dole-Shalala has recommended that DoD take the lead role 
in coordinating long-term care for men and women with traumatic brain 
injury and post-traumatic stress disorder after they've been released 
from the military medical system. The report recommends these 
individuals, as veterans, retain lifetime access to DoD healthcare 
through its TRICARE program, rather than make a smooth transition to VA 
care as the primary locus of their long-term rehabilitation. While we 
do not object on its face to continued TRICARE eligibility for this 
newest generation of veterans, no former injured veteran group has ever 
been given this government benefit (even following the Persian Gulf 
War, when casualties were light). This proposal, if approved by 
Congress, would set a precedent to continue for veterans of any future 
U.S. conflict. After several decades of growing reliance on DoD, rather 
than VA, by service-disabled veterans, we question whether the VA 
healthcare system we know today would be able to retain its viability 
if wounded war veterans were still attached on a long-term basis 
primarily to military medicine. The military's top mission in 
healthcare is the maintenance of readiness. Giving the military a new 
mission to provide lifelong care to severely disabled veterans will sap 
resources and challenge the military services' ability to sustain a 
strong readiness posture.
    Mr. Chairman, we are most troubled by an ill-advised Dole-Shalala 
recommendation for a seemingly wholesale and radical overhaul of the 
disability evaluation and compensation systems in use today in DoD and 
VA. Dole-Shalala would establish a complicated and different system of 
compensation payments for our newest injured military members while 
failing to address the accuracy and timeliness problems that have 
plagued both the VA and DoD for many years. Dole-Shalala would have the 
government adjudicate disability for new and future injuries based on 
two primary factors--loss of earnings and diminished quality of life--
instead of retaining and fixing the highly structured disability 
compensation system now in use that collectively considers both 
factors. Even more troubling is the Dole-Shalala recommendation to 
drastically reduce the level of government disability compensation when 
a veteran stops working or gains eligibility for receipt of Social 
Security benefits.
    Based on DAV's eight decades of contact with, and work in, the VA 
and DoD disability adjudication systems, DAV testified before the Dole-
Shalala Commission and called for adequate staffing, structured 
training programs, and strict accountability for claims processing in 
VA. Unfortunately, the Commission ignored our recommendations. Our 
testimony to the Commission is attached to this testimony to provide 
the Committee an opportunity to fully consider our views as provided 
previously to the Dole-Shalala Commission. Dole-Shalala had the 
opportunity to push the VA to take the first genuine steps toward 
effectively reducing to a minimum the present massive claims backlog. 
Sadly, it chose not to do so by failing to address the staffing, 
accuracy and timeliness problems that have plagued both VA and DoD and 
instead proposed a program exclusively attuned to new combat-wounded 
veterans. Without that important and vital mandate as suggested by DAV, 
the VA may never be fully responsive to the needs of disabled veterans 
already in its claims adjudication queue. We question where this leaves 
the 600,000 veterans of earlier military service now awaiting 
resolution of their VA claims. Implementing this Dole-Shalala 
recommendation would set a dual standard for disabled veterans--one 
that DAV could not support.
    Mr. Chairman, it may be good to remind the Committee that this is 
not our first, nor probably our last, war. Currently, like many other 
veterans organizations, members of DAV are largely drawn from the 
Vietnam War generation. We at DAV are wartime veterans and have 
suffered many of the same kinds of injuries that are being suffered now 
in Baghdad or Kabul in our latest wars. Had it not been for the 
existence of a caring, attentive VA system almost 40 years ago, 
including its health and compensation programs that sustained us and 
our families through the long-term rehabilitation process, and the VA's 
Vocational Rehabilitation Program (under title 38, United States Code, 
Chapter 31), that enabled us to embark on many rewarding careers, as 
disabled veterans we simply could not know where our lives might have 
taken us. The VA healthcare system has been an intimate part of our 
lives for decades since those traumatic ``Alive Day'' events in the 
early lives of DAV members. The quality of care and dedication to 
purpose and commitment of VA employees would be difficult to match 
elsewhere, in public or private systems.
    We believe VA has a system that has worked well for years, is time 
tested and proven, but is now under fire because of the process, as 
opposed to the fundamentals. We believe the fundamentals are sound at 
VA and should be preserved. To provide VA what it needs in financial 
resources to employ and train sufficient staff, and to hold them 
accountable for the work they are supposed to do, would go a long way 
to keeping the system solvent well into the future to meet the needs of 
older veterans, the newest generation of wounded combat veterans, and 
future generations to come. Said another way, we at DAV do not see the 
need for wholesale changes and the development of an entirely new 
compensation and benefit system at VA to replace, for new veterans what 
has worked successfully to assist veterans over many decades.
    In 2004, in section 1501 of Public Law 108-136, the National 
Defense Authorization Act for FY 2004, Congress authorized a Veterans 
Disability Benefits Commission to examine VA's disability compensation 
system, and to make a report with recommendations for any needed 
reforms. The report of that Commission is due for release next month. 
We hope this Committee will examine that report at least as closely as 
you examine this one from Dole-Shalala, to determine a proper and 
equitable disability compensation policy for war-wounded veterans, 
whether new or old.
    Mr. Chairman, in summary DAV is concerned about the Dole-Shalala 
Commission report, especially in the areas indicated. When the 
Administration's legislative proposal is released to implement the 
intent of the Commission's recommendations, we are hopeful DAV will 
have an opportunity to review it and provide the Committee further 
commentary before you act on that proposal.
    Mr. Chairman, this concludes DAV's statement. Again, on behalf of 
DAV, thank you for the opportunity to provide this testimony.

                                 
                     Statement of Hon. Jeff Miller,
         a Representative in Congress from the State of Florida
    Thank you, Mr. Chairman.
    Providing top-notch medical care and a seamless transition for 
separating servicemembers between the Department of Veterans Affairs 
(VA) and the Department of Defense (DoD) is a priority. This is 
especially important when we address care provided by VA to the 
severely wounded warriors from the Global War on Terror.
    Serving on both the Committee on Veterans' Affairs and the 
Committee on Armed Services, I take great interest in the medical care 
and services available to our Nation's veterans, and the men and women 
serving in uniform.
    Today we will review the recommendations to improve the care and 
services for our wounded warriors and veterans from the President's 
Commission on Care for America's Returning Wounded Warriors, co-chaired 
by Senator Bob Dole and Secretary Donna Shalala.
    The Dole-Shalala Commission based its recommendations on three 
goals to prioritize patients and families, so that we simplify the 
complicated systems that are in place while serving and supporting our 
wounded warriors from the Global War on Terror. These are important 
goals as we address the needs of our veterans and wounded warriors. The 
Commission framed its recommendations by these goals.
    Among the specific recommendations reported by the Dole-Shalala 
Commission we find the immediate creation of comprehensive recovery 
plans to provide the right care and support at the right time and place 
to help establish a continuity of care. Providing a plan would fulfill 
the goals to serve, simplify, and support. These concepts will be 
valuable to review as the Committee moves forward this Congress.
    Continued support for the severely wounded is imperative. We must 
ensure that we are able to provide care and services for our wounded, 
and I look forward to the discussion today.
    Senator Dole and Secretary Shalala, I appreciate your service to 
America and its veterans. Your contribution is appreciated.
    Thank you, Mr. Chairman. I yield back the balance of my time.
          POST-HEARING QUESTIONS AND RESPONSES FOR THE RECORD

                                     Committee on Veterans' Affairs
                                                     Washington, DC
                                                   October 18, 2007

The Honorable Donna E. Shalala
President
University of Miami
P.O. Box 248006
Coral Gables, FL 33124-4600

The Honorable Bob Dole
Alston & Bird, LLP
950 F Street, NW
Washington, DC 20004

Dear Ms. Shalala and Senator Dole:

    In reference to our Full Committee hearing ``Findings of the 
President's Commission on Care for America's Returning Wounded 
Warriors'' on September 19, 2007, I would appreciate it if you could 
answer the enclosed hearing questions by the close of business on 
November 16, 2007.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all Full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Debbie Smith by fax at 202-225-2034. If you have any questions, please 
call 202-225-9756.

            Sincerely,

                                                         BOB FILNER
                                                           Chairman

                               __________

     Response to Questions from the Honorable Bob Filner, Chairman,
  Committee on Veterans' Affairs, to Hon. Donna E. Shalala, Co-Chair,
     President's Commission on Care for America's Returning Wounded
    Warriors, and President, University of Miami, and Hon. Bob Dole,
         President's Commission on Care for America's Returning
                            Wounded Warriors

Recommendation #2

Completely Restructure the Disability and Compensation System

    The report recommends that the VA update its current disability 
rating system to reflect current injuries and modern concepts of the 
impact of disabilities on quality of life.

    Q. What kinds of problems did you see with the current disability 
rating schedule?

    Response: The current system is not contemporary and reflects 
neither quality of life nor earnings loss adequately. For example, 
results from the Center for Naval Analysis study provided to the 
Veteran's Disability Benefits Commission identify the inadequate 
treatment of Post-Traumatic Stress Disorder in the rating schedule. We 
heard from several of the Nation's leading disability experts that the 
system is in need of fundamental change, a finding that has been 
confirmed by two recent reports from the Institute of Medicine, and by 
the Veteran's Disability Benefits Commission.

    Q. What would you like to see modified or added to the current 
system?

    Response: We have called for the addition of Quality of Life 
payments and a top to bottom revision of the disability system. We have 
also recommended routine and regular evaluation and updating of the 
system going forward.

    The report recommends that all disability-related payments and 
benefits for veterans would be obtained through VA. There are listed 
three types of payments: transition payments, the earnings-loss 
payments and the quality-of-life payments. It is not clear in the 
report how these payments affect other government payments. The 
earnings-loss payments, similar to compensation payments of today, are 
to make up for any reduced earning capacity. Right now, a disability 
compensation payment is not taxed.

    Q. Under the proposed changes, would this payment be taxed?

    Response: The Commission did not take a position on taxation of 
disability-related payments.

    Q. What happens to this payment once a veteran is eligible to 
receive Social Security? Does the payment stop?

    Response: Under the proposed new system for payments to disabled 
veterans, the annuity payment and quality-of-life payments would 
continue throughout retirement while earnings loss would convert to 
Social Security payments after retirement.
    The streamlined disability compensation system calls for periodic 
reassessments of veterans' disability ratings.

    Q. Where did the Commission get the 3-year timeframe from?

    Response: The Commission considered the frequency of recommended 
health evaluations for many stable medical evaluations, ranging from 
annual exams for breast cancer screening to every five years for colon 
cancer screening. We selected every three years as an average. We 
believe that annual evaluations would present a burden to the system 
and to the veteran. However, given the nature of some problems, like 
Post-Traumatic Stress Disorder, we believed that 5 years would be too 
long.

    Q. Is that the average length of time under the current system that 
veterans generally apply for an increase in a service-connected 
disability?

    Response: Not that we are aware of.

    Q. Will this reassessment take the place of the veteran's current 
ability to apply for increases in service connection disability ratings 
if and when the disability becomes more debilitating?

    Response: No.

    Q. Is it the Commission's intention to limit those types of claims 
so VBA can cut down on their workload?

    Response: No. Resources should be provided to be sure that veterans 
are taken care of in a timely manner.

    Q. Is it the Commission's intention for the streamlined system in 
the report to apply to all veterans or just those that are severely 
injured?

    Response: All veterans.

Recommendation #5

Rapidly Transfer Patient Information Between DoD and VA

    Recommendation 5, Rapidly Transfer Patient Information Between DoD 
and VA, lists three caveats with it. One of the caveats is: underlying 
organizational problems must be fixed first, or information technology 
merely perpetuates them. VA and DoD have struggled for years to find a 
fix.

    Q. Could you elaborate on what some of the organizational problems 
are?

    Response: None of the services have systems that easily ``talk to 
each other.'' We provide a number of specific examples in the 
Commission's Subcommittee Report on Information Systems (page 115 in 
the Subcommittee report). Each service has a separate personnel system 
that feeds only some information to a central DoD data archive. The 
Army computer systems and the Air Force computer systems are not fully 
compatible, and we found that electronic medical records for Air Force 
servicemembers may not be available to the Army physicians who may 
treat them. Most information systems have been developed to support 
specific functions and were not originally designed to be integrated. 
This information exchange is further compounded by the need to share 
information between the VA and the DoD. Even the VA's path-breaking 
Vista medical record system today consists of 128 different systems at 
individual medical facilities and it does not achieve full 
interoperability. Thus inter- and intra-departmental issues abound.

    Q. What does the Commission recommend as a ``fix'' to the 
underlying organizational problems?

    Response: It is necessary to focus on the outcome--information 
availability--not the computer systems themselves. The first step is to 
assure that all information that supports the development and 
implementation of the patient's recovery plan and is needed to provide 
healthcare and benefits is viewable by relevant DoD and VA staff within 
the next year. That means that clinicians, administrators, and benefit 
administrators must be able to see the relevant information in 
electronic form so that appropriate decisions may be made and patient 
progress may be monitored. We have supplied in our Subcommittee report 
on page 131 a template for a Scorecard for Information Exchanges that 
can be used as an aid to track the progress for sharing specified 
categories of essential data.

                                 

     Response to Questions from the Honorable Joe Donnelly, Member,
  Committee on Veterans' Affairs, to Hon. Donna E. Shalala, Co-Chair,
     President's Commission on Care for America's Returning Wounded
    Warriors, and President, University of Miami, and Hon. Bob Dole,
         President's Commission on Care for America's Returning
                            Wounded Warriors

    Q.(1). Would you support a shift away from the current claims 
process to approving veterans' disability claims based on a presumption 
of service connectedness?

    Response: The scope of the Commission's recommendations did not 
include the topic of presumption of service connectedness for the 
purpose of VA claims filing. We did, however, look at the Benefits 
Delivery at Discharge system, which has been successful in expediting 
VA disability evaluation for servicemembers before they leave military 
service with a medical separation or retirement. That program would 
presumably mitigate the need for presumption at the time of 
hospitalization with a known outcome of military discharge.

    Q.(2). To what extent would such a change be applied? Would you 
only apply the presumption process to new claims of recent veterans, or 
for new claims by all veterans?

    Response: Again, we did not explore the presumption concept and, 
therefore, cannot comment.
    As questions 3-5 also pertain to presumption and were not a focus 
of the Commission, we are unable to provide comment.



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