[House Hearing, 111 Congress]
[From the U.S. Government Printing Office]





              LEGISLATIVE HEARING ON H.R. 3843, H.R. 4041,
              H.R. 5428, H.R. 5516, H.R. 5543, H.R. 5641,
              H.R. 5996, H.R. 6123, H.R. 6127, H.R. 6220,
                         AND DRAFT LEGISLATION

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

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

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

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                           SEPTEMBER 29, 2010

                               __________

                           Serial No. 111-101

                               __________

       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     HENRY E. BROWN, Jr., South 
Dakota                               Carolina
HARRY E. MITCHELL, Arizona           JEFF MILLER, Florida
JOHN J. HALL, New York               JOHN BOOZMAN, Arkansas
DEBORAH L. HALVORSON, Illinois       BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia      DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico             GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas             VERN BUCHANAN, Florida
JOE DONNELLY, Indiana                DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia

                   Malcom A. Shorter, Staff Director

                                 ______

                         SUBCOMMITTEE ON HEALTH

                  MICHAEL H. MICHAUD, Maine, Chairman

CORRINE BROWN, Florida               HENRY E. BROWN, Jr., South 
VIC SNYDER, Arkansas                 Carolina, Ranking
HARRY TEAGUE, New Mexico             CLIFF STEARNS, Florida
CIRO D. RODRIGUEZ, Texas             JERRY MORAN, Kansas
JOE DONNELLY, Indiana                JOHN BOOZMAN, Arkansas
JERRY McNERNEY, California           GUS M. BILIRAKIS, Florida
GLENN C. NYE, Virginia               VERN BUCHANAN, Florida
DEBORAH L. HALVORSON, Illinois
THOMAS S.P. PERRIELLO, Virginia

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










                            C O N T E N T S

                               __________

                           September 29, 2010

                                                                   Page
Legislative Hearing on H.R. 3843, H.R. 4041, H.R. 5428, H.R. 
  5516, H.R. 5543, H.R. 5641, H.R. 5996, H.R. 6123, H.R. 6127, 
  H.R. 6220, and Draft Legislation...............................     1

                           OPENING STATEMENTS

Chairman Michael H. Michaud......................................     1
    Prepared statement of Chairman Michaud.......................    25
Hon. Henry E. Brown, Jr., Ranking Republican Member..............     1
    Prepared statement of Congressman Brown......................    25

                               WITNESSES

U.S. Department of Veterans Affairs, Robert L. Jesse, M.D., 
  Ph.D., Principal Deputy Under Secretary for Health, Veterans 
  Health Administration..........................................    18
    Prepared statement of Dr. Jesse..............................    71

                                 ______

American Legion, Jacob B. Gadd, Deputy Director, Veterans Affairs 
  and Rehabilitation Commission..................................    10
    Prepared statement of Mr. Gadd...............................    47
Barrow, Hon. John, a Representative in Congress from the State of 
  Georgia........................................................     6
    Prepared statement of Congressman Barrow.....................    28
Disabled American Veterans, Adrian M. Atizado, Assistant National 
  Legislative Director...........................................    13
    Prepared statement of Mr. Atizado............................    56
Paralyzed Veterans of America, Carl Blake, National Legislative 
  Director.......................................................    11
    Prepared statement of Mr. Blake..............................    52
Pingree, Hon. Chellie, a Representative in Congress from the 
  State of Maine.................................................    17
    Prepared statement of Congresswoman Pingree..................    71
Sestak, Hon. Joe, a Representative in Congress from the State of 
  Pennsylvania...................................................     2
    Prepared statement of Congressman Sestak.....................    26
Stearns, Hon. Cliff, a Representative in Congress from the State 
  of Florida.....................................................     7
    Prepared statement of Congressman Stearns....................    34
Walz, Hon. Timothy J., a Representative in Congress from the 
  State of Minnesota.............................................     4
    Prepared statement of Congressman Walz.......................    28
Wounded Warrior Project, Ralph Ibson, Senior Fellow for Policy...    15
    Prepared statement of Mr. Ibson..............................    67

                       SUBMISSIONS FOR THE RECORD

American Federation of Government Employees, AFL-CIO, and AFGE 
  National Veterans Affairs Council, statement...................    80
Buyer, Hon. Steve, Ranking Republican Member, Full Committee on 
  Veterans' Affairs, and a Representative in Congress from the 
  State of Indiana, statement....................................    82
Filner, Hon. Bob, Chairman, Full Committee on Veterans' Affairs, 
  and a Representative in Congress from the State of California, 
  statement......................................................    84
Independence Through Enhancement of Medicare and Medicaid 
  Coalition, letter..............................................    84
National Coalition for Homeless Veterans, statement..............    85
National Association for the Advancement of Orthotics and 
  Prosthetics, Thomas Guth, C.P., President, letter..............    87
National Nurses United, statement................................    88
Veterans of Foreign Wars of the United States, Michael O'Rourke, 
  Assistant Director, National Veterans Service, statement.......    89
Vietnam Veterans of America, Richard F. Weidman, Executive 
  Director for Policy and Government Affairs, statement..........    93

                   MATERIAL SUBMITTED FOR THE RECORD

Post-Hearing Questions and Responses for the Record:

    Hon. Michael H. Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs to Jacob B. Gadd, Deputy 
      Director, Veterans Affairs and Rehabilitation Commission, 
      America Legion, letter dated October 4, 2010, and response 
      letter dated November 15, 2010.............................    97
    Hon. Michael H. Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs to Carl Blake, National 
      Legislative Director, Paralyzed Veterans of America, letter 
      dated October 4, 2010, and response letter dated November 
      15, 2010...................................................   101
    Hon. Michael H. Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs to Adrian M. Atizado, 
      Assistant National Legislative Director, Disabled American 
      Veterans, letter dated October 4, 2010, and Mr. Atizado's 
      responses..................................................   104
    Hon. Michael H. Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs to Ralph Ibson, Senior 
      Fellow for Policy, Wounded Warrior Project, letter dated 
      October 4, 2010, and Mr. Ibson's responses.................   110
    Hon. Michael H. Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs to Hon. Eric K. Shinseki, 
      Secretary, U.S. Department of Veterans Affairs, letter 
      dated October 4, 2010, and VA responses....................   113
    Hon. Cliff Stearns, Republican Member, Subcommittee on 
      Health, Committee on Veterans' Affairs, to Hon. Eric K. 
      Shinseki, Secretary, U.S. Department of Veterans Affairs, 
      letter dated November 16, 2010, and VA responses...........   120

 
LEGISLATIVE HEARING ON H.R. 3843, H.R. 4041, H.R. 5428, H.R. 5516, H.R. 
5543, H.R. 5641, H.R. 5996, H.R. 6123, H.R. 6127, H.R. 6220, AND DRAFT 
                              LEGISLATION

                              ----------                              


                     WEDNESDAY, SEPTEMBER 29, 2010

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 10:00 a.m., in 
Room 334, Cannon House Office Building, Hon. Michael Michaud 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Michaud, Perriello, Brown of South 
Carolina, and Stearns.

             OPENING STATEMENT OF CHAIRMAN MICHAUD

    Mr. Michaud. I would like to call the hearing to order, and 
thank everyone for coming today.
    Today's legislative hearing is an opportunity for Members 
of Congress, veterans, the U.S. Department of Veterans Affairs 
(VA), and other interested parties to provide their views and 
discussion on legislation that has been introduced within the 
Subcommittee's jurisdiction.
    This is an important part of the legislative process that 
will encourage a frank discussion of ideas. We have 12 
important bills before us today.
    We have been hearing that votes might be called between 
11:00 and 12:00, so I would ask unanimous consent that my full 
remarks be submitted for the record so we can try to speed up 
the hearing process. Hearing no objection, so ordered.
    Mr. Michaud. So I now would recognize Mr. Brown, our 
distinguished Ranking Member, for any opening statement that he 
may have.
    [The prepared statement of Chairman Michaud appears on 
p. 25.]

         OPENING STATEMENT OF HON. HENRY E. BROWN, JR.

    Mr. Brown of South Carolina. Thank you, Mr. Chairman.
    I, too, would like to submit my opening statement for the 
record. And I would like unanimous consent to also offer 
Ranking Member of the full Committee, Steve Buyer's statement 
for the record.
    Mr. Michaud. Without objection, so ordered.
    [The prepared statement of Congressman Brown appears on 
p. 25.]
    [The prepared statement of Congressman Buyer appears on 
p. 82.]
    Mr. Michaud. We will now go to our first panel. And I would 
recognize Mr. Sestak, to introduce his bill to the Committee.
    And I want to thank you very much, first of all for your 
service to our great Nation and also for your willingness to 
come today.

  STATEMENTS OF HON. JOE SESTAK, A REPRESENTATIVE IN CONGRESS 
    FROM THE STATE OF PENNSYLVANIA; HON. TIMOTHY J. WALZ, A 
 REPRESENTATIVE IN CONGRESS FROM THE STATE OF MINNESOTA; HON. 
  JOHN BARROW, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF 
 GEORGIA; AND HON. CLIFF STEARNS, A REPRESENTATIVE IN CONGRESS 
                   FROM THE STATE OF FLORIDA

                  STATEMENT OF HON. JOE SESTAK

    Mr. Sestak. Thank you, Mr. Chairman and Ranking Member 
Brown.
    First I would like to acknowledge the great work that this 
Subcommittee has done in the recent Congress. It is providing 
unprecedented ways and means to care for our veterans, those 
who have gone into harm's way on our behalf.
    However, with these additional resources, the VA has a 
responsibility to Congress, the American public, and most 
especially our veterans to see that it operates the highest 
possible standards of care.
    In support of that goal, I am here to discuss my bill, H.R. 
3843, the ``Transparency for America's Heroes Act.''
    This legislation directs the Secretary of Veterans Affairs 
to make available on the VA Web site redacted records and 
documents, but not personal identifying information, created by 
the VA as part of a medical quality assurance program.
    It would also require the Secretary to ensure that such 
records created during the 2-year period prior to the enactment 
of this Act are also made available in a similar manner.
    I authored this bill because I have grown increasingly 
troubled by reports that give rise to concern of a lingering 
lack of consistent care and accountability within the VA.
    I must be very clear that I hold in highest regard the 
thousands of dedicated professionals of the VA, many who have 
spent their entire careers in the service of our veterans. 
However, for the past 24 months, there have been too many 
revelations of substandard care for our vets.
    Congress, and the American public, have been belatedly 
informed of prostate cancer victims who received insufficient 
treatment, the possible exposure of more than 1,800 veterans to 
serious diseases including hepatitis and human immunodeficiency 
virus (HIV) while undergoing routine dental procedures, 
deficiency in thoracic care.
    And last September, we learned only after a Freedom of 
Information Act (FOIA) request was filed that some elderly 
veterans were being subjected to substandard, potentially 
neglectful care in the Philadelphia Community Living Center at 
Philadelphia VA Medical Center.
    The nursing home, according to the Long-Term Care 
Institute's report, ``Failed to provide a sanitary and safe 
environment for the residents. And there was a significant 
failure to promote and protect the residents' rights to 
autonomy and to be treated with respect and dignity.''
    Some of the examples cited shock the conscious. For 
example, one patient with an open foot wound was left 
unattended for so long that live maggots were found falling out 
of the wound. Additionally, the floor was found to be covered 
with dried blood and feeding tubes.
    Another diabetic patient complained of chronic failure on 
the staff's part to administer his insulin shots on schedule.
    After hearing these reports, it came to my attention that 
there were two other recent inspections, one by the Office of 
Inspector General (OIG) of the VA and one by the Joint 
Commission on Accreditation of Healthcare Organizations, both 
of which concluded the facility met quality standards based on 
the metrics used.
    However, it took this separate external investigation of 
the Long-Term Care Institute, using a different set of 
inspection criteria to find the maggots, to identify the 
serious problems at the facility under its older leadership.
    What concerns me is the two VA conducted reviews failed to 
discover these deficiencies and that a Freedom of Information 
Act request was required to bring this latest revelation, this 
known latest revelation of poor care to light.
    In fact, the report should not have even been released 
after the FOIA petition was filed under the current law because 
the third-party inspection was conducted on the VA's quality 
assurance authority. And in this case, the report was 
inadvertently leaked by a VA official who did not follow the 
normal protocol.
    This leads me to believe that there may be numerous of 
other cases of deficient care, which will never see the light 
of day because of the inspections in question like the one 
conducted by the Long-Term Care Institute that were conducted 
under the VA quality assurance authority.
    Under current law, records and documents created by the VA 
as part of a designated quality assurance program are 
confidential and privileged and as a result cannot be disclosed 
to any person or entity except when specifically authorized by 
statute.
    And, yet, in Pennsylvania, similar facilities' reports for 
citizens of America that are not veterans are placed on Web 
sites.
    The standard rationale for this practice is according to 
the VA to, ``Create a proactive culture of quality improvement 
allowing for early identification and resolution of quality 
issues.'' Obviously that was not done.
    The VA also states that, ``Elimination of protected 
document status for quality management activity documents would 
possibly have a chilling effect on the level of objectivity 
reflected within these improvement activities.''
    As a former Admiral who led men and women into battle, I 
disagree with this assessment. I am convinced there is a need 
for a cultural and procedural sea change in the way the VA 
medical system operates and that the best way to ensure quality 
care in the VA is through a stringent, transparent oversight.
    I certainly learned in the Navy to expect what you inspect 
and to know what you have found. This entails vigilance on the 
part of both Congress and the general public. If there are 
other instances of inadequate VA care, they should be revealed 
immediately along with a confirmation that appropriate 
corrective actions have been taken like they were not in this 
case.
    My bill, as I conclude, would accomplish this without 
releasing sensitive information, which could be used to 
identify patients and health care professionals. After all, 
even my personal service record can be given out in public, 
redacted obviously.
    If we fail to ensure this kind of accountability, the goals 
of the current Administration, the hard work of the recent 
Congress to finally provide our veterans the care and resources 
they have been denied for so long will be compromised. At issue 
is the very credibility and accountability of one of our 
Nation's most important health care providers and that of the 
government itself.
    I am reminded of the long-term consequences for us, the 
Executive Branch, to treat veterans and their families in 
responsible kind of ways we have tried to do after a failure 
for too long, particularly after Vietnam.
    As our troops continue to return from Iraq and Afghanistan, 
we can and must do better. Thank you, Mr. Chairman.
    [The prepared statement of Congressman Sestak appears on 
p. 26.]
    Mr. Michaud. Thank you very much, Mr. Sestak, for that 
description of your piece of legislation.
    Are there any questions of the Subcommittee for Mr. Sestak?
    Hearing none, thank you very much.
    Mr. Sestak. Thank you, Mr. Chairman.
    Thank you, Mr. Brown.
    Mr. Michaud. I would like to recognize Mr. Walz, who is 
also a Member of the Veterans' Affairs Committee who serves his 
country with distinction, to introduce his legislation.
    Mr. Walz.

               STATEMENT OF HON. TIMOTHY J. WALZ

    Mr. Walz. Well, thank you, Chairman Michaud and Ranking 
Member Brown, for this opportunity to be here.
    I also want to thank you and tell you what a privilege it 
is to serve with you on the full Committee. The two of you put 
veterans first and foremost in everything you do. And for that, 
I am incredibly grateful.
    I am here today to testify on a bipartisan bill introduced 
by myself, Mr. Bilirakis, Mr. Miller, and Mr. Pascrell, H.R. 
6123, the ``Veterans Traumatic Brain Injury and Rehabilitative 
Services Improvement Act.''
    First and foremost, the care that our soldiers are getting 
at our VA hospitals is top quality. I think all of us in this 
room have recognized the incredible efforts that have been 
made, especially dealing with traumatic brain injury (TBI). But 
one of the things that I think we see missing is a cohesive, 
holistic approach to this care.
    And this bill does a couple of things that are critically 
important for these veterans to achieve the quality of life we 
want to have them achieve.
    We are doing a great job of the VA doing on the health 
professional side of things, but it would cover other VA 
support services that contribute to the maximum quality of 
life, things like helping with reemployment, helping with other 
things as far as adaptive types of things, and then doing a 
second thing that is not clarified in the current provisions, 
and this makes it a little broader. We are asking them to not 
simply improve lost functioning but to maintain that 
improvement once it is gained.
    Some of the brain-based research and the things we are 
seeing show that we can continue to get improvement or at least 
hold those achievements that we have gotten for these veterans. 
And I want to make sure that that gets there.
    The ambiguities in the law make the TBI treatment very 
narrow. It is incredibly good quality of care on the physical 
side of things. We are not encompassing the whole range of 
things that we could do. So we need to make sure that there is 
a comprehensive approach. That is what this bill ensures. It 
provides comprehensive care instead of just physical care.
    And I want to be very clear with our VA folks who are here, 
and we get great input from them on this. This is not creating 
any new programs. It is integrating existing programs for the 
quality of life improvement of the veterans. It is just a 
better way of defining how we care for these TBI patients. It 
is a better way of making sure that it is veteran and family 
centered in how that care goes across the spectrum of things.
    This bill has the full support of the Wounded Warrior 
Project, the Disabled American Veterans, the Blinded Veterans, 
and the Enlisted Association of the National Guard.
    And I want to take special time to thank Ralph Ibson and 
Christine Hill at the Wounded Warrior Project for bringing 
this. These are folks that are out there every day with our 
heroes. They are out there trying to understand what it is 
going to take to bring them back to a quality of life that get 
as close to approximation as we can to a normal existence for 
these folks. And that is what we want to try and do.
    So I am appreciative of the work that has been done on 
this. I want to be very clear. I am appreciative of the 
incredible care that is given to these wounded warriors through 
the VA. I think we can define with this bill a little broader 
on what the VA can go ahead and deliver in terms of 
comprehensive, holistic care to these veterans.
    And I think at the end of the day, the American people want 
to see us do everything possible to take these wounded warriors 
back home, to give them all the care possible, and to improve 
their quality of life to allow them to function both in the 
workplace, in social settings, and beyond just physical 
functioning.
    So with that, I would be happy to take any question and, 
again, thank both of you for the work you are doing.
    [The prepared statement of Congressman Walz appears on p. 
28.]
    Mr. Michaud. Thank you very much, Mr. Walz, and also thank 
you very much for your hard work and dedication on the 
Veterans' Affairs Committee. We value your opinion and 
appreciate all the hard work that you have been doing. So, 
thank you.
    Mr. Walz. Thank you, Mr. Chairman.
    Mr. Michaud. Are there any questions?
    Seeing none, thank you very much.
    Mr. Walz. Thank you.
    Mr. Michaud. Mr. Barrow, I also want to thank you for 
coming today to bring forward H.R. 4041 and I look forward to 
hearing your testimony. Mr. Barrow.

                 STATEMENT OF HON. JOHN BARROW

    Mr. Barrow. Well, thank you, Mr. Chairman. It is an honor 
to be with you and thank you for allowing me to testify today.
    I want to thank you and my South Carolina neighbor, Mr. 
Brown, for the tremendous leadership you all are showing in 
closing the gap that has existed for too long now between the 
promises that have been made to our veterans and the resources 
we have committed toward meeting those needs and fulfilling 
those promises.
    The most consistent and frustrating feedback that I get 
from people I represent is from veterans having problems with 
the VA. I suspect it is the same for some of you in your 
districts as well.
    The initial disability determination can take too long. 
Communication with the VA can be weak. Once they are in the 
system, it is hard to navigate. Facilities can be too far away.
    Well, I can see how major programs in the VA could benefit 
from a major overhaul and I realize that is not going to happen 
any time soon. For better or for worse, the system works well 
enough for enough folks that the demand for a major overhaul 
will be a long time coming. But I do not think any of us really 
believes that the current system works as well as it could or 
should.
    The problem with today's VA is its complexity. The medical 
needs of returning veterans are more complex than they have 
ever been. We design very intricate treatments and benefits and 
services to meet those needs. Unfortunately, it has become so 
complex that you need specialized training just to wade through 
the bureaucracy of it all.
    My purpose in coming today is to promote a bill I have 
introduced, H.R. 4041, which will give veterans the tools they 
need to navigate this maze.
    We all agree that every wounded warrior should have an 
individualized plan for recovery coordinated by a professional 
who is trained to successfully navigate the VA system of 
services and benefits.
    The Dole-Shalala Commission calls these professionals 
Federal Recovery Coordinators (FRCs) and made them a major 
component of their comprehensive recommendations to improve the 
VA. The Federal Recovery Coordinator Program has been 
authorized by Congress since 2008, but today there are only 20 
Federal Recovery Coordinators spread across the entire country 
coordinating the care of only around 500 wounded veterans.
    My bill will increase the number of Federal Recovery 
Coordinators, formalize their training, and establish 
guidelines and best practices for successful care coordination.
    As envisioned and designed by the Dole-Shalala Commission, 
a Federal Recovery Coordinator would be a nurse or a social 
worker with a Master's Degree who has excellent communication, 
leadership, and resource navigation skills. Today's wounded 
warrior might have a unique combination of traumatic physical 
injury, post-traumatic stress disorder (PTSD), substance abuse, 
or marital problems, trouble finding a job, or trouble 
reintegrating back into the community. A recovery coordinator 
acts as an air traffic controller to guide veterans to the 
proper treatment and benefit options.
    I have submitted for the record personal testimonies from a 
few returnees that I represent whose Federal Recovery 
Coordinators have been a Godsend. I commend them to you.
    Despite its obvious benefits and successes, the program is 
in its infancy and needs some help in order to be all that it 
can be. My bill will help in three specific ways.
    First and foremost, the bill authorizes formal training for 
45 new Federal Recovery Coordinators in the next 3 years. It is 
obvious that we have too many veterans who desperately need 
these services and we do not have nearly enough coordinators to 
meet the demand.
    Second, my bill authorizes the development of specialized 
case management software to complement the work of trained care 
coordinators.
    Third, my bill authorizes the development of uniform best 
practices for recovery coordination. The coordinators out there 
today are blazing valuable new trails, but they work out of 
sight of each other. We need to develop and promote what works 
best so that all of our wounded veterans will get the best 
chance at getting what they need.
    Our goal here has to be helping the veterans who need it 
and to do it as fast and effectively as we possibly can. I have 
seen the Federal Recovery Coordinator Program in action and I 
am convinced this really is the best way forward.
    I appreciate the opportunity to testify before you. I 
appreciate the Committee's willingness to take a deeper look at 
this legislation. And I will be happy to answer any questions.
    [The prepared statement of Congressman Barrow appears on 
p. 28.]
    Mr. Michaud. Thank you very much, Mr. Barrow, for your 
description of the legislation you presented today. I really 
appreciate your advocacy on behalf of our veterans as well.
    Are there any questions for Mr. Barrow?
    Thank you very much, Mr. Barrow. I appreciate your coming.
    Mr. Barrow. Thank you, Mr. Chairman.
    Mr. Michaud. I would like to recognize Mr. Stearns who also 
sits on the Veterans' Affairs Committee. I really appreciate 
your efforts in helping us deal with veterans' issues. And Mr. 
Stearns has two bills before us today, H.R. 5516 and H.R. 5996.
    So, Mr. Stearns.

                STATEMENT OF HON. CLIFF STEARNS

    Mr. Stearns. Good morning and thank you, Mr. Chairman.
    And thank you, Ranking Member, Mr. Brown of South Carolina.
    As you mentioned, I have two bills before the Committee 
today, H.R. 5516, the ``Access to Appropriate Immunization for 
Veterans,'' and H.R. 5996, a bill to help veterans with chronic 
obstructive pulmonary disease, COPD.
    The first bill is a bipartisan bill that I am proud to have 
introduced as a co-founder of the COPD Caucus. COPD is the 
fourth leading cause, of death in the United States. It is 
predicted to be the third leading cause of death by the year 
2020 beating both diabetes and stroke. And 126,000 Americans 
die each year from this disease. That is about one death every 
4 minutes.
    My bill, Mr. Chairman, would increase the VA's ability to 
diagnose, treat, and manage COPD. COPD is a chronic condition 
that does not have a cure. Early detection and treatment is 
important to slow or arrest the progression of the disease.
    It is estimated that more than 12 million people are 
diagnosed with COPD and, yet, this number is believed to be 
small as COPD is often under-diagnosed. The Centers for Disease 
Control and Prevention, CDC, estimates that over 24 million 
Americans have symptoms of COPD.
    Despite all this, there is a lack of awareness by patients 
and doctors about this disease. It is a progressive disease. 
Early detection is extremely important. Because there is no 
cure, early treatment is vital. Because the COPD rate is three 
times higher in the veterans' population, Mr. Chairman, than 
the civilian population, how can the VA not be providing this 
type of specialized care? COPD is the fourth most common 
diagnoses among hospitalized veterans ages 65 to 74.
    H.R. 5996 would have the VA develop treatment protocols and 
related tools for the diagnosis, treatment, and management of 
chronic obstructive pulmonary disease. It would also have the 
VA establish a pilot smoking cessation program targeted towards 
individuals who have COPD.
    While there are many ways that someone can develop this 
type of disease, the most common is from smoking. However, it 
should be noted that COPD has underlying genetic risk factors 
and healthy nonsmokers can also develop COPD.
    I think it is important to note that this is not giving VA 
any new authority. VA already has the authority to do what I am 
asking for. But for whatever reason, they have not aggressively 
moved to develop these treatment protocols for the fourth 
leading cause of death in the United States. My bill would have 
the VA begin to develop these treatments for our veterans.
    This bill has the support of the U.S. COPD Coalition, the 
COPD Foundation, the American Thoracic Society, the American 
Association for Respiratory Care, and the Alpha-1 Foundation 
and the Alpha-1 Association.
    And I would like to submit, Mr. Chairman, by unanimous 
consent the letters of support for the record.
    Mr. Michaud. Is there any objection? Hearing none, so 
ordered.
    Mr. Stearns. The other bill is the ``Access to Appropriate 
Immunizations for Veterans Act of 2010,'' H.R. 5516. The VA 
already has the authority to provide vaccines to veterans to 
immunize them against preventable diseases.
    However, the VA has only established performance measures 
for two vaccines. For these two vaccines against the flu and 
pneumonia, the vaccination rate increased from 27 percent to 
almost 80 percent and hospitalization rates dropped in half.
    My bill would extend all the Centers for Disease Control 
and Prevention's recommended vaccines to the performance 
measures.
    It is important to note that the vaccines are not just for 
children. In fact, just last week, the New York Times ran an 
article on how important it is for adults to receive vaccines 
and booster shots.
    I would like to read a part of this article quickly. 
``Adult immunizations are not just an important way to prevent 
the spread of the disease, immunizations are also a 
phenomenally cost-effective way to preserve health. When you 
compare the cost of getting sick with these diseases to the 
cost of a simple vaccine, it is a modest investment, said Dr. 
Robert Hopkins, a professor of internal medicine and pediatrics 
at the University of Arkansas for Medical Centers.''
    According to the CDC, each year, approximately 70,000 adult 
Americans die from vaccine preventable diseases. Influenza 
alone is responsible for over one million ambulatory care 
visits, 200,000 hospitalizations, and 30,000 deaths.
    Only 7 percent of Americans over the age of 60 have 
received the vaccine to protect them from shingles, a painful 
nerve infection.
    Just 11 percent of young women have received the vaccine 
against HPV (human papillomavirus), the virus that causes 70 
percent of cervical cancers.
    Many of our veterans who are in a high-risk category of 
contracting vaccine preventable diseases, including those with 
HIV, hepatitis C, and substance abuse disorder, are enrolled in 
the VA health care system and could simply benefit from 
receiving these vaccines.
    I want the VA to provide superior quality care to our 
veterans. Adding vaccinations to the performance measure is a 
simple common-sense idea that will increase the level of care 
available and save money by stopping preventable diseases.
    The bill would also require the VA to report back to 
Congress on their progress of supporting vaccinations within 
the veterans' populations.
    And I would like in conclusion to enter the New York Times 
article into the record and the CDC's recommended vaccination 
schedule for adults by unanimous consent.
    Mr. Michaud. Is there any objection?
    Hearing none, so ordered.
    Mr. Stearns. And thank you, Mr. Chairman, for allowing me 
to testify.
    [The prepared statement and attachments of Congressman 
Stearns appears on p. 34.]
    Mr. Michaud. Thank you very much, Mr. Stearns, for your 
testimony on both bills.
    Are there any questions from the Committee?
    Hearing none, thank you very much.
    I would like to call up the second panel. And while they 
are coming up, I will introduce them. We have Jacob Gadd from 
the American Legion; Carl Blake from the Paralyzed Veterans of 
America (PVA); Adrian Atizado from the Disabled American 
Veterans (DAV); and Ralph Ibson from the Wounded Warrior 
Project (WWP).
    We also heard from Mr. Filner and Ms. Pingree. They will be 
here a little bit later to present their testimony on the bills 
that they have introduced.
    We will start with Mr. Gadd from the American Legion.

STATEMENTS OF JACOB B. GADD, DEPUTY DIRECTOR, VETERANS AFFAIRS 
  AND REHABILITATION COMMISSION, AMERICAN LEGION; CARL BLAKE, 
 NATIONAL LEGISLATIVE DIRECTOR, PARALYZED VETERANS OF AMERICA; 
  ADRIAN M. ATIZADO, ASSISTANT NATIONAL LEGISLATIVE DIRECTOR, 
DISABLED AMERICAN VETERANS; AND RALPH IBSON, SENIOR FELLOW FOR 
                POLICY, WOUNDED WARRIOR PROJECT

                   STATEMENT OF JACOB B. GADD

    Mr. Gadd. Mr. Chairman and Members of the Subcommittee, 
thank you for this opportunity today for the American Legion to 
present our views on today's pending legislation.
    As this legislation covers many different pieces of 
legislation, I will highlight a few of the bills and draft 
legislation beginning with H.R. 4041, to authorize certain 
improvements in the Federal Recovery Coordinator Program.
    In 2007, the American Legion approved Resolution 29, 
Improvements to Implement a Seamless Transition, where we 
recommended a single recovery coordinator to ensure efficient 
rehabilitation and transition from military to civilian life 
and eliminate the delays and gaps in treatment and services.
    The program was designed and created an individualized care 
coordination plan for severely injured servicemembers in order 
to ensure a warm handoff for severely wounded servicemembers 
transitioning between the U.S. Department of Defense and VA.
    With close to two million servicemembers having deployed in 
Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF), 
and now New Dawn, VA has only reported to date that less than 
1,000 servicemembers have been assisted through this program.
    The American Legion, therefore, recommends expanding the 
program areas of the FRC Program to include program 
eligibility, increasing the FRC staff to one individual 
coordinator per State, and improving communication at the 
national, State, and local levels.
    First, the American Legion believes that coordination of 
care, especially those who are severely wounded, is essential 
to ensure they receive the education and benefits that they 
need and have earned.
    However, the American Legion believes efforts to improve 
care coordination must be directed at not only the severely 
wounded but any veteran transitioning and to ensure they do not 
fall through the cracks.
    Second, VA reported in 2010 that five new FRCs are in the 
process of being hired, which brings the total number to 25 
across the country.
    The American Legion recommends having an FRC within each 
State to ensure all active-duty Reserve and Guard units receive 
the same education, outreach, and benefits assistance.
    Third, in some cases, the American Legion has had 
difficulty contacting the FRCs through phone, e-mail, or 
mailing address. In addition, the program should increase its 
outreach through use of a dedicated Web page to update current 
contact information.
    Finally, in regards to development of a computerized 
tracking program, the American Legion applauds VA's new 
application, the care management and tracking and reporting 
application, CMTRA. This tracking tool allows VA to coordinate 
care amongst a wide variety of providers such as the OEF/OIF 
care management team.
    However, the American Legion recommends that consolidation 
of a new software tool be compatible with the CMTRA tool to 
prevent redundancy or to have any veterans that may fall 
through the cracks.
    Next, H.R. 5641, VA's authorized under title 38, Code of 
Federal Regulations to provide a comprehensive array of 
medically necessary in-home services. VA defines a medical 
foster home as a noninstitutional long-term care setting for 
veterans.
    The Medical Foster (MF) Program is owned or rented by the 
medical foster home caregiver. Each VA medical center facility 
appoints an MF coordinator and ensures quality assurance, 
inspections, maintaining of files and patients.
    The American Legion would like to take additional time to 
contact some veterans within this program to see their safety 
and get feedback from them on this program.
    Draft legislation to amend title 38 to ensure that the 
Secretary provides veterans with information concerning 
service-connected disabilities, several Department service 
officers for the American Legion have identified that the 
Veterans Health Administration (VHA) providers are not 
assisting veterans with questions a provider interprets as 
claims related.
    The American Legion is working with Central Office to 
understand the reasons for this disconnect between VHA and the 
Veterans Benefits Administration (VBA) and we intend to 
recommend a Fast Letter or new VHA directive be sent to the 
field to clarify this policy on VA treating physicians in the 
case where medical evidence on the veteran's behalf is there 
and the provider from VHA is not helping with the VBA side on 
the claims process.
    As always, the American Legion thanks this Committee for 
the opportunity to testify and represent the positions of over 
2.4 million veteran members. Thank you.
    [The prepared statement of Mr. Gadd appears on p. 47.]
    Mr. Michaud. Thank you very much.
    Mr. Blake.

                    STATEMENT OF CARL BLAKE

    Mr. Blake. Chairman Michaud, Members of the Subcommittee, 
on behalf of Paralyzed Veterans of America, I would like to 
thank you for the opportunity to be here to testify today.
    Since you have my full written statement for the record, I 
will limit my comments to just a select few bills.
    PVA cautiously supports H.R. 3843, the ``Transparency for 
America's Heroes Act.'' Transparency is critical for the public 
to be able to see and understand what its government is doing.
    Requiring VA to publish redacted medical quality assurance 
records on the VA's Web site will provide users of the VA a 
better understanding of the successes or failures of the VA and 
the quality of care delivered to veterans.
    This may encourage greater efforts on the part of VA 
employee staff and leadership to ensure that the best care is 
provided to veterans while ensuring openness.
    However, PVA's concern stems from the need for privacy with 
these health care records. And the comments of Congressman 
Sestak notwithstanding, it is important that sufficient 
safeguards be put in place to prevent the unintended release of 
personal health information that may be detrimental to a VA 
patient.
    PVA supports H.R. 5428, to better educate injured and 
amputee veterans on their rights and the requirement that VA 
staff who work at prosthetics and orthotics clinics or who work 
as patient advocates for veterans understand these rights as 
well.
    This bill would ensure that VA prosthetics clinics around 
the country prominently display the Injured and Amputee 
Veterans' Bill of Rights and that VA employees fully understand 
it.
    This reaffirms the idea that a veteran in need of an 
assistive device or prosthetic gets the highest quality item 
available and in a timely manner.
    As expressed in previous testimony on this topic, PVA is 
concerned, however, that this legislation's language seems to 
ignore veterans who may be in need of special equipment who 
suffer from a specific disease and not just a physical injury.
    PVA supports H.R. 5543, to repeal the prohibition on 
collective bargaining with respect to compensation for VA 
employees which may improve the collective bargaining rights 
and procedures for certain health care professionals in the VA.
    AS PVA testified in March of this year, these changes would 
be a positive step in addressing the recruitment and retention 
challenges the VA faces to hire key health care professionals, 
particularly registered nurses, physicians, physician 
assistants, and other selected specialists.
    PVA generally supports H.R. 5641, the ``Heroes at Home 
Act.'' However, it is essential that proper protections are put 
in place to ensure that it is the desire of the veteran to be 
transferred to a non-VA nursing home and only in the case that 
the foster home meets VA standards at the time of transfer.
    PVA generally supports H.R. 6127. However, we do have some 
concerns with the issues surrounding this bill. While we see no 
real argument with granting these men and women who experienced 
the exposures outlined by this bill, Access to the VA health 
care system, we question why this is the only group singled out 
for enrollment.
    Given the long-standing discussions about Operation Iraqi 
Freedom, veterans being exposed to burn pits or servicemembers 
exposed to other hazardous materials in any number of settings, 
we believe proper consideration needs to be given to a broader 
spectrum of veterans and servicemembers.
    PVA generally supports the provisions of the discussion 
draft on improvements to VA homeless programs. Too many 
veterans continue to live on the streets due to drug, mental 
health, financial, and employment challenges.
    Expansion of grant programs for improvements to facilities 
and increased outreach to more homeless veterans may help them 
receive services and rehabilitation and achieve the Secretary's 
goal to end veterans' homelessness.
    But as PVA testified last October, we do have some concerns 
about the long-term effects of the legislation. By adjusting 
the payments for geographic areas, we believe it is aimed at 
providing greater funding to higher cost localities. This may 
actually reduce the total number of homeless veterans that can 
be served if future increases in overall program funding are 
insufficient.
    While the argument could be made that reductions in funding 
for low cost areas may offset increases to high cost areas, the 
funding levels provided for homeless programs are seldom 
sufficient anyway to provide for all the veterans who may need 
to take advantage of these critical services.
    PVA would recommend a very cautious approach on this 
legislation to ensure that the most vulnerable veterans are not 
inadvertently hurt in efforts to provide greater funds for some 
of them.
    PVA would like to thank the Subcommittee once again for the 
opportunity to testify and I would be happy to answer any 
questions that you might have. Thank you.
    [The prepared statement of Mr. Blake appears on p. 52.]
    Mr. Michaud. Thank you very much, Mr. Blake.
    Mr. Atizado.

                 STATEMENT OF ADRIAN M. ATIZADO

    Mr. Atizado. Mr. Chairman, Members of the Subcommittee, 
thank you for inviting DAV to testify at this important hearing 
of the Subcommittee on Health.
    DAV is an organization of 1.2 million service-disabled 
veterans and devote our energies to rebuilding the lives of 
disabled veterans and their families.
    For the sake of brevity, I will only present a number of 
bills and would refer the Subcommittee to our written 
testimony.
    DAV is pleased to support H.R. 5516 based on our National 
Resolution No. 36. Our Resolution calls for VA to maintain a 
comprehensive high-quality health care system specifically 
including preventative health services. Preventative health 
services are an important component of the maintenance of 
general health, especially in elderly and disabled populations.
    This bill could contribute to significant cost avoidance by 
reducing the spread of infectious diseases and by obviating the 
need for health interventions in acute illnesses.
    DAV applauds the intent of H.R. 5641, the ``Heroes at Home 
Act,'' which would allow VA to contract with certified medical 
foster homes and pay for care of veterans already eligible for 
VA paid nursing home care.
    DAV is pleased with VA's innovation by offering medical 
foster homes as part of its long-term care program. Notably 
patient participation while voluntary into this program reports 
and yields exceedingly high veteran satisfaction.
    Under this program, the cost to VA is less than $60 a day. 
Understandably, VA perceives this program as a cost-effective 
alternative to nursing home placement and it is gaining 
popularity in the VA based on its expansion of this program.
    However, because this program operates under VA's community 
residential care authority, veterans in medical foster home 
programs have to pay for their care from about $50 to as much 
as $130 a day even veterans who are otherwise entitled to 
nursing home care fully paid for by VA whether it is under the 
law or by VA's policy.
    As part of The Independent Budget, DAV is greatly concerned 
that veterans living in medical foster homes are required to 
use personal funds as payment. These would include VA 
disability compensation. In addition, veterans who do not have 
the resources to pay a medical foster home caregiver may not 
avail themselves of such a critical benefit.
    DAV urges the Subcommittee to favorably consider this bill 
and that it be moved expeditiously.
    H.R. 6123 would sharpen rehabilitative requirements within 
the VA to ensure that veterans with TBI under VA care are 
afforded the opportunity for maximal rehabilitation, which will 
hopefully lead to independence and a higher quality of life.
    DAV appreciates the bill's intent to fix an existing gap in 
current law affecting the treatment of brain injured veterans. 
And this legislation is fully consistent with our National 
Resolution and, therefore, endorse this bill and urge enactment 
by Congress.
    DAV also supports H.R. 6127, which would provide access for 
certain veterans to VA health care under the Department's 
special treatment authority under Priority Group 6.
    Much like my colleague, Mr. Blake, from PVA, we do ask for 
the Subcommittee's consideration to afford the same eligibility 
of other veterans who were exposed to toxic and environmental 
hazards, specifically those veterans who were exposed to open 
air burn pits in Iraq and Afghanistan.
    You know, tests on these burn pits, Mr. Chairman, in the 
war zones have revealed that the fires have released dioxins, 
benzene, volatile organic compounds including substances which 
cause cancer.
    Finally, DAV supports the draft legislation to make 
improvements to VA's programs for homeless veterans. As the 
Subcommittee is aware, there is a great need for specific 
emphasis on the needs of homeless women veterans, women 
veterans, and homeless veterans with children. Homeless 
veterans suffering from serious mental illness is also a 
vulnerable population.
    Section 2 would provide comprehensive services to the 
vulnerable population of homeless veterans with special needs. 
And we note that Section 3 of this bill is identical to Section 
3 of H.R. 4810, which the House has unanimously passed in March 
of this year.
    DAV believes this section would provide organizations 
serving homeless veterans the flexibility to look at their 
program design to provide the full range of supportive services 
in the most economical manner.
    Mr. Chairman, this concludes my statement. I would be happy 
to answer any questions you or other Members of the 
Subcommittee may have. Thank you.
    [The prepared statement of Mr. Atizado appears on p. 56.]
    Mr. Michaud. Thank you very much, Mr. Atizado.
    Mr. Ibson.

                    STATEMENT OF RALPH IBSON

    Mr. Ibson. Mr. Chairman, Mr. Brown, thank you for inviting 
Wounded Warrior Project to testify this morning.
    And let me preface my remarks by explaining that Wounded 
Warrior Project's public policy is informed fully by our daily 
contacts and work with wounded warriors and their family 
members across the country.
    Several of the bills under consideration today address 
issues of profound concern to those warriors and their 
families. And of those, H.R. 6123, Mr. Walz's bill, is of 
exceptional importance and addresses deep concerns that we have 
heard from many, many families.
    As Mr. Walz indicated, VA facilities have many, many 
dedicated, committed rehabilitation staff, yet the services 
provided are often limited in duration and in scope.
    Just yesterday as part of a several day workshop, an 
empowerment summit focused on and serving combat veterans with 
PTSD, I had the occasion to speak to a veteran from Maine, a 
combat veteran who explained that he also had TBI, and had not 
really made much use of his eligibility for VA care. He went to 
the Togas VA Medical Center and was advised that they would 
provide him therapy for residuals of his TBI, but limited to 12 
sessions. And the explanation was, ``we do not provide 
maintenance therapy.''
    Well, as this gentleman pointed out to me and as research 
clearly indicates, there is profound cause for concern with 
that approach where gains that have been made, cognitive and 
otherwise, can be lost and that veteran's conditions simply 
regresses.
    For young veterans with severe TBI, and there are many, 
many of them, reintegration into their communities and pursuing 
goals such as meaningful work and independent living may be as 
important as their medical recovery. But many have difficulty 
with community integration, and social isolation can be a 
persistent issue. Yet, individuals with severe TBI who receive 
individualized services to foster independence and social 
interaction are able to participate meaningfully in community 
settings.
    These patients often need more than medical rehab to 
achieve maximum independence and they encounter difficulties at 
many VA facilities, which either perceive they lack the 
authority, or simply are unwilling to provide, nonmedical 
supports that are provided in other VA programs. These include 
supported employment or life skills coaching.
    As Mr. Walz indicated, his bill is a simple one. It would 
eliminate and close gaps, eliminate barriers in the system, and 
we think lead to enhanced recovery and fuller rehabilitation 
for veterans with many levels of TBI. And we strongly support 
it.
    Let me touch on a few other bills that raise issues for 
wounded warriors.
    H.R. 5428 would direct VA to disseminate, display, and 
educate Department employees on an Injured and Amputee 
Veterans' Bill of Rights relating to VA prosthetics and 
orthotics.
    While there have been substantial improvements in VA 
prosthetics care over the years, the bill does address 
important concerns that warriors have voiced with us.
    We are not confident, however, that enacting this measure 
would solve the problems that it highlights. To direct VA to 
disseminate the list of so-called rights does not make those 
expectations enforceable, nor does the bill require VA to take 
actions that would convert those expectations into reality.
    Nevertheless we would be pleased to work with the 
Subcommittee and Committee to explore ways to bolster the bill.
    H.R. 4041 would direct VA to fund training of recovery 
coordinators through a school of nursing and medicine. We 
concur with earlier expressed views that there is a need to 
enlarge the program to make greater numbers of FRCs available, 
particularly to warriors who did not get an FRC because the 
program was created in 2007. Many of those with severe injuries 
predating that date have not had that kind of help and still 
need it.
    We are not persuaded, though, that VA needs the authority 
that H.R. 4041 would establish nor that its methodology is 
necessarily an optimal one in terms of avenues for training 
future FRCs.
    We concur with earlier expressed views that H.R. 6127 is 
consistent with earlier legislation that established health 
care eligibility related to toxic exposures. But we do question 
the incident-specific focus of the bill and believe that there 
would be merit in taking a more systematic approach given the 
range of toxic exposures that OIF/OEF veterans have 
experienced.
    And, lastly, we would comment on H.R. 3843 discussed 
earlier. We certainly share a concern for ensuring the quality 
of care afforded veterans in VA health care facilities. At the 
same time, a vibrant medical quality assurance program is an 
important element in fostering a culture of quality 
improvement.
    And while transparency is certainly important in sustaining 
confidence in the quality of VA health care, confidentiality 
has long been deemed a critical element in ensuring the 
integrity of an effective medical quality assurance program.
    While we take no position in terms of how best to balance 
those competing tensions, transparency against confidentiality 
and a strong quality assurance program, this is an area where 
we would caution the Committee to proceed in a very carefully 
and in a measured way.
    Thank you, Mr. Chairman.
    [The prepared statement of Mr. Ibson appears on p. 67.]
    Mr. Michaud. Thank you very much, Mr. Ibson.
    And I want to thank the other three panelists as well for 
your testimony on all the bills we have before us today.
    Any questions, Mr. Brown?
    Mr. Brown of South Carolina. No questions.
    Mr. Michaud. Thank you.
    As we move forward looking at these bills, later we will 
probably submit additional questions in writing to each of you. 
So, if you could respond in a timely manner, I would appreciate 
it.
    If there are no questions, I would like to thank the second 
panel.
    I would like to now recognize Congresswoman Pingree who has 
H.R. 6220. She is my colleague from Maine. I appreciate her 
willingness to come today and her advocacy on veterans' issues. 
She definitely has been a true advocate for veterans.
    I know you have been tied up in the Rules Committee, so I 
want to thank you for taking the time to come over to present 
testimony to the Subcommittee on H.R. 6220.

STATEMENT OF HON. CHELLIE PINGREE, A REPRESENTATIVE IN CONGRESS 
                    FROM THE STATE OF MAINE

    Ms. Pingree. Thank you very much, Chairman Michaud.
    I apologize for being late this morning, but it is a busy 
morning. I guess we are trying to cram everything into as 
little time as possible.
    And I want to thank you on your great work on behalf of 
veterans in the State of Maine. It is a pleasure to serve as 
your junior member in the State of Maine.
    Chairman Michaud and Ranking Member Brown, thank you for 
having me here today. I am happy to be here in front of the 
Veterans' Affairs Subcommittee on Health to talk about the bill 
I recently introduced, the ``Inform All Veterans Act,'' H.R. 
6220.
    This bill will ensure that veterans are given complete 
information about service-connected benefits at all VA medical 
centers. All too often a veteran will visit a VA medical 
center, ask how to file a claim for service-connection, and are 
either not given correct information on how to pursue their 
claim or, worse, they leave the medical center thinking their 
claim is underway when it is not.
    This is a symptom of the Veterans Health Administration, 
Veterans Benefits Administration not communicating well with 
each other, operating effectively, or operating in silos. 
Interagency communication is a necessity, especially when we 
are talking about basic earned services.
    Under this bill, the VHA would be required to ask during 
the check-in process if a veteran would like information about 
the disability claims process. If the answer is yes, then 
straightforward, easy to understand literature is shared, which 
will outline how to contact VBA to start the disability claims 
process.
    I believe Congress has a responsibility to take care of our 
veterans and I know you all do as well. We cannot do that if we 
do not inform them about health care and compensation their 
service has earned them.
    This common-sense approach will help veterans avoid the 
bureaucratic red tape that often prohibits many veterans from 
even filing a claim.
    Again, thank you, Chairman Michaud and Ranking Member 
Brown, for allowing me to be here today and for all both of you 
do on behalf of our Nation's veterans. I am happy to answer any 
questions that you have about this bill.
    [The prepared statement of Congresswoman Pingree appears on 
p. 71.]
    Mr. Michaud. Thank you very much, Ms. Pingree, for bringing 
forth the legislation.
    Mr. Brown, do you have any questions?
    Mr. Brown of South Carolina. I appreciate very much you 
coming. Certainly it has been a pleasure to serve with your 
Ranking Member from the great State of Maine.
    Ms. Pingree. I will bring that news back home. Thank you 
very much.
    Mr. Michaud. Thank you very much.
    I know Mr. Filner is on his way, but why don't we go with 
panel three who is Dr. Bob Jesse, from VHA. He is accompanied 
by Walter Hall, who is the Assistant General Counsel.

  STATEMENT OF ROBERT L. JESSE, M.D., PH.D., PRINCIPAL DEPUTY 
  UNDER SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, 
 U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY WALTER A. 
  HALL, ASSISTANT GENERAL COUNSEL, OFFICE OF GENERAL COUNSEL, 
              U.S. DEPARTMENT OF VETERANS AFFAIRS

    Dr. Jesse. Well, good morning, Mr. Chairman and Members of 
the Subcommittee. Thank you for inviting me here today to 
present the Administration's views on several bills that would 
affect the VA's programs of benefits and services.
    Joining me today is Mr. Walter Hall, the Assistant General 
Counsel.
    Before I begin my remarks, I would like to thank Ranking 
Member Brown for his service on the Committee and in Congress 
as he retires at the end of this term. America's veterans and 
VA have benefitted from your efforts. Thank you.
    Turning to the legislation under consideration, VA agrees 
with the intent of many of the items on today's docket and 
looks forward to working together to understand how we can best 
support and improve care for veterans.
    First, H.R. 3843, the ``Transparency for America's Heroes 
Act,'' would dramatically limit the scope of confidentiality of 
VA benefits in assessing the quality of its programs. While VA 
strongly supports transparency in its programs and has done 
more to enable veterans to make informed decisions with regard 
to patient care than almost any other health care system in the 
country, we do oppose this legislation.
    Confidentiality of records that contain discussion of 
quality of health care, even if they do not identify an 
individual, is instrumental to ensuring that employees are 
willing to be forthcoming about quality issues that arise at 
their facilities.
    Current law protects a limited category of records, 
specifically quality assurance records. In order to qualify for 
these protections, these records must meet the criteria 
outlined in VA's implementing regulations.
    VA welcomes the opportunity to meet with the Committee to 
discuss current protections in the law as well as additional 
approaches to increasing the transparency in VA's quality 
assurance programs.
    Similarly, VA agrees with the intent of H.R. 5428, the 
Injured and Amputee Veterans' Bill of Rights, and we recognize 
the unique needs of injured and amputee veterans. We understand 
that injured and amputee veterans have clinical needs that are 
distinct from those of other patients, but we cannot support 
rights that would limit VA's ability to monitor and control 
quality of care and provider performance.
    What we cannot provide to our own clinics in prosthetics 
and orthotic services, we readily purchase through contractual 
arrangements with more than 600 vendors and providers who are 
approved by the Department.
    VA also supports the intent of H.R. 5516, the ``Access to 
Appropriate Immunizations for Veterans Act of 2010,'' and H.R. 
5996, which would support the prevention, diagnosis, treatment, 
and management of chronic obstructive pulmonary disease.
    VA is already doing a great deal on each of these areas to 
address the goals of this legislation. For example, our medical 
benefits package offers veterans immunizations against 
infectious diseases. And VA has long maintained smoking 
cessation is a major focus for health promotion and disease 
prevention.
    The delivery of preventive care, which includes 
vaccinations and tobacco intervention has been well established 
in VA's performance measurement system for over 10 years.
    VA strongly supports a draft bill under consideration that 
reflects the Secretary's proposed legislation and we deeply 
appreciate the Committee's consideration of these initiatives. 
This bill will improve VA's ability to serve veterans and 
strengthen VA's recruitment and retention efforts in several 
important ways.
    We deeply value the contributions of our employees and 
enjoy a collaborative and positive working relationship with 
the unions across the country. We hold retention of employees 
as a critically important goal and encourage the management 
teams of VA facilities to offer professional development 
opportunities and to encourage personal growth.
    However, VA does not support H.R. 5543, a bill affecting 
collective bargaining regarding compensation other than rates 
of basic pay. VA has testified previously about other proposals 
that were very similar and VA believes that this bill suffers 
in the same ways as the earlier measures did.
    H.R. 5543 would subject many discretionary aspects of the 
title 38 compensation to collective bargaining. H.R. 5543 would 
result in unprecedented changes that would be disruptive to the 
VA health care system. It would permit unions to bargain over, 
grieve, and arbitrate a subject--employee compensation--that is 
generally exempted from collective bargaining.
    This bill would allow independent, third-party arbitrators 
and other non-VA, nonclinical, labor third parties who lack 
clinical training and expertise to make compensation 
determinations.
    Over the past year, VA has worked closely with all of our 
union partners to address concerns they have raised regarding 
the subjects that are excluded from collective bargaining by 
law.
    All these union leaders recently met with Secretary 
Shinseki to discuss recommendations of a joint union/VA work 
group. The Secretary has accepted several of the work group's 
recommendations and will make a final decision on all of them 
shortly.
    We would be glad to brief the Committee on our continuing 
efforts in this area.
    Mr. Chairman, this concludes my prepared statement. I would 
be pleased to answer any questions.
    [The prepared statement of Dr. Jesse appears on p. 71.]
    Mr. Michaud. Thank you very much, Doctor.
    In reference to H.R. 3843, in light of the recent safety 
lapse in certain medical centers involving dirty reusable 
medical equipment, I do not know why the VA would oppose this 
legislation.
    What steps has the VA taken to bring transparency to 
patient safety?
    Dr. Jesse. Well, I think the transparency comes at the end 
of a process in many respects so that when issues like the 
Reusable Medical Equipment issues arise, it does take some 
amount of time to work through the process of understanding 
what happened and who is responsible. And we have several 
mechanisms with which we can do that.
    Initially you can use the quality assurance protections to 
go and do interviews, but, in fact, what we have done in almost 
all these cases is to use administrative investigation boards, 
which actually are public. This Committee gets copies of their 
reports.
    Mr. Michaud. When you look at quality assurance, it is my 
understanding that the OIG has cited VA several times for not 
complying with their recommendations.
    I guess my only concern is, what is it going to take to get 
VA to do what it should be doing?
    Dr. Jesse. My understanding of this is that every OIG 
recommendation be closed out at some point. So they cannot be 
ignored or, you know, just be swept aside.
    And so there actually is a process for us to go through and 
to acknowledge each of the recommendations and come to an 
agreement with the OIG that, in fact, we have met what they 
requested.
    I will admit that sometimes that process is a lot longer 
than both the OIG or VA would like, but often the issues are 
very complex.
    Mr. Michaud. Yes. I have seen the OIG reports. In some 
cases, after 10 years, VA has still not acted on these 
recommendations.
    I guess the concern that I have is, veterans lives are at 
stake, so when is management going to wake up and deal with 
these serious problems? I am just concerned about VA not moving 
forward to address some of these serious concerns.
    Dr. Jesse. Yes sir, and as are we. And we actually have, I 
think, new processes at least at the administrative level to 
ensure that we are tracking and from our perspective, we have 
been ensuring that at facility levels, Veterans Integrated 
Service Network levels, attention is being paid to these 
issues.
    Sometimes it requires national solutions including, for 
instance, implementation of IT fixes that will take 
considerably more time. In the interim, we can often put in 
stop-gap measures that do not fully meet what the OIG's 
require, but at least we are moving in the correct direction.
    Mr. Michaud. On the collective bargaining issue, I have 
heard stories of VA nurses who have no recourse if they are 
denied overtime pay, which negatively affects retention.
    Does VA have administrative solutions to help address these 
problems? If not through the bill that is before us, are there 
other solutions, and how quickly would these solutions be 
available?
    Dr. Jesse. I will defer to Mr. Hall for that one.
    Mr. Hall. Yes, sir. As Dr. Jesse said in his testimony, the 
Secretary recently met with all the union leaders to discuss 
the results, the outcomes of a work group that has been 
together for the last 9 months looking at all the section 7422 
issues and coming up with recommendations as to how best 
address their concerns with the way section 7422 has been 
interpreted by the Department and to develop methods to make 
the outcomes more coherent, more understandable to them, and 
more reasonable as far as how they are interpreted to provide 
them some mechanism or some recourse when situations, which are 
not bargainable present issues, for example, the pay issues 
that technically cannot be addressed under the law for good 
reasons in certain situations, but they have overlap into 
situations where it does not seem to make much sense.
    We are going to continue to work with them and develop 
mechanisms and procedures and policies and provide training to 
both management and the unions on how those mechanisms will 
apply. And that is ongoing. It is going on now.
    Mr. Michaud. Mr. Brown.
    Mr. Brown of South Carolina. Thank you very much. I 
appreciate both of you coming today and I thank you for helping 
take care of all of our veterans coming back from these and 
previous wars.
    In previous testimony, we heard that you have somewhere 
around 300,000 employees and you treat over six million 
veterans a year. It is a massive undertaking.
    But we certainly do not want to make light of any issues 
that might come up in our Districts. We recognize that there is 
a massive task and a lot of effort going forward to serve our 
veterans. We recognize that you have an intense commitment to 
veterans just like we do and we are grateful for that.
    My question is about immunization. I know that that is a 
big thing trying to get people to be vaccinated. The flu shots 
might be available at this time.
    How do you actually go about trying to reach your base 
population?
    Dr. Jesse. Well, for influenza immunization, whether it is 
the seasonal or H1N1, this is an event that has to occur 
annually. The vaccines change, although, in fact, I think H1N1 
will be incorporated into the seasonal vaccine this year, which 
is different than say Pneumovax which only has to be done 
essentially once.
    Mr. Brown of South Carolina. Or tetanus or some other.
    Dr. Jesse. Tetanus is every 10 years. So we will start with 
the annuals. When those vaccines become available, first of 
all, that is a very strict performance measure. We look at the 
rates of immunization with expectations that everyone including 
the staff are immunized. And facilities have taken many 
different approaches to this. In the end, it is not the 
approach but the outcome that is the most important.
    But just for example, to make it easy, rather than having 
to have a clinic appointment to get your vaccine, they will 
often just set up vaccination clinics in the main lobby. So 
where I am from, even the staff, would just walk down the lobby 
and go in and get my vaccine.
    So we do that in a very concentrated period to try and get 
as many veterans as possible, but every patient presenting for 
clinic will be checked on whether they had the vaccine or not. 
And the nurses are then essentially empowered to give the 
vaccine without requiring a physician.
    My personal anecdote to this is in one of my clinics a year 
or so ago, all four of the patients, the first four patients I 
had seen had been instructed by the nurse to ask me if I had 
gotten my vaccine because they were looking out for me. So it 
is----
    Mr. Brown of South Carolina. Let me interrupt you if I 
might. I know that in the general population, the drugstores 
advertise, ``come here and get your vaccination.'' If you are a 
Medicare patient, all you need to do is sign some kind of 
document.
    Do we have any kind of a contract arrangement with these 
folks so it would make it a little easier for the veterans? I 
represent the Charleston area. We do have some clinics out in 
the north Charleston region, but the main hospital is downtown. 
And somebody, say, living in St. Stephen, or some rural parts 
of Berkeley County, the commute certainly might be a couple 
hours of time.
    Do you have working arrangements with any of the local 
providers?
    Dr. Jesse. We have arrangements through our broad outreach 
networks, but obviously you cannot do a flu vaccine through 
telehealth. So that is one area where we actually have to have 
personal contact.
    I am not aware that we do, but I will certainly take that 
back as a notion and see if we can move that forward. I do not 
know if there is any legal reason we can or cannot do it, but 
certainly we want to get them all vaccinated. And understanding 
there is a relatively narrow window of time when we have to get 
the seasonal flu shot in, it would make sense.
    Mr. Brown of South Carolina. I think the general population 
has become very concerned about getting the flu. I think there 
is a lot of national media that draws them to receive that 
vaccination.
    I was just thinking that we could make it a little bit more 
convenient for them to be able to get it. I think that would be 
so important. I appreciate your interest on that.
    Thank you.
    [The VA subsequently provided the following information:]

       Question 1: Does VA currently have any arrangements with private 
health care providers or retailers to provide influenza vaccinations to 
its enrollees?

       Response: No. All vaccinations are administered by VA staff or 
through arrangements with VA affiliates. Veterans Health Administration 
(VHA) facilities offer seasonal influenza vaccine to all enrolled 
Veterans who meet criteria for vaccination at no cost. Veterans may 
choose to receive their flu vaccine through retail establishments or 
through other places within their communities at their own or third 
party payers' expense. Local Public Health Departments often have flu 
vaccination programs that offer vaccine to anyone in the community 
including Veterans and their families, sometimes at no cost or on 
sliding scales.

       Question 2: Furthermore, does VA have the authority to enter 
into such arrangements?

       Response: Yes, VA is able to contract for these services under 
existing Federal Acquisition Regulations.
       Enrolled Veterans who require these services as part of a 
continuation of care, will be eligible for payment for these services, 
if VA facilities are unavailable, or geographically inaccessible under 
the Fee authorities. This requires a pre-authorization from VA. We do 
not have the authority to authorize services provided without pre-
authorization.
       There is also no authority to pay for these services where VA 
facilities are available or when Veterans are not actively receiving 
health care services from VA. These limitations may impact the number 
of Veterans who could be covered either under the Fee authorities or 
via a contract.
       Although VA does have the authority to preauthorize this service 
for eligible Veterans on a Fee basis, the procedural requirements prior 
to receiving such preauthorization are likely to deter most Veterans 
from utilizing such non-VA medical care. In addition, many Veterans 
would be required to receive the service at a VA facility due to the 
geographic inaccessibility criteria and the fact that Veterans 
receiving care from VA can readily be immunized during their regular 
visits to VA. If VA were to pursue such a strategy, a national contract 
is the most appropriate vehicle for providing these services.
       The challenge facing VHA (as well as in the private sector) is 
the resistance among some individuals to recognize the benefit of 
receiving flu vaccine. Reasons for not receiving flu vaccine include 
fear of needles, concerns that the vaccine isn't safe, or that the 
vaccine will actually make the recipient sick with flu, and some simply 
don't want foreign drugs in their bodies.
       We continue to educate the VA community about the safety and 
effectiveness of influenza vaccine. Availability of influenza vaccine 
is not anticipated to be an issue during the 2010-11 flu season. For 
the upcoming flu season, VA has ordered a total of 3.3 million doses of 
flu vaccine compared to 2.6 million doses ordered for the 2009-2010 flu 
season.
       In summary, public health experts recognize influenza 
vaccination as a powerful tool to prevent the spread of influenza. 
Currently flu vaccine is available through all VA medical facilities at 
no cost to eligible Veterans and staff. VA believes that our community 
approach to influenza vaccination ultimately has a positive impact on 
the health of our Veteran population, VA staff, and others within our 
facilities.

       Question 3: Would such arrangements be feasible?

       Response: It may be feasible to award a national contract for 
this purpose but it would not be cost-effective, nor is there evidence 
of a need for this service. VA vaccinates large numbers of Veterans 
through its medical centers and Community Based Outpatient Clinics 
(CBOCs) and Veterans also have access to low cost or no cost vaccine 
through their local health departments. VA procures its vaccines at 
extremely competitive prices and offers them to Veterans at all VA 
Medical Centers and CBOCs; therefore accessibility is not an issue. The 
current VA cost for each dose of influenza vaccine is $9.48 when 
administered by VA personnel. Current costs in community pharmacies 
average $30 per vaccination. If VA used a reimbursement model, it would 
cost an additional $7 to process a patient's claim, for a cost 
differential of $27.52 per patient, If 25 percent of VA's patients used 
this service, it would cost an additional $77 million dollars per year.
       New Federal recommendations from the Centers for Disease Control 
and Prevention's (CDC) Advisory Committee on Immunization Practices 
(ACIP) are that all eligible persons age 6 months and older should 
receive seasonal influenza vaccination (CDC MMWR, August 6, 2010 (59)). 
To reduce the threat of influenza-related illnesses and deaths within 
the U.S. and individual communities, VHA continues to have an 
aggressive campaign to promote influenza vaccination. Of Veterans 
enrolled in VA, flu vaccination rates for those Veterans aged 50 or 
older have continually been higher than the national average. During 
the 2008/2009 influenza season, VHA vaccinated 69 percent of those age 
50 to 64 compared to the national rate of 40 percent. For those 65 and 
older, the VHA vaccination rate was 83 percent compared to the national 
rate of 66 percent. That same year, VHA vaccinated 64 percent of health 
care workers. (VHA Office of Quality and Performance; Occupational 
Health, Safety and Prevention Strategic Health Care Group; and CDC MMWR 
August 6, 2010 (59); RR8, page 30).
       In 2009 VHA's Public Health Strategic Health Care Group (PHSHG) 
conducted national Veteran patient focus groups on influenza. From 
these focus groups, Veterans indicated a robust awareness of influenza 
vaccination campaigns and accessibility to flu vaccine. This awareness 
can be linked to facilities' implementation of best practices for flu 
vaccination and strong public health messaging to target Veteran 
populations. VHA has made flu vaccination convenient to Veterans by 
providing flexible hours for flu vaccination clinics, ``drive-thru'' 
flu vaccination programs and walk-in vaccine clinics not requiring an 
appointment.

    Mr. Michaud. Well, once again, I would like to thank you, 
Dr. Jesse and Mr. Hall, for coming today. And there probably 
will be more questions submitted for the record as we move 
forward with the bills that were included today. And I want to 
thank you for your testimony.
    And, likewise, I would like to thank the two previous 
panels as well.
    If there are no other questions, I would adjourn the 
hearing. Thank you all for coming. I appreciate it.
    Dr. Jesse. Thank you, Mr. Chairman.
    [Whereupon, at 11:05 a.m., the Subcommittee was adjourned.]



                            A P P E N D I X

                              ----------                              

        Prepared Statement of Hon. Michael H. Michaud, Chairman,
                         Subcommittee on Health

    I would like to thank everyone for coming today.
    Today's legislative hearing is an opportunity for Members of 
Congress, veterans, the VA and other interested parties to provide 
their views on and discuss introduced legislation within the 
Subcommittee's jurisdiction in a clear and orderly process. This is an 
important part of the legislative process that will encourage frank 
discussions and new ideas.
    We have twelve bills before us today which address a number of 
important issues for our veterans and provide the staff of the 
Department of Veterans Affairs with the necessary tools to provide the 
best care for our veterans. First, we have a bill that would bring more 
transparency to the VA's medical quality assurance program, through 
which the Department aims to provide a systematic review of their 
health care activities. Specifically, VA would be required to make 
medical quality assurance records available to the public so that 
veterans and the general public will have access to important 
information about the care that is provided at VA health care 
facilities. Next, we have legislation providing for a bill of rights 
for our injured and amputee veterans given the large numbers of our 
servicemembers who are returning home with injuries to or loss of their 
limbs. We also have several bills that would improve the health care 
that our veterans receive such as a pilot program for chronic 
obstructive pulmonary disease; provision of immunizations to address 
vaccine-preventable diseases; adult medical foster homes for veterans; 
improved TBI care; help for homeless veterans with special needs; and 
the extension of health care eligibility for veterans who served in the 
Qarmat Ali region of Iraq. Finally, we have bills before us today that 
would help the staff of the Department of Veterans Affairs provide 
better care for our veterans. This includes a bill to better train 
Federal Recovery Coordinators; a bill to train VA health care 
facilities staff to provide important information about VBA benefits; 
and a bill to authorize collective bargaining over certain compensation 
related labor-management disputes.
    I look forward to hearing the views of our witnesses on the bills 
before us today.

                                 
   Prepared Statement of Hon. Henry E. Brown, Jr., Ranking Republican
                     Member, Subcommittee on Health

    Thank you, Mr. Chairman, and good morning.
    We have a number of important veterans' bills before us today and I 
look forward to hearing from several of my colleagues, our friends from 
various veterans' service organizations, and representatives from the 
Department of Veterans Affairs (VA) to address their potential merits 
and/or unintended consequences.
    Our Ranking Member, Steve Buyer, is the sponsor of two of the bills 
on the agenda--H.R. 5641, the Heroes at Home Act and H.R. 6127, the 
Extension of Health Care Eligibility for Veterans who Served at Qarmat 
(Car-mot) Ali Act. Unfortunately, Steve is unable to be here this 
morning and I ask unanimous consent that his statement be included in 
the record.
    In his absence, I would like to take a few minutes to explain these 
important legislative initiatives.
    H.R. 5641, the Heroes at Home Act, would increase the long-term 
care options for veterans by allowing VA to enter into a contract with 
a certified adult foster home to pay for the long-term care of veterans 
already eligible for VA-paid nursing home care.
    Medical foster homes are non-institutional settings that provide a 
personalized approach to long-term care. Veterans who choose medical 
foster home care reside in the home of their chosen foster home 
caregiver who in turn provides that veteran with around-the-clock care 
and company.
    Each prospective caregiver is required to pass a VA screening, 
Federal background check, and home inspection and must agree to undergo 
annual caregiver training and regular announced and unannounced home 
visits by VA's adult foster home coordinators and professionals from 
VA's Home Care Team. In addition, each veteran must agree to enroll in 
VA's Home Health Services to provide added support.
    As the need for long-term care grows, it will become increasingly 
important to provide our honored veterans with options that allow them 
to make the care choice that best fits their needs. VA has been 
assisting veterans in obtaining medical foster home care since 2002 and 
many of the veterans who benefitted from this unique service have 
service-connected disability ratings that entitle them to VA-paid long-
term care.
    H.R. 5641 would authorize VA to contract with medical foster homes 
to cover the costs of care for those veterans already eligible for VA 
provided nursing home care.
    H.R. 6127, the Extension of Health Care Eligibility for Veterans 
who Served at Qarmat Ali Act, is legislation that is particularly dear 
to the veterans in my home State. It would extend the VA health care 
enrollment period by 5 years for veterans who served at Qarmat (Car-
mot) Ali, Iraq and were notified of possible exposure to a toxic 
chemical known as sodium dichromate.
    Not long after the conflict in Iraq began, Army National Guard 
units from South Carolina--my home State--as well as units from 
Indiana, Oregon, West Virginia, and individual augmentees from 17 other 
States across the Nation were called to serve at the Qarmat (Car-mot) 
Ali water treatment facility.
    Unfortunately, these veterans recently received notification by VA 
that during their service they may have been exposed to a toxic 
chemical which could result in a number of serious respiratory issues, 
skin lesions, burns, and other ear, nose, throat, and skin disorders.
    While these veterans were eligible to enroll in VA health care for 
5 years after separation from service, those who reentered civilian 
life following their 2003 deployment would have been required to enroll 
by 2008--a full 2 years before initial notification of the potential 
exposure and subsequent health risk.
    It is essential that these veterans have immediate access to VA's 
high quality health care system in order to receive preventative care 
and services to improve health outcomes and quality of life.
    Further, my good friend and colleague from Florida, Mr. Stearns, 
also has two bills before us today concerning important preventative 
care methods to improve the health and well-being of American veterans. 
I thank him for his leadership on this Subcommittee and anticipate 
hearing his comments and further discussion of these initiatives.
    I want to thank my many colleagues who have sponsored the bills on 
our agenda this morning and all of the witnesses who have taken the 
time to participate today. I yield back the balance of my time.

                                 
        Prepared Statement of Hon. Joe Sestak, a Representative
               in Congress from the State of Pennsylvania

    Chairman Michaud, Ranking Member Brown, and distinguished Members 
of the Subcommittee, to begin, I would like to acknowledge the very 
hard work of this Committee and our colleagues of both parties in the 
110th and 111th Congresses who have provided the Department of Veterans 
Affairs unprecedented ways and means to care for our Veterans and their 
families. Though the VA had been severely underfunded for too long, 
congressional efforts since 2007 now afford our Veterans of three 
generations access to the best care ever afforded those who go into 
harm's way on our behalf.
    However, with those additional resources the VA has the 
responsibility to Congress, the American public, and most especially 
our Veterans to see that it operates to the highest possible standards 
of care. In support of that goal it is an honor to appear before you 
today to discuss my bill, H.R. 3843, the Transparency for America's 
Heroes Act. This legislation directs the Secretary of Veterans Affairs 
to make available on the Department of Veterans Affairs (VA) Web site 
redacted records and documents--but not personal identifying 
information--created by the VA as part of a medical quality-assurance 
program. It would also require the Secretary to ensure that any such 
records created during the 2-year period before the enactment of this 
Act are also made available in the same manner.
    I authored this bill because I have grown increasingly troubled by 
reports that give rise to concern of a lingering lack of consistent 
care and accountability within the VA. I must be very clear that I have 
the highest regard for the thousands of dedicated professionals of the 
VA--many of whom have spent their entire careers in service to our 
Veterans. However, for the past 24 months there have been too many 
revelations of substandard care for Veterans. Congress and the American 
public have been belatedly informed of prostate cancer victims who 
received insufficient treatment, the possible exposure of more than 
1,800 Veterans to serious diseases, including Hepatitis and HIV, while 
undergoing routine dental procedures, deficiencies in thoracic care and 
last September we learned--only after a Freedom of Information Act 
request was filed--that some elderly Veterans were being subjected to 
substandard, potentially neglectful care in the Philadelphia Community 
Living Center at the Philadelphia VA Medical Center.
    The nursing home, according to the Long Term Care Institute's 
report, ``failed to provide a sanitary and safe environment for their 
residents . . . (and) there was a significant failure to promote and 
protect their residents' rights to autonomy and to be treated with 
respect and dignity.'' Some of the examples cited shock the conscience. 
For example, one patient with an open foot wound was left unattended 
for so long that maggots were found falling out of the wound. 
Additionally, the floor was found to be covered with dried blood and 
feeding tubes. Another diabetic patient complained of chronic failure 
on the staff's part to administer his insulin shots on schedule.
    After hearing these reports, it came to my attention that there 
were two other recent inspections, one by the Inspector General of the 
VA and one by the Joint Commission on Accreditation of Health Care 
Organizations, both of which concluded that the facility met quality 
standards based on the metrics used. However, it took this separate, 
external investigation by the Long Term Care Institute--using a 
different set of inspection criteria--to identify the serious problems 
at the facility under its old leadership.
    What concerns me is the two VA-conducted reviews failed to discover 
these deficiencies, and that a Freedom of Information Act (FOIA) 
request was required to bring this latest revelation of poor care to 
light. In fact, the report should not have even been released after the 
FOIA petition was filed under current law because the third-party 
inspection was conducted under the VA's quality-assurance authority. In 
this case, the report was inadvertently leaked by a VA official who did 
not follow the normal protocol. This leads me to believe that there may 
be numerous other cases of deficient care which will never see the 
light of day because the inspections in question, like the one 
conducted by the Long Term Care Institute, were conducted under the VA 
quality-assurance authority.
    Under current law, records and documents created by the VA as part 
of a designated quality-assurance program are confidential and 
privileged, and as a result cannot be disclosed to any person or entity 
except when specifically authorized by statute. The stated rationale 
for this practice is, according to the VA, to ``create a proactive 
culture of quality improvement allowing for early identification and 
resolution of quality issues.'' The VA also states that ``elimination 
of protected document status for quality management activity documents 
would possibly have a chilling effect on the level of objectivity 
reflected within these improvement activities.''
    As a former Admiral who led men and women into battle, I disagree 
with this assessment. I am convinced there is a need for a cultural and 
procedural sea-change in the way the VA medical system operates--and 
that the best way to ensure quality care in the VA is through stringent 
oversight. This entails vigilance on the part of both Congress and the 
general public. If there are any other instances of inadequate VA care, 
they should be revealed immediately along with confirmation that 
appropriate corrective actions have been taken. My bill would 
accomplish this, without releasing sensitive information which could be 
used to identify patients and health care professionals.
    If we fail to ensure this kind of accountability, the goals of the 
current administration and the hard work of the 110th and 111th 
Congress, to finally provide our Veterans the care and resources they 
have been denied for so long, will be compromised.
    At issue is the very credibility of one of our Nation's most 
important and visible health care providers and that of our government 
itself. I am reminded of the long-term consequences of government's 
failure for over two decades--both in the Executive Branch and 
Congress--to treat Veterans and their families in a responsible and 
accountable way. As our troops continue to return from Iraq and 
Afghanistan, we can, and must, do better.
    Thank you, Mr. Chairman.

                                 
      Prepared Statement of Hon. Timothy J. Walz, a Representative
                in Congress from the State of Minnesota

    Chairman Michaud, Ranking Member Brown, thank you for holding this 
legislative hearing.
    I'm here today to talk about H.R. 6123, the Veterans' Traumatic 
Brain Injury Rehabilitative Services Improvements Act.
    In short, this bi-partisan bill does two things:

      First, it would clarify that VA rehab services are not 
limited to those provided by a health professional but would cover 
other VA services or supports that contribute to maximizing 
independence and quality of life.
      Second, it would clarify that current provisions for TBI 
care are to be read more broadly, not simply to improve lost 
functioning but to prevent losing the gains that have been achieved.

    Because of ambiguities in current law, TBI treatment at the VA 
narrowly focuses TBI care on physical restoration only.
    When a veteran suffering from TBI comes to the VA for treatment, 
they need to be presented with a comprehensive approach to 
rehabilitation that will allow them to recover function, achieve 
independence and fully integrate back into their communities.
    This bill ensures we provide comprehensive care instead of just 
physical rehabilitation, which is what is presently available to our 
injured veterans, without creating any new programs within the VA. It 
simply uses the programs that are already present at the VA to build a 
more complete rehab program.
    Our wounded warriors deserve the best care and support we can give 
them, and this bill ensures that the VA uses all the tools at its 
disposal to care for those heroes that have ``borne the battle.''
    That's why this bill has the full support of the Wounded Warrior 
Project, the Disabled American Veterans, Blinded Veterans Association, 
and the Enlisted Association of the National Guard of the United 
States.
    I'd like to take this opportunity to thank Ralph Ibson and 
Christine Hill of the Wounded Warrior Project for their work on this 
bill. Without their dedication and the dedication of countless 
veterans' advocates around the country, we wouldn't be where we are 
today.
    I'd also like to thank Representatives Bilirakis, Miller, and 
Pascrell for your support and leadership on this issue.
    Thank you again, and I yield the remainder of my time.

                                 
        Prepared Statement of Hon. John Barrow, a Representative
                 in Congress from the State of Georgia

    Thank you for the chance to testify before you today.
    The most consistent and frustrating feedback I get from the people 
I represent is from veterans having problems with the VA. I suspect 
that it's the same for you in your districts. The initial disability 
determination takes too long. Communication with the VA can be weak. 
Once they're in, the system can be hard to navigate. Facilities can be 
remote.
    While I can see how major programs in the VA need a major overhaul, 
I realize that's not likely to happen any time soon. For better or 
worse, the system works well enough for enough folks that the demand 
for a major overhaul will be a long time coming. But I don't think any 
of us really believes that the current system works as well as it could 
or should.
    The problem with today's VA is its complexity. The medical needs of 
returning veterans are more complex than they've ever been. And we've 
designed very intricate treatments and benefits and services to meet 
those needs. Unfortunately, it's become so complex that you need 
specialized training to wade through the bureaucracy of it all. My 
purpose in coming here today is to introduce you to a bill I've 
introduced which will give veterans the tools to navigate the maze.
    We all agree that every wounded warrior should have an 
individualized plan for recovery, coordinated by a professional, who is 
trained to successfully navigate the VA system of services and 
benefits.
    The Dole/Shalala Commission calls these professionals Federal 
Recovery Coordinators, and made them a major component of their 
comprehensive recommendations to improve the VA.
    A Federal Recovery Coordinator Program has been authorized by 
Congress since 2008, but today there are only 20 Federal Recovery 
Coordinators spread across the entire country, coordinating the care of 
only around 500 wounded veterans. My bill will increase the number of 
Federal Recovery Coordinators, formalize their training, and establish 
guidelines and best practices for successful care coordination.
    As envisioned and designed by the Dole/Shalala Commission, a 
Federal Recovery Coordinator would be a nurse or social worker with 
master's degree, who has excellent communication, leadership, and 
resource navigation skills. Today's wounded warrior might have a unique 
combination of traumatic physical injury, PTSD, substance abuse, or 
marital problems, trouble finding a job, or trouble reintegrating back 
into the community. A Recovery Coordinator acts as an ``air traffic 
controller'' to guide veterans to the proper treatment and benefit 
options.
    I've submitted for the record personal testimonies from a few 
returnees I represent, whose Federal Recovery Coordinators have been a 
godsend. I commend them to you.
    Despite its obvious benefits and successes, the program is in its 
infancy and needs some help in order to be all that it can be. My bill 
will help in these specific ways:
    First and foremost, the bill authorizes formal training for 45 new 
FRCS in the next 3 years. It's obvious that we have too many veterans 
who desperately need these services, but we don't have nearly enough 
coordinators to meet the demand.
    Second, my bill authorizes the development of specialized case 
management software to complement the work of trained care 
coordinators.
    Third, my bill authorizes the development of uniform best practices 
for recovery coordination. The coordinators out there today are blazing 
valuable new trails, but they work out of sight of each other. We need 
to develop and promote what works best, so that all of our wounded 
warriors will have the best chance of getting what they need.
    Our goal here has to be helping the veterans who need it, and to do 
it as fast and effectively as we possibly can. I've seen the Federal 
Recovery Coordinator Program in action, and I'm convinced that this 
really is the best way forward. I appreciate the opportunity to testify 
before you, I appreciate the Committee's willingness to take a deeper 
look at this legislation, and I'll be happy to answer any questions.

                               __________

                          ADDITIONAL MATERIALS
                                                 September 27, 2010

Dear Members of the Committee:

    My husband is SGT (ret.) Darryl Wallace, an OEF veteran who was 
wounded June 9th, 2007 when an IED went off under the seat of his 
Humvee. He lost both legs in the explosion, and was sent to Walter Reed 
Army Medical Center, and eventually to the Active Duty Rehab Unit at 
the Charlie Norwood VA Medical Center in Augusta, Georgia.
    I am writing to you to let you know the most helpful thing to us in 
my husband's recovery has been the Federal Recovery Coordinator we have 
been assigned, Ms. Erin Jolly. She helps when the VA doesn't want to 
help or they are giving you the runaround. We can call our FRC and Erin 
can get stuff done.
    For example, when Darryl was overdosing all the time and he was 
being put on the psych ward, he just needed help. Our FRC was able to 
get in touch with a treatment center, get all the information together, 
and Erin was the one who got everyone in the whole process to get it 
done so Darryl could go into treatment. He is doing very well now 
because of it.
    If I ever have any questions about anything, I call our FRC and she 
can tell me the information or can find out if she doesn't know.
    FRCs do not give you the runaround.
    Once, my husband's VA physician told us she couldn't see him for a 
week, and our FRC got him in to see the doctor the same day. If it 
wouldn't have been for our FRC a lot of stuff would have been 
overlooked: pain management, his well being, and his welfare.
    Every wounded warrior needs a Federal Recovery Coordinator because 
if they don't like what a doctor or case worker is doing, the FRC will 
get it done. It's a big bureaucracy, a lot of stuff gets swept under 
the rug, and not dealt with, but the FRC makes sure it all gets 
handled.
    Our FRC prioritizes what we need, and gets us where we need to go, 
when we need to go. I have never had a problem that the FRC has not 
been able to solve. She answers calls after hours and when we need her. 
When I need her, she's there for me and my husband. She works from home 
on her laptop to help us.
    I love my FRC and I've told them that when they've called to do 
surveys.
    Every soldier that comes back needs one. Doctors are excellent but 
FRCs play a big part in the recovery too--had it not been for our FRC a 
lot of stuff would not have been dealt with.

                                                    Tiffany Wallace
                                                         Harlem, GA





                               __________

                                                 September 25, 2010

Dear Congressman Barrow:

    I believe that the Federal Recovery Coordinator program is a great 
program, especially for veterans like myself that do not know how to 
navigate through the VA system that well.
    I had received inaccurate information about and was not told about 
VA services I was entitled to. For instance, I was told I could not get 
a benefit while I was an inpatient in the PTSD program at the VA until 
after I completed the program. However, my Federal Recovery Coordinator 
told me that I could receive benefits while attending the program. This 
information was very helpful to me because I was able to get the help 
that I needed without worrying about how my family was going to 
maintain while I received treatment for PTSD.
    My Federal Recovery Coordinator also helped me complete paperwork 
to start my benefits. The Federal Recovery Coordinator also keeps me 
informed on any updates in VA benefits and services the VA has to 
offer. I greatly appreciate all the help of my Federal Recovery 
Coordinator has provided me with, without her I would have been lost.

                                                      Karl Mitchell
                                                        OIF Veteran
                                             Purple Heart recipient







                                 
       Prepared Statement of Hon. Cliff Stearns, a Representative
                 in Congress from the State of Florida

    Thank you Chairman Michaud and Ranking Member Brown.
    I have two bills before the Committee today. H.R. 5516--Access to 
Appropriate Immunizations for Veterans and H.R. 5996--a bill to help 
veterans with chronic obstructive pulmonary disease (COPD).
    H.R. 5996 is a bipartisan bill that I'm proud to have introduced as 
the co-founder of the COPD caucus. COPD is the 4th leading cause of 
death in the U.S., and is predicated to be the 3rd leading cause of 
death by 2020, beating both diabetes and stroke. 126,000 Americans die 
each year from this disease--that's about 1 death every 4 minutes.
    My bill would increase the VA's ability to diagnose, treat and 
manage COPD. COPD is a chronic condition that does not have a cure. 
Early detection and treatment is important to slow or arrest the 
progression of the disease. It is estimated that more than 12 million 
people are diagnosed with COPD and yet this number is believed to be 
too small as COPD is often under-diagnosed. The Centers for Disease 
Control and Prevention (CDC) estimates that over 24 million Americans 
have symptoms of COPD.
    Despite all this, there is a lack of COPD awareness by patients and 
doctors.
    Because this is a progressive disease, early detection is 
important.
    Because there is no cure, early treatment is vital.
    Because the COPD rate is three times higher in the veteran 
population than the civilian population, how can the VA not be 
providing this type of specialized care? COPD is the fourth most common 
diagnosis amongst hospitalized veterans aged 65-74.
    H.R. 5996 would have the VA develop treatment protocols and related 
tools for the diagnosis, treatment and management of chronic 
obstructive pulmonary disease. It would also have the VA establish a 
pilot smoking cessation program targeted towards individuals who have 
COPD. While there are many ways that someone can develop COPD, the most 
common is from smoking. However, it should also be noted that COPD has 
underlying genetic risk factors and healthy non-smokers can develop 
COPD.
    I think it's important to note that this is not giving VA any new 
authority. VA already has the authority to do what I'm asking for, but 
for whatever reason, they have not aggressively moved to develop these 
treatment protocols for the 4th leading cause of death in the United 
States. My bill would have the VA begin to develop these treatments for 
our veterans.
    H.R. 5996 has the support of the U.S. COPD Coalition, the COPD 
Foundation, the American Thoracic Society, the American Association for 
Respiratory Care, the Alpha-1 Foundation and the Alpha-1 Association. 
I'd like to submit their letters of support for the record.
    My other bill is the Access to Appropriate Immunizations for 
Veterans, H.R. 5516. The VA already has the authority to provide 
vaccines to veterans to immunize them against preventable diseases. 
However, the VA has only established performance measures for two 
vaccines. For these two vaccines against the flu and pneumonia, the 
vaccination rate increased from about 27 percent to almost 80 percent 
and hospitalization rates dropped in half.
    My bill would extend all the Centers for Disease Control & 
Prevention's recommended vaccines to the performance measures. It is 
important to note that vaccines are not just for children. In fact, 
just last week the NY Times ran an article on how important it is for 
adults to receive vaccines and booster shots.
    I'd like to read a part of this article:

       ``Adult immunizations are not just an important way to prevent 
the spread of disease. Immunizations are also a phenomenally cost-
effective way to preserve health.
       `` `When you compare the cost of getting sick with these 
diseases to the cost of a vaccine, it's a modest investment,' said Dr. 
Robert H. Hopkins, a professor of internal medicine and pediatrics at 
the University of Arkansas for Medical Sciences.''

    According to the CDC, each year approximately 70,000 adult 
Americans die from vaccine-preventable diseases. Influenza alone is 
responsible for over one million ambulatory care visits . . . 200,000 
hospitalizations . . . and 30,000 deaths. Only 7 percent of Americans 
over the age of 60 have received the vaccine to protect them from 
shingles, a painful nerve infection. Just 11 percent of young women 
have received the vaccine against HPV that cause 70 percent of all 
cervical cancers.
    Many of our veterans who are in the ``high-risk'' category of 
contracting vaccine-preventable diseases--include those with HIV, 
Hepatitis C and substance abuse disorder--are enrolled in the VA health 
care system and could benefit from receiving vaccinations.
    I want the VA to provide superior quality health care to our 
veterans. Adding vaccination to the performance measure is a simple 
common-sense idea that will increase the level of care available and 
save money by stopping preventable diseases. The bill would also 
require the VA to report back to Congress on their progress of 
supporting vaccinations within the veteran population.
    And I'd like to enter this NY Times article into the record and the 
CDC's recommended vaccination schedule for adults.

                               __________


                                                Alpha-1 Association
                                                         Miami, FL.
                                                 September 28, 2010

The Honorable Cliff Stearns
2370 Rayburn House Office Building
Washington, DC 20515

Dear Representative Stearns,

    On behalf of the Alpha-1 Association's Board of Directors, I wish 
to express our heartfelt appreciation for your leadership in Chronic 
Obstructive Pulmonary Disease (COPD) in the veterans' community and to 
express our support for the passage of H.R. 5996.
    The Alpha-1 Association is a patient-focused and patient-driven 
organization dedicated to identifying individuals affected by Alpha-1 
and improving the quality of their lives through support, education, 
advocacy and to encourage participation in research. As a 501(c) (3) 
not-for-profit membership organization, the Association has been 
providing services to Alphas and their families since 1991.
    This bill affects our patient community. According to the National 
Heart, Lung & Blood Institute, 3 percent of the 12 million people that 
have been diagnosed with COPD in the United States have Alpha-1.
    Alpha-1 is a genetic condition that may result in serious, chronic 
lung and/or liver disease at various ages in life (children and 
adults). It is often misdiagnosed as asthma or smoking-related Chronic 
Obstructive Pulmonary Disease (COPD).
    Individuals with Alpha-1 may develop emphysema even if they have 
never smoked. Despite treatments, including protein replacement, adults 
may require a lung transplant due to severe emphysema.
    As the foremost provider of health care services to over 8 million 
veterans, the Department of Veterans Affairs has a unique opportunity 
to become a leader in the fight against Alpha-1 (Genetic COPD). H.R. 
5996 will allow the VA to take a comprehensive approach in reducing the 
burden of Alpha-1 through innovative prevention, education and 
treatment strategies. It will also provide for the critically needed 
research into best practices that will help to simultaneously reduce 
costs and improve quality of life.
    Our Association and the COPD community care deeply about the need 
to address COPD in America's veteran population. The VA system has been 
a leader in health systems research and H.R. 5996 will build on a 
record of using innovative methods to improve the health of the 
veterans it serves. We encourage your colleagues to join you in support 
of H.R. 5996. Congress' actions will mark a great step towards 
addressing the burden that COPD places on veterans, their families and 
the health care delivery system.
    We are happy to support your efforts in any way that will aid you 
in obtaining passage of H.R. 5996.

            Sincerely,

                                                      Marlene Erven
                                                 Executive Director

                               __________

                          American Association for Respiratory Care
                                                        Irving, TX.
                                                    August 15, 2010

The Honorable Cliff Stearns
2370 Rayburn House Office Building
Washington, DC 20515

Dear Representative Stearns:

    The American Association for Respiratory Care (AARC) a 50,000 
member professional association for respiratory therapists endorses and 
fully supports H.R. 5996. This legislation will direct the Secretary of 
Veterans Affairs to improve the prevention, diagnosis, and treatment of 
veterans with chronic obstructive pulmonary disease (COPD).
    Respiratory therapists provide clinical care and services to 
pulmonary patients across the continuum of care ranging from the 
hospital settings, to rehabilitation centers, to skilled nursing 
facilities, to home care and in physician offices.
    Among the important provisions of H.R. 5996 is a special emphasis 
on assisting our Nation's veterans with smoking cessation efforts--a 
leading contributor to COPD. Respiratory therapists are on the front 
lines as health care professionals who assist the public with smoking 
prevention and cessation efforts.
    There are over 1,700 respiratory therapists currently employed in 
the Veterans health care system. With the enactment of H.R. 5996, there 
will be a cadre of respiratory therapists already in place to help 
implement the directives mandated by this important legislation.
    Thank you again for your foresight and commitment to our Nation's 
veterans and their health care.

            Sincerely,

                                             Tim Myers, BS, RRT-NPS
                                                          President

                               __________

                                          American Lung Association
                                                    Washington, DC.
                                                    October 4, 2010

The Honorable Cliff Stearns
U.S. House of Representatives
Washington, DC 20515

Dear Representative Stearns:

    The American Lung Association is pleased to support H.R. 5596, 
legislation to improve the prevention, diagnosis, and treatment of 
veterans with chronic obstructive pulmonary disease (COPD). Chronic 
obstructive pulmonary disease takes a tremendous human and financial 
toll on the Department of Veterans Affairs. An estimated 8 percent of 
veterans in the Department of Veterans Affairs (VA) health care system 
have been diagnosed with COPD. COPD ranks as the fourth most common 
reason for hospitalization in the VA patient population. It is the 
fourth most common cause of death in the United States, and it is 
projected to become the third leading cause of mortality by 2020.
    H.R. 5996 will require the development of treatment protocols and 
related tools for the prevention, diagnosis, treatment, and management 
of chronic obstructive pulmonary disease. The legislation also will 
bolster biomedical and prosthetic research programs regarding this 
disease. These steps are urgently needed to help improve patient 
outcomes.
    Between 80 and 90 percent of all COPD cases are caused by smoking. 
The best way to prevent COPD and many diseases the VA health care 
system manages is to quit smoking or not to smoke in the first place. 
H.R. 5996 will help address this by directing the VA, in conjunction 
with Centers for Disease Control and Prevention, to develop improved 
techniques and best practices for assisting veterans with chronic 
obstructive pulmonary disease in successfully quitting smoking.
    According to the 2008 Study of Veteran Enrollees' Health and 
Reliance Upon VA, over 70 percent of VA enrollees report that they have 
smoked at one time in their lives. Currently 19.7 percent smoke. This 
is down from 22.2 percent in 2005 and 21.5 percent in 2007 and shows 
some important momentum in the right direction. Among the 70 percent of 
the VA population who has ever smoked, over twenty 5 percent (25.5) say 
they've recently quit smoking, again, a step in the right direction.
    Sadly, the VA will continue to battle this problem for some time to 
come. The current smoking rate for active duty military is 30.4 
percent, with smoking rates highest among personnel ages 18 to 25--
especially among soldiers and Marines. The Department of Veterans 
Affairs estimates that more than 50 percent of all active duty 
personnel stationed in Iraq smoke.
    H.R. 5596 is an important step to address COPD and the toll of 
tobacco on our Nation's veterans. We look forward to working with you 
to pass this lifesaving legislation.

            Sincerely,

                                                  Charles D. Connor
                              President and Chief Executive Officer

cc: The Honorable John Lewis&

                               __________

                                                    COPD Foundation
                                                    Washington, DC.
                                                    August 10, 2010

The Honorable Cliff Stearns
2370 Rayburn House Office Building
Washington, DC 20515

Dear Representative Stearns,

    On behalf of the COPD Foundation's Board of Directors, I wish to 
express our heartfelt appreciation for your leadership in Chronic 
Obstructive Pulmonary Disease (COPD) in the veterans' community and to 
express our support for the passage of H.R. 5996.
    The COPD Foundation is the national not-for-profit organization 
solely dedicated to representing individuals with COPD in the United 
States. As you know, COPD, or Chronic Obstructive Pulmonary Disease, is 
an umbrella term used to describe progressive lung diseases, 
encompassing emphysema, chronic bronchitis, refractory asthma, and 
severe bronchiectasis.
    The NIH estimates that 12 million adults have COPD and another 12 
million are undiagnosed or developing COPD. COPD is currently the 
fourth leading cause of death in the U.S. and it is estimated to become 
the third leading cause of death by 2020. The impacts on the economy 
are severe, with national costs projected to be $49.9 billion in 2010, 
in part due to COPD's status as the second leading cause of disability.
    As the foremost provider of health care services to over 8 million 
veterans, the Department of Veterans Affairs has a unique opportunity 
to become a leader in the fight against COPD. H.R. 5996 will allow the 
VA to take a comprehensive approach to reducing the burden of COPD 
through innovative prevention, education and treatment strategies. It 
also provides for critically needed research into best practices that 
will help to simultaneously reduce costs and improve quality of life.
    Our organization and the COPD community care deeply about the need 
to address COPD in America's veteran population. A 2003 study revealed 
that COPD was the fourth most common diagnosis amongst hospitalized 
veterans and a strong predictor for patient readmission following a 
hospital stay. The VA system has been a leader in health systems 
research and H.R. 5996 will build on a record of using innovative 
methods to improve the health of the veterans it serves. We encourage 
your colleagues to join you in support of H.R. 5996. Congress' actions 
will mark a great step towards addressing the burden that COPD places 
on veterans, their families and the health care delivery system.
    We were excited to learn that the House Committee on Veterans' 
Affairs will hold a hearing on September 29, 2010 that will include a 
discussion of H.R. 5996. If there is an opportunity to provide a 
witness at this hearing we would be pleased to identify a patient, 
physician or researcher who could lend substance to the discussion of 
COPD in the Veterans' population. We are happy to support your efforts 
in any way that will aid you in obtaining passage of H.R. 5996.

            Sincerely,

                                                      John W. Walsh
                                                          President

                               __________

                                                            EFFORTS
                                                   Kansas City, MO.
                                                    October 1, 2010


Dear Representative Stearns,

    On behalf of EFFORTS, www.emphysema.net, an online COPD, support, 
advocacy organization we wish to thank you for your leadership with 
regard to COPD and our Veterans and to offer our full support for the 
passage of H.R. 5996.
    Currently, COPD ranks as the fourth leading cause of death in the 
U.S. behind heart disease, cancer, and cardiovascular disease, and it 
is the only major disease that continues to show increased mortality 
rates each year. In contrast, seven of the other ten leading causes of 
death actually showed decreases in mortality.
    In Healthy People 2010, a publication of The Centers for Disease 
Control (CDC) and the National Institutes of Health (NIH), one central 
recommendation was that developing better methods for early detection 
of COPD is of utmost importance. It is often stated that COPD is 
diagnosed after age 65. However, in a recent survey of 338 members of 
our EFFORTS organization, we found that the age of diagnosis averaged 
47 years for females and 56 years for males. It was also noted that 
many were experiencing symptoms of their disease long before they were 
actually diagnosed. Unfortunately, it is not at all uncommon for 
someone to have lost 50 percent or more of his/her lung function before 
they are diagnosed.
    COPD is an enormous economic burden to society. It strikes during 
the height of the productive years, significantly interferes with the 
ability to earn a living, forces many to go on Medicare disability or 
take early retirement at an early age, and often disrupts the lives of 
the individual and family for many years before death occurs. According 
to data from the NHLBI, the direct costs of health care services and 
indirect costs related to loss of productivity for COPD were $26 
billion in 1998 and $30.4 billion in 2000. Medical expenses for COPD 
patients are extremely high because of frequent visits to the emergency 
room, extended hospital stays, and expensive medications. In 1997, 
there were an estimated 13.4 million physician office visits and more 
than 600,000 hospitalizations for COPD (NHLBI, 2001). Data from the 
Centers for Disease Control indicate that diseases of the respiratory 
system rank #3 in the number of emergency room visits. It is expected 
that all of the costs associated with COPD will continue to spiral 
upward because the prevalence of COPD is continuing to rise each year.
    There are only a few treatment options available to the millions of 
patients who suffer from this killer disease. None provides a cure and 
only treat the symptoms. Physicians can experiment with medications 
developed for asthma, consider surgery, prescribe oxygen, and/or refer 
the patient for pulmonary rehabilitation. Unfortunately, Lung Volume 
Reduction Surgery (LVRS), a procedure shown to be helpful to some but 
not all patients, is not covered by Medicare and many insurance 
companies because it is considered to be an experimental procedure. 
Lung transplantation is a viable option, but the strict medical 
requirements and critical shortage of organ donors make it available to 
a relatively small number of patients. Pulmonary rehabilitation, 
universally recognized as extremely important for optimizing patients' 
overall physical conditioning, is not universally available to everyone 
in need because it is not covered by Medicare in most States.
    One medicine was developed specifically for COPD a few years ago. 
Another ``blockbuster'' drug with great promise has been tested and 
approved in several countries outside the U.S., but has not yet been 
approved by the FDA. At a recent hearing at the FDA (9/02), it was 
determined that although this important drug was safe and shown to 
bring significant improvement in measures of lung function, the FDA 
still wanted additional testing. This ruling will cause a significant 
delay in the availability of this important drug to people with COPD.
    We believe that the continuing rise in death and disability due to 
COPD in this country is distinct public health emergency. Millions of 
children under the age of 18 begin smoking every day. Approximately 15 
percent to 20 percent of those who smoke will eventually develop 
severely disabling COPD, and there are growing concerns about the 
harmful effects of our environment on lung function.
    Many patients with COPD are totally reliant on the Veterans 
Administration for their medical care. As an organization, EFFORTS is 
excited to learn that the House Committee on Veterans Affairs will be 
holding a hearing that will include a discussion of COPD and will 
support your efforts in any way that will aid the passage of H.R. 5996.

            Sincerely,

                                            EFFORTS Executive Board
                                            Joan Esposito V.P. N.J.
                                                 Ann Lornie V.P. UK
                                                   Maggie Borger IL
                                                     Edna Fiore CO.
                                                    Jean Rommes IA.
                                            Michael MacDonald MA. &
                                                  Linda Watson N.Y.
                                                          President

                               __________

                                        NTM Info and Research, Inc.
                                                  Coral Gables, FL.
                                                    October 1, 2010

The Honorable Cliff Stearns
2370 House Office Building
Washington, DC 20515

Dear Representative Stearns,

    On behalf of NTM Info & Research (NTMir), I wish to express our 
appreciation for your leadership in Chronic Obstructive Pulmonary 
Disease (COPD) in the veterans' community and to express our support 
for the passage of H.R. 5996.
    NTMir is the national not-for-profit organization dedicated to 
pulmonary nontuberculous mycobacterial (NTM) disease. COPD, or Chronic 
Obstructive Pulmonary Disease, is an umbrella term used to describe 
progressive lung diseases, encompassing emphysema, chronic bronchitis, 
refractory asthma, severe bronchiectasis, and NTM lung disease.
    The NIH estimates that 12 million adults have COPD and another 12 
million are undiagnosed or developing COPD. COPD is currently the 
fourth leading cause of death in the U.S. and is estimated to become 
the third leading cause of death by 2020. The impacts on the economy 
are severe, with national costs projected to be $49.9 billion in 2010, 
in part due to COPD's status as the second leading cause of disability.
    As the foremost provider of health care services to over 8 million 
veterans, the Department of Veterans Affairs has a unique opportunity 
to become a leader in the fight against COPD. H.R. 5996 will allow the 
VA to take a comprehensive approach to reducing the burden of COPD 
through innovative prevention, education and treatment strategies. It 
also provides for critically needed research into best practices that 
will help to simultaneously reduce costs and improve quality of life.
    NTMir and the COPD community care deeply about the need to address 
COPD in America's veteran population. A 2003 study revealed that COPD 
was the fourth most common diagnosis among hospitalized veterans and a 
strong predictor for patient readmission following a hospital stay. The 
VA system has been a leader in health systems research and H.R. 5996 
will build on a record of using innovative methods to improve the 
health of the veterans it serves. We encourage your colleagues to join 
you in support of H.R. 5996. Congress' actions will mark a great step 
toward addressing the burden that COPD places on veterans, their 
families and the health care delivery system.

            Sincerely,

                                                     Philip Leitman
                                                          President

                               __________

             Respiratory Health Association of Metropolitan Chicago
                                                       Chicago, IL.
                                                    October 4, 2010

Honorable Cliff Stearns
U.S. Representative
2370 Rayburn House Office Bldg.
Washington, DC 20515

Dear Congressman Stearns,

    Respiratory Health Association of Metropolitan Chicago (RHAMC) 
urges support of H.R. 5996 which seeks to improve the prevention, 
diagnosis, and treatment of veterans with COPD. The legislation directs 
the Veterans Administration Secretary to focus attention and resources 
toward addressing COPD within the population they serve.
    RHAMC has been dedicated to community lung health since 1906. Our 
mission is to promote healthy lungs and fight lung disease through 
research, advocacy and education. RHAMC launched the COPD Initiative in 
response to the growing impact of COPD upon our communities. The goals 
are to increase COPD awareness, educate the public and health care 
community, advance COPD policies, advocate for people living with COPD.
    There is a growing, active and engaged COPD patient community that 
is advocating for improved programming and coverage addressing COPD. 
The patients and caregivers in our communities seek more resources 
dedicated to addressing COPD.
    COPD is the fourth leading cause of death in Illinois. An estimated 
500,000 adults in Illinois alone suffer from COPD. Smoking is the 
primary cause, but exposure to lung irritants like vapors and dusts in 
occupational settings as well as secondhand smoke contribute to COPD. 
In the past 5 years, more women died of COPD than men in the United 
States. In Illinois, more women than men are hospitalized every year 
for COPD.
    Veterans Administration needs to take a comprehensive approach to 
reducing the burden of COPD through innovative prevention, education 
and treatment strategies. This legislation also provides for critically 
needed research into best practices that will help to simultaneously 
reduce costs and improve quality of life.
    We applaud the House Committee on Veterans' Affairs for addressing 
this issue and we support passage of H.R. 5996.

            Sincerely,

                                                     Joel J. Africk
                              President and Chief Executive Officer

                               __________

                             New York Times
                           September 24, 2010
      Cost and Lack of Awareness Hamper Adult Vaccination Efforts
                           By Lesley Alderman
    VACCINES are not just for children.
    About 11,500 cases of whooping cough, or pertussis, have been 
reported nationwide so far this year. In California, where the 
infections are nearing a record high, nine infants have died.
    It is likely that some of those children had not received all their 
shots, experts say. But some of those deaths might have been prevented 
if more adults, too, had been immunized.
    Though public health authorities have long recommended that adults 
get a pertussis booster shot, just half have done so. Without it, they 
risk passing this illness to vulnerable children.
    ``Almost everyone understands how important it is for children to 
be immunized,'' said Dr. Melinda Wharton, deputy director of the 
National Center for Immunization and Respiratory Diseases at the 
Centers for Disease Control and Prevention, ``but adults need vaccines 
too.''
    Far too few get them. The C.D.C. recommends that people 19 and 
older receive immunizations against as many as 14 infectious diseases. 
(Not all adults require every vaccine.) Yet most adults rarely think 
about getting the shots--until they step on a rusty nail or begin 
planning travel to a developing country.
    Only 7 percent of Americans over age 60, for instance, have 
received the herpes zoster vaccine, which prevents shingles, a painful 
nerve infection. Just 11 percent of young women have received the 
vaccine against the two types of human papilloma virus that cause 70 
percent of all cervical cancers.
    Why are adults so behind on vaccinations? For one thing, the shots 
can be expensive (from $20 to $200 a dose for some, and some require 
three doses). But a bigger part of the problem is a lack of awareness. 
Doctors often fail to remind patients that they require booster shots, 
and consumers are not well informed about the need.
    In a 2007 survey by the National Foundation for Infectious 
Diseases, 40 percent of respondents incorrectly stated that, if they 
had received vaccines as a child, they did not need them again; 18 
percent said vaccines were not necessary for adults.
    The new health care law should help get more adults to roll up 
their sleeves. Under the law, group and individual health plans, as 
well as Medicare, must provide preventive health services, including 
immunizations recommended by the C.D.C., free of charge. That means no 
co-payments, co-insurance or deductibles.
    The hope is that since vaccines will be free, more doctors will 
suggest them and more patients will ask for them, said Jeffrey Levi, 
executive director of Trust for America's Health, a nonprofit group 
that works to prevent epidemics.
    Here's the catch. If you are in a group or individual health plan, 
your plan must be new, or it must have undergone substantial changes, 
in order for the new requirements to apply. In addition, certain recent 
vaccine recommendations will not be covered right away. If you are 
uncertain, call your insurer.
    Adult immunizations are not just an important way to prevent the 
spread of disease. Immunizations are also a phenomenally cost-effective 
way to preserve health.
    ``When you compare the cost of getting sick with these diseases to 
the cost of a vaccine, it's a modest investment,'' said Dr. Robert H. 
Hopkins, a professor of internal medicine and pediatrics at the 
University of Arkansas for Medical Sciences.
    If you end up in the emergency room with a bad case of the flu or 
pneumonia, your bill could be thousands of dollars. A flu shot is just 
$20, or often free; the pneumonia vaccine is about $77.
    Here is how to get up-to-date on your shots--whether you have a new 
insurance plan, an old plan or no plan at all.
    THE VACCINES YOU NEED Tear out the immunization chart accompanying 
this article or print it out online. Note the vaccines you should be 
getting, based on your age and health status.
    This year, for the first time, the C.D.C. recommends that everyone, 
regardless of age or health, get an influenza shot. Most people need 
only one. This year the flu shot provides protection against the H1N1 
virus and two seasonal viruses.
    Most other vaccines are intended for specific age groups or for 
those with particular risk factors. The zoster vaccine, for example, 
has been tested only in older people. There is little evidence that it 
could benefit younger people, whose immune systems are still strong.
    Next, figure out which vaccines you have already received. Your 
doctor should be able to help. But if you have switched physicians a 
number of times, you may have to reconstruct your history on your own.
    ``When in doubt, get vaccinated,'' said Dr. Hopkins. ``There's very 
little risk with getting a second dose of a vaccine.''
    IF YOU HAVE INSURANCE Call your primary care physician and explain 
that you would like to get your vaccinations updated.
    Some offices do not stock vaccines, so it is wise to tell the staff 
in advance what you will need. You may find that certain vaccines are 
not available right away; your doctor can tell you where to find them, 
or how long the wait will be.
    Next, call your insurer and ask if they will cover vaccines free of 
charge. If not, ask how much they charge. If the fees are high, see 
below for alternate options.
    IF YOU LACK COVERAGE You can still pay out-of-pocket for 
immunizations at the doctor's office, of course. But the shots may be 
less expensive at other places.
    YOUR HEALTH DEPARTMENT If money is tight, find out if your State or 
community health department provides vaccinations for adults. 
Unfortunately, there is no Federally funded program for adult 
immunizations, only for children.
    The C.D.C. Web site provides an interactive map to help locate the 
health department or immunization clinic in your area.
    YOUR LOCAL PHARMACY Many retail clinics administer vaccines, 
including CVS MinuteClinics and Walgreens Take Care Clinics. 
MinuteClinics offer 10 vaccines for adults, including shots for 
hepatitis A ($117) and B ($102), meningitis ($147), pneumococcal 
disease ($77) and DTaP, which protects you from diphtheria, tetanus and 
pertussis ($82).
    There are 500 CVS clinics across the country, and all are open 
seven days a week. No appointments or prescriptions are necessary. 
Walgreens clinics offer travel vaccines, like the one for typhoid 
fever, as well.
    Even if your local pharmacy does not have a clinic, you may be able 
to get some of the shots you need there. In all States, pharmacists are 
licensed to give flu shots; in some States, they can administer other 
vaccines as well, like the one to protect against pneumonia.
    Check with a local pharmacy and find out what shots they are 
licensed to provide and at what cost.
    YOUR EMPLOYER Inquire at your company's human resources or wellness 
office. Some companies provide free flu shots for employees, as well as 
their families. Few companies provide other vaccines, but it can't hurt 
to ask.
    Remember that when you get immunized, you are not only ensuring 
your own good health but the health of those around you.





                               Footnotes
      Recommended Adult Immunization Schedule--UNITED STATES 2010
   For complete statements by the Advisory Committee on Immunization
    Practices (ACIP), visit www.cdc.gov/vaccines/pubs/ACIP-list.htm.
     1.  Tetanus, diphtheria, and acellular pertussis (Td/Tdap) 
vaccination
    Tdap should replace a single dose of Td for adults aged 19 through 
64 years who have not received a dose of Tdap previously.
    Adults with uncertain or incomplete history of primary vaccination 
series with tetanus and diphtheria toxoid-containing vaccines should 
begin or complete a primary vaccination series. A primary series for 
adults is 3 doses of tetanus and diphtheria toxoid-containing vaccines; 
administer the first 2 doses at least 4 weeks apart and the third dose 
6-12 months after the second; Tdap can substitute for any one of the 
doses of Td in the 3-dose primary series. The booster dose of tetanus 
and diphtheria toxoid-containing vaccine should be administered to 
adults who have completed a primary series and if the last vaccination 
was received ;10 years previously. Tdap or Td vaccine may be used, as 
indicated.
    If a woman is pregnant and received the last Td vaccination ;10 
years previously, administer Td during the second or third trimester. 
If the woman received the last Td vaccination <10 years previously, 
administer Tdap during the immediate postpartum period. A dose of Tdap 
is recommended for postpartum women, close contacts of infants aged <12 
months, and all health-care personnel with direct patient contact if 
they have not previously received Tdap. An interval as short as 2 years 
from the last Td is suggested; shorter intervals can be used. Td may be 
deferred during pregnancy and Tdap substituted in the immediate 
postpartum period, or Tdap can be administered instead of Td to a 
pregnant woman.
    Consult the ACIP statement for recommendations for giving Td as 
prophylaxis in wound management.
     2.  Human papillomavirus (HPV) vaccination
    HPV vaccination is recommended at age 11 or 12 years with catch-up 
vaccination at ages 13 through 26 years.
    Ideally, vaccine should be administered before potential exposure 
to HPV through sexual activity; however, females who are sexually 
active should still be vaccinated consistent with age-based 
recommendations. Sexually active females who have not been infected 
with any of the four HPV vaccine types (types 6, 11, 16, 18, all of 
which HPV4 prevents) or any of the two HPV vaccine types (types 16 and 
18, both of which HPV2 prevents) receive the full benefit of the 
vaccination. Vaccination is less beneficial for females who have 
already been infected with one or more of the HPV vaccine types. HPV4 
or HPV2 can be administered to persons with a history of genital warts, 
abnormal Papanicolaou test, or positive HPV DNA test, because these 
conditions are not evidence of prior infection with all vaccine HPV 
types.
    HPV4 may be administered to males aged 9 through 26 years to reduce 
their likelihood of acquiring genital warts. HPV4 would be most 
effective when administered before exposure to HPV through sexual 
contact.
    A complete series for either HPV4 or HPV2 consists of 3 doses. The 
second dose should be administered 1-2 months after the first dose; the 
third dose should be administered 6 months after the first dose.
    Although HPV vaccination is not specifically recommended for 
persons with the medical indications described in Figure 2, ``Vaccines 
that might be indicated for adults based on medical and other 
indications,'' it may be administered to these persons because the HPV 
vaccine is not a live-virus vaccine. However, the immune response and 
vaccine efficacy might be less for persons with the medical indications 
described in Figure 2 than in persons who do not have the medical 
indications described or who are immunocompetent. Health-care personnel 
are not at increased risk because of occupational exposure, and should 
be vaccinated consistent with age-based recommendations.
     3.  Varicella vaccination
    All adults without evidence of immunity to varicella should receive 
2 doses of single-antigen varicella vaccine if not previously 
vaccinated or the second dose if they have received only 1 dose, unless 
they have a medical contraindication. Special consideration should be 
given to those who (1) have close contact with persons at high risk for 
severe disease (e.g., health-care personnel and family contacts of 
persons with immunocompromising conditions) or (2) are at high risk for 
exposure or transmission (e.g., teachers; child-care employees; 
residents and staff members of institutional settings, including 
correctional institutions; college students; military personnel; 
adolescents and adults living in households with children; nonpregnant 
women of childbearing age; and international travelers).
    Evidence of immunity to varicella in adults includes any of the 
following: (1) documentation of 2 doses of varicella vaccine at least 4 
weeks apart; (2) U.S.-born before 1980 (although for health-care 
personnel and pregnant women, birth before 1980 should not be 
considered evidence of immunity); (3) history of varicella based on 
diagnosis or verification of varicella by a health-care provider (for a 
patient reporting a history of or presenting with an atypical case, a 
mild case, or both, health-care providers should seek either an 
epidemiologic link with a typical varicella case or to a laboratory-
confirmed case or evidence of laboratory confirmation, if it was 
performed at the time of acute disease); (4) history of herpes zoster 
based on diagnosis or verification of herpes zoster by a health-care 
provider; or (5) laboratory evidence of immunity or laboratory 
confirmation of disease.
    Pregnant women should be assessed for evidence of varicella 
immunity. Women who do not have evidence of immunity should receive the 
first dose of varicella vaccine upon completion or termination of 
pregnancy and before discharge from the health-care facility. The 
second dose should be administered 4-8 weeks after the first dose.
     4.  Herpes zoster vaccination
    A single dose of zoster vaccine is recommended for adults aged ;60 
years regardless of whether they report a prior episode of herpes 
zoster. Persons with chronic medical conditions may be vaccinated 
unless their condition constitutes a contraindication.
     5. Measles, mumps, rubella (MMR) vaccination
    Adults born before 1957 generally are considered immune to measles 
and mumps.
    Measles component: Adults born during or after 1957 should receive 
1 or more doses of MMR vaccine unless they have (1) a medical 
contraindication; (2) documentation of vaccination with 1 or more doses 
of MMR vaccine; (3) laboratory evidence of immunity; or (4) 
documentation of physician-diagnosed measles.
    A second dose of MMR vaccine, administered 4 weeks after the first 
dose, is recommended for adults who (1) have been recently exposed to 
measles or are in an outbreak setting; (2) have been vaccinated 
previously with killed measles vaccine; (3) have been vaccinated with 
an unknown type of measles vaccine during 1963-1967; (4) are students 
in postsecondary educational institutions; (5) work in a health-care 
facility; or (6) plan to travel internationally.
    Mumps component: Adults born during or after 1957 should receive 1 
dose of MMR vaccine unless they have (1) a medical contraindication; 
(2) documentation of vaccination with 1 or more doses of MMR vaccine; 
(3) laboratory evidence of immunity; or (4) documentation of physician-
diagnosed mumps.
    A second dose of MMR vaccine, administered 4 weeks after the first 
dose, is recommended for adults who (1) live in a community 
experiencing a mumps outbreak and are in an affected age group; (2) are 
students in postsecondary educational institutions; (3) work in a 
health-care facility; or (4) plan to travel internationally.
    Rubella component: 1 dose of MMR vaccine is recommended for women 
who do not have documentation of rubella vaccination, or who lack 
laboratory evidence of immunity. For women of childbearing age, 
regardless of birth year, rubella immunity should be determined and 
women should be counseled regarding congenital rubella syndrome. Women 
who do not have evidence of immunity should receive MMR vaccine upon 
completion or termination of pregnancy and before discharge from the 
health-care facility.
    Health-care personnel born before 1957: For unvaccinated health-
care personnel born before 1957 who lack laboratory evidence of 
measles, mumps, and/or rubella immunity or laboratory confirmation of 
disease, health-care facilities should consider vaccinating personnel 
with 2 doses of MMR vaccine at the appropriate interval (for measles 
and mumps) and 1 dose of MMR vaccine (for rubella), respectively.
    During outbreaks, health-care facilities should recommend that 
unvaccinated health-care personnel born before 1957, who lack 
laboratory evidence of measles, mumps, and/or rubella immunity or 
laboratory confirmation of disease, receive 2 doses of MMR vaccine 
during an outbreak of measles or mumps, and 1 dose during an outbreak 
of rubella.
    Complete information about evidence of immunity is available at 
www.cdc.gov/vaccines/recs/provisional/default.htm.
     6.  Seasonal Influenza vaccination
    Vaccinate all persons aged ;50 years and any younger persons who 
would like to decrease their risk of getting influenza. Vaccinate 
persons aged 19 through 49 years with any of the following indications.
    Medical: Chronic disorders of the cardiovascular or pulmonary 
systems, including asthma; chronic metabolic diseases, including 
diabetes mellitus; renal or hepatic dysfunction, hemoglobinopathies, or 
immunocompromising conditions (including immunocompromising conditions 
caused by medications or HIV); cognitive, neurologic or neuromuscular 
disorders; and pregnancy during the influenza season. No data exist on 
the risk for severe or complicated influenza disease among persons with 
asplenia; however, influenza is a risk factor for secondary bacterial 
infections that can cause severe disease among persons with asplenia.
    Occupational: All health-care personnel, including those employed 
by long-term care and assisted-living facilities, and caregivers of 
children aged <5 years.
    Other: Residents of nursing homes and other long-term care and 
assisted-living facilities; persons likely to transmit influenza to 
persons at high risk (e.g., in-home household contacts and caregivers 
of children aged <5 years, persons aged ;50 years, and persons of all 
ages with high-risk conditions).
    Healthy, nonpregnant adults aged <50 years without high-risk 
medical conditions who are not contacts of severely immunocompromised 
persons in special-care units may receive either intranasally 
administered live, attenuated influenza vaccine (FluMist) or 
inactivated vaccine. Other persons should receive the inactivated 
vaccine.
     7.  Pneumococcal polysaccharide (PPSV) vaccination
    Vaccinate all persons with the following indications.
    Medical: Chronic lung disease (including asthma); chronic 
cardiovascular diseases; diabetes mellitus; chronic liver diseases, 
cirrhosis; chronic alcoholism; functional or anatomic asplenia (e.g., 
sickle cell disease or splenectomy [if elective splenectomy is planned, 
vaccinate at least 2 weeks before surgery]); immunocompromising 
conditions including chronic renal failure or nephrotic syndrome; and 
cochlear implants and cerebrospinal fluid leaks. Vaccinate as close to 
HIV diagnosis as possible.
    Other: Residents of nursing homes or long-term care facilities and 
persons who smoke cigarettes. Routine use of PPSV is not recommended 
for American Indians/Alaska Natives or persons aged <65 years unless 
they have underlying medical conditions that are PPSV indications. 
However, public health authorities may consider recommending PPSV for 
American Indians/Alaska Natives and persons aged 50 through 64 years 
who are living in areas where the risk for invasive pneumococcal 
disease is increased.
     8.  Revaccination with PPSV
    One-time revaccination after 5 years is recommended for persons 
with chronic renal failure or nephrotic syndrome; functional or 
anatomic asplenia (e.g., sickle cell disease or splenectomy); and for 
persons with immunocompromising conditions. For persons aged ;65 years, 
one-time revaccination is recommended if they were vaccinated ;5 years 
previously and were younger than aged <65 years at the time of primary 
vaccination.
     9.  Hepatitis A vaccination
    Vaccinate persons with any of the following indications and any 
person seeking protection from hepatitis A virus (HAV) infection.
    Behavioral: Men who have sex with men and persons who use injection 
drugs.
    Occupational: Persons working with HAV-infected primates or with 
HAV in a research laboratory setting.
    Medical: Persons with chronic liver disease and persons who receive 
clotting factor concentrates.
    Other: Persons traveling to or working in countries that have high 
or intermediate endemicity of hepatitis A (a list of countries is 
available at wwwn.cdc.gov/travel/contentdiseases.aspx).
    Unvaccinated persons who anticipate close personal contact (e.g., 
household contact or regular babysitting) with an international adoptee 
from a country of high or intermediate endemicity during the first 60 
days after arrival of the adoptee in the United States should consider 
vaccination. The first dose of the 2-dose hepatitis A vaccine series 
should be administered as soon as adoption is planned, ideally ;2 weeks 
before the arrival of the adoptee.
    Single-antigen vaccine formulations should be administered in a 2-
dose schedule at either 0 and 6-12 months (Havrix), or 0 and 6-18 
months (Vaqta). If the combined hepatitis A and hepatitis B vaccine 
(Twinrix) is used, administer 3 doses at 0, 1, and 6 months; 
alternatively, a 4-dose schedule, administered on days 0, 7, and 21-30 
followed by a booster dose at month 12 may be used.
    10.  Hepatitis B vaccination
    Vaccinate persons with any of the following indications and any 
person seeking protection from hepatitis B virus (HBV) infection.
    Behavioral: Sexually active persons who are not in a long-term, 
mutually monogamous relationship (e.g., persons with more than one sex 
partner during the previous 6 months); persons seeking evaluation or 
treatment for a sexually transmitted disease (STD); current or recent 
injection-drug users; and men who have sex with men.
    Occupational: Health-care personnel and public-safety workers who 
are exposed to blood or other potentially infectious body fluids.
    Medical: Persons with end-stage renal disease, including patients 
receiving hemodialysis; persons with HIV infection; and persons with 
chronic liver disease.
    Other: Household contacts and sex partners of persons with chronic 
HBV infection; clients and staff members of institutions for persons 
with developmental disabilities; and international travelers to 
countries with high or intermediate prevalence of chronic HBV infection 
(a list of countries is available at www.cdc.gov/travel/
contentdiseases.aspx).
    Hepatitis B vaccination is recommended for all adults in the 
following settings: STD treatment facilities; HIV testing and treatment 
facilities; facilities providing drug-abuse treatment and prevention 
services; health-care settings targeting services to injection-drug 
users or men who have sex with men; correctional facilities; end-stage 
renal disease programs and facilities for chronic hemodialysis 
patients; and institutions and nonresidential daycare facilities for 
persons with developmental disabilities.
    Administer or complete a 3-dose series of HepB to those persons not 
previously vaccinated. The second dose should be administered 1 month 
after the first dose; the third dose should be administered at least 2 
months after the second dose (and at least 4 months after the first 
dose). If the combined hepatitis A and hepatitis B vaccine (Twinrix) is 
used, administer 3 doses at 0, 1, and 6 months; alternatively, a 4-dose 
schedule, administered on days 0, 7, and 21-30 followed by a booster 
dose at month 12 may be used.
    Adult patients receiving hemodialysis or with other 
immunocompromising conditions should receive 1 dose of 40  g/mL 
(Recombivax HB) administered on a 3-dose schedule or 2 doses of 20  g/
mL (Engerix-B) administered simultaneously on a 4-dose schedule at 0, 
1, 2 and 6 months.
    11.  Meningococcal vaccination
    Meningococcal vaccine should be administered to persons with the 
following indications.
    Medical: Adults with anatomic or functional asplenia, or persistent 
complement component deficiencies.
    Other: First-year college students living in dormitories; 
microbiologists routinely exposed to isolates of Neisseria 
meningitidis; military recruits; and persons who travel to or live in 
countries in which meningococcal disease is hyperendemic or epidemic 
(e.g., the ``meningitis belt'' of sub-Saharan Africa during the dry 
season [December through June]), particularly if their contact with 
local populations will be prolonged. Vaccination is required by the 
government of Saudi Arabia for all travelers to Mecca during the annual 
Hajj.
    Meningococcal conjugate vaccine (MCV4) is preferred for adults with 
any of the preceding indications who are aged :55 years; meningococcal 
polysaccharide vaccine (MPSV4) is preferred for adults aged ;56 years. 
Revaccination with MCV4 after 5 years is recommended for adults 
previously vaccinated with MCV4 or MPSV4 who remain at increased risk 
for infection (e.g., adults with anatomic or functional asplenia). 
Persons whose only risk factor is living in on-campus housing are not 
recommended to receive an additional dose.
    12.  Selected conditions for which Haemophilus influenzae type b 
(Hib) vaccine may be used
    Hib vaccine generally is not recommended for persons aged ;5 years. 
No efficacy data are available on which to base a recommendation 
concerning use of Hib vaccine for older children and adults. However, 
studies suggest good immunogenicity in patients who have sickle cell 
disease, leukemia, or HIV infection or who have had a splenectomy. 
Administering 1 dose of Hib vaccine to these high-risk persons who have 
not previously received Hib vaccine is not contraindicated.
    13.  Immunocompromising conditions
    Inactivated vaccines generally are acceptable (e.g., pneumococcal, 
meningococcal, influenza [inactivated influenza vaccine]) and live 
vaccines generally are avoided in persons with immune deficiencies or 
immunocompromising conditions. Information on specific conditions is 
available at www.cdc.gov/vaccines/pubs/acip-list.htm.

                                 
         Prepared Statement of Jacob B. Gadd, Deputy Director,
    Veterans Affairs and Rehabilitation Commission, American Legion
    Mr. Chairman and Members of the Committee:
    Thank you for this opportunity for The American Legion to present 
our views on today's pending legislation.
H.R. 3843_``Transparency for America's Heroes Act''
    This bill would direct the Secretary of Veterans Affairs to place 
medical quality-assurance records on the Department of Veterans Affairs 
(VA) Web site.
    The American Legion has no position on this legislation.
H.R. 4041_To Authorize Certain Improvements in the Federal Recovery 
        Coordinator Program
    The purpose of this bill is to improve upon the Federal Recovery 
Coordinator (FRC) program by having VA establish recovery coordinator 
training at a qualified nursing or medical school selected by the 
Secretary of VA. The qualified nursing or medical school will lead a 
literature review and development of evidence-based guidelines for 
recovery coordination, development of training modules for care 
coordination and software that is compatible with VA systems for 
recovery coordination. It will also lead a consensus conference on 
evidence-based care coordination. Additionally, this bill authorizes 
the qualified nursing or medical school to train 45 recovery 
coordinators over the course of 3 years.
    In 2007, The American Legion approved Resolution 29, Improvements 
to Implement a Seamless Transition, which fully supported legislation 
to designate a single Recovery Coordinator to ensure an efficient 
rehabilitation and transition from military to civilian life and 
eliminate delays and gaps in treatment and services. By the provisions 
of the National Defense Authorization Act, Public Law 110-181, the FRC 
program began in 2008. The program was designed to create 
individualized care coordination plans for severely injured 
servicemembers in order to ensure a warm handoff for severely wounded 
servicemembers transitioning between DoD and VA as well as coordinate 
state and local resources. With close to two million servicemembers 
having deployed in Operations Iraqi Freedom (OIF), Enduring Freedom 
(OEF) and New Dawn, VA only reported to date that less than 1,000 
servicemembers have been assisted. The American Legion recommends 1) 
expanding the program areas of the FRC program to include program 
eligibility, 2) increasing FRC staff to one individual coordinator per 
state and 3) improved communication at the national, state and local 
levels.
    The American Legion believes that coordination of care, especially 
for those who are severely wounded, is essential to ensure they receive 
the education and benefits they need and deserve. However, The American 
Legion believes efforts to improve care coordination must be directed 
at not only the severely wounded but any veteran transitioning to 
ensure they do not fall through the cracks. Currently, only those 
servicemembers diagnosed with Traumatic Brain Injury (TBI), Post 
Traumatic Stress (PTS), visual impairment, amputation, burns or spinal 
cord injury are eligible for assistance through the program. The 
American Legion supports expansion of FRC program eligibility for any 
veteran transitioning from active duty, guard or reserve for any 
illness or injury.
    VA reported in 2010 that five new FRCs are in the process of being 
hired, which will bring the total number of full-time FRC staff to 25 
across the country. These FRCs are stationed at: Walter Reed Army 
Medical Center; National Naval Medical Center; Brooke Army Medical 
Center; Balboa Naval Medical Center; San Diego Naval Medical Center; 
Camp Pendleton, CA; Eisenhower Army Medical Center, GA; Michael E. 
DeBakey VA Medical Center, TX; Richmond VA Medical Center; and, Palo 
Alto VA Medical Center. The American Legion recommends having a FRC 
within each state to ensure all active duty, reserve and guard units 
receive the same education, outreach and benefits assistance.
    The American Legion's flagship transition program, Heroes to 
Hometowns, seeks to coordinate national, State and local resources 
similar to the FRC program. The Heroes to Hometowns program assists 
veterans with filing VA claims or benefits, applying for Temporary 
Financial Assistance (TFA) as well as coordinating education or 
employment opportunities before the servicemember returns to his or her 
community. Even though FRC helped in the creation of the National 
Community Resource Directory, The American Legion recommends enhanced 
communication between national, state and local levels to ensure 
maximum awareness of benefits available. Many times, The American 
Legion has had difficulty contacting the FRCs through phone, email or 
mailing address. In addition, the program should increase its outreach 
through use of a dedicated Web page to update current contact 
information.
    In regards to the development of a computerized tracking program, 
The American Legion applauds the new application created by VA in 2009, 
the Care Management and Tracking and Reporting Application (CMTRA). 
This tracking tool allows VA to coordinate care amongst a wide variety 
of providers such as the OEF/OIF care management team and specialty 
care providers to establish an individualized care plan for each 
veteran. The American Legion recommends consolidation and expansion of 
a single tracking tool between DoD, VA and the private sector to 
prevent redundancy or any veterans that may fall through the cracks.
H.R. 5428_To Direct the Secretary of Veterans Affairs to Educate 
        Certain Staff of the Department of Veterans Affairs and to 
        Inform Veterans about the Injured and Amputee Veterans Bill of 
        Rights
    This bill seeks to ensure print materials are created about the 
Injured and Amputee Veterans Bill of Rights and posted in VA 
prosthetics and orthotics clinics so that veterans are aware of their 
rights. In addition, staff of these clinics would be required to 
receive training on these patient rights and the Secretary would be 
responsible for providing outreach through Web sites or veteran service 
organizations.
    Many veterans of Iraq and Afghanistan have been subjected to 
Improvised Explosive Devices (IEDs) which have resulted in a 
significant increase in the number of amputations from previous 
conflicts. DoD reported in 2010 that there have been a total of 1,552 
servicemembers that suffered amputations. Promoting information about 
veterans' rights in the clinics as well as increases through targeted 
outreach will help VA improve their business processes and encourage 
veterans to receive their treatment at VA.
    The American Legion continues to advocate for advancement in VA's 
outreach practices and stands ready to assist VA in promoting benefits 
and services.
    The American Legion fully supports this legislation.
H.R. 5516_``Access to Appropriate Immunizations for Veterans Act of 
        2010''
    The purpose of this bill is to ensure quality and timely scheduling 
of patient immunizations by VA. Specifically, this bill will ``create 
quality measures and statistical metrics as well as an annual report to 
ensure VA is meeting its obligations in providing immunizations.''
    One of the provisions of this bill requires VA to keep metrics and 
measures in place to track influenza and pneumococcal vaccinations. The 
Veterans Health Administration (VHA) issued a VHA Directive on November 
12, 2009 that stated, ``Influenza vaccination rates of veteran patients 
are monitored in the VHA performance measurement system, under the 
`seasonal outpatient influenza measure.' '' The directive also mandates 
vaccination and documentation of the influenza immunization by all 
patients, staff and volunteers within VA Medical Centers. However, an 
overall performance measure for all immunizations provided by the 
Department of Veterans Affairs is not monitored by VA Central Office. 
In VA's FY 2009 Performance and Accountability Report, two evaluation 
metrics-Clinical Practice Guidelines (CPGI) and Prevention Index (PI) 
are utilized to track VA's progress for this initiative. The results 
from Strategic Goal Three, ``Prevention Index IV'' reported an 89 
percent goal attained by VA in ``promoting healthy lifestyle changes 
with early identification of disease, immunizations and prevention 
screenings.''
    While The American Legion does not have a specific resolution 
supporting patient immunizations quality and scheduling, The American 
Legion supports quality and performance measures designed to enhance 
veterans' safety and quality of care.
H.R. 5543_To Repeal the Prohibition on Collective Bargaining with 
        Respect to Matters and Questions Regarding Compensation of 
        Employees of the Department of Veterans Affairs other than 
        Rates of Basic Pay
    This bill seeks to revoke the collective bargaining rules on open 
disclosure of compensation of VA employees, with the exception of 
employee's basic pay fee structure. It is the policy of The American 
Legion not to be involved with VA's management and employee relations.
    The American Legion does not have a specific position on this piece 
of legislation.
H.R. 5641_To Authorize the Secretary of Veterans Affairs to Enter Into 
        Contracts for the Transfer of Veterans to Non-Department Adult 
        Foster Homes for Veterans Who Are Unable to Live Independently
    VA is authorized under Title 38, Code of Federal Regulations (CFR) 
Section 17.38 (a)(1)(ix)) to provide a comprehensive array of medically 
necessary in-home services to enrolled veterans. This bill seeks to add 
a provision in title 38, United States Code (U.S.C.), Section 1720 that 
VA would be authorized to transfer veterans needing long-term care 
services to ``Foster Homes,'' upon the request of the veteran or 
Secretary of Veterans Affairs.
    VA issued VHA Handbook 1141.02, Medical Foster Home Procedures, in 
November 2009, which outlined the Department's policy on definition, 
responsibilities, selection, training, quality monitoring and financial 
arrangements for this program.
    VA defines a Medical Foster Home (MFH) in VHA Handbook 1141.02 as: 
(1) MFH is an adult foster home combined with a VA interdisciplinary 
home care team, such as VA Home Based Primary Care (HBPC) or Spinal 
Cord Injury--Home Care (SCI-HC), to provide non-institutional long-term 
care for veterans who are unable to live independently and prefer a 
family setting. (2) MFH is a form of Community Residential Care (CRC) 
for the more medically complex and disabled veterans, and is generally 
distinguished from other CRC homes by the following: (a) the home is 
owned or rented by the MFH caregiver; (b) the MFH caregiver lives in 
the MFH and provides personal care and supervision, (c) There are not 
more than three residents receiving care in the MFH, including both 
veterans and non-veterans, (d) veteran MFH residents are enrolled in a 
VA HBPC or SCI-HC Program. Each VA Medical Center facility appoints a 
MFH Coordinator which oversees the recruitment of staff, new 
applications for MFH in the community, training, quality assurance and 
inspections, and maintaining files of patients and MFH caregivers.
    While this program has been highlighted and encouraged because of 
the additional cost savings and access to care options for the veteran 
and VA, The American Legion seeks additional feedback from users of 
this MFH program about the level of patient safety and feedback on 
their quality of care that would be provided in a non-traditional care 
setting.
    The American Legion does not have an official position at this 
time.
H.R. 5996_To Direct the Secretary of Veterans Affairs to Improve the 
        Prevention, Diagnosis, and Treatment of Veterans with Chronic 
        Obstructive Pulmonary Disease
    The purpose of this bill is to improve patient care and treatment 
for Chronic Obstructive Pulmonary Disease (COPD) by: ``(1) developing 
treatment protocols and tools for the prevention, diagnosis, treatment 
and management, (2) improving biomedical and prosthetic research, (3) 
entering into a pilot program with VA, Centers for Disease Control and 
Prevention (CDC), Indian Health Service, Health Resources and Services 
Agency to develop best practices in treatment of COPD and (4) VA and 
CDC research unique needs and develop smoking cessation tools and 
techniques.''
    The American Legion concurs with this piece of legislation to 
improve upon current knowledge, research and treatment of COPD.
H.R. 6123_To Amend Title 38, United States Code, to Improve the 
        Provision of Rehabilitative Services for Veterans with 
        Traumatic Brain Injury, and for other purposes
    The purpose of this bill is to improve rehabilitation services for 
veterans suffering from traumatic brain injury (TBI). Because of 
ambiguities in current law, TBI treatment at VA narrowly focuses TBI 
care on physical restoration. This legislation would clarify the 
definition of rehabilitation so veterans will receive care that 
adequately addresses their physical and mental health needs, as well as 
quality of life and prospects for long-term recovery and success.
    The American Legion supports this bill as it seeks to provide 
comprehensive care instead of just physical rehabilitation for veterans 
suffering from TBI. The American Legion is very supportive of ensuring 
that the quality of life of our wounded servicemembers is addressed 
with as much fervor as the simple, physical aftereffects.
H.R. 6127_To Amend Title 38, United States Code, to Provide for the 
        Continued Provision of Health Care Services to Certain Veterans 
        Who Were Exposed to Sodium Dichromate While Serving as a Member 
        of the Armed Forces At or Near the Water Injection Plant at 
        Qarmat Ali, Iraq, During Operation Iraqi Freedom
    During the spring and summer of 2003, about 800 servicemembers 
guarded a water injection facility in the Basrah oil fields at Qarmat 
Ali, Iraq. Servicemembers included National Guard, Reserve, and Active 
Duty Soldiers. This facility was contaminated with sodium dichromate 
dust, which is a source of hexavalent chromium, a chemical that is 
known to cause cancer. Health problems associated with such exposure 
include respiratory issues, skin lesions, burns, increased rates of 
lung cancer, and other ear, nose, throat, and skin disorders.
    Some of the Qarmat Ali veterans who separated from service 
following their deployment in 2003 may no longer be eligible to enroll 
in VA health care under the 5-year open enrollment period Congress 
established for non-service connected veterans. As a result, they must 
first file a claim and seek a service-connected disability rating 
before enrolling in the VA health care system and gaining access to the 
comprehensive medical care VA provides.
    H.R. 6127 would correct this unintended gap in services by 
extending the enrollment eligibility period for Qarmat Ali veterans by 
5 years from the date of notification. This would allow them to 
immediately begin receiving services at VA medical facilities for any 
and all of their health care needs.
    In 2010, the American Legion approved Resolution 12: The American 
Legion Policy on Hazardous Environmental Exposures. The resolution 
supports legislative and administrative actions by Congress and VA to 
properly study the long-term effects of all environmental exposures and 
ensure that veterans are properly cared for and compensated for 
diseases and other disabilities scientifically associated with a 
particular exposure. Included within the scope of this resolution are 
environmental exposures such as Agent Orange, Gulf-War related hazards, 
ionizing radiation, Project Shipboard Hazard and Defense (SHAD), ground 
water contamination at Camp Lejuene, multiple contaminants at Fort 
Drum, NY, Fort Dugway, UT and Fort McClellan, AL and overseas concerns 
related to sodium dichromate, toxic exposures at the Naval Air Facility 
in Atsugi, Japan and burn pits in Balad, Iraq and other locations which 
have all caused a variety of health problems.
    While the American Legion supports H.R. 6127 as far as it goes, we 
would additionally recommend a comprehensive environmental exposures 
bill that would provide for the conduct of full studies to determine 
the health consequences of exposure to suspected environmental hazards 
so that veterans can receive the proper care and compensation due them 
as a result of their service to our Nation.
Draft Legislation to Amend Title 38, USC, to Make Certain Improvements 
        in Programs for Homeless Veterans Administered by the Secretary 
        of Veterans Affairs, and for Other Purposes
    This bill seeks to expand the VA grant program for homeless 
veterans with special needs, which includes those seriously mentally 
ill, frail and elderly, terminally ill and homeless women veterans. 
This bill would also change reimbursement policy from a per diem rate 
to annual cost of furnishing services. This emphasis on these special 
subgroups and the reimbursement change would provide needed attention 
and resources that will enable Homeless Service Care Providers to 
assist these homeless veterans with needed care and services. For 
example, the number of homeless woman veterans has doubled in the past 
decade, up from 3 percent to 5 percent according to VA. This increase 
of women veterans is due to their exposure to combat related 
situations.
    With the continuance of the wars in Iraq and Afghanistan, it is 
widely known that psychological stress, such as post-traumatic stress, 
TBI and other mental illnesses play a significant role in pushing a 
certain population of veterans into homelessness. Funding, along with 
grants that go to homeless veterans programs and organizations that 
assist this vulnerable demographic, are desperately needed. The 
American Legion understands that homeless veterans need a sustained 
coordinated effort that provides secure housing and nutritious meals; 
essential physical health care, substance abuse aftercare and mental 
health counseling; as well as personal development and empowerment. If 
enacted, this grant program will provide necessary medical and 
rehabilitative services to homeless veterans with special needs that 
will allow them to readjust and live a better quality of life.
    The American Legion supports improvements to VA's homeless programs 
but encourages Congress and VA to address the growing concern with 
homeless women veterans, especially those with children.
Draft Legislation to Amend Title 38, United States Code, to Ensure That 
        the Secretary of Veterans Affairs Provides Veterans With 
        Information Concerning Service-Connected Disabilities at Health 
        Care Facilities
    The purpose of this draft legislation is to ensure that the VA's 
Veterans Health Administration (VHA) provides veterans accessing their 
health care benefits with information or assistance in obtaining their 
claims and ratings benefits from the Veteran Benefit Administration 
(VBA). To accomplish this objective, this draft legislation suggests 
listing VBA claims information and benefits in various locations in VA 
Medical Centers, that VHA staff in the hospital discuss VBA benefits 
with each of their enrolled patients and provide contact information to 
help the veteran initiate their VBA claims and benefits.
    Several American Legion Department (State) Service Officers have 
identified that VHA providers are not assisting veterans with questions 
the provider interprets as ``claims-related.'' Additionally, there is a 
lack of awareness on the part of VHA providers that Veteran Service 
Organizations (VSO) are available for referral to assist veterans with 
the VA claims process. In a specific case, there was a lack of required 
training on veteran-specific health issues and potential benefits 
claims with Cold Injury Residuals, Agent Orange and other presumptive 
conditions. Also, Vietnam veterans diagnosed and treated for prostate 
cancer by a VA urologist were not advised to file a claim and missed an 
opportunity for 100 percent service connection as a result.
    The American Legion is working with VA Central Office to understand 
the reasons for this disconnect between VHA and VBA and we intend to 
recommend a Fast Letter or new VHA directive be sent to the field to 
clarify VA's policy on treating physicians providing the necessary 
medical evidence on the veteran's behalf as the VA provider can act as 
an advocate in the claims process.
    The American Legion supports this draft legislation and recommends 
each VA Medical Center Facility have a VHA/VBA training liaison 
position to facilitate biannual training and updates on VBA regulations 
for VHA providers so that these providers will inform veterans of their 
earned benefits and rights to file a claim for VBA compensation and 
pension.
Draft Legislation to Amend Title 38, United States Code, to Make 
        Certain Improvements in Laws Relating to Health Care for 
        Veterans, and for Other Purposes
    This draft legislation seeks to make improvements to several health 
care matters. First, the legislation would allow VA's Under Secretary 
for Health to provide assistance in organizing and hosting the 
Association of Military Surgeons in the United States annual meeting. 
The American Legion does not have an official position or affiliation 
with this group but generally supports advances and benchmarking 
between DoD, VA and other Federal agencies in terms of research, 
provider training and education.
    Secondly, the draft legislation recommends clarification to VA's 
regulations on contracting with Non-Department Facilities and that the 
Secretary of Veterans Affairs ``provide individual authorization or act 
in such other manner as the Secretary determines appropriate.'' The 
American Legion has two positions on this section. First, The American 
Legion's Resolution 172: GI Bill of Health, adopted at the 2010 
Convention states that veterans be authorized to utilize any 
appropriate government health care facility in order to reduce travel 
time, travel expense and undue stress on the veteran and/or their 
caregiver. Secondly, VA is authorized to contract or fee-base care into 
the community. The American Legion's System Worth Saving Task Force 
noted that in each of the 32 VA Medical Facilities visited this year, 
the facility Purchased Care budget continues to increase. In the last 4 
years, VA's Purchased Care costs have doubled. The American Legion 
attributes this increase to the lack of specialty providers and access 
to care in rural communities. The American Legion believes that any 
veteran should be able to receive quality care close to their home but 
that VA must hire the needed specialty providers and increase access to 
prevent the rising costs of Purchased Care in the community.
    Thirdly, the draft legislation would extend the life of the VA 
Advisory Committee on Homeless Veterans beyond its present termination 
date of December 30, 2011 to December 30, 2014. The American Legion 
supports this extension.
    Fourth, this legislation seeks to amend the participating provider 
agreement to improve on collection of third-party reimbursements. Under 
the terms of the 1997 Balanced Budget Act, VHA was given the authority 
to bill, collect, and retain third-party reimbursements for outpatient 
medications, nursing home and hospital care. The American Legion 
supports improvements in VA's ability to recover third-party 
reimbursements for treatment of non-service medication conditions and 
supports the intent of this section.
    Fifth, the draft legislation addresses a VA employment requirement 
for participants in the health professionals' educational assistance 
program. The American Legion does not have a resolution or comments on 
this provision of the legislation.
    Six, the legislation recommended ``on-call'' pay for VHA employees 
in IT fields. In addition, the seventh recommendation from the draft 
legislation proposes that VA not be authorized to pay for more than 
1,000 physicians and dentists employees within IT fields. The 
legislation stipulates that providers must have qualifying board 
certification and training and that their pay be tied to VA's pay 
schedules. It is the policy of The American Legion not to be involved 
with VA's management and employee relations and therefore does not have 
a position on these provisions.
    The eighth section of the draft legislative seeks to extend VA's 
Joint Incentives Program from September 30, 2015 to September 30, 2020. 
The joint incentives program was designed to allow both DoD and VA 
Executive Committees to maintain a joint account to promote 
coordination, sharing and funding of programs between both agencies. 
The American Legion does not have a specific resolution but supports 
the general intent of this program and its extension.
    The last provision of this draft legislation recommends creation of 
Franchise Fund to refund veterans whose third-party insurances were 
billed incorrectly. While there may be a delay in VA recouping third-
party insurance payments, this Franchise Fund would allow VA to 
promptly fund the veterans' third party account until the veterans' 
third-party insurance company fixes the mistake. The American Legion 
supports this provision.
    As always, the American Legion thanks this Committee for the 
opportunity to testify and represent the positions of the over 2.4 
million veteran members of this organization.

                                 
    Prepared Statement of Carl Blake, National Legislative Director,
                     Paralyzed Veterans of America

    Chairman Michaud and Members of the Subcommittee, on behalf of 
Paralyzed Veterans of America (PVA), I would like to thank you for the 
opportunity to present PVA's views on legislation pending before the 
Subcommittee. PVA appreciates the efforts of the Subcommittee to 
support the Department of Veterans Affairs (VA) and the care of our 
Nation's veterans. With the inevitable future budget challenges to 
come, PVA looks forward to your support to protect those who have done 
so much to protect us all, America's veterans. In particular, we hope 
for your continued support of those requiring specialized health care, 
a vital service that is often unmatched in the civilian health care 
sector.
        H.R. 3843, the ``Transparency for America's Heroes Act''
    PVA cautiously supports H.R. 3843, the ``Transparency for America's 
Heroes Act.'' Transparency is critical for the public to be able to see 
and understand what its government is doing. In the case of VA quality-
assurance records, it only makes sense that this transparency is 
critical to veterans, and those who serve veterans such as Veterans 
Service Organizations (VSO), and their understanding of how well VA is 
doing its job. Requiring VA to publish redacted medical quality-
assurance records on the VA's Web site will provide users of the VA a 
better understanding of the successes or failures of the VA in the 
quality of care they provide our veterans. This may encourage greater 
efforts on the part of VA employees, staff and leaders to ensure the 
best care is provided to veterans while ensuring openness. PVA's 
concern stems from the need for privacy in health care records. It is 
important that sufficient safeguards be put in place to prevent the 
unintended release of personal health information that may be 
detrimental to a VA patient.
     H.R. 4041, to authorize improvements in the Federal Recovery 
                          Coordinator Program
    PVA fully supports H.R. 4041 that will implement the Federal 
Recovery Coordinator Program. PVA agrees with the recommendation of the 
Dole-Shalala Commission that a nationwide Federal Recovery Coordinator 
Program will expand partnerships and collaborations to benefit veterans 
of Operation Iraqi Freedom and Operation Enduring Freedom. As specified 
in the legislation, there are a large number of services available to 
transitioning veterans, but no good mechanism for coordinating medical 
care for wounded warriors. There are so many programs that veterans can 
have a difficult time navigating through this sea of help. While this 
coordinator program may not solve all the challenges of coordinating 
care, it will go a long way to providing for knowledgeable health care 
professionals that can help wounded warriors navigate the often 
confusing maze of services.
    In addition, provisions of the legislation that will establish a 
qualified nursing or medical school lead to review and develop 
evidence-based guidelines for recovery coordination should ensure that 
the program meets the needs of those being trained and the veterans 
that are served. While initially only 45 coordinators are authorized to 
be trained, PVA would recommend an expansion of the program dependent 
on its demonstrated success.
      H.R. 5428, to direct the Secretary of VA to educate VA staff
    PVA supports H.R. 5428 to better educate injured and amputee 
veterans on their rights and the requirement that VA staff who work at 
prosthetics and orthotics clinics or who work as patient advocates for 
veterans understand these rights as well. This bill would ensure that 
VA prosthetics clinics around the country prominently display the 
``Injured and Amputee Veterans Bill of Rights'' and that VA employees 
understand it. This reaffirms the idea that a veteran in need of an 
assistive device or prosthetic gets the highest quality item available 
and in a timely manner. As expressed in previous testimony on this 
topic, PVA is concerned that this legislation's language seems to 
ignore veterans who may be in need of special equipment who suffer from 
a specific disease and not a physical injury.
 H.R. 5516, the ``Access to Appropriate Immunizations for Veterans Act 
                               of 2010''
    PVA strongly supports H.R. 5516, the ``Access to Appropriate 
Immunizations for Veterans Act of 2010.'' It is accepted fact that 
proper and timely administration of immunizations can prevent the onset 
of more significant medical issues. By requiring the Secretary to 
ensure these immunizations are administered in compliance with the 
recommended adult immunization schedule, and requiring quality measures 
to ensure this is done, it can be expected that veterans using the VA 
will be healthier and less likely to suffer potential medical ailments. 
The Department of Defense (DoD) follows these procedures to ensure a 
more ready military force. It only makes medical and economic sense 
that the health gains achieved by the DoD program for individuals prior 
to leaving service should be continued to maintain and benefit the 
health of veterans. Proper and timely immunizations are a guarantee of 
better medical health in the VA patient population.
     H.R. 5543, to repeal the prohibition on collective bargaining
    PVA supports H.R. 5543 to repeal the prohibition on collective 
bargaining with respect to compensation for VA employees which may 
improve the collective bargaining rights and procedures for certain 
health care professionals in the VA. As PVA testified in March of this 
year, these changes may be a positive step in addressing the 
recruitment and retention challenges the VA faces to hire key health 
care professionals, particularly registered nurses (RN), physicians, 
physician assistants, and other selected specialists. While PVA 
supports the repeal, this support is contingent on determinations that 
such repeal will in no way affect the care provided to veterans. This 
is the single purpose of the VA and its employees and must always 
remain so.
                 H.R. 5641, the ``Heroes at Home Act''
    PVA generally supports H.R. 5641, the ``Heroes at Home Act.'' 
However, it is essential that proper protections are put in place to 
ensure that it is the desire of the veteran to be transferred to a non-
VA nursing home and only in the case that the foster home meets VA 
standards at the time of transfer. It is critical that to support this 
program, VA verifies that the home is in compliance with VA standards 
before a veteran is transferred. Too often a facility may have been in 
compliance in the past and the same certification is used to judge the 
current status of the facility. This must not be allowed to occur in 
the case of these vulnerable veterans.
H.R. 5996, to direct the Secretary to improve the treatment of veterans 
                         with pulmonary disease
    PVA supports H.R. 5996 to direct the Secretary to improve the 
treatment of veterans with chronic obstructive pulmonary disease 
(COPD), develop a pilot program to demonstrate best practices for 
diagnosis and management of COPD, and develop improved techniques and 
best practices for smoking cessation. However, PVA is concerned with 
language in Section 1(a) that it is ``Subject to the availability of 
appropriations provided for such purpose . . . '' This legislation 
essentially establishes an unfunded mandate that Congress is telling 
the Secretary he can ignore. While this may be a result of the current 
tight budget environment, if this legislation is needed to provide for 
our Nation's veterans, the Secretary should be instructed to implement 
the programs and they should be appropriately funded by Congress. This 
legislation outlines excellent programs to improve the health of 
veterans. Without stronger requirements directing the Secretary to 
implement these programs, they may not be implemented by VA due to its 
other competing requirements.
H.R. 6123, ``Veterans' Traumatic Brain Injury Rehabilitative Services' 
                       Improvement Act of 2010''
    PVA supports H.R. 6123, the ``Veterans' Traumatic Brain Injury 
Rehabilitative Services' Improvement Act of 2010.'' Together with 
Improvised Explosive Devices (IED), Traumatic Brain Injury (TBI) has 
become a signature wound of the current wars in Afghanistan and Iraq. 
Today, we still do not fully understand the impact or gravity of TBI. 
In April 2008, the RAND Corporation Center for Military Health Policy 
Research completed a comprehensive study titled Invisible Wounds of 
War: Psychological and Cognitive Injuries, Their Consequences, and 
Services to Assist Recovery. RAND found that the effects of TBI were 
poorly understood, leaving a gap in knowledge related to how extensive 
the problem is or how to handle it. RAND found 57 percent of those 
reporting a probable TBI had not been evaluated by a physician for 
brain injury. Military service personnel who sustain catastrophic 
physical injuries and suffer severe TBI are easily recognized, and the 
treatment regimen is well established. In recent testimony, PVA has 
raised continuing concerns about servicemembers who do not have the 
immediate outward signs of TBI getting appropriate care. The military 
has implemented procedures to temporarily withdraw individuals from 
combat operations following IED attacks for an assessment of possible 
TBI, creating a significant military impact, but believing it necessary 
for soldier health even if it reduced combat forces.
    On July 12, 2006, the VA Office of the Inspector General (OIG) 
issued Health Status of and Services for Operation Enduring Freedom/
Operation Iraqi Freedom Veterans after Traumatic Brain Injury 
Rehabilitation. The report found that better coordination of care 
between DoD and VA health-care services was needed to enable veterans 
to make a smooth transition. While VA and DoD have done extensive 
improvements of coordination since that report, the OIG Office of 
Health Care Inspections conducted follow-on interviews to determine 
changes since the initial interviews conducted in 2006. The OIG 
concluded that 3 years after completion of initial inpatient 
rehabilitation, many veterans with TBI continue to have significant 
disabilities and, although case management has improved, it is not 
uniformly provided to these patients.
    Because all the impacts of TBI are still unknown, this legislation 
to expand services and care, providing for quality of life and not just 
independence, and emphasizing rehabilitative services, is important to 
the ongoing care of TBI patients. It is imperative that a continuum of 
care for the long term be provided to veterans suffering from TBI. PVA 
believes this legislation is a step toward ensuring that care.
                               H.R. 6127
    PVA generally supports this legislation; however, we do have some 
concerns with the issues surrounding this bill. While we see no real 
argument with granting these men and women who experienced the 
exposures outlined by this bill access to the VA health care system, we 
question why this is the only group singled out for enrollment. Given 
the longstanding discussions about Operation Iraqi Freedom veterans 
being exposed to burns pits or servicemembers exposed to hazardous 
materials in any number of settings, we believe proper consideration 
needs to be given to a broader spectrum of veterans and servicemembers.
  H.R. 6188, the ``Veterans Homelessness Prevention and Early Warning 
                                 Act''
    PVA also supports the draft legislation that outlines the VA's 
notice and response requirements for defaults in loan payments 
guaranteed by the VA. The recent collapse of the housing market coupled 
with the struggles that many veterans face in the employment market 
have created a situation where many veterans and their families are 
defaulting on home loans and often losing their homes. This legislation 
will ensure that veterans who are placed in this situation are quickly 
identified so that they may be provided needed assistance by the VA.
  Draft Legislation on Ensuring VA Provides Veterans with Information 
               Concerning Service-Connected Disabilities
    PVA supports the draft legislation to ensure health care 
professionals of VA provide veterans with information concerning 
service-connected disabilities and information on submitting claims, 
establishing service connection for a disability and contact 
information of appropriate VA offices. The claims process can be 
cumbersome and daunting and information to ease this process will be 
helpful for the veterans. PVA would also hope that as part of this 
process, VA would inform veterans of the availability of help from 
congressionally chartered Veterans Service Organizations (VSO) that can 
provide free help to veterans in understanding their rights and 
pursuing any appropriate claims for service-connected injuries.
       Draft Legislation on Improvements to VA Homeless Programs
    PVA generally supports the provisions of the discussion draft on 
improvements to VA homeless programs. Too many veterans continue to 
live on the streets due to drug, mental health, financial and 
employment challenges. The expansion of grant programs for improvements 
to facilities and increased outreach to more homeless veterans may help 
them receive services and rehabilitation and achieve the Secretary's 
goal to end veterans' homelessness. In addition, the improvement of 
payments for providing services to homeless veterans may increase the 
number of veterans who can be served by homeless veteran providers. But 
as PVA testified last October, we do have some concerns about the long-
term effects of the legislation.
    PVA has always supported the idea of comprehensive care for 
homeless veterans. Seldom is there one issue that leads veterans to 
become homeless. Comprehensive care can be expensive. Additionally, 
often homeless veterans reside in urban areas where the cost of living 
is very high and there are limited opportunities for help. Section 3 of 
the discussion draft allows the Secretary to increase the rates of 
payment to reflect anticipated changes in the cost of services and 
takes into account the cost of providing these services in particular 
geographic areas.
    While we welcome this consideration, PVA is concerned about the 
long-term effects on VA homeless program funding. By adjusting the 
payments for geographic areas, which we believe is aimed at providing 
greater funding to high cost localities, this may actually reduce the 
total number of homeless veterans that can be served if future 
increases in overall program funding are insufficient. While the 
argument could be made that ``reductions'' in funding for low cost 
areas may offset increases to high cost areas, the funding levels 
provided for homeless programs are seldom sufficient to provide for all 
the veterans who may need to take advantage of these critical services.
    PVA would recommend a very cautious approach on this legislation to 
ensure the most vulnerable veterans are not inadvertently hurt in 
efforts to provide greater funds for some of them.
                     Draft Health Care Legislation
    PVA supports the draft legislation that would address a number of 
items in the VA health care system. We are particularly pleased to see 
that the Subcommittee is considering the extension of the Advisory 
Committee on Homeless Veterans, particularly in light of the focus that 
the Administration has placed on eliminating homelessness among 
veterans.
    We do have a question about Section 4 of the legislation. We are 
unclear about the additional authority beyond simple contracting for 
services in non-Department facilities outlined in Section 4 of the 
bill. Specifically, we would like to know what purpose this expansion 
of authorizing language serves and how it will serve to benefit the 
VA's processes?
    PVA would like to thank the Subcommittee once again for allowing us 
to provide testimony on these important health care issues facing our 
veterans. We certainly appreciate the continued attention this 
Subcommittee has placed on these issues. I would be happy to answer any 
questions that you might have. Thank you.

                                 
      Prepared Statement of Adrian M. Atizado, Assistant National
            Legislative Director, Disabled American Veterans

    Mr. Chairman and Members of the Subcommittee:
    Thank you for inviting the Disabled American Veterans (DAV) to 
testify at this important hearing of the Subcommittee on Health. DAV is 
an organization of 1.2 million service-disabled veterans, and we devote 
our energies to rebuilding the lives of disabled veterans and their 
families.
    Mr. Chairman, the DAV appreciates your leadership in enhancing 
Department of Veterans Affairs (VA) health care programs on which many 
service-connected disabled veterans must rely. At the Subcommittee's 
request, the DAV is pleased to present our views on eleven (11) bills 
before the Subcommittee today.
            H.R. 3843--Transparency for America's Heroes Act
    This measure would amend title 38, United States Code, Sec. 5705 to 
make available on VA's Web site certain redacted records, documents, or 
parts of documents that are associated with the Department's medical 
quality-assurance program. It would also require such records or 
documents created during the 2-year period before the bill's enactment 
to be similarly made available. Current law specifies that such records 
``are confidential and privileged and may not be disclosed to any 
person or entity.'' 38 U.S.C. Sec. 5705(a).
    The existing restrictions protect the integrity of the VA's medical 
quality assurance program, carried out by or for VA for the purpose of 
improving the quality of medical care or improving the utilization of 
health care resources in VA medical facilities. These review activities 
may involve continuous or periodic data collection and may relate to 
the structure, process, or outcome of health care provided in the VA. 
38 CFR Sec. 17.500.
The Need for Confidentiality
    H.R. 3843 would amend title 38, United States Code, Sec. 5705 
affecting disclosure of records and documents resulting from medical 
quality assurance activities and designated across a number of foci.\1\ 
These records and documents are a crucial part of VA's health care 
quality and safety activities.
---------------------------------------------------------------------------
    \1\ Department of Veterans Affairs, VHA Directive 2008-077: Quality 
Management (QM) and Patient Safety Activities That Can Generate 
Confidential Documents, November 7, 2008.
---------------------------------------------------------------------------
    The VA has implemented nationwide internal and external reporting 
systems for organizational learning and improvement that supplement the 
existing accountability systems. These systems are designed around 
confidentiality to encourage maximal reporting of potential and 
actually occurring problems by non-punitive methods that would then be 
converted into corrective actions. Authoritative sources,2,3 
surveys, and focus groups of both VA and external health care workers 
found that health care providers' view of punitive actions extended 
beyond typical administrative punishment to include factors such as 
embarrassment, shame, and negative impact on professional reputation. 
Protection from these factors means emphasizing prevention--not 
punishment, and is essential for VA to continue receiving candid 
reports on adverse events and/or close calls from which it could then 
learn and undertake improvement and prevention efforts. Assuring non-
punitive, confidential, and voluntary programs is necessary for the 
Department to receive reports to subsequently implement corrective 
actions.
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    \2\ Institute of Medicine, ``To Err is Human: Building a Safer 
Health System'', November 1999.
    \3\ The Joint Commission, ``2008 Comprehensive Accreditation Manual 
for Hospitals: The Official Handbook,'' PI-1.
---------------------------------------------------------------------------
    Conversely, the Institute for Healthcare Improvement (IHI) has 
found that all employee reporting programs (voluntary and mandatory) 
result in substantial underreporting.\4\ Several studies have shown 
that computer monitoring strategies have identified many times more 
potential adverse events than were reported through employee reporting 
mechanisms.5,6,7 The IHI's ``Trigger Tools'' are also used 
to identify adverse events and detect safety 
problems.8,9,10,11 Moreover, not having specific facility 
and patient information has caused frustration when VA Central Office 
and oversight bodies have requested Veterans Health Administration 
(VHA) data regarding adverse events. Facility patient safety managers 
have also had to create secondary, duplicative systems in order to 
capture the patient information needed for effective reviews and 
reports.
---------------------------------------------------------------------------
    \4\ Institute for Healthcare Improvement, ``Introduction to Trigger 
Tools for Identifying
Adverse Events,'' Available at: http://www.ihi.org/IHI/Topics/
PatientSafety/SafetyGeneral/Tools/
IntrotoTriggerToolsforIdentifyingAEs.htm, Accessed: August 25, 2010.
    \5\ David W. Bates, MD, MSc, et al., ``Detecting Adverse Events 
Using Information Technology,'' J Am Med Inform Assoc, Vol. 10, No. 2, 
March-April 2003, pp. 115-128.
    \6\ M. K. Szekendi, et al., ``Active surveillance using electronic 
triggers to detect adverse events in hospitalized patients,'' Qual Saf 
Health Care, Vol. 15, June 2006, pp. 184-190.
    \7\ C. W. Johnson, ``How will we get the data and what will we do 
with it then? Issues in the reporting of adverse health care events,'' 
Qual Saf Health Care, Vol. 12, December 2003, p. ii64.
    \8\ Rozich JD, Haraden CR, Resar RK. Adverse drug event trigger 
tool: A practical methodology for measuring medication related harm. 
Quality and Safety in Health Care. 2003 Jun;12(3):194-200.
    \9\ Sharek PJ, Horbar JD, Mason W, et al. Adverse events in the 
neonatal intensive care unit: Development, testing, and findings of an 
NICU-focused trigger tool to identify harm in North American NICUs. 
Pediatrics. 2006 Oct;118(4):1332-1340.
    \10\ Griffin FA, Classen DC. Detection of adverse events in 
surgical patients using the Trigger Tool approach. Quality and Safety 
in Health Care. 2008 Aug;17(4):253-258.
    \11\ Classen DC, Lloyd RC, Provost L, Griffin FA, Resar R. 
Development and evaluation of the Institute for Healthcare Improvement 
Global Trigger Tool. Journal of Patient Safety. 2008 Sep;4(3):169-177.
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    In this instance, consideration of H.R. 3843 requires a balance 
between confidentiality and transparency to maintain VA employees' 
perception that VA's quality and safety activities would not become 
punitive in nature, while continuing to allow for candid reporting.
The Need for Transparency: Health Care
    Under Executive Order 13410, ``[h]ealth care programs administered 
or sponsored by the Federal Government promote quality and efficient 
delivery of health care through the use of health information 
technology, [and] transparency regarding health care quality.'' Its 
purpose also includes making relevant information available to program 
beneficiaries, enrollees, and providers in a readily useable manner and 
in collaboration with similar initiatives in the private sector and 
non-Federal public sector. In addition, VA has been actively seeking 
ways for veteran patients and their families to take a more active role 
in their health care, and to help manage their health care rather than 
being advised what to do through a provider-centered 
system.12,13
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    \12\ Department of Veterans Affairs. ``Patient Centered Medical 
Home Model Concept Paper,'' March 15, 2010. Available at: http://
www1.va.gov/PrimaryCare/docs/pcmh_ConceptPaper.doc; Accessed: August 
26, 2010.
    \13\ http://www.patientsafety.gov/patients.html#intro; Accessed: 
August 26, 2010.
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    There is a clear recognition that veterans and their families need 
accurate information about the quality of care in VA-owned or 
contracted facilities in order to make informed choices. These choices 
depend, in part, on the most complete, timely information available.
    In the 111th Congress, VA testified on a succeeding bill, S. 1427, 
``Department of Veterans Affairs Hospital Quality Report Card Act of 
2009.'' VA indicated that health care transparency is one of its major 
Strategic Transformation Initiatives this fiscal year and is working 
with the Centers for Medicare and Medicaid Services (CMS) to post VA 
comparable data on the CMS ``Hospital Compare'' Web site (http://
www.hospitalcompare.hhs.gov). The Department reported it was similarly 
exploring other public reporting programs.\14\
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    \14\ Cross, Gerald M, Acting Under Secretary for Health, Department 
of Veterans Affairs. Statement to the Senate, Committee on Veterans 
Affairs. ``Hearing on Pending Legislation,'' Hearing, October 21, 2009. 
Available at: http://www.veterans.senate.gov/
hearings.cfm?action=release .display&release_id=faa07041-78f1-45c7-
93f1-fff7b5a6f978; Accessed: August 26, 2010.
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    In the 110th Congress, DAV testified before this Subcommittee on a 
similar bill, H.R. 1448, ``The VA Hospital Quality Report Card Act of 
2007.'' This bill sought to establish a ``hospital report card'' 
covering a variety of activities of inpatient hospital care occurring 
in the medical centers of the Department to provide increased 
disclosure and accountability in the VA system. The DAV supported this 
bill, because it was consistent with trends occurring in private sector 
health care enabling patients to review the quality and safety of their 
care.
    Notably, VA at that time opposed the bill as written as too 
prescriptive in its requirements, and stated that much of the 
information required by H.R. 1448 is available through other avenues, 
such as The Joint Commission's (previously known as the Joint 
Commission on Accreditation for Healthcare Organizations) Web site that 
provides standardized comparative data in a form that has been tested 
for consumer understandability and usefulness.

    S. 1427 (111th) and H.R. 1448 (110th), both sought to provide 
easily accessible reports published in acceptable lay terms on the 
quality of VA's medical centers that include quality-measures data that 
allow for an assessment of health care effectiveness, safety, 
timeliness, efficiency, patient-centeredness, and equity. In contrast, 
the bill now before the Subcommittee would simply make publicly 
available redacted versions of VA's medical quality-assurance records. 
It is uncertain whether making such documents available on VA's Web 
site would meet the needs of veterans and their families to make 
informed decisions.

    Other key issues related to transparency must also be addressed in 
addition to availability of information via the Internet. Any such 
reports should be readable, understandable, and meaningful. Also, 
accommodation should be provided so individuals may gain access by 
telephone or mail requests, and during personal onsite visits. Finally, 
and equally important, VA should encourage wide public awareness of the 
availability of such information, how and where to access it, and 
appropriate limitations on its use. We ask the Subcommittee staff to 
address these shortcomings in the bill.
The Need for Transparency: Disability Compensation
    Title 38, United States Code, Sec. 5705 is also the basis for 
needed transparency in our organization's work representing service-
connected disabled veterans' claim for disabilities suffered as the 
result of VA medical treatment governed by title 38, United States 
Code, Sec. 1151.
    According to VHA Handbook 1050.01, VHA National Patient Safety 
Improvement Handbook (May 23, 2008), VHA facility staff have an 
obligation to inform--or disclose to--patients any adverse events 
consequent to their care. Routine disclosure of adverse events to 
patients has been VHA's national policy since 1995. However, a 2008 
report by VA's Office of Inspector General (VAOIG) shows that only 21 
(54 percent) of 39 audited facilities had provided full disclosure.\15\
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    \15\ Department of Veterans Affairs, Office of Inspector General, 
Evaluation of Quality Management in Veterans Health Administration 
Facilities Fiscal Year 2007, May 2008.
---------------------------------------------------------------------------
    Without such disclosure, many claims based on Sec. 1151 have been 
denied because of confidentiality protections afforded to quality 
assurance records under title 38, United States Code, Sec. 5705 and 
title 38, Code of Federal Regulations, Sec. Sec. 17.500-17.511. 
Analysis of such records could demonstrate proximate causes of injury 
by carelessness, negligence, lack of proper skill, error in judgment, 
equipment failure, or similar instance of fault on the part of the 
Department's employees in furnishing the hospital care or medical 
services involved that caused the injuries.
    According to title 38, United States Code, Sec. 5705(b) and subject 
to protections in title 5, United States Code, 552a (the Privacy Act), 
title 38, United States Code, Sec. 5701 (veterans' names and 
addresses), and title 38, United States Code, Sec. 7332 (drug and 
alcohol abuse, sickle cell anemia, HIV infection), the Secretary must, 
upon request, disclose quality assurance documents to several branches 
of government, organizations, and persons. Moreover, the statute does 
not prohibit the release of medical quality assurance records within 
VA. See Sec. 5705(b)(5) (``Nothing in this section shall be construed 
as limiting the use of [medical quality assurance records] within the 
Department.''). DAV believes this authority includes VA employees such 
as regional office (RO) adjudicators and rating boards, physicians who 
conduct VA examinations, and Members of the Board of Veterans Appeals 
(Board) since these VA employees are clearly ``within VA.'' However, we 
commonly find claims based on title 38, United States Code, Sec. 1151 
not fully developed because those claims do not contain quality 
assurance records to validate the injuries claimed.
    In 2000, Congress passed the ``duty to assist'' legislation that 
requires the Department to assist a veteran in gathering all records 
relevant to a claim. 38 U.S.C. Sec. 5103A(c)(2). In not exercising the 
authority provided under title 38, United States Code Sec. 5705(b)(5), 
the RO or the Board as part of their duty to assist the claimant 
violates the statutory mandate to gather all relevant medical records 
set forth in title 38, United States Code, Sec. 5103A(c)(2). 
Furthermore, DAV believes the VA adjudication manual instructions for 
medical quality-assurance records conflict with the statutory 
requirements of title 38, United States Code, Sec. Sec. 5103a and 5705 
and violates the duty to assist provisions in the development of a 
claim made pursuant to a law administered by the Secretary.
    A note contained in the VA Adjudication Manual \16\ that discusses 
quality-assurance records states:
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    \16\ VA Adjudication Manual 21-1, Part IV, Chapter 22, Subchapter 
1, Sec. 22.03.

       Do not request quality assurance investigative reports. These 
reports are confidential under 38 U.S.C. Sec. 5705 and cannot be used 
as evidence in adjudication of claims under 38 U.S.C. Sec. 1151. If 
quality assurance investigative reports are received from a VA medical 
facility, return the reports immediately. Do not file copies of these 
---------------------------------------------------------------------------
reports in the veteran's folder.

    At best, the Department's instructions are an erroneous 
interpretation of VA's statutory obligations, conflict with his duties 
and responsibilities set forth in title 38, United States Code, 
Sec. Sec. 5103A and 5705, and are not entitled to any ``Chevron'' 
deference. See Chevron U.S.A. Inc. v. Natural Resources Defense 
Council, 467 U.S. 837 (1984); see also Timex V.I., Inc. v. United 
States, 157 F.3d 879 (Fed. Cir. 1998) at 881-882.
    In these instances, our organization must argue for a determination 
as to whether medical quality-assurance records relevant to a veteran's 
claim exist, then collect the records if they do exist, and consider 
the veteran's claim in light of such records. We believe it should be 
held that this VA Adjudication Manual provision violates the duty to 
assist provisions in the development of a claim made pursuant to a law 
administered by the Secretary. In this light, and with our stated 
caveat relating to access to this information by means other than the 
Internet, we support the purposes of this bill and urge the 
Subcommittee to advance this legislation in an amended form. Also, we 
ask the Subcommittee to work with your colleagues on the Disability 
Assistance and Memorial Affairs Subcommittee to address our concerns 
with respect to the non-availability of quality assurance records to 
assist disabled veterans with their claims under Sec. 1151 of title 38, 
United States Code.
  H.R. 4041--To authorize certain improvements in the Federal Recovery
              Coordinator Program, and for other purposes.
    This measure would require VA to identify a qualified nursing or 
medical school to develop a literature review and evidence-based 
guidelines for recovery coordination, establish a consensus conference, 
and develop training modules for care coordination. The bill would 
authorize $1.2 million for that effort. Also, the bill would authorize 
$500,000 for training 45 recovery coordinators by the designated 
nursing or medical school, and would authorize $1.2 million for the 
development, validation and piloting of technology tools and software 
that is compatible with VA and Department of Defense (DoD) systems for 
recovery coordination.
    DAV remains concerned about the gaps that exist in the Federal 
Recovery Coordination Program (FRCP) and social work case management. 
These gaps were highlighted by disabled veterans and their families in 
hearings held by the House Veterans' Affairs Subcommittee on Oversight 
and Investigation in 2009 and 2010 and warrant continued oversight and 
evaluation by this Subcommittee.
    Issues discussed during those hearings include a multilayer 
bureaucracy of clinical case managers at VA, DoD and private 
facilities, Wounded Transition Unit (WTU) Liaisons, DoD Military 
Liaisons, VA Clinical Rehabilitation Nurses, Transition Patient 
Advocates, Veterans Benefits Administration (VBA) Counselors, 
transition support coaches, multiple health care providers, and Federal 
Recovery Coordinators (FRCs) to make and facilitate key referrals and 
consultations to manage the patient's needs toward achieving Federal 
Individualized Recovery Plan (FIRP) goals. Another is the integration 
of Information Technology (IT) access within VA and the Military 
Training Facility (MTF)--although DoD and VA state that these 
challenges will be overcome with the implementation of more IT 
integration between VA and DoD through such initiatives as the single 
common personal identifier, which is a significant step toward making 
the complex Virtual Lifetime Electronic Record (VLER).
    The capacity for individual attention paid by FRCs to each client 
in their caseload to meet individual needs and achieve FIRP goals is a 
primary concern for DAV. We believe caseload standards should be based 
on the scope of professional responsibilities, the volume of clients to 
be served, the amount of time the FRC needs to spend with clients, the 
breadth and complexity of client problems or services, and the length 
and duration of case mix in determining case manager-client 
involvement. The number of cases an FRC can realistically handle is 
limited to the degree to which caseloads consist of acute, high-risk, 
multi-need clients--that is, the degree of acuity of the medical 
condition and complexity of non-medical needs of their clients.
    Further, as part of The Independent Budget, the DAV recommends DoD 
and VA must outline the requirements for assigning new or additional 
FRCs caring for severely injured servicemembers in concert with 
tracking workload, geographic distribution, and the complexity and 
acuity of injured servicemembers' medical conditions.
    A September 16, 2008, report to Congress on the development of a 
comprehensive policy for DoD and VA on the care, management, and 
transition of recovering servicemembers addresses the maximum number of 
recovering servicemembers whose cases may be assigned to a recovery 
care coordinator as required by the Wounded Warrior Act. It states that 
the appropriate workload or case ratio for FRCs is not known. These are 
new positions for which there are no comparable data or ratios. 
Currently, all FRCs are tracking time utilization. New cases are 
distributed based on existing caseloads. In the near future, the FRCP 
will implement acuity based measures to more precisely balance 
caseloads.\17\
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    \17\ Report to Congress on the Comprehensive Policy Improvements to 
the Care, Management and Transition of Recovering Servicemembers (NDAA 
Section 1611 and 1615), September 16, 2008. Available at: http://
prhome.defense.gov/WWCTP/docs/09-16-08_1900_Final_Report_to
_Congress_-_1611_and_1615.pdf; Accessed: September 2, 2010.
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    According to VA testimony in April 2009 about the FRCP, predicting 
the total number of FRCs required for the program at any point in time 
depends on the number of eligible servicemembers and veterans enrolling 
and workload criteria based on intensity of needs. The program 
supervisor located in VA's Central Office in Washington, D.C. monitors 
time utilization statistics and the program has developed a hiring plan 
based on estimates of eligible populations and a variety of estimated 
workloads. If referral and enrollment rates are higher or lower than 
projected, the number of new FRCs hired can be adjusted 
accordingly.\18\
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    \18\ Guice, Karen, Executive Director of the Federal Recovery 
Coordination Program, Department of Veterans Affairs. Statement to the 
Subcommittee on Oversight and Investigations, House Committee on 
Veterans Affairs. ``Leaving No One Behind: Is the Federal Recovery 
Coordination Program Working?'' Hearing, April 28, 2009. Available at: 
http://www4.va.gov/OCA/testimony/hvac/soi/090428KG.asp; Accessed: 
September 2, 2010.
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    DAV believes FRC caseload size must realistically allow for 
meaningful opportunities for face-to-face client contact. As caseload 
size increases, the FRC has a declining capacity to perform ongoing 
comprehensive coordination of care and support activities such as 
follow-up, monitoring, and reassessment. However, flexibility of 
caseload should exist but only for a limited time frame as is provided 
in the Wounded Warrior Act. Overburdened FRCs do not serve the program 
mission, the veteran, servicemembers, or their families. It is the 
joint responsibility of VA, DoD, and the FRCP to address and remedy 
caseload issues and concerns. To this end, we encourage the 
Subcommittee to work with both VA and DoD to determine whether 
additional FRCs are needed and if so, what the appropriate number would 
be.
FRCP Education, Training, and Technology Tools
    The Wounded Warrior Act requires a comprehensive policy on 
improvements to care, management, and transition of recovering 
servicemembers that includes standard training requirements and 
curricula for recovery care coordinators under the program. The 
requirement for successful completion of the training program before a 
person may assume the coordinator duties.
    We understand there are efforts underway to explore whether the 
Medical College of Georgia (MCG) School of Nursing Clinical Nurse 
Leader curriculum could be adapted for the needed national training 
program for FRCs. The MSC School of Nursing has proposed a 6-month, 
post-Master's certificate program using their clinical nurse leader 
program to help train and certify VA and DoD's recovery coordinators. 
Notably, the Charlie Norwood VA Medical Center, the Eisenhower Army 
Medical Center at Fort Gordon, and the MCG School of Nursing, are 
currently collaborating in the treatment of severely injured 
servicemembers. The Charlie Norwood VA hosts an active duty 
rehabilitation facility for military personnel.
    Although the FRCP is operated as a joint DoD and VA program, VA is 
responsible for the administrative duties, and program personnel are 
employees of the agency. VA support includes technical and information 
technology support, human resources management, and programmatic 
support from both VBA and VHA. DoD provides assistance to the program 
through the Line of Action Co-Lead and the Strategic Oversight 
Committee and staff. This support includes assistance with development 
of appropriate tools, and coordination of activities. FRCs are also 
supported by their host facilities as determined by a Memorandum of 
Agreement with each facility. These are in addition to the financial 
requirements for both DoD and as noted in the Memorandum of 
Understanding of October 30, 2007.
    DAV urges the Subcommittee to work with both VA and DoD to 
determine whether the provisions of H.R. 4041 to require a literature 
review, evidence-based guidelines for recovery coordination, consensus 
conference, and training modules for care coordination would enhance 
the FRCP.
    Also, the bill seems ambiguous in both the purpose and intended 
uses of the care coordination software and the language in Section 
2(c)(1)(A), which would require the VA to enter into relationship with 
a subcontractor. Further, we urge the Subcommittee to include a public 
reporting requirement summarizing the results of the software pilot 
program. Finally, we recommend technical changes to the language, since 
the program to which it refers is the Federal Recovery Coordination, 
not Coordinator, Program.
   H.R. 5428--To direct the Secretary of Veterans Affairs to educate
   certain staff of the Department of Veterans Affairs and to inform 
                                veterans
         about the Injured and Amputee Veterans Bill of Rights,
                        and for other purposes.
    This bill would ensure that an ``Injured and Amputee Veterans Bill 
of Rights'' is printed on signage and displayed prominently in every VA 
prosthetics and orthotics clinic, while requiring VA employees at the 
clinics and patient advocates serving veterans receiving care there to 
receive training on such Bill of Rights.
    The bill would require the Secretary of Veterans Affairs to conduct 
outreach to inform veterans of such Bill of Rights, and would direct VA 
to monitor and resolve related complaints from veterans. VA would be 
required to collect information relating to alleged mistreatment of 
injured and amputee veterans at each VA medical center and to submit 
such information quarterly to the VA's Chief Consultant in Prosthetics 
and Sensory Aids for the purposes of investigation and resolution of 
such complaints.
    Although DAV has no specific resolution calling for an Injured and 
Amputee Bill of Rights, DAV fully supports VA's Amputee System of care. 
DAV, as part of The Independent Budget, strongly supports full 
implementation of the VA amputation system of care program and 
encourages Congress to provide adequate resources for the staffing and 
training of this important program. The Independent Budget recommends 
that VA expeditiously implement the proposed system providing proper 
staffing levels and training to ensure VA provides superior health 
services for aging and newly injured veterans who need these unique 
services. Also, the VISN prosthetics representatives should maintain 
and disseminate objectives, policies, guidelines, and regulations on 
all issues of interpretation of prosthetics policies, including 
administration and oversight of VHA's Prosthetics and Orthotics 
Laboratories. The overall goals of this bill appear to be in line with 
these stated recommendations and objectives; therefore, we have no 
objection of the passage of this measure.
H.R. 5516--Access to Appropriate Immunizations for Veterans Act of 2010
    This measure would require the Secretary of Veterans Affairs to 
make available periodic immunizations against certain infectious 
diseases as adjudged necessary by the Secretary of Health and Human 
Services through the recommended adult immunization schedule 
established by the Advisory Committee on Immunization Practices. The 
bill would include such immunizations within the authorized 
preventative health services available for VA-enrolled veterans. The 
bill would establish publicly reported performance and quality measures 
consistent with the required program of immunizations authorized by the 
bill. The bill would require annual reports to Congress by the 
Secretary confirming the existence, compliance and performance of the 
immunization program authorized by the bill.
    Although DAV has no adopted resolution from our membership dealing 
specifically with this matter of immunizations for infectious diseases, 
the delegates to our most recent National Convention in Atlanta, 
Georgia, July 31-August 3, 2010, adopted Resolution No. 036, calling on 
VA to maintain a comprehensive, high quality, and fully funded health 
care system for the Nation's sick and disabled veterans, specifically 
including preventative health services. Preventative health services 
are an important component of the maintenance of general health, 
especially in elderly and disabled populations with compromised immune 
systems. If carried out sufficiently, the intent of this bill could 
also contribute to significant cost avoidance in health care by 
reducing the spread of infectious diseases and obviating the need for 
health interventions in acute illnesses of those without such 
immunizations. Therefore, DAV is pleased to support this bill and urges 
its enactment.
    H.R. 5543--To amend title 38, United States Code, to repeal the 
                              prohibition
     on collective bargaining with respect to matters and questions 
                               regarding
 compensation of employees of the Department of Veterans Affairs other
            than rates of basic pay, and for other purposes.
    Mr. Chairman, this bill would restore some bargaining rights for 
clinical care employees of the VHA that were eroded by the former 
Administration. The bill would amend subsections (b) and (d) of section 
7422 of title 38, United States Code, by striking ``compensation'' both 
places it appears and inserting ``basic rates of pay'' in its place. 
The intent of the bill would be to authorize employee representatives 
of recognized bargaining units to bargain with VHA management over 
matters of employee compensation other than rates of basic pay.
    DAV does not have an approved resolution from our membership on the 
specific issues addressed by this bill. However, we believe labor 
organizations that represent employees in recognized bargaining units 
within the VA health care system have an innate right to information 
and reasonable participation that result in making the VA health care 
system a workplace of choice, and in particular, to fully represent VA 
employees on issues impacting their working conditions.
    Congress passed section 7422, title 38, United States Code, in 
1991, in order to grant specific bargaining rights to labor in VA 
professional units, and to promote effective interactions and 
negotiation between VA management and its labor force representatives 
concerned about the status and working conditions of VA physicians, 
nurses and other direct caregivers appointed under title 38, United 
States Code. In providing this authority, Congress granted to VA 
employees and their recognized representatives a right that already 
existed for all other Federal employees appointed under title 5, United 
States Code. Nevertheless, Federal labor organizations have reported 
that VA severely restricted the recognized Federal bargaining unit 
representatives from participating in, or even being informed about, a 
number of human resources decisions and policies that directly impact 
conditions of employment of the VA professional staffs within these 
bargaining units. We are advised by labor organizations that when 
management actions are challenged, VA officials (many at the local 
level) have used subsections (b), (c) and (d) of section 7422 as a 
statutory shield to obstruct any labor involvement to correct or 
ameliorate the negative impact of VA's management decisions on 
employees, even when management is allegedly not complying with clear 
statutory mandates (e.g., locality pay surveys and alternative work 
schedules for registered nurses, physician market pay compensation 
panels, etc.).
    We believe this bill, which would rescind VA's ability to bargain 
on matters of compensation other than rates of basic pay, is an 
appropriate remedy to address part of the bargaining problem in the VA 
professional ranks. We understand recently VA has given Federal labor 
organizations some indication of additional flexibility in negotiating 
labor-management issues such as some features of compensation, and we 
are hopeful that this change signals a new trend in these key 
relationships that directly affect sick and disabled veterans. We 
endorse the intent of this bill and urge its enactment, while 
continuing to hope that VA and Federal labor organizations can find a 
sustained basis for compromise.
                     H.R. 5641--Heroes at Home Act
    Since 1951, the VA's Community Residential Care (CRC) Program has 
provided health care and sheltered supervision to eligible veterans not 
in need of acute hospital care, but who, because of medical and/or 
psychosocial health conditions, are not able to live independently and 
have no suitable family or significant others to aid them.
    The CRC Program is an important component in VA's continuum of 
long-term care services operating under the authority of title 38, 
United States Code, Section 1730. Any veteran who lives in an approved 
CRC residence in the community is under the oversight of the CRC 
Program. This program has evolved through the years to encompass 
Medical Foster Home (MFH), Assisted Living, Personal Care Home, Family 
Care Home, and Psychiatric CRC Home.
    New partnerships between Home Based Primary Care (HBPC) and the 
MFHs and CRCs have allowed veterans to live independently in the 
community, as a preferred means to receive family-style living with 
room, board, and personal care. Under the MFH Program, the 
administrative costs for VHA are less than $10 per day, and the cost of 
Home Based Primary Care, medications and supplies averages less than 
$50 per day. Understandably, VA perceives this program as a cost-
effective alternative to nursing home placement, and it is gaining 
popularity as evidenced by the program's expansion.
    DAV is pleased with VA's innovation by offering the MFH program as 
part of its long-term care program. Notably, patient participation in 
this program, while voluntary, yields very high satisfaction ratings 
from veterans. But because MHF operates under the CRC authority, 
participating veterans must pay the MFH caregiver approximately $1,500 
to $4,000 per month for room and board, 24-hour supervision, assistance 
with medications, and whatever personal care may be needed.\19\ Even 
veterans who are otherwise entitled to nursing home care fully paid for 
by VA under the Veterans Millennium Health Care and Benefits Act 
(Millennium Act) \20\ or under VA's policy on nursing home 
eligibility\21\, must pay to live independently in a CRC or MFH. 
According to VA, MFH is appropriate for certain veterans whose 
conditions warrant a nursing home level of care but who prefer a non-
institutional setting. In other words, were it not for MFH, veterans 
who meet the nursing home level of care standards would qualify for VA 
paid care to receive it. In addition, veterans who do not have the 
resources to pay the MFH caregiver are not able to avail themselves of 
this benefit.
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    \19\ 38 U.S.C. Sec. 1730(a)(3).
    \20\ P.L. 106-117, 113 Stat. 1545 (1999) required that through 
December 31, 2003, VA provide nursing home care to those veterans with 
a service-connected disability rated at 70 percent or greater, those 
requiring nursing home care because of a condition related to their 
military service who do not have a service-connected disability rating 
of 70 percent or greater, and those who were admitted to VA nursing 
homes on or before the effective date of the act. Subsequent law 
extended these provisions.
    \21\ VA's policy on nursing home eligibility required that VISNs 
provide nursing home care to veterans with 60 percent service-connected 
disability ratings who are also classified as unemployable or Permanent 
and Total Disabled.
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    We applaud the intent of H.R. 5641, a bill that would allow VA to 
contract with a certified MFH and pay for care of veterans already 
eligible for VA paid nursing home care. As part of The Independent 
Budget, DAV is greatly concerned that veterans living in the MFH 
environment are required to pay for their stays using personal funds, 
including their VA disability compensation.
    Given the purposes of this bill and its probable cost, we are 
concerned VA will not enter into such contracts. In VA's Geriatrics and 
Extended Care (GEC) Strategic Plan,\22\, VA acknowledges the 
eligibility mismatch between inpatient and non-institutional long-term 
care and possible adverse impact on VA's extended care program. 
Similarly, DAV recognizes VA long-term care services, especially 
alternative, non-bed, community and home-based programs, are not 
uniformly available in all VA health care facilities. Accordingly, the 
delegates to our most recent National Convention assembled in Atlanta, 
Georgia, July 31-August 3, 2010, passed National Resolution No. 209, 
calling for legislation to expand the comprehensive program of long-
term care services for service-connected disabled veterans regardless 
of their disability ratings.
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    \22\ U.S. Department of Veterans Affairs. Patient Care Services. 
Geriatrics and Extended Care Strategic Plan. Washington DC, December 
24, 2008.
---------------------------------------------------------------------------
    In a special article written for the State of the Art Planning 
Committee by Kenneth Shay, DDS, MS, Director of VA Geriatric Programs, 
and James F. Burris, MD, Chief Consultant for VA Geriatrics and 
Extended Care, they note there are three fundamental building blocks of 
long-term care for chronically ill elders. They are personal care, 
housing, and chronic disease care. Meaningful goals for long-term care 
relate to maintaining and improving function and quality of life while 
maximizing safety and autonomy. Because these goals are not always 
compatible, there need to be tradeoffs and ranked priorities. In 
addition, they cite the most-rapid growth in non-VA extended care 
options has been in ``assisted living,'' a loosely defined and 
minimally regulated set of residential and care services that VA does 
not have statutory authority to provide or pay for. Yet suitably 
supportive housing is a key component of non-institutional long-term 
care, so VA has sought to implement alternative, creative solutions to 
facilitate disabled veterans' access to supportive living options 
without the agency actually paying the costs of room and board.\23\
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    \23\ Shay K, Burris JF. Setting the stage for a new strategic plan 
for geriatrics and extended care in the Veterans Health Administration: 
summary of the 2008 VA State of the Art Conference, ``The changing 
faces of geriatrics and extended care: meeting the needs of veterans in 
the next decade''. J Am Geriatr Soc. 2008 Dec;56(12):2330-9.
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    Assisted living bridges the gap between home care and nursing 
homes. Assisted living is a general term that refers to a wide variety 
of residential settings that provide 24-hour room and board and 
supportive services to residents requiring minimal need for assistance 
to those who require some ongoing assistance with personal care and 
activities of daily living. VA's MFH program is commonly known as adult 
foster care homes in the private sector and some residences that are 
licensed as adult foster care homes may call themselves ``assisted 
living.'' An adult foster care is a residential setting that provides 
24-hour room and board, personal care, protection and supervision for 
adults, including the elderly who require supervision on an ongoing 
basis but do not require continuous nursing care.
    Clearly, VA's MFH program should be realigned under a more 
appropriate statutory authority. Public Law 106-117 authorized an 
Assisted Living Pilot Program (ALPP) carried out in VA's VISN 20. 
Conducted from January 29, 2003, through June 23, 2004, and involving 
634 veterans who were placed in assisted living facilities, the pilot 
project yielded an overall assessment report submitted to Congress 
stating, ``the ALPP could fill an important niche in the continuum of 
long-term-care services at a time when VA is facing a steep increase in 
the number of chronically ill elderly who will need increasing amounts 
of long-term care.'' \24\ Unfortunately, VA's transmittal letter that 
conveyed the ALPP report to Congress stated that VA was not seeking 
authority at that time to provide assisted living services, because VA 
considered assisted living to be primarily a housing function.
---------------------------------------------------------------------------
    \24\ Susan H, Marylou G, et al., Evaluation of Assisted Living 
Pilot Program. Report to Congress. Washington, DC, Office of Geriatrics 
and Extended Care, VHA, July 2004.
---------------------------------------------------------------------------
    Despite VA's reticence, the 2004 ALPP report seemed most favorable, 
and assisted living appears to be an unqualified success. In fact, 
Title XVII, Section 1705, of the National Defense Authorization Act for 
Fiscal Year 2008, Public Law 110-181, authorizes VA to provide assisted 
living services.
    Current estimates show more than 900,000 Americans live in 
approximately 39,500 assisted living residences in the United 
States.\25\ The 2009 MetLife survey put the average cost of assisted 
living providing 10 or more services at $41,628 annually in 2009, but 
found that private room nursing home rates average $79,935 per year, 
and semi-private room rates average $72,270 per year.\26\ In fiscal 
year (FY) 2009, VA spent over $5.2 billion--about 12 percent of its 
total health care spending--to provide for veterans' long-term care 
needs. Nearly 82 percent ($4.2 billion) of VA's total long-term care 
spending in FY 2009 was for nursing home care. For FY 2011, VA expects 
to spend over $6.8 billion--over 13 percent of its total health care 
budget--to provide for veterans' long-term care needs. Over 78 percent 
($5.4 billion) of VA's total long-term care spending in FY 2011 will be 
for nursing home care.
---------------------------------------------------------------------------
    \25\ American Association of Homes and Services for the Aging. 
Aging Services: The Facts. Available at: www.aahsa.org. Accessed on:
    \26\ MetLife Mature Market Institute. The 2009 MetLife Market 
Survey of Nursing Home,
Assisted Living, Adult Day Services, and Home Care Costs. New York, NY 
2009. Available
at: http: // www.metlife.com / assets / cao / mmi / publications / 
studies / mmi-market-survey-nursing-home-assisted-living.pdf. Accessed 
on: September 8, 2010.
---------------------------------------------------------------------------
    While DAV would not oppose favorable consideration of this measure, 
we ask this Subcommittee to address our concerns and the glaring hole 
in VA's long-term care program considering the Department's stated long 
term care mission is to ``continue to focus its long-term care 
treatment in the least restrictive and most clinically appropriate 
setting by providing more non-institutional care than ever before and 
providing Veterans with care closer to where they live.'' \27\ This is 
not the case today.
---------------------------------------------------------------------------
    \27\ Department of Veterans Affairs. FY 2011 Budget Submission: 
Medical Programs and Information Technology Programs. Vol. 2:1A-8. 
Washington, DC. February 2010.
---------------------------------------------------------------------------
 H.R. 5996--To direct the Secretary of Veterans Affairs to improve the
     prevention, diagnosis, and treatment of veterans with chronic 
                              obstructive
                           pulmonary disease.
    This bill would require VA to develop treatment protocols and 
related tools for the prevention, diagnosis, treatment, and management 
of chronic obstructive pulmonary disease (COPD), and improve biomedical 
and prosthetic research programs regarding COPD.
    The bill would require VA to develop pilot programs to demonstrate 
best practices for the diagnosis and management of COPD, in 
coordination with the Director of the Centers for Disease Control and 
Prevention (CDC), the Director of the Indian Health Service, and the 
Administrator of the Health Resources and Services Administration. 
Moreover, the bill would require VA to develop improved techniques and 
best practices, in coordination with the Director of the CDC, for 
assisting individuals with COPD in smoking cessation.
    DAV has no specific resolution adopted by our membership to support 
this particular measure; however, we recognize that until 1976, 
cigarettes were routinely included free of charge in military field 
rations and for decades were sold at deeply discounted prices in 
commissaries and exchanges. Except for Navy and Marine bases, tobacco 
products are still sold at discounted prices in military exchanges and 
commissaries. Military-induced smoking accounts for a significant 
percentage of the higher lung cancer rates, perhaps as high as 50 
percent to 70 percent of the excess deaths. The percentage of active 
duty military who ever smoked was highest during the Korean and Vietnam 
Wars (75%). Currently overall 32.2 percent of active duty military 
personnel smoke versus 19.8 percent of adults in the civilian 
population and 22.2 percent of veterans overall.
    In terms of maintaining and improving the general health of 
veterans and of our membership, and consistent with VA's health 
maintenance mission, DAV would offer no objection to the enactment of 
this bill.
  H.R. 6123--Veterans' Traumatic Brain Injury Rehabilitative Services'
                        Improvements Act of 2010
    If enacted this bill would sharpen rehabilitative requirements 
within the VA to ensure that veterans with traumatic brain injury (TBI) 
under VA care are afforded opportunity for maximal rehabilitation, 
including in their behavioral and mental health care needs, and to 
sustain improvements they have made during the acute rehabilitative 
period following injury, and hopefully leading to independence and a 
better quality of life. The bill would redefine the term 
``rehabilitative services'' as it appears in section 1701(8) of title 
38, United States Code, by including elements that address sustenance 
of VA efforts to prevent loss of functional gains achieved early in the 
rehabilitative process, and to maximize an injured individual's 
independence. Finally, the bill would amend section 1710E(a) of title 
38, United States Code, to clarify that in the instance of the 
Secretary's execution of a cooperative agreement with a public or 
private entity with long-term neurobehavioral rehabilitation and 
recovery programs, for hospital care or medical services for a brain-
injured veterans, that such cooperative agreements would also include 
rehabilitative services for these veterans.
    We appreciate the intentions of the sponsors of this bill to fill 
an existing gap in current law affecting the treatment of brain injured 
veterans. Our members adopted DAV National Resolution No. 215 at our 
most recent convention, held in Atlanta, Georgia July 31-August 3, 
2010. That resolution urges Congress and the Department of Veterans 
Affairs to establish a comprehensive rehabilitation program, and to 
sustain effective programs for veterans with traumatic brain injury. 
This legislation is fully consistent with our resolution; therefore, we 
endorse the bill and urge Congressional enactment.
    H.R. 6127--To amend title 38, United States Code, to provide for
   the continued provision of health care services to certain veterans
 who were exposed to sodium dichromate while serving as a member of the
    Armed Forces at or near the water injection plant at Qarmat Ali,
                 Iraq, during Operation Iraqi Freedom.
    This measure would provide access to VA health care for veterans 
who were in and around the water injection facility in the Basrah oil 
fields at Qarmat Ali, Iraq, during the spring and summer of 2003. These 
veterans would be able to enroll, within a 5 year window of 
notification of exposure from the VA, into the VA health care system 
under the Department's ``special treatment'' authority of Priority 
Group 6 to receive VA health care.
    DAV supports this bill in accordance with our Resolution No. 298 
calling for congressional oversight and Federal vigilance to provide 
for research, health care, and improved surveillance of disabling 
conditions resulting from military toxic and environmental hazards 
exposures. We also ask for the Subcommittee's consideration to afford 
the same eligibility to those veterans who were exposed to toxic 
substances as a result of disposing a poisonous mixture of plastics, 
metals, paints, solvents, tires, used medical waste and asbestos 
insulation in open-air trash burn pits in Iraq and Afghanistan. Tests 
on the burn pits in the war zones have shown that the fires released 
dioxins, benzene and volatile organic compounds, including substances 
known to cause cancer.
    Exposure to these toxic substances is not in question since VA is 
already gathering data to monitor potential health problems in troops 
who say they were made ill by exposure to smoke from open-air burn pits 
in Iraq and Afghanistan with the goal of establishing potential 
correlations with health problems among affected veterans.
  Draft Legislation--To amend title 38, United States Code, to ensure 
                                  that
  the Secretary of Veterans Affairs provides veterans with information
  concerning service-connected disabilities at health care facilities.
    DAV supports the intention of this bill in particular ensuring the 
availability of information at readily accessible locations. We urge 
the Subcommittee to include contact information of congressionally 
chartered Veterans Service Organizations (VSO) that can provide free 
counseling and assistance to veterans and their dependents in pursuing 
claims for compensation of service-connected conditions. We are 
concerned however, with the administrative burden on VA employees 
orally being required to ask each veteran who visits a VA facility if 
the veteran would like to receive information when the total number 
outpatient care encounters in FY 2009 was 92,892,834.\28\ While we 
support the good intentions of this bill, this notification requirement 
may prove impossible to implement.
---------------------------------------------------------------------------
    \28\ Department of Veterans Affairs, Office of Inspector General, 
Health care Inspection Review of Inappropriate Copayment Billing for 
Treatment Related to Military Sexual Trauma, February 2008.
---------------------------------------------------------------------------
   Draft Legislation--To amend title 38, United States Code, to make 
                                certain
   improvements in programs for homeless veterans administered by the
         Secretary of Veterans Affairs, and for other purposes.
    Veterans are over-represented in the homeless population. According 
to the VA, about one-third of the adult homeless population has served 
in uniform. Current population estimates suggest that over 130,000 
veterans are homeless on any given night and twice as many experience 
homelessness at some point during the course of a year. Homelessness is 
also a growing problem for our veterans returning from Iraq and 
Afghanistan, especially as they face higher rates of unemployment, and 
often carry the effects of posttraumatic stress disorder (PTSD) and 
traumatic brain injury (TBI) into their post-service years. Statistics 
from VA and the National Coalition for Homeless Veterans (NCHV) 
indicate two-thirds of homeless veterans do not receive the help they 
need to transition from homelessness to become productive citizens.
    Section 2 of this draft bill would expand the existing special 
needs grant program by including new eligible public or nonprofit 
private entities that meet prescribed criteria and requirements as well 
as authorize increased appropriations levels for this program. Those 
homeless veterans with special needs include women, women with minor 
dependents, frail elderly; terminally ill; or chronically mentally ill.
    Mr. Chairman, there is a great need for specific emphasis on the 
needs of homeless women veterans, homeless veterans with children, and 
homeless veterans suffering from serious mental illness. We have 
greater numbers of women veterans coming to VA with post-deployment 
mental health needs due to combat exposure, which puts them at higher 
risk for becoming homeless. Likewise, many homeless veterans with minor 
children have been unable to avail themselves of VA's excellent 
programs because no support for their children is available in VA 
programs. It is clear this measure will provide comprehensive services 
to this vulnerable population including homeless veterans who are frail 
elderly, terminally ill, or suffering from serious mental illness.
    Section 3 of this draft bill would increase the amount authorized 
to be appropriated for the Grant and Per Diem (GPD) program for 
homeless veterans to reflect anticipated changes in the cost of 
furnishing services and to take into account the cost of providing 
services in a particular geographic area. It would also make these 
payments based on annual costs instead of daily costs. This section is 
identical to Section 3 of H.R. 4810, the End Veterans Homelessness Act 
of 2010, which was unanimously passed by the House on March 22, 2010. 
H.R. 4810 includes provisions addressing VA's concern outlined in 
testimony submitted to this Subcommittee on October 1, 2009, by 
allowing the Department to make payments to per diem grant recipients 
on a quarterly basis, and would create a quarterly reconciliation 
process where adjustments are made to increase or decrease payments. 
DAV believes Section 3 of the draft bill would provide organizations 
serving homeless veterans the flexibility to look at their program 
designs to provide the full range of supportive services in the most 
economical manner.
    The delegates to our most recent National Convention in Atlanta, 
Georgia, July 31-August 3, 2010, adopted Resolution No. 223, which 
urges Congress to sustain sufficient funding to support the VA's 
initiative to eliminate homelessness among veterans in the next 5 years 
and strengthen the capacity of the VA Homeless Veterans program.
    Furthermore, our resolution urges Congress to continue to authorize 
and appropriate funds for competitive grants to community-based and 
public organizations including the Department of Housing and Urban 
Development to provide health and supportive services to homeless 
veterans placed in permanent housing. Accordingly, DAV supports this 
measure but urges the Subcommittee to ensure adequate funding levels 
are appropriated for VA homeless programs, which historically have been 
seldom sufficient to provide for all the veterans who may need to take 
advantage of these critical services.
    Mr. Chairman, this concludes DAV's testimony on these measures. DAV 
appreciates the opportunity to offer our positions on these bills. I 
would be pleased to address any questions from you or other Members of 
the Subcommittee.

                                 
      Prepared Statement of Ralph Ibson, Senior Fellow for Policy,
                        Wounded Warrior Project

    Chairman Michaud, Ranking Member Brown and Members of the 
Subcommittee:
    Thank you for inviting Wounded Warrior Project (WWP) to offer our 
views on legislation pending before the Subcommittee.
    Wounded Warrior Project was founded on the concept of warriors 
helping warriors. From our outstanding service programs to advocacy, we 
work to help ensure that this generation of wounded warriors thrives--
physically, psychologically and economically. WWP's policy objectives 
are targeted to filling gaps in programs or policies--and eliminating 
barriers--that impede warriors from thriving. As such, we bring an 
important perspective to this morning's hearing.
    Our public policy positions reflect the experiences and concerns of 
those wounded warriors and family members we serve on a day to day 
basis around the country. Several of the issues that would be addressed 
by legislation under consideration today are of great interest to our 
constituency, and we look forward to discussing those bills. Several 
other bills address concerns that our warriors and families have simply 
not encountered, and we will not offer a position on those issues.
    One of the bills before you, H.R. 6123, addresses some of the 
deepest concerns we have heard from warrior's families, and we are very 
pleased to be able to enthusiastically support this important bill.
                 Traumatic Brain Injury Rehabilitation
    Impressive military logistics and advances in military medicine 
have saved the lives of OEF/OIF combatants who would likely not have 
survived in previous conflicts. As a result, servicemembers are 
returning home in unprecedented numbers with severe polytraumatic 
injuries. Among the most complex are severe traumatic brain injuries. 
Each case of traumatic brain injury is unique. Depending on the injury 
site and other factors, individuals may experience a wide range of 
problems--from profound neurological and cognitive deficits manifested 
in difficulty with speaking, vision, eating, or incontinence to marked 
behavioral symptoms. While individuals who have experienced a mild or 
moderate TBI may experience symptoms that are only temporary and 
eventually dissipate, others may experience symptoms such as headaches 
and difficulty concentrating for years to come. Those with severe TBI 
may face such profound cognitive and neurological impairment that they 
require a lifetime of caretaking. As clinicians themselves recognize, 
it is difficult to predict a person's ultimate level of recovery.\1\ 
But to be effective in helping an individual recover from a brain 
injury and return to a life as independent and productive as possible, 
rehabilitation must be targeted to the specific needs of the individual 
patient. In VA parlance, rehabilitation must be ``veteran-centered.''
---------------------------------------------------------------------------
    \1\ Sharon M. Benedict, PhD, ``Polytrauma Rehabilitation Family 
Education Manual,'' Department of Veterans Affairs Polytrauma 
Rehabilitation Center, McGuire VA Medical Center, Richmond, Virginia; 
http://saa.dva.state.wi.us/Docs/TBI/Family_Ed_Manual112007.pdf 
(accessed April 27, 2010).
---------------------------------------------------------------------------
    While many VA facilities have dedicated rehabilitation-medicine 
staff, the scope of services actually provided to veterans with a 
severe TBI can be limited, both in duration and in the range of 
services VA will provide or authorize. It is all too common for 
families--reliant on VA to help a loved one recover after sustaining a 
severe traumatic brain injury--to be told that VA can no longer provide 
a particular service because the veteran is no longer making 
significant progress. Yet ongoing rehabilitation is often needed to 
maintain function,\2\ and veterans with traumatic brain injury who are 
denied maintenance therapy can easily regress and lose cognitive, 
physical and other gains made during earlier rehabilitation.
---------------------------------------------------------------------------
    \2\ Ibid.
---------------------------------------------------------------------------
    Some do make a good recovery after suffering a severe TBI. But many 
have considerable difficulty with community integration even after 
undergoing rehabilitative care, and may need further services and 
supports.\3\ Medical literature has documented the need to use 
rehabilitative therapy long after acute care ends to maintain function 
and quality of life.4,5,6 While improvement may plateau at a 
certain point in the recovery process, it is essential that progress is 
maintained through continued therapy and support. The literature is 
clear in demonstrating the fluctuation that severe TBI patients may 
experience over the course of a lifetime. One study found that even 10 
to 20 years after injury individuals were still suffering from feelings 
of hostility, depression, anxiety, and further deficiencies in 
psychomotor reaction and processing speed.\7\ While some are able to 
maintain functional improvements gained during acute rehabilitative 
therapy, others continue to experience losses in independence, 
employability, and cognitive function with increasing intervals of 
time.\8\ Given such variation in individual progress rehabilitation 
plans must be dynamic, innovative, and long term--involving patient-
centered planning and provision of a range of individualized 
services.\9\
---------------------------------------------------------------------------
    \3\ Nathan D. Cope, M.D., and William E. Reynolds, DDS, MPH; 
``Systems of Care,'' in Textbook of Traumatic Brain Injury (4th ed.), 
American Psychiatric Publishing (2b), 533-568.
    \4\ Hoofien D, Gilboa A, Vakils E, et al. ``Traumatic brain injury 
(TBI) 10-20 years later: a comprehensive outcome study of psychiatric 
symptomatology, cognitive abilities and psychosocial functioning.'' 
Brain Injury 15.3(2001):189-209.
    \5\ Sander A, Roebuck T, Struchen M, et al. ``Long-term maintenance 
of gains obtained in postacute rehabilitation by persons with traumatic 
brain injury.'' Journal of Head Trauma Rehabilitation 16.4(2001): 356-
373.
    \6\ Sloan S, Winkler D, Callaway L. ``Community Integration 
Following Severe Traumatic Brain Injury: Outcomes and Best Practice.'' 
Brain Impairment 5.1(May 2004): 12-29.
    \7\ Hoofien, et al. 201
    \8\ Sander, et al. 370
    \9\ Sloan, et al. 22
---------------------------------------------------------------------------
    For this generation of young veterans, reintegration into their 
communities and pursuing life goals such as meaningful employment, 
marriage, and independent living may be as important as their medical 
recovery. Yet studies have found that as many as 45 percent of 
individuals with a severe traumatic brain injury are poorly 
reintegrated into their community, and social isolation is reported as 
one of the most persistent issues experienced by such patients.\10\ Yet 
research has demonstrated that individuals with severe TBI who have 
individualized plans and services to foster independent living skills 
and social interaction are able to participate meaningfully in 
community settings.\11\ While improving and maintaining physical and 
cognitive function is paramount to social functioning, many aspects of 
community reintegration cannot be achieved solely through medical 
services. Other non-medical models of rehabilitative care--including 
life-skills coaching, supported employment, and community-reintegration 
therapy--have provided critical support for community integration. But 
while such supports can afford TBI patients opportunities for gaining 
greater independence and improved quality of life, VA medical 
facilities too often deny requests to provide these ``non-medical'' 
supports for TBI patients. While such services could often be provided 
under existing law through other VA programs,\12\ it is troubling that 
institutional barriers stand in the way of meeting veterans' needs 
under a ``one-VA'' approach. Instead, rigid adherence to a medical 
model and foreclosing social supports is, unfortunately, a formula for 
denying veterans with severe traumatic brain injury the promise of full 
recovery. This barrier must be eliminated.
---------------------------------------------------------------------------
    \10\ Sloan, et al. 12
    \11\ Nathan D. Cope, M.D., and William E. Reynolds, DDS, MPH; 
``Systems of Care,'' 533-568.
    \12\ See VA's program of independent living services (administered 
by the Veterans Benefits Administration) under 38 U.S.C. sec. 3120, and 
VA's authority under 38 U.S.C. sec. 1718(d)(2) to furnish supported 
employment services as part of the rehabilitative services provided 
under the compensated work therapy program (administered by the 
Veterans Health Administration).
---------------------------------------------------------------------------
    H.R. 6123 would amend current law to clarify the scope of VA's 
responsibilities in providing rehabilitative care to veterans with 
traumatic brain injury. While current law (codified in sections 1710C 
and 1710D of title 38, U.S. Code) directs VA to provide comprehensive 
care in accord with individualized rehabilitation plans to veterans 
with traumatic brain injury, in some instances warriors with severe 
traumatic brain injury are not receiving services they need, and in 
other instances, VA has cut off rehabilitative services prematurely.
    Ambiguities in current law appear to contribute to such problems. 
For example, while the above-cited provisions of law do not define the 
term ``rehabilitation,'' the phrase ``rehabilitative services'' is 
defined for VA health-care purposes (in section 1701(8)) to mean ``such 
professional, counseling, and guidance services and treatment programs 
as are necessary to restore, to the maximum extent possible, the 
physical, mental, and psychological functioning of an ill or disabled 
person.'' That provision could be read to limit services to restoring 
function, but not to maintaining gains that had been made. (Yet 
limiting TBI rehab care in that manner risks setting back progress that 
has been made.) The definition is also limited to services to restore 
``physical, mental and psychological functioning.'' In our view, 
rehabilitation from a traumatic brain injury should be broader, to 
include also cognitive and vocational functioning, and, should not 
necessarily be limited to services furnished by health professionals.
    In essence, H.R. 6123 would provide that in VA's planning for and 
providing care to veterans with traumatic brain injuries--

    1.  rehabilitative services must be directed not simply to 
``improving functioning'' but to sustaining improvement and preventing 
loss of functional gains that have been achieved (and, as such, 
rehabilitation may be continued indefinitely); and
    2.  rehabilitative services are not limited to services provided by 
health professionals but include any other services or supports that 
contribute to maximizing the veteran's independence and quality of 
life.

    WWP strongly supports this legislation. It would eliminate barriers 
too many have experienced. Most importantly, it would offer the promise 
of making good on the profound obligation we owe those who struggle 
with complex life-changing brain injuries.
                    Prosthetic and Orthotic Services
    Turning to another area of keen importance, H.R. 5428 would 
establish new requirements regarding VA provision of prosthetic and 
orthotic care. Specifically, it would direct VA to disseminate, 
display, and educate department employees on an Injured and Amputee 
Veterans Bill of Rights; and establish a process for collecting, 
monitoring and resolving complaints. We applaud this bill's focus on 
provision of high quality prosthetic and orthotic technology and 
service, and concur that the proposed bill of rights aptly captures 
many concerns voiced by warriors we serve. But we do not believe that 
H.R. 5428 goes far enough to resolve those concerns, and would be 
pleased to work with the Subcommittee to explore avenues for bolstering 
the bill.
    To illustrate the concerns we have encountered, let me share a 
perspective from retired Army captain Jonathan Pruden, who in 2003 
became one of the first IED casualties of Operation Iraqi Freedom. 
After 20 operations at 7 different hospitals that included amputation 
of his right leg, he works with hundreds of wounded warriors in 
Florida, Georgia, South Carolina and Alabama as one of our Area 
Outreach Coordinators. Reflecting his own experience, Captain Pruden 
reported that--

       ``VA had attempted three times to make an orthotic for me, but 
I'm still wearing the delaminating pair I received at Walter Reed in 
2004. I receive my care from a private prosthetist because I feel that 
the VA practitioners I met were not going to be able to provide the 
level of expertise, fit, or care I desired.

       ``For many years now the majority of VA patients have been 
middle-aged to elderly. I can't tell you how many times I was asked if 
I lost my leg due to diabetes or vascular disease. When I went in to my 
local prosthetics clinic and started to ask about a Renegade foot vs. a 
flex foot or a Ceterus, I got blank stares and a few `Oh, yea, I've 
heard about those. They're pretty cool aren't they?' As of October 
about 30 percent of VA prosthetists had no national certifications. The 
technology and funding seem to be there but without practitioners who 
really care it won't matter.''

    He described the experience of having been asked recently by the 
head of his local VA prosthetics lab to come in and have a socket made 
using a new computer-aided design (CAD) device. ``I was happy to do 
it,'' he said, ``and went in for a training session with the company 
technician. Unfortunately, the only ones who learned how to use the 
device were the chief and me. The other prosthetists were present but 
clearly showed no interest in learning how to use the new device. Their 
attitude seemed to be, that they had been doing this for a long time 
and could do what they needed without all this high-tech gadgetry.''
    While there have been substantial improvements in VA prosthetic and 
orthotic care over the years, the VA-launched Survey for Prosthetic Use 
highlights the need for further changes. It showed, for example, that 
overall only 16 percent of Vietnam veteran survey participants and 9 
percent of OIF/OEF survey participants received prostheses directly 
from VA, while 78 percent of Vietnam participants and 42 percent of 
OIF/OEF participants used prostheses from private sources under 
contract with VA.\13\ Among its other findings were that participants 
experienced lower satisfaction when VA was compared with private and 
DoD care except for participants with upper-limb loss for whom 
satisfaction with prosthetic providers was similar across all 
conflicts. A concern across all survey participants was the dearth of 
information on new prosthetic devices. The study's findings on 
differences in satisfaction between sources of care suggest a need for 
continued provider education and system evaluation.\14\
---------------------------------------------------------------------------
    \13\ D.G. Smith and G.E. Reiber, ``VA paradigm shift in care of 
veterans with limb loss,'' Journal of Rehabilitation Research and 
Development, vol. 47, number 4 (2010).
    \14\ G.M. Berke, J. Fergason, J.R. Milani, J. Hattingh, M. 
McDowell, V. Nguyen, G.E. Reiber; ``Comparison of satisfaction with 
current prosthetic care in veterans and servicemembers from Vietnam and 
OIF/OEF conflicts with major traumatic limb loss,'' Journal of 
Rehabilitation Research and Development, vol. 47, number 4 (2010) 361-
71.
---------------------------------------------------------------------------
    H.R. 5428, in listing rights that VA should provide to veterans who 
have lost a limb, identifies many important expectations VA should be 
meeting, and unfortunately, often is not--ranging from continuity and 
comparability of care in the transition from DoD to VA to consistent 
services and technology at all VA medical facilities. We share some of 
the frustration underlying this legislation, and welcome Chairman 
Filner's spotlighting these issues. But we are not confident that 
enacting this measure would resolve the problems it highlights. 
Directing VA to disseminate and display a list of ``rights'' does not 
make those expectations enforceable; nor does it require VA to take the 
kind of steps that would convert amputees' expectations into reality. 
Accordingly, we recommend that the bill be expanded to direct the 
Department to institute the kind of changes needed to realize the 
measure's objectives.
                The Federal Recovery Coordinator Program
    H.R. 4041 would direct VA to fund the training of recovery 
coordinators through a school of nursing or medicine. We know from the 
experience of severely wounded warriors and their families how 
singularly important the Federal Recovery Coordinator (FRC) Program has 
been. We have also testified to the need to ``grow'' that program--to 
ensure, for example, that those who sustained profound injuries prior 
to the creation of the FRC program, and who still need such help be 
assigned a qualified FRC. The number of FRC's has not grown 
commensurately with the need for such support. So we welcome the vision 
inherent in the bill that there is a need for additional trained 
recovery coordinators. Given the requirements of these demanding 
positions, FRC's must be highly experienced health professionals who 
are knowledgeable about the health and benefits systems on which 
warriors and their families may depend. As such, FRCs may need 
specialized education and training. But it is not clear that VA needs 
legislation to mount such training; further we defer to the Director of 
the FRC program as to whether the model called for under that bill is 
necessarily the optimal way to meet the program's training needs.
                           Other Legislation
    H.R. 5641 would provide specific authority for VA's medical foster-
home program--an initiative under which VA both places veterans who 
need long-term daily care in family-like settings under contract 
arrangements and provides those veterans with home-health services. 
Such arrangements can provide a good option for chronically ill or 
severely disabled veterans who cannot live with their own families and 
do not want to be institutionalized. While we understand that this 
program was designed to help older veterans, it may meet a need on the 
part of some number of much younger OEF/OIF veterans as well. We 
support this provision.
    H.R. 6127 would provide VA health care eligibility to veterans who 
have received government notification of possible exposure to a 
particular carcinogen at or near a specific site in Iraq in 2003 and 
have enrolled in the VA health care system within 5 years after such 
notification. H.R. 6127 is generally consistent with prior laws, under 
which Congress has extended health care eligibility to veterans 
presumed to have been exposed to toxic substances (including herbicides 
in Vietnam, radiation, and chemical and biological warfare testing). We 
have no objection to extending that principle, but question legislating 
on an incident by incident basis. Given the potential range of toxic 
substances to which veterans might have been exposed in Iraq and 
Afghanistan--we recommend that consideration be given to a systematic 
approach to addressing toxic exposures that are the subject of VA or 
DoD notifications to veterans or servicemembers.
    Homeless Veterans' draft bill: The Subcommittee has before it a 
draft bill that would make revisions to certain grant programs designed 
to assist homeless veterans. Among its provisions, the bill would 
clarify that any public or nonprofit private entity with the capacity 
to administer a grant is eligible for grant support to assist homeless 
``special needs' '' veterans; would establish specific requirements for 
such grants; and increase the authorized funding levels for such 
grants. It would also revise the framework of the current ``grant and 
per diem'' comprehensive service program to eliminate the requirement 
that payments to grantees be based on a daily cost of care, and would 
provide for annual adjustments in rates of payment. WWP applauds the 
goal of eliminating homelessness among veterans, and recognizes the 
benefits of VA's partnering with public and nonprofit entities that are 
dedicated to helping homeless veterans. We have no objection to fine-
tuning these grant programs, though we have no position on the specific 
changes proposed in this measure.
    H.R. 3843 would require VA to publish on its Web site an easily 
accessible, redacted version of all medical quality-assurance records, 
no later than 30 days after the record is created, to include all such 
records created during the 2 years prior to the date of enactment. As 
we understand it, such records would be redacted to delete the names 
and other identifying information of any individual patient or 
employee.
    This Committee has a long record of concern for ensuring the 
quality of the care afforded veterans in the VA health care system--a 
concern WWP certainly shares. A vibrant, healthy medical quality-
assurance program is one important element in fostering a culture of 
quality-improvement in health-care delivery. Certainly, transparency is 
an important element in sustaining confidence in the quality of VA 
care. At the same time, confidentiality has long been deemed a critical 
element of ensuring the integrity of an effective medical quality-
assurance program. This bill raises questions in that regard. Would 
redacted records still contain enough information to lead to 
unwarranted identification of patients or clinicians, particularly at 
smaller facilities? Would providers, fearful of such disclosures, be 
more likely to compromise the quality-assurance process? WWP has no 
position on how best to balance the inherent conflict this bill raises 
between transparency and ensuring robust systemic health care reviews, 
but believes this is an area in which to proceed cautiously.
    Thank you for considering our views on these bills. WWP has no 
position on the other bills under consideration this morning.

                                 
      Prepared Statement of Hon. Chellie Pingree, a Representative
                  in Congress from the State of Maine

    Chairman Michaud, Ranking Member Brown, thank you for having me 
here today. I am happy to be here in front of the Veterans Affairs 
Subcommittee on Health to talk about a bill I recently introduced, the 
Inform All Veterans Act, H.R. 6220. This bill will ensure that veterans 
are given complete information about service connected benefits at all 
VA Medical Centers.
    All too often, a veteran will visit a VA Medical Center, ask how to 
file a claim for service connection, and are either not given the 
correct information on how to pursue their claim, or worse they leave 
the Medical Center thinking that their claim is under way when it is 
not.
    This is a symptom of the Veterans Health Administration and 
Veterans Benefits Administration not communicating with each other 
effectively and operating as silos. Interagency communication is a 
necessity, especially when we are talking about basic, earned services.
    Under this bill, the VHA would be required to ask during the check-
in process if a veteran would like information about the disability 
claims process. If the answer is yes, then straightforward, easy to 
understand literature is shared which will outline how to contact VBA 
or a Veterans Service Officer to start the disability claims process.
    Congress has a responsibility to take care of our veterans. We 
cannot do that if we do not inform them about the health care and 
compensation their service has earned. This common sense approach will 
help veterans avoid the bureaucratic red tape that prohibits many 
veterans from even filing a claim.
    Again, thank you Chairman Michaud and Ranking Member Brown for 
allowing me to be here today, and for all you have done on behalf of 
our Nation's veterans. I am happy to answer any questions the panel has 
about this bill.

                                 
  Prepared Statement of Robert L. Jesse, M.D., Ph.D., Principal Deputy
      Under Secretary for Health, Veterans Health Administration,
                  U.S. Department of Veterans Affairs

    Good Morning Mr. Chairman and Members of the Subcommittee:
    Thank you for inviting me here today to present the 
Administration's views on several bills that would affect the 
Department of Veterans Affairs' programs of benefits and services. With 
me today is Walter A. Hall, Assistant General Counsel. Unfortunately, 
we do not yet have views and estimates for H.R. 6123, H.R. 6127, or the 
draft bills on homeless programs, homeless prevention, and requirements 
for providing Veterans with information regarding compensation claims 
and service-connected disabilities. We will forward these as soon as 
they are available.
H.R. 3843--``Transparency for America's Heroes Act''
    Public Law 96-385, enacted on October 7, 1980, established the 
confidentiality of medical quality-assurance records now codified at 38 
U.S.C. 5705. H.R. 3843 would amend section 5705 to dramatically limit 
the scope of this confidentiality. Specifically, the bill would limit 
confidentiality to records containing the name or other identifying 
information of a patient, employee, or other individual associated with 
VA for purposes of a medical-quality assurance program if disclosure 
would clearly constitute an invasion of personal privacy. However, this 
provision would permit the wholesale release of information if the name 
or other identifying information is redacted. Moreover, H.R. 3843 would 
require VA to make quality-assurance records available on the 
Department's Web site within 30 days of their creation. The bill would 
also require VA to make available on the Internet all quality-assurance 
records created in the 2-year period preceding enactment of this Act.
    VA strongly opposes this legislation. Confidentiality is a 
fundamental and critical element of quality-assurance programs. It 
improves patient safety outcomes by creating an environment in which 
providers may report and examine patient safety events without fear of 
recrimination or an increased risk of liability. As with VA, the 
Department of Defense, all 50 states and the District of Columbia have 
statutory restrictions on disclosure of quality-assurance information. 
The public reporting requirements in H.R. 3843 would require a dramatic 
departure from this widely held standard and would create an abrupt and 
highly disruptive reversal of longstanding and successful VA policy. VA 
policy currently provides confidentiality for certain records that 
contain discussions of quality of health care, even if they do not 
identify an individual. If this information were released, employees 
may be less willing to be forthcoming about quality issues that arise 
at their facilities. In addition, implementing the legislation would be 
both costly and logistically challenging.
    While opposed to H.R. 3843, VA is committed to transparency 
regarding the quality and safety of the care it provides. Since 2008, 
VA has published a Hospital Report Card containing extensive quality 
and safety performance data for each of our 153 medical centers. In 
addition, select quality data from VA medical centers is posted on the 
Centers for Medicare and Medicaid Services' Hospital Compare Web site. 
This transparency allows Veterans and other stakeholders to compare the 
quality of VA medical centers with other hospitals in their 
communities. Due to both logistical and legal reasons, not all VHA 
quality data is available on Hospital Compare. VA has created its own 
Hospital Compare site to address this gap, although VA's site provides 
comparisons among VA medical centers rather than other hospitals in a 
Veteran's community. VA also hosts an additional Web site which 
publishes industry-standard quality scores developed by The Joint 
Commission and the National Committee on Quality Assurance. While 
targeting a more technical audience, this site allows readers to 
compare VA to other facilities, both locally and nationally. An 
enhanced version of this Web site is expected to launch in October 
2010.
    We understand that some of the interest in transparency is to 
promote accountability. VA strongly believes that our employees must be 
held to the highest standard when delivering care; however, it is also 
imperative that employees know that they can report information fully 
and completely so that changes can be made and care can be improved. 
The agency is concerned that the release of quality-assurance documents 
may create a chilling effect, deterring our employees from providing 
accurate information and resulting in poorer quality care. VA welcomes 
the opportunity to meet with the Committee to discuss employee 
accountability as well as additional approaches to increasing the 
transparency in VA's quality-assurance programs.
    VA estimates the cost of this provision to be $22 million in FY 
2011, $47.9 million over 5 years, and $88.5 million over 10 years.
H.R. 4041--``Improvements in the Federal Recovery Coordinator Program''
    H.R. 4041 would require VA to train recovery coordinators at a 
qualified nursing or medical school. This school would also lead a 
literature review and a consensus conference and develop training 
modules for care coordination as well as software that is compatible 
with VA systems. H.R. 4041 would authorize appropriations of $1.2M to 
carry out these elements of the bill and direct the Secretary to 
subcontract for the development of care-coordination software. It would 
also require VA to convene a conference for care coordinator tool 
validation and to conduct a software pilot program. $1.2M would be 
authorized to carry out these provisions. Section 2(d) would authorize 
the qualified nursing or medical school to train 45 recovery 
coordinators, and authorize $500,000 for this training for each of 
fiscal years 2010, 2011, and 2012.
    VA does not support H.R. 4041. VA has established measures in place 
that address the goals of this legislation. The Federal Recovery 
Coordination Program (FRCP) was created in 2007 in response to a 
recommendation from the President's Commission on Care for America's 
Returning Wounded Warriors. The program has been successfully 
implemented in 13 sites around the country and there are currently 20 
Federal Recovery Coordinators (FRCs) Newly hired FRCs come to VA's 
Central Office for intense training and orientation. During this 
training, subject-matter experts provide in-depth reviews of topics 
frequently encountered by FRCs in the course of assisting their 
clients. Topics range from Social Security Disability Insurance to the 
Department of Defense (DoD) disability evaluation system. After 
completion of orientation, the new FRCs return to their station where 
they complete all necessary training and paperwork unique to their host 
facility. They also engage in a mentor/mentee relationship with another 
more experienced FRC, which helps with process questions and resource 
identification. Weekly supervisor calls also provide a structured 
review of cases and one-on-one problem solving is available during the 
week if needed. In addition to the initial orientation, FRCs also 
receive quarterly training (4 weeks total) and have standard 
educational requirements for the program and to meet their state 
license standards. Training topics are identified by the FRCs for these 
events to maximize their learning around specific information needed to 
assist clients.
    The language of section 2(b) of H.R. 4041 would require recovery 
coordinators to be trained at a nursing or medical school; however, it 
is unclear what that training would add to the current content-focused 
training provided by subject matter experts. Moreover, this section 
would also require the school to lead a literature review and develop 
evidence-based guidelines for recovery coordination. A structured 
evidence-based review is unlikely to produce much insight or definition 
as there is a lack of supporting data. The cost of implementing this 
section is estimated to be $1.2 million.
    Section 2(c) of the bill would require the development of a care 
coordination software tool and a program piloting the software. It is 
unclear whether this tool is intended to be used for training or for 
functional data management. FRCP already has a functional data 
management tool that is sufficiently flexible to meet the growing needs 
of the program. It is contained within the Veterans Tracking 
Application (VTA) and iterative enhancements to the system over the 
past 2 years have provided increasingly easier data entry and report-
writing capabilities. Through a related effort, FRCP is also part of an 
information sharing initiative which will improve efficiency and 
accuracy by enabling information transfer among facilities. It is 
estimated that the software and pilot required by this section would 
cost $1.2 million. We note that the word ``subcontractor'' in section 
2(c)(1) should be ``contractor.''
    Section 2(d) of H.R. 4041 would authorize training for 45 
coordinators. We do not understand the rationale for this specific 
number. Current staffing is based on the need for additional personnel 
through monitoring of referrals to the FRCP program. As discussed 
above, there are currently 20 coordinators in the system and we are in 
the process of hiring an additional five FTE's to serve in facilities 
in CA, TX, VA, and Washington D.C. The cost of section 2(d) is 
estimated to be $500,000 in FY 2010, 2011, and 2012.
    VA estimates the total cost of H.R. 4041 to be $3.9 million over 3 
years.
H.R. 5428--``Injured and Amputee Bill of Rights''
    H.R. 5428 would require the Secretary to establish a Bill of Rights 
for injured and amputee Veterans that would be displayed prominently in 
prosthetic and orthotics clinics throughout VA. H.R. 5428 would also 
require the Veteran liaison at each medical center to collect 
information relating to the alleged mistreatment of injured and amputee 
Veterans. Each quarter this information would have to be reported to 
the Department's Chief Consultant, Prosthetic and Sensory Aids who 
would be required to investigate and address the alleged mistreatment.
    We recognize the unique needs of injured and amputee veterans. 
Across the country, VA clinics and Prosthetic and Orthotic Services 
provide specialized care and treatment to these brave men and women. We 
understand that injured and amputee veterans have clinical and medical 
needs that set them apart from other patients at VA facilities--but 
they are not set apart in their rights. The basic tenets of patient 
care should not vary based either on the condition or injury 
experienced by a Veteran or the type of medical services a Veteran 
receives. VA does not support H.R. 5428, because this legislation would 
confer unique rights upon a limited group of Veterans. Giving special 
rights to amputee patients that are not available to other enrolled 
Veterans would result in inconsistent and inequitable treatment among 
our Veteran-patients.
    VA adheres to strict standards of patient treatment. VA regulations 
require that a comprehensive list of patient's rights be posted 
prominently in all VA facilities. Patients who are concerned about the 
quality of their care have a number of options already available for 
addressing these issues. Every VA medical center has a patient advocate 
dedicated to addressing the clinical and non-clinical complaints and 
concerns of our Veterans and their families. Many facilities also 
include a ``Letter to the Director'' drop box where Veterans can 
communicate directly with the Director and raise issues and concerns. 
In addition, VA's Prosthetic and Sensory Aid Service maintains a Web 
site that offers Veterans and family members an opportunity to ask 
questions or raise concerns directly with VA Central Office Staff. The 
Department also works closely with Veterans Service Organizations to 
identify and respond to any concerns with quality and access to care.
    If extended to the entire patient population, the Department would 
support the majority of ``rights'' that are included in this `Bill of 
Rights,' e.g., the right to receive appropriate treatment, the right to 
participate meaningfully in treatment decisions, etc. However, a few of 
the ``rights'' raise serious concerns. Specifically, the Veteran's 
``right to select the practitioner that best meets his or her orthotic 
and prosthetic needs, including a private practitioner with specialized 
expertise,'' is not sound from a medical perspective. VA's 
practitioners are highly qualified, and VA is able to continually 
monitor their performance through its rigorous quality management 
programs. As part of those programs, VA has an extensive credentialing 
and privileging program, which surpasses those found in the private 
sector. VA, generally, does not have ready and efficient access to 
Veterans' non-VA medical records, as few private providers, if any, 
employ an electronic medical record. Were these Veterans permitted to 
choose their own private providers, VA could not oversee the quality of 
their care, ensure their private providers possess adequate 
qualifications, and ensure they receive a continuum of services. One 
must also bear in mind that VA's legal privacy and confidentiality 
requirements exceed those applicable to the private sector.
    In short, VA has the needed expertise in managing Veterans' unique 
issues, including unparalleled expertise in managing and caring for 
amputee patients, particularly those wounded in combat. What we cannot 
provide through our own clinics and Prosthetic and Orthotic Services, 
we readily purchase through contractual arrangements with more than 600 
vendors and providers who are approved by the Department. Although our 
Prosthetics and Orthotics Service labs are top-notch and very 
successful in timely meeting Veterans' needs, we actively evaluate our 
programs to identify any areas in need of improvement. With respect to 
our contractor-prosthetists, we conduct quality-management programs to 
oversee their performance, thereby protecting our Veterans and assuring 
they receive quality services. These efforts would be significantly 
hindered were Veterans permitted to self-refer to private prosthetists 
and practitioners. Veterans could become a vulnerable marketing target 
by those holding themselves out as having special expertise in this 
field.
    Moreover, including that ``right'' in a ``bill of rights'' would be 
misleading. Congress has very carefully limited our authority to pay 
for non-VA care and services. Stating that a Veteran has the ``right'' 
to choose one's own provider would still not make the Veteran eligible 
for private care at VA-expense if he or she does not otherwise meet the 
eligibility terms of 38 U.S.C. 1703. This ``right'' could mislead 
Veterans into believing they are entitled to seek prosthetic or 
orthotic care or services from a non-VA provider at VA-expense. As a 
result, some could incur private medical expenses for which they would 
be personally liable.
    There would be no additional costs associated with enactment of 
H.R. 5428.
H.R. 5516--``Access to Appropriate Immunizations for Veterans Act of 
        2010''
    H.R. 5516 would amend the definition of ``preventive health 
services'' in 38 U.S.C. 1701 to specifically include immunizations. 
This bill would further amend section 1701 to include the term 
``recommended adult immunization schedule'' and define it to mean the 
schedule established by the Advisory Committee on Immunization 
Practices (ACIP). H.R. 5516 would also amend section 1706 of title 38, 
to require the Secretary to develop quality measures and metrics to 
ensure that Veterans receive immunizations on schedule. These metrics 
would be required to include targets for compliance and, to the extent 
possible, should be consistent and implemented concurrently with the 
metrics for influenza and pneumococcal vaccinations. Moreover, the bill 
would require that these quality standards be established via notice 
and comment rulemaking. H.R. 5516 would also require that details 
regarding immunization schedules and quality metrics be included in the 
annual preventative services report required by 38 U.S.C. 1704 
beginning in January of 2011.
    VA does not support H.R. 5516. VA currently conducts ongoing 
initiatives that address the goals of this legislation. The current 
definition of ``preventive health services'' at 38 U.S.C. 1701 includes 
immunization against infectious disease. Moreover, these immunizations 
are specifically included in VA's medical benefits package. VA is an 
ex-officio member of the ACIP and develops its clinical guidance on 
immunizations in accordance with ACIP recommendations. All ACIP-
recommended vaccines, which include hepatitis A, hepatitis B, human 
papillomavirus, influenza, measles/mumps/rubella, meningococcal, 
pneumococcal, tetanus/diphtheria/pertussis, tetanus/diphtheria, 
varicella, and zoster, are currently available to Veterans (as 
clinically appropriate) at VA medical facilities.
    The delivery of preventive care, which includes vaccinations, has 
been well-established in the VA Performance Measurement system for more 
than 10 years with targets that are appropriate for the type of 
preventive service or vaccine. VA updates these performance measures to 
reflect changes in medical practice over time. Requiring that the 
quality metric, including targets for compliance, be established via 
notice and comment rulemaking would limit VA's ability to respond 
quickly to new research or medical findings regarding a vaccine. 
Moreover, because the clinical indications and population size for 
vaccines vary by vaccine, blanket monitoring of performance of all 
vaccines could be cost prohibitive and may not have a substantial 
positive clinical impact at the patient level.
    Accurately costing this bill is difficult as it will depend on the 
current use of individual vaccines and the specific performance 
measures that would be established by VA for those vaccines. If H.R. 
5516 results in a 10 percent increase in the use of vaccines by VA than 
we estimate the cost of H.R. 5516 would be $5 million in 2012, $32.3 
million over 5 years, and $90.7 million over 10 years.
H.R. 5543--``Collective Bargaining Regarding Compensation Other Than 
        Rates of Basic Pay''
    H.R. 5543 would amend 38 U.S.C. 7422 by replacing the word 
``compensation'' in sections (b) and (d) with the words ``rates of 
basic pay.''
    VA has serious concerns with this bill as it would repeal the 
prohibition on collective bargaining with respect to compensation of 
title 38 employees.
    VA would like to stress to the Committee that we deeply value the 
contributions of our employees, and enjoy a collaborative, positive 
working relationship with unions across the country. We hold retention 
of employees as a critically important goal, and encourage the 
management teams of VA facilities to offer professional development 
opportunities and encourage personal growth.
    Currently, 38 U.S.C. 7422(b) and (d) exempt ``any matter or 
question concerning or arising out of . . . the establishment, 
determination, and adjustment of [title 38] employee compensation'' 
from collective bargaining. This bill would replace the word 
``compensation'' with the phrase ``rates of basic pay.'' This change 
would apparently make all matters relating to the compensation of title 
38 employees (physicians, dentists, nurses, et al.) over which the 
Secretary has been granted any discretion subject to collective 
bargaining. In order to provide the Secretary with the flexibility 
necessary to administer the title 38 system, Congress has granted the 
Secretary significant discretion in determining the compensation of 
VA's health care professionals. When Congress first authorized title 38 
employees to engage in collective bargaining with respect to conditions 
of employment, it expressly exempted bargaining over ``compensation'' 
in recognition of the U.S. Supreme Court's ruling in Ft. Stewart 
Schools v. FLRA, 495 U.S. 641 (1990). In that case the Court held that 
the term ``conditions of employment,'' as used in the Federal Service 
Labor-Management Relations Statute (5 U.S.C. 7101), included salary, to 
the extent that the agency has discretion in establishing, 
implementing, or adjusting employee compensation. Id. at 646-47. Thus, 
Congress sought to make clear in 38 U.S.C. 7422(b) that title 38 
employees' right to bargain with respect to ``conditions of 
employment'' did not include the right to bargain over compensation. 
Over the years, Congress has authorized VA to exercise considerable 
discretion and flexibility with respect to title 38 compensation to 
enable VA to recruit and retain the highest quality health care 
providers.
    The term ``rates of basic pay'' is not defined in title 38. 
However, the Agency has defined ``basic pay'' as the ``rate of pay 
fixed by law or administrative action for the position held by an 
employee before any deductions and exclusive of additional pay of any 
kind.'' VA Handbook 5007, Part IX, par. 5. Such additional pay includes 
market pay, performance pay, and any other recruitment or retention 
incentives. Id. Accordingly, H.R. 5543 would subject many discretionary 
aspects of title 38 compensation to collective bargaining. For example, 
there are two discretionary components of compensation for VA 
physicians and dentists under the title 38 pay system--market pay and 
performance pay. Market pay, when combined with basic pay, is meant to 
reflect the recruitment and retention needs for the specialty or 
assignment of the particular physician or dentist in a VA facility. 
Basic pay for physicians and dentists is set by law and would remain 
non-negotiable under this bill, but the Secretary has discretion to set 
market pay on a case-by-case basis. Market pay is determined through a 
peer-review process based on factors such as experience, 
qualifications, complexity of the position, and difficulty recruiting 
for the position. In many cases, market pay exceeds basic pay. In those 
situations, this bill would render a large portion or even the majority 
of most physicians' pay subject to collective bargaining. The Secretary 
also has discretion over the amount of performance pay, which is a 
statutorily authorized element of annual pay paid to physicians and 
dentists for meeting goals and performance objectives. Under this bill, 
performance pay would also be negotiable. Likewise, pay for nurses 
entails discretion because it is set by locality pay surveys. Further, 
Congress has granted VA other pay flexibilities involving discretion, 
including premium pay, on-call pay, alternate work schedules, Baylor 
Plan, special salary rates, and recruitment and retention bonuses. The 
ability to exercise these pay flexibilities is a vital recruitment and 
retention tool. It is necessary to allow VA to compete with the private 
sector and to attract and retain clinical staff who deliver health care 
to Veterans. As described below, this flexibility would be greatly 
hindered by the collective bargaining ramifications of H.R. 5543.
    This bill would obligate VA to negotiate with unions over all 
discretionary matters relating to compensation, and to permit employees 
to file grievances and receive relief from arbitrators when they are 
unsatisfied with VA decisions about discretionary pay. If VA were 
obligated to negotiate over such matters, it could be barred from 
implementing decisions about discretionary pay until it either reaches 
agreements with its unions or until it receives a binding decision from 
the Federal Service Impasses Panel. This potential barrier could 
significantly hinder our ability and flexibility to hire clinical staff 
as needed to meet patient care needs both qualitatively and in a timely 
manner. Additionally, VA may be required to pay more than is necessary 
to recruit and retain title 38 employees.
    Moreover, any time an employee was unsatisfied with VA's 
determination of his or her discretionary pay, he or she could grieve 
and ultimately take the matter to binding arbitration. This step would 
allow an arbitrator to substitute his or her judgment for that of VA 
and, with regard to physician market pay, to override peer review 
recommendations. This bill would allow independent third-party 
arbitrators and other non-VA, non-clinical labor third parties who lack 
clinical training and expertise to make compensation determinations. VA 
would have limited, if any, recourse to appeal such decisions.
    Importantly, H.R. 5543 would result in unprecedented changes in how 
the Federal Government operates. It would permit unions to bargain 
over, grieve, and arbitrate a subject--employee compensation--that is 
generally exempted from collective bargaining even under title 5. 
Although Congress has built much more Agency discretion into the title 
38 compensation system both to achieve the desired flexibility and 
because the system is unique to VA, permitting title 38 employees to 
negotiate the discretionary aspects of their compensation would simply 
be at odds with how other Federal employees are generally treated. 
Further, collective bargaining over discretionary aspects of pay is 
unnecessary. VA's retention rates for physicians and dentists are 
comparable to private sector retention rates, while retention rates for 
VA registered nurses significantly exceed those of the private sector, 
strongly suggesting that the lack of bargaining ability over 
discretionary aspects of pay has minimal impact on VA's ability to 
retain title 38 employees.
    We are not able to estimate the cost of H.R. 5543 for two reasons. 
First, if VA is required to negotiate over compensation matters, and if 
the Agency is unable to reach agreements with the unions, the final 
decisions on pay will ultimately rest with the Federal Service Impasses 
Panel. The Panel has discretion to order VA to comply with the unions' 
proposals. Second, if pay issues become grievable and arbitrable, the 
final decisions on pay will rest in the hands of arbitrators.
    On the whole, our efforts to recruit and retain health care 
professionals have been widely successful, notwithstanding the 
exclusion of matters concerning or arising out of compensation from 
collective bargaining. We would be glad to share applicable data with 
the Committee and brief the members on our continuing efforts in this 
area.
H.R. 5996--``Prevention, Diagnosis, Treatment and Management of Chronic 
        Obstructive Pulmonary Disease''
    Subject to the availability of appropriations, H.R. 5996 would 
require the Secretary to develop treatment protocols and related tools 
for the prevention, diagnosis, treatment, and management of Chronic 
Obstructive Pulmonary Disease (COPD) as well as to improve biomedical 
and prosthetic research programs on this disease. Moreover, in 
conjunction with the Centers for Disease Control and Prevention (CDC), 
the Indian Health Service, and the Health Resources and Service Agency, 
VA would be required to develop a pilot program to demonstrate best 
practices for the diagnosis and management of COPD. The bill also 
specifies that the Secretary and the CDC shall develop improved 
techniques and best practices for assisting individuals with COPD in 
quitting smoking.
    VA supports the intent of H.R. 5996 as it has significant potential 
to improve the health care outcomes of Veterans, but it already has the 
authority to develop the treatment protocols and related tools and to 
improve the research programs on this disease. COPD is currently the 
4th leading cause of death in the United States, and it currently 
impacts more than 500,000 Veterans. The primary cause of COPD, smoking, 
also remains prevalent among Veterans. More than 30 percent of Veterans 
are active smokers, and among those diagnosed with COPD, the rate of 
active smoking is approximately 50 percent.
    VA has long maintained smoking cessation as a major focus for 
health promotion and disease prevention. VA's national performance 
measure on tobacco use requires that all Veterans seen in outpatient 
settings be screened once a year for smoking; if they are currently 
using tobacco, they are provided with brief counseling, offered 
prescriptions for nicotine replacement therapy and other smoking-
cessation medications, and provided with referrals to VA smoking 
cessation programs. VA has also been working with DoD to identify areas 
for collaboration to establish tobacco use cessation programs that 
would provide a seamless transition in care and reduce the impact of 
smoking-related illnesses among both Servicemembers and Veteran 
populations.
    VA supports the bill's focus on the special needs of COPD patients 
who struggle with their smoking addictions. The knowledge gained would 
benefit the population at large. VA believes this focus would 
particularly improve care and outcomes for Veterans with COPD, improve 
rates of smoking cessation among patients with COPD, and reduce the 
risk and incidence of other smoking-related illnesses (e.g., lung 
cancer, heart disease).
    The cost of this bill is estimated to be $25.9 million over 5 
years.
Draft Bill 1--Improvements in Programs for Homeless Veterans
    Section 2 of the draft bill would amend 38 U.S.C. 2061 to grant VA 
permanent authority to offer capital grants for homeless Veterans with 
special needs on the same basis as the grants currently made to 
homeless Veteran providers under the VA Homeless Grant and Per Diem 
(GPD) Program pursuant to 38 U.S.C. 2011. Veterans with special needs 
are: those who are women, including women who have care of minor 
dependents; frail elderly; terminally ill; or chronically mentally ill 
homeless veterans. Section 2 would further amend section 2061 by 
removing the requirement that VA make grants to VA health care 
facilities.
    Section 3 of the draft bill would amend 38 U.S.C. 2012 to change 
grant payments for furnishing services to homeless Veterans from a per 
diem basis to the annual cost basis. It would also remove the 
prohibition on VA providing a rate in excess of the rate authorized for 
State domiciliaries and grant the Secretary the discretion to set a 
maximum amount payable to grant recipients. Section 3 would also direct 
the Secretary to adjust the rate of payment to reflect anticipated 
changes in the cost of furnishing services and take into account the 
cost of services in different geographic areas. It would also make the 
requirement that the Secretary consider other available sources of 
funding discretionary. Section 3, paragraph E would require the 
Secretary to make quarterly payments based on the estimated annual 
basis and would further require recipients to declare the actual amount 
paid by quarter for services provided and repay any outstanding 
balances if the amount spent by the recipient is less than the 
estimated quarterly disbursement. Similarly, if recipients spend more 
than the estimated amount, determined on a quarterly basis, the 
Secretary would be required to make an additional payment equal to that 
sum. Payment to recipients would be limited to the amount of the annual 
grant payment as determined by the Secretary. Finally, section 3 would 
allow grant recipients to use VA grants to match other payments or 
grants from other providers.
    While there are some similarities between this draft bill and a 
recent VA legislative proposal, VA needs additional time to evaluate 
this bill in conjunction with the Administration's focus on permanent 
housing models for the homeless. We will provide views and costs as 
soon as they are available.
Draft Bill 2--``Miscellaneous Health Care Provisions''
Annual Meeting of the Association of Military Surgeons in the United 
        States
    Section 3 would permit the Under Secretary for Health to assist the 
Association of Military Surgeons of the United States in organizing and 
hosting the annual meeting of the Association. The military services 
are able to assist the Association with its annual meeting due to 
Public Law 39 (enacted January 30, 1903), which incorporated the 
Association of Military Surgeons of the United States. That law made 
the Secretaries of Treasury, War, and Navy and the Surgeons General of 
the Army, Navy, and Marine--Hospital Service ex officio members of the 
Association. VA would like an authorization to also assist with the 
annual meetings. These meetings are valuable to VA because they permit 
sharing with other Federal health-care entities and provide learning 
opportunities for VA employees through lectures, panel discussions, and 
poster discussions.
    The cost associated with enactment of this section will be 
insignificant.
Hospital Care and Medical Services in Non-Department Facilities
    Section 4 would grant VA increased flexibility in entering into 
fee-basis arrangements to obtain hospital care and medical services for 
eligible Veterans. These arrangements would be authorized when VA is 
unable to furnish economical hospital care or medical services due to 
geographical inaccessibility, or when VA facilities are unavailable to 
furnish needed care or services. The statute as currently written 
states that these arrangements be accomplished by ``contracts'' with 
non-VA ``facilities.'' This bill would expressly provide that VA, 
notwithstanding any other law, may ``purchase, enter into a contract, 
provide individual authorization or act in such other manner as the 
Secretary determines appropriate'' with non-VA facilities in order to 
furnish hospital and outpatient care to eligible Veterans.
    VA supports section 4. There are no costs associated with this 
section as it would be consistent with VA's current practice under 
current law.
Extension of the Advisory Committee on Homeless Veterans
    Section 5 would amend 38 U.S.C. 2066 to extend Congressional 
authority to continue the Advisory Committee for Homeless Veterans for 
an additional 3 years until December 30, 2014.
    This Committee was Congressionally mandated by Public Law 107-95. 
The mission of the Committee is to provide advice and make 
recommendations to the Secretary on issues affecting homeless Veterans 
and determine if the Department of Veterans Affairs (VA) and other 
programs and services are meeting those needs. It has proven valuable, 
and VA has implemented many of the Committee's recommendations through 
policy and regulatory changes to enhance access and services for 
homeless Veterans.
    The cost of the Advisory Committee on Homeless Veterans was 
$141,000 in FY 2009 and VA estimates that this cost will increase by 
three to 5 percent for the additional 3 years of operation and is 
estimated to be $.5 million.
Authority to Recover Medical Care Costs from Third Party Providers
    Section 6 would amend section 1729(f) of title 38, United States 
Code, to make clear that the absence of a participating provider 
agreement or other contractual arrangement with a third party may not 
operate to prevent, or reduce the amount of, any recovery or collection 
by the United States under this section. Subsection (b) would amend 
section 1729(i)(1)(A) of title 38, United States Code, to clarify the 
definition of a ``health-plan contract'' by specifying health 
maintenance organizations, competitive medical plans, health care 
prepayment plans, preferred or participating provider organizations, 
individual practice associations, and other medical benefit plans are 
included. These amendments would apply only to care and services 
furnished under chapter 17 of title 38, United States Code, on and 
after the date of the enactment.
    There are no direct costs associated with this section, other than 
administrative costs associated with collecting revenue. VA supports 
this provision and estimates the adoption of this section would 
increase collections beginning in fiscal year 2012 by $87.7 million and 
$1.04 billion over a 10-year period.
Health Professionals Educational Assistance Programs
    Section 7 would amend 38 U.S.C. 7675 to impose on full-time student 
participants in the Employee Incentive Scholarship Program (EISP) who 
leave VA employment prior to completion of their education program the 
same liability as is currently imposed on part-time students. The 
current statute clearly limits part-time student participants' 
liability for breach of the EISP agreement. This proposal would make 
both full- and part-time students liable for breach of the EISP 
agreement. Currently, all other employee recruitment/retention 
incentive programs have a service obligation and liability component.
    VA supports this provision and estimates enactment would result in 
savings of approximately $36,000 in fiscal year 2010 and a total 
approximate savings of $189,000 over a 4-year period.
On-Call Pay for VHA IT Specialists
    Section 8 would amend 38 U.S.C. 7457 and authorize the Secretary to 
pay on-call pay to Information Technology (``IT'') Specialists whose 
primary responsibilities are to perform services incident to direct 
patient-care services at VHA health care facilities. Prior to 2006, 
title 5 IT staff working in VA health care facilities were employed by 
the Veterans Health Administration (``VHA'') and were authorized to 
receive on-call pay under title 38. In 2006, the Department's Office of 
Information and Technology (``OI&T'') was reorganized as a separate 
staff office and, as a result, title 5 IT staff were transferred out of 
VHA, and lost their authorization for on-call pay. On-call coverage is 
needed because the Department is unable, given staffing availability 
and cost, to staff OI&T on a 24-hour basis. This proposal would allow 
the Department to properly support patient care operations on a 24-hour 
basis. This is crucial, as VHA's delivery of health care is dependent 
upon the electronic health record.
    VA estimates the cost of this section to be $6.3 million for FY 
2011, $37.3 million over 5 years, and $93.9 million over 10 years.
Pay for Physicians and Dentists Employed by the Office of Information 
        and Technology
    Section 9 would amend 38 U.S.C. 7431 to authorize the Secretary to 
pay physicians and dentists employed by the Department's Office of 
Information and Technology (``OI&T'') in accordance with title 38 pay 
authorities. Prior to 2006, physicians and dentists who served in 
information technology (``IT'') positions providing support to the 
Veterans Health Administration (``VHA'') worked in VHA units and were 
covered by title 38 pay authorities. In 2006, OI&T was reorganized as a 
separate Department staff office and, as a result, IT personnel were 
transferred out of VHA, and lost their authorization for title 38 pay. 
This provision would allow VA to recruit and retain physicians and 
dentists in OI&T leadership positions by inserting a new subsection 
into section 7431. Title 38 pay authorities are specifically designed 
to allow VA to recruit and retain highly qualified health care 
personnel for Veterans. The ability to offer title 38 pay to physicians 
and dentists within OI&T is crucial in maintaining the Department's 
position as a world leader in health care information technology 
because it would allow the Department to recruit and retain senior IT 
executives who, because of their experience as physicians and dentists, 
possess intimate knowledge and expertise in both health care processes 
and information technology.
    While VA believes that 25 positions would be sufficient, this draft 
bill would permit 100 positions at any time. To be eligible, a 
physician or dentist must be board-certified. The Secretary would 
ensure that the authority is used only for physicians and dentists 
serving in key executive positions in which experience as a physician 
or dentist is critical to accomplishment of the Department's mission. 
Covered physicians and dentists must be paid using the pay schedules 
established for executives in the Veterans Health Administration whose 
primary duties are to manage personnel and programs rather than perform 
clinical duties as a physician or dentist--currently, Pay Table 6 for 
Executive Assignments, which has three tiers: Tier 1: $145,000-
$265,000, Tier 2: $145,000-$245,000, and Tier 3: $130,000-$235,000.
    Section 9 includes conforming amendments to title 5 that make clear 
that physicians and dentists receiving rates of basic pay under title 
38, including those covered by proposed section 7431(i), are not 
covered by the provisions governing the General Schedule and the Senior 
Executive Service. Section 9 also amends 5 U.S.C. 5371 (OPM's statutory 
authority to provide title 38 pay authority to other agencies) so that 
OPM may authorize other agencies to apply title 38 pay provisions to 
employees who would otherwise be in the Senior Executive Service.
    The Department estimates the cost of the 100 employees allowed for 
in the bill to be $13.7 million in FY 2011, $71.9 million over 5 years, 
and $153.23 million over 10 years. If VA employed 25 of these 
employees, the costs are estimated to be $3.4 million in FY 2011, 
$17.96 million over 5 years, and $38.3 million over 10 years.
Extension of the Joint Incentives Program
    Section 10 would change the termination date for the DoD-VA Joint 
Incentives Program from September 30, 2015 to September 30, 2020, 
enabling both agencies to contribute to the Joint Incentive Fund, which 
fund funds creative coordination and sharing initiatives at the 
facility, intraregional, and nationwide levels. VA supports this 
extension. There are no costs associated with this provision.
Use of the Franchise Fund to Expedite Collection of Erroneous Payments
    Section 11 would amend the paragraph under the heading ``Franchise 
Fund'' in title I of the Departments of Veterans Affairs and Housing 
and Urban Development, and Independent Agencies Appropriations Act, 
1997 (Public Law 104-204), which was amended by section 208 of title II 
of the Military Quality of Life and Veterans Affairs Appropriations 
Act, 1996 (Public Law 109-114), to authorize the VA Franchise Fund to 
use amounts available to cover its operating expenses to correct 
erroneous or improper payments made by Franchise Fund employees.
    The Government Management Reform Act (GMRA) of 1994 (Public Law 
103-356) and the Departments of Veterans Affairs and Housing and Urban 
Development, and Independent Agencies Appropriations Act, 1997 (Public 
Law 104-204) authorize VA to provide certain common administrative 
services to VA and other government agencies on a fee-for-service 
basis. One such service is payment processing. As a service provider, 
the VA Franchise Fund acts as an agent for its customers by processing 
payments on their behalf. The Franchise Fund has service level 
agreements (SLAs) with VA customers to pay vendor invoices using the 
customer's appropriated funds. Occasionally, the Franchise Fund makes a 
payment error, e.g., payment issued to an incorrect vendor. Currently, 
customers provide additional funds to the Franchise Fund to make the 
correct payment, pending recovery of the improper payment.
    This section would authorize the customer involved with the 
improper payment to establish a refund receivable from the Franchise 
Fund and immediately recover the related budget authority. The Fund 
would in turn establish a refund receivable from the vendor and record 
it in its accounting records. The budget authority would not accrue to 
the VA Franchise Fund until funds are recovered from the vendor.
    Under this approach, the customer's appropriation would remain 
whole. The Franchise Fund, acting as the agent, would set up a refund 
receivable and use resources from the Fund to immediately refund the 
corrected payment to its customers. This would occur while the Fund is 
pursuing recovery of the improper payment from the vendor. VA supports 
this provision. The VA Franchise Fund has established effective 
processes to recover funds through bills of collection, payment 
offsets, the Treasury Offset Program, or civil court collection. The 
Franchise Fund's collection experience demonstrates a high percentage 
of collections and a low risk for loss of improper payments.
    There are no costs associated with this provision.
    Mr. Chairman, this concludes my prepared statement. I would be 
pleased to answer any questions you or any Members of the Committee may 
have.

                                 
   Statement of American Federation of Government Employees, AFL-CIO,
               and AFGE National Veterans Affairs Council
    Mr. Chairman and Members of the Subcommittee:
    The American Federation of Government Employees (AFGE) and the AFGE 
National VA Council (NVAC) appreciate the opportunity to submit a 
statement for the record on H.R. 5543.
    AFGE and NVAC represent nearly 200,000 employees in the Department 
of Veterans Affairs (VA), more than two-thirds of whom are employees of 
VA's world class health care system. They are proud of the care they 
provide to veterans every day. They also take great pride in the 
Veterans Health Administration's (VHA) best practices and state-of-the-
art health care information technology that was developed through the 
joint input of labor and management.
    Sadly, in 2003, the highly effective joint labor-management 
agreement on bargaining rights of VA's Title 38 health care 
professionals was nullified. In its place, the VA implemented a new 
policy that deprives Title 38 clinicians of basic rights to grieve and 
negotiate over matters related to compensation, patient care and peer 
review.
    Seven years and many, many wasted VA health care dollars later, it 
is urgent that this unfair treatment of VA's Title 38 clinicians cease 
and that the VA return to a bargaining rights policy that resolves 
labor-management disputes more efficiently. As a first step, AFGE and 
NVAC urge the Committee to approve H.R. 5543 to restore equal rights to 
bargain over compensation matters. This bill will restore Congressional 
intent in enacting Title 38 bargaining rights in 1991 and will also 
allow these clinicians to enforce their rights under important VA 
recruitment and retention laws over the past decade.
    Under current VA policy, Title 38 clinicians--including physicians, 
dentists, registered nurses (RN), physician assistants, chiropractors, 
optometrists and podiatrists--face work environments plagued by 
arbitrary and unfair pay policies. Many of these clinicians bring to 
the VA invaluable experience as military personnel providing care on 
the battlefield. Yet, they are singled out for unfair treatment. They 
cannot challenge management pay policies that violate Federal law or VA 
regulations simply because they are ``pure Title 38 employees'' 
appointed under Section 7401(1) of Title 38, instead of ``Hybrid Title 
38 employees'' appointed under Section 7401(3) with full Title 5 
bargaining rights.
    As a result, a Title 38 RN has no recourse if she or he is denied 
overtime pay, while a Hybrid Title 38 licensed practical nurse can file 
a grievance over the same issue. Similarly, the union cannot negotiate 
over retention pay criteria for a Title 38 psychiatrist, but can 
negotiate over the implementation of similar pay policies for a Hybrid 
Title 38 psychologist.
    If these Title 38 health care professionals decide to leave the VA 
to work at a another Federal facility, such as a military hospital or a 
Federal prison clinic, they will acquire full collective bargaining 
rights under Title 5.
    Thus, the choice is clear: if the VA wants to be an employer of 
choice in today's health care market and compete effectively for health 
care professionals in short supply, it must provide equal compensation 
bargaining rights to its Title 38 clinicians.
    H.R. 5543 offers a very modest change to Section 7422, the 
bargaining rights provision of Title 38. It simply clarifies that, like 
all Federal employees, VA Title 38 clinicians can bargain over the 
implementation of pay laws and regulations, but that only Congress and 
the VA Secretary can set basic rates of pay.
    The narrow scope of H.R. 5543 addresses opponents' assertions that 
employees will try to bargain over Federal pay scales. The language of 
this bill limits bargaining to compensation issues other than basic 
rates of pay that Congress has specifically addressed in legislation to 
help the VA recruit and retain health care personnel such as RN 
locality pay and physician and dentist market pay and performance pay. 
H.R. 5543 would also protect Title 38 clinicians from violations of 
routine pay laws that all public and private sector registered nurses 
count on, such as the right to additional pay for working evenings and 
weekends.
    AFGE and NVAC note that the VA has never offered this Committee an 
example of an employee's attempt to use bargaining rights to set 
Federal pay rates, and that there is not a single Undersecretary of 
Health ``7422'' case involving such an attempt.
    To address another concern raised by some opponents, the 
recommendations of the recent ``7422 workgroup'' that are pending 
before the Secretary are no substitute for legislative change. Yes, 
they have the potential to improve Title 38 labor-management relations 
to some extent and we appreciate the Secretary's willingness to review 
current policy. However, even if the recommendations are adopted, they 
cannot take the place of legislation that clarifies the scope of the 
law. These recommendations very modest in scope, and would not provide 
Title 38 clinicians with equal bargaining rights. Also, they lack the 
force of law; Courts and arbitrators will continue to defer to the 
Secretary's discretion under Title 38 absent legislation. Finally, as 
we saw in 2003, policies issued during one administration can be easily 
tossed out by the next. If the VA is to effectively compete with other 
health care employers, it must assure current and prospective hires 
that they can count on fair treatment and the ability to enforce pay 
laws and regulations.
    VA's current policy on compensation bargaining rights has weakened 
critical legislation that Congress passed in recent years to recruit 
and retain a strong health care workforce. For example, Congress 
enacted legislation in 2004 to use local panels of physicians to set 
market pay that would be competitive with local markets (P.L. 108-445). 
The USH ruled that AFGE's national grievance over the composition of 
the pay panels was barred by the ``compensation'' exception. (Decision 
dated 3/2/07). Currently, VA physicians in numerous facilities are 
unable to challenge unfair performance pay criteria that penalize them 
for hospital-wide performance even though P.L. 108-445 specifically 
refers to ``individual achievement.''
    Finally, how dangerous can this simple clarification in the law be? 
The VA has already agreed to full bargaining rights for new Title 38 
clinicians at the new joint VA-Navy facility at North Chicago. Section 
1703 of Public Law 111-84 provides that Navy civilian health care 
professionals who are transferring to the VA workforce after completion 
of this facility merger will retain full Title 5 collective bargaining 
rights for 2 years in matters related to compensation, as well as 
patient care and peer review. AFGE and NVAC look forward to working 
with the VA to implement this 2 year pilot project when it begins next 
month.
    Thank you for the opportunity to share the views of AFGE and NVAC 
on this important legislation for maintaining a strong VA health care 
workforce.

                                 
       Statement of Hon. Steve Buyer, Ranking Republican Member,
       Full Committee on Veterans' Affairs, and a Representative
                 in Congress from the State of Indiana
    Upon introduction of H.R. 5641, I made the following introductory 
statement:
    ``Today, I am introducing H.R. 5641, a bill to allow the Department 
of Veterans Affairs (VA) to enter into contracts with adult foster 
homes to provide life-long care to veterans unable to live 
independently.
    Adult foster homes are designed to provide non-institutional long-
term care to veterans who prefer a more personalized, familial setting 
than traditional nursing homes are able to provide.
    VA has been helping to place veterans in adult foster homes since 
2002 and over time more than 600 veterans in need have paid to receive 
such care. As we speak, 219 veterans are living in these special homes.
    The need for long term care is increasing as veterans from past 
conflicts get older, and it will continue to grow as wounded warriors 
return home from Iraq and Afghanistan with severe injuries that require 
life-long assistance. While nursing homes will always be a valuable 
tool for providing lasting care, for some the individualized, home-like 
atmosphere of an adult foster home is a much more attractive 
alternative than the prospect of moving into a traditional nursing 
home.
    The advantages of adult foster homes are clear. Veterans who opt 
for foster home care will move into a home owned or rented by their 
chosen foster home caregiver. The caregiver--who has passed a VA 
screening, Federal background check, and home inspection and agreed to 
undergo annual training- resides with the veteran and provides them 
with 24-hour supervision and personalized care. For as long as that 
veteran resides in the home, VA adult foster home coordinators and 
members of a VA Home Care Team will make both announced and unannounced 
visits at least three times every month to ensure the veteran is safe 
and the home and caregiver are in compliance with VA's high quality 
standards.
    Additionally, the Home Care Team will provide veterans with 
comprehensive, interdisciplinary primary care and provide the 
caregivers with supportive education and training.
    Many veterans who choose to reside in an adult foster home would 
otherwise be in need of nursing home care and would qualify for VA 
benefits to receive it. However, because VA is not authorized to 
provide veterans with assisted living benefits, these veterans must pay 
for the care they receive in adult foster homes out of their own 
pockets.
    Twenty-four percent of veterans who have received care in a Medical 
Foster Home qualify for VA's highest priority group due to having 
disabilities rated 50 percent or more service connected or having 
otherwise been found unemployable due to service connected conditions. 
Given that many of the veterans who are benefitting from this 
individualized, non-institutional care are disabled, afflicted with 
chronic disease, often elderly, and frequently 70 percent or more 
service connected, placing the entire cost burden for adult foster 
homes on their backs is no way to thank them for their valiant years in 
service. What's more, it creates an inequity of benefits between those 
who can afford to pay for such care and those that cannot.
    The legislation I am introducing today would give VA the authority 
to enter into a contract with a certified adult foster home to pay for 
care for certain veterans already eligible for VA paid nursing home 
care. By doing so, it would ensure more veterans have the option to 
choose a treatment setting that best suits their needs free of 
financial constraints.
    Our veterans in need of life-long care have earned the right to 
decide which long-term care environment would make them feel most at 
home. And, I encourage my colleagues to join with me in cosponsoring 
this legislation to make that decision easier.
    Thank you and I yield back the balance of my time.''
    Further, upon introduction of H.R. 6127, I made the following 
introductory statement:
    ``Today I am introducing a bill, H.R. 6127, the Extension of Health 
Care Eligibility for Veterans who Served at Qarmat Ali Act, to extend 
the VA health care enrollment period for certain veterans who served in 
the Qarmat Ali region of Iraq.
    Soon after the conflict in Iraq began in 2003, Army National Guard 
units from my home state of Indiana as well as units from Oregon, West 
Virginia, and South Carolina and National Guardsmen mobilized as 
individual augmentees from across the Nation were called up and tasked 
with guarding the Qarmat Ali water treatment facility.
    For 6 months--from April to September--these National Guardsmen 
from across the Nation bravely guarded the plant, located just outside 
Basra. Their mission was to secure the facility and provide protective 
services for the independent contractors who were working throughout 
the region to restore Iraqi oil production.
    Recently, they have been notified of their possible exposure to a 
toxic chemical known as sodium dichromate and are being asked to come 
forward, be evaluated, and enroll in VA's Gulf War Registry. Health 
problems associated with such exposure include respiratory issues, skin 
lesions, and burns. Contact may cause increased rates of lung cancer 
and other ear, nose, throat, and skin disorders.
    The men and women of these National Guard units completed their 
mission--and served our country--well. It was hard for me to discover 
that despite their safe return, their service may continue to be put 
them at risk. In particular, I am very sensitive to the Hoosiers who 
may have been injured.
    Under current law, combat veterans who served on active duty in a 
theater of combat operations during a period of war after the Persian 
Gulf War or in combat against a hostile force during a period of 
``hostilities'' after November 11, 1998 are eligible to enroll in the 
VA health care system, notwithstanding sufficient evidence of service-
connection, for 5 years following separation from service.
    This includes members of the National Guard and Reserve who were 
activated and served in combat support or direct operations as long as 
they meet certain requirements.
    When Congress established the 5 year period of open enrollment for 
VA health care it was with the understanding that some wounds of war 
may not manifest themselves until years after a veteran leaves military 
duty.
    But despite our best intentions, we are finding that some veterans 
are faced with combat-related health problems that were not apparent 
even 5 years after the veteran re-entered civilian life. This creates a 
gap in services that unfairly penalizes these men and women for 
conditions out of their control.
    I commend the VA for their efforts to contact these veterans and 
create the Qarmat Ali Registry to aggressively track and treat veterans 
exposed to this toxic chemical as part of the Gulf War Registry.
    However, it is also important for them to have immediate access to 
VA's high quality health care system. The use of VA health care will 
help to identify potential medical conditions, and provide counseling, 
immunizations, and medications to prevent illness. Appropriate 
preventative care can substantially improve health outcomes and the 
quality of life for our honored heroes.
    But, some of the Qarmat Ali veterans who separated from service 
following their deployment in 2003 may no longer be eligible to enroll 
in VA health care under the 5-year open enrollment period. As a result, 
they must first file a claim and seek a service-connected disability 
rating before enrolling in the VA health care system and gaining access 
to the comprehensive medical care VA provides.
    Unfortunately, the claims process can be both time-consuming and 
daunting. It is unacceptable that the Qarmat Ali veterans, already 
subjected to harmful toxins during service to our country, must now 
await the outcome of a lengthy and sometimes adversarial claims 
processing system before they can enroll in VA health care.
    The VA was established expressly to care for veterans like these 
who willingly left their homes, families, and lives to protect and 
defend our Nation and may find themselves sick or injured as a result 
of such selflessness
    H.R. 6127 would correct this unintended gap in services by 
extending the enrollment eligibility period for Qarmat Ali veterans by 
5 years from the date of notification. This would allow them to 
immediately begin receiving services at VA medical facilities for any 
and all of their health care needs.
    Breaking down barriers to needed care is the very least we, as a 
grateful Nation, can do for the men and women who fight for our 
freedoms, in Qarmat Ali and around the world.
    I urge my colleagues to join me in supporting H.R. 6127 and these 
brave American heroes. Thank you, and I yield back the balance of my 
time.''

                                 
                Statement of Hon. Bob Filner, Chairman,
 Full Committee on Veterans' Affairs, and a Representative in Congress 
                      from the State of California
    Chairman Michaud, thank you for the opportunity to testify before 
the Subcommittee on Health on H.R. 5428, a bill of rights for injured 
and amputee veterans and H.R. 5543, a collective bargaining rights bill 
for VA clinicians.
    We are all too familiar with the wide-spread use of improvised 
explosive devices (IEDs) in Operation Enduring Freedom and Operation 
New Dawn. Many of our servicemembers are returning home with 
amputations as a direct result of blast injuries and this is why I have 
introduced H.R. 5428.
    H.R. 5428 directs VA to display and educate VA employees about the 
injured and amputee veterans' bill of rights at each VA prosthetics and 
orthotics clinic. In addition, my bill requires VA to monitor and 
resolve complaints from injured and amputee veterans alleging 
mistreatment.
    I believe that this bill will go a long way in not only protecting 
the rights of our injured and amputee veterans, but will also play an 
important role in ensuring consistency in the quality of orthotic and 
prosthetic care that our veterans receive throughout the VA health care 
system.
    Next, I would like to discuss H.R. 5543, a bill which would allow 
collective bargaining over compensation related labor-management 
disputes. Examples of such disputes include locality pay, overtime pay, 
shift differential pay, and performance pay.
    I would like to emphasize that my bill continues to protect the 
basic rates of pay so that VA employees cannot bargain over the Federal 
pay scales. However, I have heard stories where a VA nurse's overtime 
pay is miscalculated but there is no recourse for addressing this 
inaccuracy.
    H.R. 5543 would also help VA with their recruitment and retention 
efforts since prospective employees would have the assurance that they 
will be treated fairly when it comes to the enforcement of pay laws and 
regulations.
    Thank you again for the opportunity to share my thoughts with you, 
and I hope that I can count on your support for H.R. 5428 and H.R. 
5543.

                                 

Independence Through Enhancement of Medicare and Medicaid Coalition
                                                 September 24, 2010

The Honorable Bob Filner
Chairman, House Veterans Affairs Committee
United States House of Representatives
Washington, DC 20515

RE: Support for H.R. 5428; the Injured and Amputee Veterans Bill of 
Rights

Dear Chairman Filner:

    The undersigned members of the Independence Through Enhancement of 
Medicare and Medicaid (ITEM) Coalition write to strongly support your 
legislation, H.R. 5428, the Injured and Amputee Veterans Bill of 
Rights, and ask that you help pass this legislation in this Congress as 
expeditiously as possible.
    This bill would establish a written list of rights that all injured 
and amputee veterans have access to high quality orthotic and 
prosthetic (O&P) care. O&P care, consisting of orthopedic braces, 
artificial limbs, and the clinical services necessary to treat the 
patient, is vital to veterans who have lost limbs or have sustained 
injuries or disorders of the arms, legs, back and neck.
    The rights created by this legislation are currently available to 
veterans but are inconsistently applied throughout the VA health 
system. This inconsistency leads to a lack of access to appropriate O&P 
care in different areas of the country. This legislation would make 
veterans aware of their right to high quality care provided by 
qualified practitioners, to appropriate technology to meet their 
specific needs, and to a second opinion regarding treatment options. 
Veterans also have a right to a continuum of care when transferring 
from the Department of Defense to the VA, and to a functional spare 
prosthesis or orthosis if necessary, to name a few.
    With the national spotlight on injured and amputee veterans in the 
wake of the Iraq and Afghanistan wars, veterans often receive the care 
they need. But when the spotlight dims, it is critical that veterans' 
rights to high quality O&P care are well established and well 
understood by veterans themselves. To help enforce these rights, the 
Veterans Administration would be required to post this ``Bill of 
Rights'' in every VA O&P Clinic across the country, to post it on the 
VA Web site, and to create a complaint mechanism where disputes can be 
resolved.
    The ITEM Coalition urges Congress to pass the Injured and Amputee 
Veterans Bill of Rights to give all veterans access to consistent, high 
quality orthotic and prosthetic care. We thank you for your leadership 
in introducing this important bill and look forward to working with you 
and your staff to enact H.R. 5428 into law this year.
    For more information, please contact Peter Thomas, ITEM Coalition 
Counsel, at (202) 466-6550.

            Sincerely,

                            Advanced Medical Technology Association
           American Academy of Physical Medicine and Rehabilitation
                   American Association of People with Disabilities
                      American Association on Health and Disability
                       American Congress of Rehabilitative Medicine
              American Medical Rehabilitation Providers Association
                                 American Music Therapy Association
                        American Therapeutic Recreation Association
                                       Amputee Coalition of America
                   Association of Assistive Technology Act Programs
                               Association of Rehabilitative Nurses
                                       Blinded Veterans Association
                                Brain Injury Association of America
                              Christopher and Dana Reeve Foundation
                                      Disability Health Access, LLC
                       Disability Rights Education and Defense Fund
                                                       Easter Seals
              Harris Family Center for Disability and Health Policy
                                Hearing Loss Association of America
                                       Helen Keller National Center
         National Association for the Advancement of Orthotics and 
                                                        Prosthetics
National Association of County Behavioral Health and Developmental 
                                               Disability Directors
           National Association of State Head Injury Administrators
                             National Council on Independent Living
                                 National Disability Rights Network
                                     National Down Syndrome Society
                                National Multiple Sclerosis Society
                                   National Rehabilitation Hospital
                            National Spinal Cord Injury Association
                                      Paralyzed Veterans of America
    Rehabilitation Engineering and Assistive Technology Society of 
                                                      North America
                                           Spina Bifida Association
                                                               TASH
                                          United Spinal Association
                                                          VetsFirst
Cc:  The Honorable Nancy Pelosi
    The Honorable Steny Hoyer
    The Honorable John Boehner
    The Honorable Steve Buyer

                                 
         Statement of National Coalition for Homeless Veterans
    Chairman Michaud, Ranking Member Brown, and distinguished Members 
of the Subcommittee:
    Thank you for the opportunity to present this statement to the U.S. 
House Committee on Veterans' Affairs, Subcommittee on Health. The 
National Coalition for Homeless Veterans (NCHV) is honored to do so and 
pleased to convey its support and recommendations for the draft 
legislation on homelessness to amend title 38, United States Code, to 
make certain improvements in programs for homeless veterans 
administered by the Secretary of Veterans Affairs, and for other 
purposes.
    NCHV proudly represents over 2,300 community- and faith-based 
homeless veteran service providers nationwide. These groups, whom U.S. 
Department of Veterans Affairs (VA) Secretary Eric Shinseki calls ``the 
real creative geniuses'' in ending veteran homelessness, are largely 
responsible for the drastic reduction in homeless veterans over the 
past 6 years--from 250,000 on any given night in 2004 to 107,000 in 
2010, according to annual VA CHALENG reports.
    VA reaches an incredible number of homeless veterans through its 
Homeless Providers Grant and Per Diem Program (GPD)--a transitional 
housing program that is the foundation of VA and community 
partnerships. In 2005, the department introduced the ``grant program 
for homeless veterans with special needs,'' as it is called in statute, 
into the GPD in order to serve four critical demographics:

      Women, including those with dependent children
      Frail elderly
      Terminally ill
      Chronically mentally ill

    The draft legislation in question would directly affect the GPD and 
the special needs grant program.
Background
    On Oct. 1, 2009, NCHV President and CEO John Driscoll testified 
before this Subcommittee on the need for four bills: H.R. 2504, H.R. 
2559, H.R. 2735 and H.R. 3073. An amended version of the third bill, 
H.R. 2735, became wrapped into Section 3 of H.R. 4810, the End Veteran 
Homelessness Act of 2010. That language appears identical to Section 3 
of the current draft legislation, ``Improvement of Payments for 
Providing Services to Homeless Veterans.'' H.R. 4810 passed in the 
House by a 413-0 vote and was referred to the Senate.
Improving Grant and Per Diem Payments
    GPD grantees are reimbursed for providing transitional housing and 
supportive services based on the reimbursements provided to state 
veterans' homes. Depending on the amount of other Federal funding that 
service providers receive, these rates--which peak at $35.84 per 
veteran, per day--may be reduced. This policy is outdated considering 
the cost of comprehensive services that individuals need to rebuild 
their lives. By striking ``per diem'' from current statute and 
inserting ``annual cost of furnishing services,'' this bill would 
enable organizations to better serve homeless veteran clients with 
serious mental illness, substance abuse issues, histories of 
incarceration and disabilities.
    Community-based organizations serving these populations need round-
the-clock clinical staff, medications handlers, security personnel and 
unique facility safety enhancements. Our concern is that without this 
provision, community-based organizations will continue to struggle to 
provide transitional housing and supports for these hard-to-serve 
homeless veterans.
    Section 3 of the draft legislation would allow providers to use GPD 
funds to match other Federal funding sources. Other Federal service 
grants not only allow but encourage cross-agency collaboration. 
Penalizing GPD providers--who currently cannot draw GPD funds in 
anticipation of allowable, budgeted program expenses--by reducing per 
diem payments based on other income is counterproductive and impairs 
the delivery of services to homeless veterans. If service providers are 
going to end veteran homelessness in the next 4 years, they must be 
afforded every opportunity to make their projects work.
    VA deserves commendation for its increased investment in the GPD. 
However, since its inception the program has undergone significant 
changes in complexity, scope of services and targeted populations. This 
draft legislation would provide several modifications needed to advance 
the program's success preparing homeless veterans for transition to 
permanent housing and independent living.
Expanding the Special Needs Grant Program
    The other major section of this draft bill, Section 2, 
``Enhancement of the Grant Program for Homeless Veterans with Special 
Needs,'' would modify and expand VA's special needs grant program. The 
program is currently limited to GPD recipients and authorized at $5 
million through fiscal year (FY) 2011. This legislation would open the 
program to new eligible public or nonprofit entities, and increase its 
authorization to $21 million by FY 2013.
    NCHV recognizes this as an opportunity to widen the availability of 
services to homeless veterans whom the VA and its community partners 
have identified as needing specialized care. Women veterans, the 
fastest-growing subgroup of the homeless veteran population, will 
particularly benefit from these changes to the GPD. By VA's estimates, 
women will account for about 15 percent of the Nation's veterans within 
10 years. Although we do not yet know the full service needs of the 
latest generation of servicemembers returning from operations in Iraq 
and Afghanistan, we do know that specialized care will be required for 
single-parent homeless families and those at high risk of homelessness 
due to health and economic challenges.
    Despite NCHV's overall support for this bill, we recommend Sec. 2 
(g) (5)--which requires special needs grant recipients ``to seek to 
employ homeless veterans and formerly homeless veterans in positions 
created for purposes of the grant for which those veterans are 
qualified''--be removed.
    The meaning of this provision is not clear. The VA Special Needs 
Grants are primarily to provide transitional housing and supportive 
services to homeless veterans in specialized settings, but are not 
specifically designed to ensure employment. Most organizations that 
receive GPD funds from the VA provide employment preparation, job 
search and placement assistance, but those are funded through 
Department of Labor programs, including the Homeless Veterans 
Reintegration Program, and the Disabled Veterans Outreach Program and 
Local Veterans Employment Representatives at all one-stop career 
centers across the Nation. This provision seems to go against the 
universal objective of avoiding costly duplication of services.
In Summation
    The Health Subcommittee has provided leadership for the most 
significant pieces of homeless veterans legislation advanced in the 
111th Congress. Its members and staffs have played a powerful role in 
the newfound campaign to end veteran homelessness in 5 years. With one 
of those years already behind us, there is an even greater sense of 
urgency for action: We must ensure that our programmatic approaches are 
adaptable so that service providers' efforts are not stunted by 
outdated policies.
    From the House Committee on Veterans' Affairs to the thousands of 
community- and faith-based organizations NCHV represents across this 
Nation, we share a common goal of ending veteran homelessness. We are 
honored to be a part of this historic undertaking, and we look forward 
to continuing to work with this Subcommittee in order to achieve that 
reality.

                                 

         National Association for the Advancement of Orthotics and 
                                                        Prosthetics
                                                    Washington, DC.
                                                 September 24, 2010





The Honorable Bob Filner                  The Honorable Michael Michaud

Chairman                                                       Chairman

House Veterans Affairs Committee           House VA Health Subcommittee

U.S. House of Representatives             U.S. House of Representatives

Washington, DC 20515                               Washington, DC 20515



RE: Testimony for the Written Record: Strong Support for H.R. 5428, the 
Injured and Amputee Veterans Bill of Rights

Dear Chairman Filner and Chairman Michaud:

    The National Association for the Advancement of Orthotics and 
Prosthetics (``NAAOP'') strongly supports H.R. 5428, the Injured and 
Amputee Veterans Bill of Rights. We thank you for your leadership on 
this important issue and look forward to working with you to enact this 
key legislation this year for all veterans with amputations and other 
orthopedic injuries who require orthotic and prosthetic (``O&P'') care.
    As servicemembers return from the conflicts of the past decade with 
amputations and musculoskeletal and neuromuscular injuries, they are 
joining many other veterans who receive services from the Veteran's 
Administration (``VA'') health care system who require artificial limbs 
and orthopedic braces. In order to ameliorate the impact of these 
potentially debilitating injuries and to ensure consistent access to 
O&P patient care, the VA should establish a written set of standards 
that outline the expectations that all veterans should have with 
respect to their prosthetic and orthotic needs.
    The Injured and Amputee Veterans Bill of Rights, H.R. 5428, 
accomplishes this by proposing the establishment of a written ``Bill of 
Rights'' for recipients of VA health care who require orthotic and 
prosthetic care. This Bill of Rights will help inform and ensure that 
veterans across the country have comparable access to the highest 
quality O&P care regardless of their geographic location. It will 
ensure that veterans know they are entitled to the most appropriate O&P 
technology provided by a skilled practitioner of their choosing 
(whether or not that practitioner has a formal contract with the VA). 
They will know they have the right to a second opinion with respect to 
treatment decisions and to continuity of care when being transferred 
from the Department of Defense health program to the VA health system, 
as well as other rights and protections.
    Overall, the VA has provided quality orthotic and prosthetic care 
to veterans over the years, whether or not their underlying impairment 
has been service-connected. But there are many areas where 
inconsistencies across the country are apparent and require 
improvement. As the national focus on those injured by war begins to 
wane in the coming years, we are concerned that these inconsistencies 
will intensify across the country. That is why enactment of this 
legislation in the 111th Congress is so important.
    Your bill proposes a straightforward mechanism for ``enforcement'' 
of this ``Bill of Rights,'' an explicit requirement that every O&P 
clinic and rehabilitation department in every VA facility throughout 
the country be required to prominently display this Bill of Rights. The 
VA Web site is also required to post the Bill of Rights. In this 
manner, veterans with amputations and other injuries across the country 
will be able to read and understand what they can expect from the VA 
health care system. And if a veteran is not having their orthotic or 
prosthetic needs met, they will be able to avail themselves of their 
rights and work through the VA system to access the care they require.
    The Bill of Rights would help educate injured and amputee veterans 
of their rights with respect to O&P care, and would allow them an 
avenue to report violations of that set of standards to the VA central 
office. In this manner, Congress would have easy access to the level of 
compliance with this Bill of Rights across the country and could target 
particular regions of the country where problems persist.
    Again, we thank you for your leadership on this important issue and 
look forward to working with you to enact this legislation by the end 
of the 111th Congress.

            Sincerely,

                                                  Thomas Guth, C.P.
                                                          President

                                 
                  Statement of National Nurses United
    Thank you for the opportunity to comment for the record on H.R. 
5543, a bill to improve the collective bargaining rights and procedures 
for certain employees of the Department of Veterans Affairs. National 
Nurses United, the Nation's largest nurse union, represents nurses at 
22 VA facilities throughout the United States. However, this bill is 
incredibly important not just to our nurses who work at the Department 
of Veterans Affairs (VA), but to our entire 155,000 national 
membership. Denying the most basic protections to one nurse is an 
injustice to all nurses.
    We thank Chairman Filner for introducing this important 
legislation, and for his work on the broader legislation, H.R. 949. We 
appreciate your commitment to fair treatment for all VA health care 
workers. It's simply unacceptable that nurses would be treated as 
second-class citizens for the purposes of collective bargaining.
    This bill fixes one way in which nurses collective bargaining 
rights are different than the rights of other clinicians at the VA and 
other Federally employed nurses by allowing them to bargain over pay 
issues not related to the setting of base pay.
    One need only look to the disparate treatment of nurses at a newly 
merged VA/Navy Hospital in Chicago to see how irrational it is to apply 
more restrictive collective bargaining rights on the VA nurses who are 
working side by side with the Navy nurses. It begs the question of what 
the difference is between the care given to active duty members of the 
United States Navy and veterans. Members of the armed services of the 
United States should and do receive excellent health care, and they get 
it from nurses with collective bargaining rights that all nurses should 
have, at a minimum.
    National Nurses United is confident that if private employers and 
other Federal employers can negotiate with nurses without the 
restrictions in 38 U.S.C. 7422, it should be well within the capacity 
of the VA to manage basic collective bargaining rights for its nurses.
    We appreciate the formation of a working group to address the 
grievances that nurses have had with the Department's interpretation of 
section 7422. We hope that this workgroup will help to demonstrate the 
reality that when leadership of any organization is willing to bring 
workers to the table, everybody wins. However, such a working group can 
only hope to resolve worker complaints about the system as long as the 
Administration decides to honor their end of the bargain. Without a 
legislative solution, any future Administration can roll back such an 
agreement with impunity.
    The collective bargaining process is entirely consistent with the 
concept of ``patient centered medicine''. Nurses, as the front line 
workers in the health care system, have a right and a duty to be 
patient advocates. As such, they are quite motivated and well qualified 
to advocate for the highest quality care available for the heroic men 
and women who have laid their lives and health on the line in defense 
of our Nation.
    Delivering the best quality care means providing nurses and other 
health care workers the support that they need so that they can spend 
their time advocating for patients. When that's not the case, everyone 
loses. For example, a nurse in Buffalo, New York recently volunteered 
to give up home and family time to work through the weekend to provide 
flu shots to veterans. Her contract clearly stated that she was to be 
paid premium pay for those overtime hours. However, in addition to 
never receiving the compensation she was entitled to, she was told that 
she could also not file a grievance through her union for that overtime 
pay, because of the exemptions in section 7422. Most rational observers 
would make the determination that the pay exemptions in 7422 would only 
apply to the setting of salary levels, not filing grievances over 
violations of an existing employment contract.
    Passing H.R. 5543 would mean that a nurse like the one in Buffalo 
would be able to focus on taking care of patients rather than arguing 
with the boss over her paycheck. That is good for nurses and the heroes 
they heal.
    We ask that the Committee work to pass H.R. 5543 to ensure that 
hard-working front line nurses at the VA are treated fairly--not only 
in comparison with other government nurses and VA clinicians--but with 
the respect due any worker. Nurses choose to devote their careers to 
helping the sick and the wounded, and to preventing illness. This is 
not a choice made out of greed, cynicism, or self-concern. Once made, 
this choice leads a practicing nurse to bear witness to pain and 
suffering, but also hope and triumph the likes of which are nearly 
impossible to describe in a few pages of Congressional testimony. It is 
simply remarkable that anyone would choose to characterize their desire 
for adequate representation for themselves and their patients as self-
interested and harmful to patient care. That is why the broader 
bargaining rights in H.R. 949 have the support of the Disabled American 
Veterans, Paralyzed Veterans of America, and Vietnam Veterans of 
America. If the veterans who have come to rely on VA nurses can back 
our rights to advocate for ourselves and our patients, then so should 
the VA, and so should Congress.

                                 
           Statement of Michael O'Rourke, Assistant Director,
   National Veterans Service, Veterans of Foreign Wars of the United 
                                 States

    CHAIRMAN MICHAUD, RANKING MEMBER BROWN AND MEMBERS OF THE 
SUBCOMMITTEE:
    On behalf of the 2.1 million members of the Veterans of Foreign 
Wars of the United States and our Auxiliaries, the VFW would like to 
thank this Committee for the opportunity to present our views on 
today's pending legislation.
    H.R. 3843, To amend title 38, United States Code, to direct VA to 
publish redacted medical quality-assurance records of the Department of 
Veterans Affairs on the Internet Web site of the Department
    VFW supports the Transparency for America's Heroes Act. This bill 
would require VA to publish and make available inspection reports of VA 
facilities thirty-days after completion of the review on its Web site.
    Recent reports of contaminated instruments, unsupervised medical 
procedures and adverse conditions at a Philadelphia long-term care 
facility erode faith in the VA health care system. We believe that 
having information easily available to patients and stakeholders renews 
the emphasis on quality, accountability and sound health care 
procedures provided by all staff in every VA facility.
    By providing quality assurance records on VA's Web site you will 
close the gap between patient, VA and quality health care. It also 
offers a sense of accountability and willingness by VA to clarify 
procedures within its health care system.
    We would ask that resources and funding for VA's IT Department 
remain at appropriate levels to ensure continued efforts are made 
toward providing the information needed to implement this new effort 
toward transparency.
    H.R. 4041, To authorize certain improvements in the Federal 
Recovery Coordinator Program, and for other purposes
    VFW supports this bill as it would improve the current Federal 
Recovery Coordinator Program (FRCP) by authorizing and funding forty-
five recovery care coordinators to be trained at qualified nursing and 
medical schools selected by VA. It would also provide for the 
development of evidence-based guidelines for care coordination and best 
practices for models of care used as part of the FRCP.
    The FRCP was established to assist recovering servicemembers and 
their families by providing information with access to care, services 
and benefits within VA and DoD.
    In 2007, DoD and VA partnered to create a Federal Recovery 
Coordination Program to coordinate clinical and nonclinical care for 
the most severely injured and ill servicemembers. Today, the program is 
up and running at six military treatment centers and two VA medical 
centers, but predicting the total number of coordinators needed is 
difficult. The program itself has struggled with referrals as it 
depends on the number of eligible servicemembers and veterans enrolling 
and their specifics needs.
    VFW believes that utilizing nursing and medical schools to train 
coordinators is a positive step forward and highlights the need for 
fundamental changes in care management. Today's injured servicemembers 
deserve greater coordination as they struggle with complex injuries 
that often hinder their transition from military to civilian life. 
Having someone trained properly to guide the way is only the first step 
toward recovery.
    H.R. 5428, To direct the Secretary of VA to educate certain staff 
of the Department of Veterans Affairs and to inform veterans about the 
Injured and Amputee Veterans Bill of Rights, and for other purposes
    The VFW supports this legislation, which would require the display 
of an injured and amputee veterans bill of rights. The display 
reaffirms and clarifies the rights of these injured servicemen and 
women, letting them know what they can expect from VA.
    We believe that this bill would ensure consistency in the orthotic 
and prosthetic (O&P) benefit program under the VA health care system. 
It would also allow veterans to select the practioner that best meets 
their needs, and provide them ample access to vocational 
rehabilitation, employment and housing assistance. The bill also goes 
one step further by requiring all VA O&P clinics to post the bill of 
rights and create a mechanism of enforcement by establishing a 
complaint system so that veterans can report mistreatment or a lapse in 
care.
    H.R. 5516, The Access to Appropriate Immunizations for Veterans Act 
of 2010
    VFW supports legislation that would improve health outcomes for 
veterans by expanding VA performance measures to cover vaccines 
recommended by the Center for Disease Control and Prevention (CDC). The 
recommended adult immunization schedule is periodically reviewed and 
revised so that vaccinations are scheduled at the time in which they 
are needed most.
    Currently VA only administers the influenza and pneumococcal 
vaccinations. Congressman Stearns' legislation would authorize VA 
performance measures to cover all vaccinations recommended by VA and 
CDC so veterans, especially those in ``high risk'' categories, would 
receive timely access to vaccines that may help prevent diseases and 
long-term hospital stays. By following suggested vaccine protocols, we 
see a win-win in the delivery of health care and improved health care 
outcomes within VA.
    H.R. 5543, A bill to alter collective bargaining rights of VA 
employees
    This bill would permit VA employees to contest aspects of their 
pay. Under this legislation, employees would be able to file grievances 
and negotiate all compensation that is not considered basic pay, to 
include bonuses, merit pay, and other compensable items. It would still 
bar VA employees from petitioning for a basic pay structure that 
differs or is inconsistent with the General Schedule or other Federal 
basic pay structures; it would merely give them the option to file a 
grievance with respect to additional pay. The VFW has no position on 
this legislation.
    H.R. 5641, Legislation that would authorize the Secretary of 
Veterans Affairs to enter into contracts to transfer veterans that are 
unable to live independently into adult foster homes.
    The VFW supports this bill, which would add language to Section 
1720 of Title 38 to allow veterans who receive VA care and require a 
protracted period of nursing home care to transfer into an adult foster 
home. Under the bill, such homes must have the goal of providing non-
institutional, long-term, supportive care. VA currently has the 
authority to reimburse institutional care facilities such as nursing 
homes for long-term domiciliary care, but veterans living in adult 
foster homes must do so at their own expense. To grant VA authority to 
reimburse adult foster homes would provide veterans with an additional 
residency choice and improve the quality of life for those who would 
prefer this option.
    The language protects veterans who may wish to reside in such a 
setting by requiring caregivers to reside on premises, to receive 
annual training, and to provide 24-hour care. The adequacy of their 
living conditions would be ensured through language that would grant 
needed devices in the home, such as lifts or closed captioning devices. 
As part of the contracting process, adult foster homes would be 
required to accept announced and unannounced visits, and the caregivers 
who run them would be screened by the VA in addition to being required 
to pass a Federal background check.
    We believe this language defines what and who can serve veterans 
through an adult foster home in an adequately narrow way, while also 
responsibly providing the chance to live in a family setting that will 
be more beneficial for the physical and mental health of veterans of 
all ages.
    H.R. 5996, Legislation to direct the Secretary of Veterans Affairs 
to take a more aggressive posture in its treatment of Chronic 
Obstructive Pulmonary Disease.
    The VFW supports this effort. Chronic Obstructive Pulmonary Disease 
(COPD) affects our veterans at a rate approximately three times higher 
than their civilian counterparts, and it is the fourth most common 
diagnosis among hospitalized veterans. And among veterans age 65-74, it 
is the most common diagnosis leading to hospitalization.
    This legislation would improve our response to COPD by requiring VA 
to develop treatment protocols to prevent, diagnose, treat and manage 
the disease and also to improve biomedical and prosthetic research. It 
also requires the VA to develop pilot programs to gain a better 
understanding of best practices in this area of medicine. Finally, the 
bill contains provisions that require VA to develop better smoking 
cessation programs to improve techniques and best practices to assist 
veterans who want to improve their health outlook by successfully 
quitting smoking.
    H.R. 6123, To amend title 38, United States Code, to improve the 
provision of rehabilitative services for veterans with Traumatic Brain 
Injury
    The VFW supports this legislation, as it would make significant 
improvements to Chapter 17 of Title 38 by expanding the plan for 
rehabilitation and reintegration of TBI patients to account for the 
individual's independence and quality of life.
    It expands objectives for the rehabilitation of veterans suffering 
from a TBI to include behavioral and mental health concerns. As a 
result of this bill, the phrase `rehabilitative services' vice 
treatments would be an overarching theme in Chapter 17, thereby 
conforming the code to the prevailing wisdom that TBI patients deserve 
more than mere treatment of their injuries--rather, they deserve 
ongoing evaluation and additional intervention where necessary to 
ensure a full recovery. We believe the changes in this bill would make 
it easier for veterans struggling with the aftermath of a TBI to 
receive such coverage.
    Finally, this bill would also support TBI patients by associating 
sections of the law related to TBI rehabilitation and community 
reintegration to a broader definition of the term `rehabilitative 
services' in Title 38 that comprises a range of services such as 
professional counseling and guidance services. Our veterans deserve an 
optimal chance to lead productive lives, and this bill would help to 
ensure our response to Traumatic Brain Injuries consists of more than 
just healing the physical wounds of war.
    H.R. 6127, A bill to provide for the continued provision of health 
care services to certain veterans who were exposed to sodium dichromate 
while serving as a member of the Armed Forces at or near the water 
injection plant at Qarmat Ali, Iraq, during Operation Iraqi Freedom.
    Over the course of the last several months, information has 
surfaced revealing that approximately 800 servicemembers were exposed 
to harmful chemicals while guarding sensitive infrastructure in Iraq 
during the first half of 2003. These servicemembers, Guardsmen and 
women from a number of different states, were not exposed to a quantity 
of contaminant considered to be causal to any harmful effects; however, 
the VFW fully supports taking extraordinary precautions in this case.
    This legislation would extend enrollment eligibility into the VA 
health care system for all veterans exposed to sodium dichromate at 
Qarmat Ali by 5 years from the day they were notified of their 
exposure. We have been assured that the VA is reaching out to inform 
those exposed of their options for care and to advise them on VA 
recommended examinations and treatments, and the VFW appreciates this 
effort on their behalf. We support this legislative effort to give them 
every reasonable opportunity to seek VA health care as a result of 
their sacrifice and selfless service to our country.
    Draft bill, To amend title 38, United States Code, to make certain 
improvements in programs for homeless veterans administered by the 
Secretary of Veterans Affairs and for other purposes.
    VFW supports draft legislation that would enhance many homeless 
veterans programs. This bill greatly increases funding for various 
homeless programs and expands the availability of resources needed by 
homeless veterans, while including provisions that encourage treatment 
facilities providing care to homeless veterans to use the available 
funding effectively.
    The bill also addresses the shortfall in funding for aiding 
homeless veterans. Prior to this bill funding for health care 
facilities for treatment of homeless veterans was $5 million a year. 
With this bill funding would increase in FY 2011 to $10 million, $15 
million in FY 2012, and top out at $21 million in FY 2013. The increase 
in funding is needed and would help to expand services across the board 
for homeless veterans programs.
    The VFW commends the Committee for taking a step in the right 
direction; however, we are concerned that the structure of this 
temporary increase does not adequately reflect the needs of our 
veterans. Thousands of Iraq and Afghanistan veterans are returning home 
to tough economic conditions, often having to give up homes and housing 
to support the mission, and we believe there is a clear preponderance 
of data that demonstrates the need for scrutiny of these programs in 
addition to this supplemental funding. All veterans should have access 
to every resource they are entitled to when they are in need, and the 
VFW is convinced that in order to meet that need, funding levels should 
not be reduced to levels prior to FY 2011.
    The VFW recognizes the many challenges our Nation faces in 
addressing homelessness among our veterans. For many, the road to 
homelessness is littered with complications related to medical 
conditions such as post-traumatic stress disorder, traumatic brain 
injury, or drug and alcohol addiction. The provision of temporary 
housing and/or job placement is only a treatment of some of the 
symptoms of homelessness, and is far from a cure.
    By striking the term ``health care facilities'' and amending it to 
read ``eligible entities for the purpose of establishing programs, or 
expanding or modifying programs that provide assistance to homeless 
veterans'' they would have at their disposal an improved array of 
options. Specifically, rehabilitation facilities, work placement 
services, and homeless shelters that do not necessarily provide medical 
care would be authorized to receive funding in exchange for their 
services. This multi-pronged approach represents a long overdue 
tactical change that will help to combat homelessness among the veteran 
population.
    We also applaud the changes in Section 2061 that will institute 
various safeguards to ensure that funding is used properly by approved 
facilities. Proper use of funding and proper oversight--wise 
stewardship of the taxpayer's dollar--should never be an ancillary 
concern, particularly in this fiscally constrained environment. Making 
sure that the funds available are spent wisely or be returned to the VA 
encourages programs to use every available dollar to improve and expand 
their services. With countless veterans suffering from both the visible 
and invisible wounds of war completing their overseas tours and 
separating from the military with bleak job prospects at home, we must 
ensure an adequate safety net for those veterans who are experiencing 
hard times.
    Draft bill, To amend title 38, United States Code, to ensure that 
health care professionals of VA provide veterans with information 
concerning service-connected disabilities.
    VFW supports draft legislation that would encourage VA health care 
professionals to furnish information to veterans about benefits 
provided by the Veterans Health Administration, including guidance on 
how to apply for compensation relating to a service-connected 
disability. Far too many veterans seeking health care services from VA 
are not aware of the full range of their earned benefits or how to 
acquire them. VA health care professionals should be providing needed 
information, advice and assistance. We believe such a change would help 
facilitate the acquisition of earned and needed compensation, pension, 
and other benefits. We believe that this is an important opportunity 
for VA to continue to improve upon their outreach services on behalf of 
those who have worn the uniform and served our great Nation.
    Thank you for the opportunity to present our views before this 
Subcommittee.

                                 
      Prepared Statement of Richard F. Weidman, Executive Director
     for Policy and Government Affairs, Vietnam Veterans of America

    Mr. Chairman, Ranking Member Brown, and distinguished members of 
the House Veterans' Affairs Subcommittee on Health, Vietnam Veterans of 
America appreciates the opportunity to present our views on nine bills 
up for your consideration this morning.
    H.R. 3843, the ``Transparency for America's Heroes Act,'' would 
direct the Secretary of Veterans Affairs to publish on the VA Web site 
redacted medical quality-assurance records and documents (but not 
personal identifying information) created by the VA.
    In general, despite lapses in care at individual medical centers, 
the VA--actually, the Veterans Health Administration--provides good to 
excellent care at medical centers and community-based outpatient 
clinics for more than five million veterans annually. If the VA is to 
achieve and retain the confidence of the veterans it serves, opening 
for ease of public inspection quality-assurance records makes good 
managerial sense. If passage of H.R. 3843 can help bring a measure of 
transparency to what has, for the most part, been a cloistered process, 
it has VVA's full endorsement.
    H.R. 4041 would direct the Secretary of Veterans Affairs to provide 
collaborative recovery coordinator training at a ``qualified'' nursing 
or medical school, and would authorize said nursing or medical school 
to train 45 recovery coordinators.
    While this bill, on the surface, sounds important, and while it 
addresses a very real need, VVA believes it is in the purview of the VA 
Secretary to determine how best to set up recovery coordinator training 
and train whatever number of recovery coordinators he deems fit.
    At the same time, Congress needs to exercise its powers of 
oversight to ensure that the VA does all that is necessary to 
coordinate the treatment and recovery of badly wounded or injured 
veterans. We do not believe that a prescriptive bill such as H.R. 4041 
will necessarily be an effective way to get VHA to comply with its 
national mandate, although we certainly understand your frustration 
with the VHA on this and other issues that should be ``no-brainers'' 
for the VHA to accomplish.
    We would respectfully point out that provisions in H.R. 4041, 
specifically for the development of ``care coordination software,'' 
open the possibility of a boondoggle, and seem at odds with the 
centralization of IT within the VA.
    H.R. 5428 would direct the Secretary of Veterans Affairs to ensure 
that an Injured and Amputee Veterans Bill of Rights is printed on 
signage in accessible formats and displayed prominently and 
conspicuously in each VA prosthetics and orthotics clinic. It would 
require that VA employees who work at such clinics, as well as patient 
advocates for veterans who receive care there, receive training on the 
elements in said Bill of Rights. It also would direct the Secretary to 
conduct outreach to inform veterans of this Bill of Rights.
    The difficulty we have with this piece of legislation is elemental: 
If Congress sees fit to enact a Bill of Rights for injured and amputee 
veterans, why not enact a similar Bill of Rights for blinded veterans, 
and one for homeless veterans, and one for women veterans? Or perhaps 
one Bill of Rights for all veterans? (This latter VVA would heartily 
endorse.)
    We also quibble with the provision that would direct the Secretary 
to conduct outreach to inform veterans of the provisions in an Injured 
and Amputee Veterans Bill of Rights. The VA needs to do a far better 
job in informing all veterans, and their families, about the health 
care and other benefits earned by veterans by virtue of their service 
in uniform, and about health conditions that may derive from a 
veteran's time in service. Under the leadership of Secretary Shinseki, 
the VA is finally moving in this direction, although it admittedly has 
little expertise with marketing and advertising.
    We would quibble, too, with the provision of submitting a quarterly 
report to the VA's Chief Consultant of Prosthetics and Sensory Aids on 
information collected relating to alleged mistreatment of injured and 
amputee veterans. If this is to be done for one subgroup of veterans, 
why not for all subgroups of veterans? Or, better yet, simply for all 
veterans?
    H.R. 5516, the ``Access to Appropriate Immunizations for Veterans 
Act of 2010,'' would include within authorized preventive health 
services available to veterans through the Department of Veterans 
Affairs immunizations against infectious diseases on the recommended 
adult immunization schedule established by the Advisory Committee on 
Immunization Practices established by the Secretary of Health and Human 
Services and delegated to the Centers for Disease Control and 
Prevention.
    This bill makes good sense insofar as it focuses on vaccinations 
for infectious diseases with vaccines approved by the FDA. We would 
hope, however, that it doesn't do for veterans what was done for 
active-duty troops in the all too recent past, who were forced to be 
inoculated against smallpox and then anthrax in a panic over the 
possibility that rogue enemies could somehow unleash these viruses on 
an unsuspecting American military and public.
    VVA also urges this distinguished Committee to take similar action 
for all pharmaceutical treatments approved by the FDA, and 
automatically list them on the VA formulary unless it is demonstrated 
through open hearings that a product is not effective or potentially 
harmful. The VA formulary process needs to be brought out into the 
light of day, exposed to the sunshine, and codified in statute to end 
the backroom deals in the ``dead of night'' non-transparent process 
that the VA currently uses. This President has often emphasized his 
Administration's commitment to ``Open Government.'' VVA lauds that 
principle, and urges the Congress to bring that open government process 
to listing of pharmaceuticals. Enacting a process that mirrors the DoD 
formulary process into Title 38 for VA is appropriate, and should be a 
high priority for the Congress to get done within the next year.
    VVA supports the enactment of H.R. 5516.
    H.R. 5543 would repeal the prohibition on collective bargaining 
with respect to matters and questions concerning compensation of 
employees of the Department of Veterans Affairs other than rates of 
basic pay.
    VVA sees no legitimate reason why VA clinicians and other health 
care professionals are barred from bargaining over additional 
compensation issues such as overtime pay and physician performance 
bonuses. VVA sees no credible rationale why these professionals are not 
accorded the same rights as are other Federal employees when it comes 
to seeking redress in disputes with management.
    Frankly, the VA nursing service has for far too long been plagued 
by a destructive mind-set that favors ``nurse executives'' and is 
disdainful of bedside nurses and other actual caregivers who actually 
touch patients and are the heart of the provision of good medical care. 
This inappropriate and ugly attitude manifests in the treating of the 
staff members who provide actual ``hands-on'' care virtually as chattel 
who should have no say in working conditions. This must end.
    Because enactment of H.R. 5543 would bring a long-needed measure of 
justice for health care professionals at VA medical facilities, VVA 
strongly supports its passage.
    H.R. 5641, dubbed the ``Heroes at Home Act,'' would authorize the 
Secretary of Veterans Affairs to enter into contracts for the transfer 
to non-Department adult foster homes for veterans who are unable to 
live independently.
    If such a veteran who is eligible to be transferred to a non-VA 
nursing home prefers to be transferred instead to a home designed to 
provide non-institutional, long-term, supportive care in a family 
setting, VVA sees no reason why policy--and the legal foundation for 
such policy--would not facilitate this. Nursing homes, even well run 
facilities, can be oppressive places. Adult foster homes, with proper 
oversight by the VA, can be attractive alternatives. As such, VVA 
supports enactment of this legislation.
    VVA also notes that much more attention overall needs to be paid to 
our most vulnerable veterans, especially in regard to those with 
guardians and whose funds are controlled by someone else who is 
supposed to be looking out for those who cannot care for themselves. A 
GAO report that examines all aspects of fiduciaries would be useful in 
this regard.
    H.R. 5996 would direct the Secretary of Veterans Affairs to improve 
the prevention, diagnosis, and treatment of veterans with chronic 
obstructive pulmonary disease ``subject to the availability of 
appropriations provided for such purpose.''
    While we have no problem with the intent of this legislation, the 
only way it will realistically happen is if Congress does in fact 
appropriate funds for its implementation. That said, Congress ought to 
mandate the VA to develop techniques and strategies to encourage 
veterans who smoke to cease smoking, whether they have developed COPD 
or not, and to prioritize an anti-smoking campaign at the top of its 
preventive health programs. If passed without specifically targeted 
funding, H.R. 5996 will be little more than another item on a laundry 
list of ``Things to Do'' at VA medical facilities.
    VVA specifically notes that there are pharmacological treatments 
and other treatment modalities available in the private sectors that 
are difficult if not virtually impossible to get on the VA formulary. 
We suspect that much of the problem here is the ``blame game'' that 
goes ``It is his own fault he is sick, so we should not do much to help 
him.'' That attitude has no place in veterans' health care.
    H.R. 6123, the ``Veterans' Traumatic Brain Injury Rehabilitative 
Services' Improvements Act of 2010,'' would in essence tweak Section 
1710C of title 38 to more broadly define provisions for assisting 
veterans afflicted with Traumatic Brain Injury (TBI), the ``signature 
injury'' of the wars in Afghanistan and Iraq. VVA supports the intent 
of this legislation.
    H.R. 6127 would provide for the continued provision of health care 
services to veterans who were exposed to sodium dichromate while 
serving in the U.S. Armed Forces at or near the water injection plant 
at Qarmat Ali, Iraq, during Operation Iraqi Freedom.
    Toxic substances can be insidious; often their effects do not 
manifest till health conditions develop years after a veteran's 
exposure in the military. As Vietnam veterans, we know this to be the 
case vis a vis exposure to dioxin, to Agent Orange, when we served in 
Southeast Asia. Because we are still learning about the effects of 
exposure to sodium dichromate to troops who were stationed at or near 
Qarmat Ali, extending their eligibility for VA health care would be a 
prudent investment in maintaining their health and treating maladies 
that may have derived from their service in Operation Iraqi Freedom.
    We would submit, however, that the VA has an obligation to track 
the health status of all veterans thus exposed so as to better 
determine what health conditions may, in fact, be attributed to 
exposure to sodium dichromate. There may also be other toxins that 
emanate from these same or similar sources, so VVA urges more complete 
epidemiological tracking of health problems in returning warriors, 
depending on when and where they served. Ensuring such tracking ought 
to be an added provision of H.R. 6127.
    H.R. 6188, the Veterans' Homelessness Prevention and Early Warning 
Act of 2010, would amend paragraph (4) of subsection (a) of section 
3732(a)(4)(A) of title 38, United States Code, to ensure that a case 
manager develops a plan to provide alternate housing for the veteran in 
the event that the veteran loses the veteran's home. VVA supports 
enactment of this bill.
    Draft legislation to make certain improvements in programs for 
homeless veterans administered by the Secretary of Veterans Affairs 
contains many very well-thought out facets that should assist Secretary 
Shinseki and his staff in their efforts to end homelessness among 
veterans by 2015.
    Ending homelessness among veterans surely is a worthy goal. If 
policies, processes, and practices by the VA and other entities of 
three levels of government--local, state, and Federal--can function in 
concert, to create a continuum of care, we would hope that homelessness 
among veterans can continue to be reduced significantly, although some 
veterans for whatever reasons will choose to live their life on the 
streets, in flophouses, or out in the woods.
    This legislation does contain some particularly important clauses. 
For instance, it would direct grant recipients, as a condition of 
accepting a grant, to ``maintain referral networks . . . for 
establishing eligibility for assistance and obtaining services, under 
available entitlement and assistance programs.''
    We do believe, however, that the schedule of appropriations for 
grants--$10 million for FY 2011, $15 million for FY 2012, and $21 
million for FY 2013--perhaps ought to be reversed. Why? Because if the 
programs and services currently in existence, and additional programs 
and services as established by this and other legislation succeed in 
achieving their stated purpose, there will be fewer veterans to avail 
themselves of these programs and services. Hence, we would suggest that 
appropriations be at a constant level, e.g., $15 million for each of 
the next three fiscal years.

                               __________

    It should be noted that VVA continues to urge that VA Homeless 
Grant and Per Diem (HGPD) funding must be considered a payment rather 
than a reimbursement for expenses, a key distinction that will enable 
the community-based organizations that deliver the majority of these 
services to operate more effectively.
    This legislation attempts to make the funding provided to HGPD 
providers more accessible by creating a vehicle to enable them to 
better access reimbursement. If a provider is able to draw from the 
available funds on a monthly basis with program expenditures for 
reconciliation on a quarterly basis, then VVA supports this language.
    If funds are available on a ``short turnaround'' drawdown that is 
directly deposited into provider accounts, monies would be more 
immediately available. The current method of voucher submissions 
through local medical centers creates a lag in payment for weeks. With 
the monthly drawdown, a non-profit agency would not have to utilize its 
line of credit (if it even has one) to make payroll or pay program 
expenses. Also, the fees associated with this practice cannot be 
charged back as an expense to the program.
    VVA also supports allowing greater than quarterly expenditures in 
any given quarter if a need for these additional expenses exists.
    Community non-profit providers, most of them small, that serve 
homeless veterans cannot survive if they are permitted to draw down 
from the quarterly amount only on a quarterly basis. Creditors, 
purveyors, utilities, and the like must be paid monthly. Non-profits 
held to a quarterly payment method would be hard-pressed to meet their 
financial obligations in a timely fashion. If bill language means that 
the providers can only draw down from the quarterly amount on a 
quarterly basis, then VVA must oppose this provision.
    VVA also supports the submission of future anticipated expenses 
rather than past spent program expenses.
    One of the most effective front-line outreach operations funded by 
VA HGPD is the Day Service Center, sometimes referred to as a Drop-In-
Center. Few even remain in the HGPD system because of limited per diem 
funding support. These service centers are an indispensable resource 
for VA outreach. They can reach deep into the homeless veteran 
population on the streets and in the shelters of our cities and towns. 
They are the portal from the streets and shelters to substance abuse 
treatment, job placement, job training, VA benefits, VA medical and 
mental health care and treatment, homeless domiciliary placement, and 
transitional housing. They are the first step to independent living. 
They can be the first step to ending homelessness. But this can only 
happen if they are able to operate in an effective environment.
    Under the VA HGPD program, non-profits receive per diem at rates 
based on an hourly calculation per diem (one-eighth of the allowable 
per diem for residential programs) for the time that the homeless 
veteran is physically in the center. While this may cover the cost of 
the coffee and food that the veteran receives, it does not come close 
to paying for the professional staff that must provide the assistance 
and comprehensive services long after that veteran leaves the facility, 
and the demands on staff require a significant amount of time, energy, 
and manpower in order to be effective and, hence, successful.
    It is unfortunate that the current per diem funding model is simply 
not sufficient to sustain the operations of many community-based 
service centers. Many have either closed or never opened after being 
funded by VA HGPD. The VA acknowledges and understands that this 
situation exists.
    At the very least, VVA hopes that Service Centers are also included 
in the annual set-aside program funding available monthly with 
quarterly reconciliation. If not, we believe that it is necessary to 
create ``Service Center Staffing/Operational'' grants, much like the VA 
``Special Needs'' grants that were previously legislated, although this 
is hardly an optimal solution, particularly with regards to funding 
programs that work with some of the hardest to place and most chronic 
of our homeless veteran population.
    Draft legislation to ensure that the Secretary of Veterans Affairs 
provides veterans with information concerning service-connected 
disabilities at health care facilities makes sense insofar as it goes. 
However, it does not go far enough.
    VVA would like to see Congress orient a major outreach campaign to 
all veterans, not only to those veterans who already use VA health care 
facilities. Seven out of ten veterans do not obtain health care at VA 
facilities, and far too many of them are unaware not only of the 
benefits to which they are entitled by virtue of their service to this 
Nation, but of health conditions that may derive from their time in 
service because of exposure to toxic substances.
    The VA needs to conceptualize and coordinate an outreach and 
information campaign that avails itself of public service announcements 
featuring real veterans as well as recognizable stars like Gary Sinise 
and Dennis Franz; signage on billboards; point-of-purchase displays in 
hardware stores, sporting emporiums, doctors' offices, and other places 
patronized by veterans and their families (because more often than not 
veterans are reached through their families).
    Thanks you for the opportunity to appear here this morning to 
express the views of VVA. I will be pleased to answer any questions, 
Mr. Chairman.
                   MATERIAL SUBMITTED FOR THE RECORD

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                    October 4, 2010

Mr. Jacob B. Gadd
Deputy Director, Veterans Affairs and Rehabilitation Commission
The American Legion
1608 K Street, NW
Washington, DC 20006

Dear Mr. Gadd:

    Thank you for your testimony at the U.S. House of Representatives 
Committee on Veterans' Affairs Subcommittee on Health legislative 
hearing on H.R. 3843, H.R. 4041, H.R. 5428, H.R. 5516, H.R. 5543, H.R. 
5641, H.R. 5996, H.R. 6123, H.R. 6127, H.R. 6220, Draft Legislation on 
Homelessness, and Draft Legislation on VA Health care Provisions, which 
took place on September 30, 2010.
    Please provide answers to the following questions by Monday, 
November 15, 2010, to Jeff Burdette, Legislative Assistant to the 
Subcommittee on Health.

     1.  In their testimony, DAV questioned whether making quality 
assurance medical records available on a VA Web site would be easily 
understandable and meaningful for our veterans and their families to 
make informed decisions. Do you share this concern? Do you have any 
specific recommendations on ways to improve this bill so that the 
quality assurance medical records that VA posts on their Web site are 
meaningful and useful?
     2.  Many of the witnesses on the second panel emphasized the need 
to balance confidentiality and transparency. In fact, VA explains that 
it is precisely the confidential nature of the quality-assurance 
program that allows providers to report and examine patient safety 
events without fear of recrimination or liability. What specific 
barriers and challenges must VA overcome before they can make quality 
assurance records available to the public without compromising patient 
confidentiality?
     3.  In your written testimony, you recommended enhanced 
communication between national, state and local levels to ensure 
maximum awareness of benefits that are available. Could you expand on 
this point and provide more detailed recommendations on ways to enhance 
communication?
     4.  Some have raised concerns about limiting the bill of rights to 
injured and amputee veterans. What are your thoughts on a bill of 
rights for all veterans which encompasses rights for injured and 
amputee veterans?
     5.  PVA raised concerns with H.R. 5428 ignoring veterans who may 
be in need of special equipment who suffer from a specific disease and 
not a physical injury. Do the other witnesses of this panel share this 
concern? Why or why not?
     6.  VVA raises some caution with H.R. 5516 by stating that they 
hope that the bill ``doesn't do for veterans what was done for active-
duty troops in the all too recent past, who were forced to be 
inoculated against smallpox and then anthrax in a panic.'' Do you share 
this concern? Why or why not?
     7.  VA explains that H.R. 5543 would ``result in unprecedented 
changes in how the Federal Government operates. It would permit unions 
to bargain over, grieve, and arbitrate a subject--employee 
compensation--that is generally exempted from collective bargaining.'' 
There was unanimous support for this bill by the witnesses on the 
second panel. How do you respond to VA's concerns?
     8.  In addition to the provisions of H.R. 6123, the TBI 
Improvement Act, please share your insight on additional authorities 
that would be helpful in ensuring better health outcomes for our 
veterans with TBI.
     9.  PVA recommends that a broader spectrum of veterans is targeted 
instead of singling out the Qarmat Ali veterans for enrollment in H.R. 
6127. Do the other witnesses of this panel share PVA's recommendation? 
Why or why not?
    10.  In your testimony, you recommended that each VA medical center 
create a VHA/VBA training liaison position to facilitate biannual 
training and updates on VBA regulations for VHA providers. Which VHA 
providers should participate in this training and should other, non-
providers who work at the VA medical centers partake in this training?
    11.  In your testimony, you identified the need for ``Congress and 
VA to address the growing concern with homeless women veterans, 
especially those with children.'' The draft homeless veterans bill is 
targeted to the special needs population, which include women veterans 
with children. In addition to the creation of a new capital grants 
program as specified in the draft bill, what other programs and 
services should VA provide to help women veterans with children?

    Thank you again for taking the time to answer these questions. The 
Committee looks forward to receiving your answers by November 15, 2010.

            Sincerely,

                                                 MICHAEL H. MICHAUD
                                                           Chairman

                               __________

                                                    American Legion
                                                    Washington, DC.
                                                  November 15, 2010

Honorable Michael Michaud, Chairman
Veterans' Affairs Subcommittee on Health
U.S. House of Representatives
A335 Cannon Office Building
Washington, DC 20515-6335

Dear Chairman Michaud:

    Thank you again for allowing The American Legion to testify at the 
September 29th hearing regarding pending legislation affecting 
veterans' health issues. This letter is in response to your Post-
Hearing Questions:

    Question 1: In their testimony, DAV questioned whether making 
quality assurance medical records available on a VA Web site would be 
easily understandable and meaningful for our veterans and their 
families to make informed decisions. Do you share this concern? Do you 
have any specific recommendations on ways to improve this bill so that 
the quality assurance medical records that VA posts on their Web site 
are meaningful and useful?

    Response: The American Legion has a number of concerns regarding 
the publication of quality assurance medical records online. Even a 
cursory examination of VA data security over the last several years 
will show a troubling pattern of data breaches and compromised security 
of veterans' personal information. Obviously, this would remain a 
primary concern of the Legion, the protection of veterans' personal 
information. While it is possible to redact this information towards 
the end of protecting patient privacy, it is unclear as to whether this 
redacted information could be of use. The American Legion does support 
more clarity and transparency from VA in all aspects of quality 
assurance, but to be of real benefit there would need to be more detail 
concerning making this information useful to a layman such as a veteran 
or their family. The most helpful information for veterans would be an 
indication of what common errors and deficiencies are at a particular 
medical institution.

    Question 2: Many of the witnesses on the second panel emphasized to 
balance confidentiality and transparency. In fact, VA explains that it 
is precisely the confidential nature of the quality assurance program 
that allows providers to report and examine patient safety events 
without fear of recrimination or liability. What specific barriers and 
challenges must VA overcome before they can make quality assurance 
records available to the public without compromising patient 
confidentiality?

    Response: To begin with, The American Legion must reiterate that 
data security has been a major issue for VA over the last several 
years, and it will take time to rebuild confidence in data security. VA 
can help with this by adopting even more transparency in the measures 
they are taking to protect patient information. At the very least, all 
potential identifying information must be stripped away to prevent 
possible identification and exploitation of that information.

    Question 3: In your written testimony, you recommended enhanced 
communication between national, State and local levels to ensure 
maximum awareness of the benefits that are available. Could you expand 
on this point and provide more detailed recommendations on ways to 
enhance communication?

    Response: One of the largest concerns that The American Legion has 
recognized through the System Worth Saving visits made annually to VA 
medical facilities is that there is a lack of consistency from VISN to 
VISN in the implementation of policy. More control through Central 
Office to ensure standardization should be the starting point. 
Following on from there, VA should target individual communities 
through public awareness campaigns to let veterans know of the 
resources in their area and the availability of these benefits. Rather 
than worrying about how to reach veterans, VA should adopt the attitude 
that veterans are an integral part of every community and simply seek 
to reach out to the general public and increase awareness. Many 
veterans may not know they can receive treatment at CBOC clinics or 
pharmacy benefits, yet through public service advertising on TV and on 
the Internet, veterans can be directed to VA Web sites and facilities 
to determine the benefits to which they are entitled.
    Furthermore, on numerous occasions The American Legion experienced 
difficulties in contacting the Federal Recovery Coordinators (FRCs). As 
a result, we would like to recommend increasing the FRC staff to one 
coordinator in each state as opposed to only 25 coordinators throughout 
the country. This effort should alleviate the workload and enhance 
communication across the National and local levels.

    Question 4: Some have raised concerns about limiting the bill of 
rights to injured and amputee veterans. What are your thoughts on a 
bill of rights for all veterans which encompasses rights for injured 
and amputee veterans?

    Response: The American Legion believes that the intent of this 
legislation is to focus on a certain group of veterans with certain 
life-altering conditions. Veterans with amputations and other severe 
injuries face unique issues and barriers compared to veterans with 
minor injuries. In essence, the Injured and Amputee Veterans' Bill of 
Rights is to alleviate some of the barriers that these veterans 
encounter. Therefore, the American Legion believes it should remain as 
such.

    Question 5: PVA raised concerns with H.R. 5428 ignoring veterans 
who may be in need of special equipment who suffer from a specific 
disease and not a physical injury. Do the other witnesses of this panel 
share this concern? Why or why not?

    Response: The American Legion stands by its position that the 
Injured and Amputee Bill of Rights should focus on injured and amputee 
veterans. However, we would like to emphasize that VA should continue 
to provide the best quality of health care to our veterans. Simply 
because one bill provides for a specific group of veterans does not 
alleviate VA's responsibility of care for the rest of the veterans that 
they serve.

    Question 6: VVA raises some caution with H.R. 5516 by stating that 
they hope the bill ``doesn't do for veterans what was done for active 
duty troops in the all too recent past, who were forced to be 
inoculated against smallpox and anthrax in a panic.'' Do you share this 
concern? Why or why not?

    Response: The American Legion fully supports VA's efforts to 
provide for necessary immunization and vaccination. However, we do 
believe that this effort should be voluntary and not mandatory. It 
would impose on a patient's right to choose their treatment course if 
they had no say in whether they were vaccinated or not. For an example 
of how this is sensibly implemented, consider the current annual flu 
shots, which are provided for those veterans who choose to partake in 
them, yet are not required treatment in any way.

    Question 7: VA explains that H.R. 5543 would ``result in 
unprecedented changes in how the Federal Government operates. It would 
permit unions to bargain over, grieve and arbitrate a subject--employee 
compensation--that is generally exempted from collective bargaining.'' 
There was unanimous support for this bill by the witnesses of the 
second panel. How do you respond to VA's concerns?

    Response: The American Legion has no position and therefore does 
not support or oppose the legislation.

    Question 8: In addition to the provisions of H.R. 6123, the TBI 
Improvement Act, please share your insight on additional authorities 
that would be helpful in ensuring better health outcomes for our 
veterans with TBI.

    Response: In addition to the provisions of H.R. 6123, The American 
Legion would recommend that VA incorporate more holistic approaches as 
a part of the rehabilitative care administered to veterans who suffer 
from Traumatic Brain Injury. The holistic treatment can include more 
herbal remedy instead of pharmaceutical drugs, as well as other avenues 
such as massage therapy and meditation.

    Question 9: PVA recommends that a broader spectrum of veterans is 
targeted instead of singling out the Qarmat Ali veterans for enrollment 
in H.R. 6127. Do other witnesses of the panel share PVA's 
recommendation? Why or why not?

    Response: The American Legion fully concurs with this 
recommendation. As stated previously in testimony, The American 
Legion's policy on Hazardous Environmental Exposure requires that all 
veterans who were exposed to environmental hazards are afforded the 
necessary health care and compensation due to the extent of any lasting 
effects of the exposure.

    Question 10: In your testimony, you recommend that each VA Medical 
Center create a VHA/VBA training liaison position to facilitate 
biannual training and updates on VBA regulations for VHA providers. 
Which VHA providers should participate in this training, and should 
other, non-providers who work at the VA medical centers partake in this 
training?

    Response: During the American Legion System Worth Saving site 
visits, The American Legion found that veterans are not receiving 
information from VHA providers about their rights to file claims 
through VBA. Furthermore, during American Legion Quality Review visits 
to VBA Regional Offices, it became apparent that communication of 
information between medical centers and the offices processing 
veterans' claims were vastly improved when there was a dedicated 
individual set to facilitate this task. Based on these findings, The 
American Legion recommends that VA hire a VHA/VBA Liaison within each 
VA Medical Center to initiate biannual training to VHA primary care 
providers so that they are educated on VBA regulations and can pass on 
that information to their patients during their routine visits. In 
addition, The American Legion recommends that the same VHA/VBA bi-
training also be provided to a single primary care provider at the 
Community Based Outpatient Clinics (CBOCs) who will then train their 
other staff members. Furthermore, enhanced communication between VBA 
and those VHA staff responsible for Compensation and Pension 
examinations is essential to ensure that VHA better understands the 
information required to fairly adjudicate a claim, the applicable law 
and how the examinations must be conducted, and any recent law changes 
or court decisions which might alter the way that these examiners 
conduct the exams. Often VHA C&P exam providers are unaware of what the 
courts have found regarding veteran rights in these exams, and this 
only contributes to inadequate exams which must be repeated and thus 
add lengthy delays to the problem and contribute to the rising VA 
backlog of claims.

    Question 11: In your testimony, you identified the need for 
``Congress and VA to address the growing concern with homeless women 
veterans, especially those with children.'' The draft homeless 
veterans' bill is targeted to the special needs population, which 
includes women veterans with children. In addition to the creation of a 
new capital grants program as specified in the draft bill, what other 
programs and services should VA provide to help women veterans with 
children?

    Response: In addition to the provisions of the draft legislation, 
the American Legion would like to urge VA to provide childcare to women 
veterans with children. According to the VA, women veterans are one of 
the fastest growing populations in the VHA system. A significant amount 
of these women veterans are of child-bearing age and are utilizing the 
VA on a more frequent basis than in the past. This is especially 
necessary for the female veterans with mental health appointments as 
children are not allowed to accompany their parents to these 
appointments.
    While this is obviously a benefit for those women veterans 
receiving health care, enhancing shelter facilities for homeless 
veterans to accommodate the needs of children is also essential, as 
well as the provision of childcare for women veterans in the vocational 
rehabilitation programs. The ability to know that children are being 
safely cared for during job interviews and essential training to 
enhance marketable job skills can be a difference maker for women 
veterans seeking employment that can lead to a stable income and the 
ability to provide for their own housing needs.
    Again, The American Legion would like to thank you and the 
Committee for the opportunity to expand on the views presented at the 
hearing and further clarify the position of the nearly 2.5 million 
members of the Nation's largest veterans' service organization. Thank 
you for your continued commitment to America's veterans and their 
families.

            Sincerely,

                                                         Jacob Gadd
      Deputy Director, National Veterans Affairs and Rehabilitation

                                 
                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                    October 4, 2010

Mr. Carl Blake
National Legislative Director
Paralyzed Veterans of America
801 18th Street, NW
Washington, D.C. 20006

Dear Mr. Blake:

    Thank you for your testimony at the U.S. House of Representatives 
Committee on Veterans' Affairs Subcommittee on Health legislative 
hearing on H.R. 3843, H.R. 4041, H.R. 5428, H.R. 5516, H.R. 5543, H.R. 
5641, H.R. 5996, H.R. 6123, H.R. 6127, H.R. 6220, Draft Legislation on 
Homelessness, and Draft Legislation on VA Health care Provisions, which 
took place on September 30, 2010.
    Please provide answers to the following questions by Monday, 
November 15, 2010, to Jeff Burdette, Legislative Assistant to the 
Subcommittee on Health.

    1.  Many of the witnesses of this panel emphasized the need to 
balance confidentiality and transparency. In fact, VA explains that it 
is precisely the confidential nature of the quality-assurance program 
that allows providers to report and examine patient safety events 
without fear of recrimination or liability. What specific barriers and 
challenges must VA overcome before they can make quality assurance 
records available to the public without compromising patient 
confidentiality?
    2.  Some have raised concerns about limiting the bill of rights to 
injured and amputee veterans. What are your thoughts on a bill of 
rights for all veterans which encompasses rights for injured and 
amputee veterans?
    3.  VVA raises some caution with H.R. 5516 by stating that they 
hope that the bill ``doesn't do for veterans what was done for active-
duty troops in the all too recent past, who were forced to be 
inoculated against smallpox and then anthrax in a panic.'' Do you share 
this thought? Why or why not?
    4.  VA explains that H.R. 5543 would ``result in unprecedented 
changes in how the Federal Government operates. It would permit unions 
to bargain over, grieve, and arbitrate a subject--employee 
compensation--that is generally exempted from collective bargaining.'' 
There was unanimous support for this bill by the witnesses on second 
panel. How do you respond to VA's concerns?
    5.  In addition to the provisions of H.R. 6123, the TBI Improvement 
Act, please share your insight on additional authorities that would be 
helpful in ensuring better health outcomes for our veterans with TBI.
    6.  In your testimony, you raised concerns about the feasibility of 
implementing the draft legislation on VHA outreach to veterans on VBA 
benefits. Do you have specific recommendations on ways to improve this 
draft bill so that we can more realistically expect VHA to implement 
the provisions of this bill?

    Thank you again for taking the time to answer these questions. The 
Committee looks forward to receiving your answers by November 15, 2010.

            Sincerely,

                                                 MICHAEL H. MICHAUD
                                                           Chairman
                                 

                                      Paralyzed Veterans of America
                                                    Washington, DC.
                                                  November 15, 2010

Honorable Michael Michaud
Chairman
House Committee on Veterans' Affairs
Subcommittee on Health
338 Cannon House Office Building
Washington, DC 20515

Dear Chairman Michaud:

    On behalf of Paralyzed Veterans of America, I would like to thank 
you for the opportunity to present our views pending legislation 
considered by the House Veterans' Affairs Subcommittee on Health at the 
hearing held on September 29, 2010. We appreciate the continued 
emphasis that the Subcommittee places on the unique health care needs 
of a diverse veterans population.
    We have included with our letter a response to each of the 
questions that you presented following the hearing. If you need 
additional information, please feel free to contact us. Thank you very 
much.

                                                         Carl Blake
                                      National Legislative Director

                               __________

    Question 1: Many of the witnesses of this panel emphasized the need 
to balance confidentiality and transparency. In fact, VA explains that 
it is precisely the confidential nature of the quality assurance 
program that allows providers to report and examine patient safety 
events without fear of recrimination or liability. What specific 
barriers and challenges must VA overcome before they can make quality 
assurance records available to the public without compromising patient 
confidentiality?
    Answer: As we stated in our testimony, in the case of VA quality-
assurance records, it only makes sense that transparency is critical to 
veterans, and those who serve veterans such as Veterans Service 
Organizations (VSO), and their understanding of how well VA is doing 
its job. Requiring VA to publish redacted medical quality-assurance 
records on the VA's Web site will provide users of the VA a better 
understanding of the successes or failures of the VA in the quality of 
care they provide our veterans. This may encourage greater efforts on 
the part of VA employees, staff and leaders to ensure the best care is 
provided to veterans while ensuring openness.
    As we also stated, PVA's concern stems from the need for privacy in 
health care records. As we have seen in recent years, carelessness and 
bad decisions have led to the release of critical personal information 
of millions of veterans, particularly as a result of mishandling of 
information technology (IT) assets. As such, focused training for the 
VA personnel responsible for publishing this information will be 
essential to ensure that seemingly simple mistakes do not lead to the 
disclosure of a veteran's personal information. The VA must 
specifically prescribe to its staff what information is suitable for 
public viewing and what information must be redacted from records. 
Additionally, safeguards should be locked in to the VA's IT system to 
ensure that personal information cannot be accessed through outside 
sources.
    Question 2: Some have raised concerns about limiting the bill of 
rights to injured and amputee veterans. What are your thoughts on a 
bill of rights for all veterans which encompasses rights for injured 
and amputee veterans?
    Answer: As we stated in our testimony, PVA supports H.R. 5428 which 
seeks to better educate injured and amputee veterans on their rights as 
well as the VA staff who work at prosthetics and orthotics clinics or 
who work as patient advocates for veterans. However, as we also 
mentioned, PVA is concerned that this legislation's language seems to 
ignore veterans who may be in need of special equipment who suffer from 
a specific disease and not a physical injury. For example, many PVA 
members face significant hardship associated with a diagnosis for 
Multiple Sclerosis (MS). Similarly, veterans who have been diagnosed 
with Amyotrophic Lateral Sclerosis (ALS) and Parkinson's disease face 
similar problems. And yet, they are equally reliant on prosthetics and 
sensory aids to function in as normal a manner as possible. We believe 
that the legislation, as written, excludes veterans such as those 
mentioned here who have significant limitations brought on by diseases, 
and not just direct injuries or amputations.
    PVA certainly supports the idea of a bill of rights for all 
veterans. In fact, if such a legislative proposal is considered, we do 
not believe any special mention is necessary for injured and amputee 
veterans. Legislation should be all-encompassing so that veterans who 
have experienced illness or disease or injury or amputation are 
included.
    Question 3: VVA raises some caution with H.R. 5516 by stating that 
they hope the bill ``doesn't do for veterans what was done for active-
duty troops in the all too recent past, who were forced to be 
inoculated against smallpox and then anthrax in a panic.'' Do you share 
this thought? Why or why not?
    Answer: PVA has no specific position on the concerns raised by 
Vietnam Veterans of America in their official statement. As explained 
in the PVA's statement to the Subcommittee, we support the legislation 
as introduced.
    Question 4: VA explains that H.R. 5543 would ``result in 
unprecedented changes in how the Federal Government operates. It would 
permit unions to bargain over, grieve, and arbitrate a subject--
employee compensation--that is generally exempted from collective 
bargaining.'' There was unanimous support for this bill by the 
witnesses on the second panel. How do you respond to VA's concerns?
    Answer: In trying to understand the concerns regarding labor 
relations in the Department of Veterans Affairs (VA), PVA has reached 
out to the various labor organizations that represent different 
segments of the health care workforce. It seems that the VA is often 
concerned about the expansion of bargaining rights under Title 38 
hiring authorities, as they may be inconsistent with the rights 
available to Federal employees under Title 5. However, the language 
included in H.R. 5543 seems to be consistent with similar authorities 
provided under Title 5.
    The American Federation of Government Employees (AFGE) has also 
informed us about the inconsistencies they see with the consolidation 
of the workforce associated with the Department of Defense (DOD) and VA 
joint health care facility in North Chicago. The Navy doctors, nurses, 
and physician assistants who became Title 38 employees were granted 
full bargaining rights (as though they were Title 5 employees) for 2 
years as a part of the merger agreement with the VA. This simply makes 
no sense as they will be working hand-in-hand with VA staff who do not 
have the same rights. Moreover, it demonstrates that the VA does not 
ultimately believe there is any real harm to the provision of health 
care services by granting these employees rights. Simply put, if it is 
good enough for one group of health care professionals, it seems that 
it would be good for another.
    Lastly, we have been told by the AFGE that the VA may be working 
towards some solutions to ease labor-management relations. In fact, in 
September, the VA Secretary approved a recommendation that allows 
bargaining over violations of VA directives about nurse overtime and 
premium pay, physician market pay and performance pay and other pay 
rules in VA directives and handbooks. We hope that this signals a move 
towards better labor-management relations across the VA which will only 
benefit the veterans who depend on the VA health care system for their 
care.
    Question 5: In addition to the provisions of H.R. 6123, the TBI 
Improvement Act, please share your insight on additional authorities 
that would be helpful in ensuring better health outcomes for our 
veterans with TBI.
    Answer: As stated in our testimony, PVA supports H.R. 6123, the 
``Veterans' Traumatic Brain Injury Rehabilitative Services' Improvement 
Act of 2010.'' In recent testimony, PVA has raised continuing concerns 
about servicemembers who do not have the immediate outward signs of TBI 
getting appropriate care. The military has implemented procedures to 
temporarily withdraw individuals from combat operations following IED 
attacks for an assessment of possible TBI, creating a significant 
military impact, but believing it necessary for soldier health even if 
it reduced combat forces.
    Because all the impacts of TBI are still unknown, this legislation 
to expand services and care, providing for quality of life and not just 
independence, and emphasizing rehabilitative services, is important to 
the ongoing care of TBI patients. It is imperative that a continuum of 
care for the long term be provided to veterans suffering from TBI. PVA 
believes this legislation is a step toward ensuring that care.
    Additionally, as referenced in The Independent Budget for FY 2011, 
PVA believes greater emphasis needs to be placed on research into the 
long-term consequences of brain injury and the development best 
practices in its treatment. Moreover, this research should include 
veterans of past military conflicts who may have experienced brain 
injury that has gone undetected, undiagnosed, or untreated.
    The impact on the family of a veteran who has experienced a brain 
injury also cannot be overstated. And yet, in many cases immediate 
family members will become the lifelong caregivers of these 
significantly disabled veterans. As such, it will be imperative that as 
the VA implements the caregiver provisions of P.L. 111-163, the 
``Caregivers and Veterans Omnibus Health Services Act of 2010,'' that 
the difficulties these families will face be considered. Any training 
provided to the caregivers will most certainly require specialized 
focus on the unique needs of veterans with traumatic brain injury and 
associated mental health problems. We encourage the Subcommittee to 
continue to monitor the progress of implementation of P.L. 111-163 to 
ensure that the VA is addressing this concern.
    Question 6: In your testimony, you raised concerns about the 
feasibility of implementing the draft legislation on VHA outreach to 
veterans on VBA benefits. Do you have specific recommendations on ways 
to improve this draft bill so that we can more realistically expect VHA 
to implement the provisions of this bill?
    Answer: PVA expressed no real concerns about the implementation of 
the legislation in our written statement. However, we must emphasize 
the need to ensure that correct and consistent information is provided 
when a veteran seeks benefits information at a VA medical facility.
    As we mentioned in our statement, we would also hope that VA will 
direct veterans seeking benefits information to veterans service 
organizations who have service programs to benefit these men and women. 
PVA maintains a highly skilled and well-educated service officer staff 
at many VA medical facilities around the country who can assist 
veterans with certain health care concerns as well as the broad range 
of benefits available. It certainly makes sense for the VA to tap into 
this resource.

                                 

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                    October 4, 2010

Mr. Adrian M. Atizado
Assistant National Legislative Director
Disabled American Veterans
807 Maine Avenue, SW
Washington, DC 20024

Dear Mr. Atizado:

    Thank you for your testimony at the U.S. House of Representatives 
Committee on Veterans' Affairs Subcommittee on Health legislative 
hearing on H.R. 3843, H.R. 4041, H.R. 5428, H.R. 5516, H.R. 5543, H.R. 
5641, H.R. 5996, H.R. 6123, H.R. 6127, H.R. 6220, Draft Legislation on 
Homelessness, and Draft Legislation on VA Healthcare Provisions, which 
took place on September 30, 2010.
    Please provide answers to the following questions by Monday, 
November 15, 2010, to Jeff Burdette, Legislative Assistant to the 
Subcommittee on Health.

    1.  Many of the witnesses of this panel emphasized the need to 
balance confidentiality and transparency. In fact, VA explains that it 
is precisely the confidential nature of the quality-assurance program 
that allows providers to report and examine patient safety events 
without fear of recrimination or liability. What specific barriers and 
challenges must VA overcome before they can make quality assurance 
records available to the public without compromising patient 
confidentiality?
    2.  Some have raised concerns about limiting the bill of rights to 
injured and amputee veterans. What are your thoughts on a bill of 
rights for all veterans which encompasses rights for injured and 
amputee veterans?
    3.  PVA raised concerns with H.R. 5428 ignoring veterans who may be 
in need of special equipment who suffer from a specific disease and not 
a physical injury. Do you share this concern? Why or why not?
    4.  VVA raises some caution with H.R. 5516 by stating that they 
hope that the bill ``doesn't do for veterans what was done for active-
duty troops in the all too recent past, who were forced to be 
inoculated against smallpox and then anthrax in a panic.'' Do the rest 
of the witnesses on this panel share this thought? Why or why not?
    5.  VA explains that H.R. 5543 would ``result in unprecedented 
changes in how the Federal Government operates. It would permit unions 
to bargain over, grieve, and arbitrate a subject--employee 
compensation--that is generally exempted from collective bargaining.'' 
There was unanimous support for this bill by the witnesses on second 
panel. How do you respond to VA's concerns?
    6.  In addition to the provisions of H.R. 6123, the TBI Improvement 
Act, please share your insight on additional authorities that would be 
helpful in ensuring better health outcomes for our veterans with TBI.
    7.  PVA recommends that a broader spectrum of veterans is targeted 
instead of singling out the Qarmat Ali veterans for enrollment in H.R. 
6127. Do you share PVA's recommendation? Why or why not?
    8.  In your testimony, you raised concerns about the feasibility of 
implementing the draft legislation on VHA outreach to veterans on VBA 
benefits. Do you have specific recommendations on ways to improve this 
draft bill so that we can more realistically expect VHA to implement 
the provisions of this bill?

    Thank you again for taking the time to answer these questions. The 
Committee looks forward to receiving your answers by November 15, 2010.

            Sincerely,

                                                 MICHAEL H. MICHAUD
                                                           Chairman

                               __________

              POST-HEARING QUESTIONS FOR ADRIAN M. ATIZADO
               OF THE DISABLED AMERICAN VETERANS FROM THE
         COMMITTEE ON VETERANS' AFFAIRS, SUBCOMMITTEE ON HEALTH
                 UNITED STATES HOUSE OF REPRESENTATIVES
                           SEPTEMBER 29, 2010
    Post-hearing questions for the record from House Subcommittee on 
Health's legislative hearing on H.R. 3843, H.R. 4041, H.R. 5428, H.R. 
5516, H.R. 5543, H.R. 5641, H.R. 5996, H.R. 6123, H.R. 6127, H.R. 6220, 
and Draft Legislation, held September 29, 2010.

    Question 1: Many of the witnesses of this panel emphasized the need 
to balance confidentiality and transparency. In fact, VA explains that 
it is precisely the confidential nature of the quality-assurance 
program that allows providers to report and examine patient safety 
events without fear of recrimination or liability. What specific 
barriers and challenges must VA overcome before they can make quality 
assurance records available to the public without compromising patient 
confidentiality?

    Answer: We again ask as we did in our written testimony whether the 
release of all the information contained in quality assurance records 
in redacted form addresses the following pertinent questions, and if 
so, at what cost.
    The central question in the particular case of the events 
surrounding the Department of Veterans Affairs (VA) Philadelphia 
Community Living Center is the appropriate notification of the public, 
including Congress, when substandard VA care is identified, and why 
such care was not identified by routine inspections. Other essential 
questions include whether different metrics are used in routine health 
care inspections and quality management programs, and if so, why.
    As to the Subcommittee's question, if redacted quality assurance 
records are to be made public, the VA must revisit its quality 
assurance program to sustain its effectiveness by emphasizing 
prevention--not punishment, which is essential for VA to continue 
receiving candid reports on adverse events and/or close calls from 
which it could then learn and undertake improvement and prevention 
efforts. As indicated in DAV's written testimony, ``[t]he Institute for 
Healthcare Improvement (IHI) has found that all employee reporting 
programs (voluntary and mandatory) result in substantial 
underreporting. Several studies have shown that computer monitoring 
strategies have identified many times more potential adverse events 
than were reported through employee reporting mechanisms. The IHI's 
`Trigger Tools' are also used to identify adverse events and detect 
safety problems. Moreover, not having specific facility and patient 
information has caused frustration when VA Central Office and oversight 
bodies have requested Veterans Health Administration (VHA) data 
regarding adverse events. Facility patient safety managers have also 
had to create secondary, duplicative systems in order to capture the 
patient information needed for effective reviews and reports.'' \1\
---------------------------------------------------------------------------
    \1\ http://www.dav.org/voters/documents/statements/
Atizado20100929.pdf.
---------------------------------------------------------------------------
    We consider information from VA quality assurance records as raw 
data that VA or some other entity will need to make into a format that 
is readable, understandable, and meaningful to the target audience. 
Also, accommodations should be provided so individuals may gain access 
by telephone or mail requests, and during personal onsite visits. 
Finally, and equally important, VA should encourage wide public 
awareness of the availability of such information, how and where to 
access it, and appropriate limitations on its use.
    On a broader scale, if such transparency through release of 
redacted quality assurance records are deemed by Congress to carry such 
weight as to overcome the concern by DAV and others that such actions 
may jeopardize VA's quality and safety activities, Congress must also 
address the circular deference problem between the Health Insurance 
Portability and Accountability Act (HIPAA) and the Freedom of 
Information Act (FOIA) and other Federal and state open records laws in 
which determination of which statute controls the public nature of the 
health care related information.
    There are existing rules, policies, and laws that favor closure of 
quality assurance records. The HIPAA Privacy Rule defines in eighteen 
criteria the type of information that would identify a patient 
(personally identifiable information) and offers standards of 
protection of the privacy of individually identifiable health 
information created or maintained by health care providers who engage 
in certain electronic transactions, health plans, and health care 
clearinghouses. The HIPAA Security Rule sets national standards for the 
security of electronic protected health information; and the 
confidentiality provisions of the Patient Safety Rule, which protect 
identifiable information being used to analyze patient safety events 
and improve patient safety.
    Other Federal law protects health care quality assurance 
information of the Department of Veterans Affairs \2\ and of the 
Department of Defense \3\ from both public disclosure under the FOIA 
and from discovery in litigation. In addition, the courts interpret the 
FOIA exemptions to protect from public disclosure information that 
would be exempt from discovery. All of these protections reflect a 
general Federal policy that protects health care quality assurance 
information from disclosure.
---------------------------------------------------------------------------
    \2\ 38 U.S.C. Sec. 5705--Confidentiality of medical quality 
assurance records.
    \3\ 10 U.S.C. Sec. 1102--Confidentiality of medical quality 
assurance records: qualified immunity for participants.
---------------------------------------------------------------------------
    In addition to these laws favoring protection of quality assurance 
records from disclosure, Recommendation 6.1 in the Institute of 
Medicine's 2000 report, To Err is Human: Building a Safer Health 
System, recommended reporting systems for quality of care and health 
care errors should be privileged. It states: ``Congress should pass 
legislation to extend peer review protections to data related to 
patient safety and quality improvement that are collected and analyzed 
by health care organizations for internal use or shared with others 
solely for purposes of improving safety and quality.'' \4\
---------------------------------------------------------------------------
    \4\ http://www.nap.edu/openbook.php?record_id=9728.
---------------------------------------------------------------------------
    On the other hand, there are rules, policy, and laws favoring 
disclosure of quality assurance records. FOIA embodies the notion that 
citizens of this Nation have a right to access documents created by the 
government. This right however is not unconditional, evidenced by 
including exemptions to the FOIA, state open record laws and Federal 
Governments. Such exemptions signify that not all government documents 
should be public for several reasons, including the principle that some 
government functions will be harmed by disclosure.
    In this vein, however, the courts have read the exemptions 
narrowly. The courts holding in Anderson v. Health & Human Services, 
907 F.2d 936, 941 (10th Cir. 1990) is that ``[t]he FOIA is to be 
broadly construed in favor of disclosure and its exemptions are to be 
narrowly construed,'' and that ``The Federal agency resisting 
disclosure bears the burden of justifying nondisclosure.''
    This burden on Federal agencies is buttressed by Executive Order 
13410, ``[h]ealth care programs administered or sponsored by the 
Federal Government promote quality and efficient delivery of health 
care through the use of health information technology, [and] 
transparency regarding health care quality.'' Its purpose also includes 
making relevant information available to program beneficiaries, 
enrollees, and providers in a readily useable manner and in 
collaboration with similar initiatives in the private sector and non-
Federal public sector. \5\
---------------------------------------------------------------------------
    \5\ http://edocket.access.gpo.gov/2006/pdf/06-7220.pdf.
---------------------------------------------------------------------------
    If Congress concurs, or rather defers, to the Department of Health 
and Human Services' (HHS) interpretation implementing HIPAA in the 
preamble of the 2000 regulations, then FOIA should control access to a 
record covered by HIPAA and FOIA. \6\ If left unaddressed then we urge 
this Subcommittee to continue to oversee VA's actions to make system 
and/or policy changes to ensure the issue of why the Department's 
quality management failed to identify substandard care and timely 
notifying the public. Furthermore, we ask the Subcommittee to ensure VA 
addresses the need for transparency of quality assurance records in the 
disability claims process described in our written testimony.
---------------------------------------------------------------------------
    \6\ Standards for Privacy or Individually Identifiable Health 
Information, 65 Fed. Reg. 82,462, 82,482 (December 28, 2000).

    Question 2: Some have raised concerns about limiting the bill of 
rights to injured and amputee veterans. What are your thoughts on a 
bill of rights for all veterans which encompasses rights for injured 
---------------------------------------------------------------------------
and amputee veterans?

    Answer: With regards to the provision of comprehensive VA health 
care services, DAV has a National Resolution, which I have included 
below, which will most likely be our primary guide on a veterans bill 
of rights:
                           RESOLUTION NO. 036
          SUPPORT THE PROVISION OF COMPREHENSIVE DEPARTMENT OF
       VETERANS AFFAIRS HEALTH CARE SERVICES TO ENROLLED VETERANS
       WHEREAS, it is the policy of the Disabled American Veterans that 
veterans should be afforded quality and timely health care services by 
the Department of Veterans Affairs (VA) because of their honorable 
service to our Nation; and
       WHEREAS, it is the conviction of the Disabled American Veterans 
that quality health care for veterans is achieved when health care 
providers are given the freedom and resources to provide the most 
effective and evidence-based care available; and
       WHEREAS, the Veterans Health Administration plays a critical 
role in the delivery of health care services to our Nation's sick and 
disabled veterans, is the largest direct Federal provider of health 
care services, the largest clinical training ground for the health 
professions, and a leader in medical research; and
       WHEREAS, although the veterans' health care system is provided 
an advance appropriation for medical care, it is still at the 
discretion of Congress to provide sufficient funding; and
       WHEREAS, in the past, because of restricted appropriation 
levels, VA has been forced at times to restrict, ration and deny access 
to health care implicitly promised in connection with veterans' 
military service; and
       WHEREAS, the VA health care system must be provided sufficient 
funding to ensure, at a minimum, the following standards are met:

        Promote and ensure health care quality and value, and 
protect veterans' safety in the health care system;
        Guarantee access to a full continuum of care, from 
preventive through hospice services;
        Receive adequate funding through appropriations for 
care of all enrolled veterans;
        Fairly and equitably distribute resources to treat the 
greatest number of veterans requiring health care;
        Furnish the gender-specific, quality and quantity of 
services necessary to meet the needs of a growing population of women 
veterans;
        Provide all medications, supplies, prosthetic devices 
and over-the-counter medication necessary for the proper treatment of 
service-connected disabled veterans;
        Preserve VA's mission and role as a provider of 
specialized services in areas such as blindness, burns, amputation, 
spinal cord injury and dysfunction, mental illness, and long-term care;
        Maintain the integrity of an independent VA health care 
delivery system as representing the primary responsible entity for the 
delivery of health care services to enrolled veterans;
        Modernize its human resources management system to 
enable VA to compete for, recruit and retain the types and quality of 
VA employees needed to provide comprehensive health care services to 
sick and disabled veterans;
        Maintain a strong and veteran-focused research program; 
NOW

       THEREFORE, BE IT RESOLVED that the Disabled American Veterans in 
National Convention assembled in Atlanta, Georgia, July 31-August 3, 
2010, supports legislation that embodies the concepts and principles 
enumerated above and establishes certainty to clearly defined VA health 
care services for enrolled veterans.

    Question 3: PVA raised concerns with H.R. 5428 ignoring veterans 
who may be in need of special equipment who suffer from a specific 
disease and not a physical injury. Do you share this concern? Why or 
why not?

    Answer: PVA's written testimony states, ``As expressed in previous 
testimony on this topic, PVA is concerned that this legislation's 
language seems to ignore veterans who may be in need of special 
equipment who suffer from a specific disease and not a physical 
injury.''
    As inferred in the Subcommittee's previous question above and the 
statement to the Subcommittee from the sponsor of the bill, \7\ the 
veteran patient population the bill is intended to primarily serve is 
the Operation Enduring Freedom and Operation New Dawn who suffer from 
blast injuries due to the widespread use of improvised explosive 
devices (IEDs) by ensuring veterans in need of an assistive device or 
prosthetic gets the highest quality item available and in a timely 
manner.
---------------------------------------------------------------------------
    \7\ http: / / www.veterans.house.gov / hearings / 
Testimony_Print.aspx?newsid=625&Name=The_
Honorable_Bob_Filner
---------------------------------------------------------------------------
    Moreover, not all treatment for all diseases and injuries require 
VA's Prosthetics and Sensory Aids Service. While DAV supports VA's 
Amputee System of care, we would generally agree the measure seems to 
ignore other veteran patients who seek care at VA.

    Question 4: VVA raises some caution with H.R. 5516 by stating that 
they hope that the bill ``doesn't do for veterans what was done for 
active-duty troops in the all too recent past, who were forced to be 
inoculated against smallpox and then anthrax in a panic.'' Do the rest 
of the witnesses on this panel share this thought? Why or why not?

    Answer: The possibility exists, however improbable. It would depend 
on how VA would implement the bill's requirement if passed by Congress.

    Question 5: VA explains that H.R. 5543 would ``result in 
unprecedented changes in how the Federal Government operates. It would 
permit unions to bargain over, grieve, and arbitrate a subject--
employee compensation--that is generally exempted from collective 
bargaining.'' There was unanimous support for this bill by the 
witnesses on second panel. How do you respond to VA's concerns?

    Answer: DAV does not have an approved resolution from our 
membership on this specific VA labor-management dispute, but we believe 
labor organizations that represent employees in recognized bargaining 
units within the VA health care and benefits systems have an innate 
right to information and reasonable participation that result in making 
VA a workplace of choice, and particularly to fully represent VA 
employees on issues impacting working conditions and ultimately patient 
care.
    The issue at hand is an imbalance between VHA and its title 38 
employees, which is undermining Congress' intent when it passed section 
7422 of title 38, United States Code, in 1991. In granting specific 
bargaining rights to labor in VA professional units, Congress 
recognized such rights promote effective interactions and negotiation 
between VA management and its labor force representatives concerned 
about the status and working conditions. In providing this authority, 
Congress granted to VA employees and their recognized representatives a 
right that already existed for all other Federal employees appointed 
under title 5, United States Code. Nevertheless, Federal labor 
organizations have reported that VA has severely restricted the 
recognized Federal bargaining unit representatives from participating 
in, or even being informed about, human resources decisions and 
policies that directly impact conditions of employment of the VA 
professional staffs within these bargaining units.
    We are advised by labor organizations that when management actions 
are challenged, VA officials (many at the local level) have used 
subsections (b), (c) and (d) of section 7422 as a statutory shield to 
obstruct any labor involvement to correct or ameliorate the negative 
impact of VA's management decisions, even when management is allegedly 
not complying with clear statutory mandates (e.g., locality pay surveys 
and alternative work schedules for nurses, physician market pay 
compensation panels, etc.).
    Facing VA's refusal to bargain, the only recourse available to 
labor organizations is to seek redress in the Federal court system. 
However, recent case law has severely weakened the rights of title 38 
appointees to obtain judicial review of arbitration decisions. Title 38 
employees also have fewer due process rights than their title 5 
counterparts in administrative appeals hearings.
    The alternative for labor organizations is to seek legislative 
action in the absence of reasonable compromise. DAV is sensitive to the 
realities of VA's human resource challenges on which this issue has a 
direct impact. Certainly retention rates are important, but this is 
only one factor that must be considered in determining whether the 
current status of this particular issue is sustainable.
    VHA is facing the challenge of an increasing percentage of workers 
becoming eligible for retirement. VHA has identified registered nurses 
(RNs) as its top occupational challenge because 40.7 percent of the 
current registered nurse (RN) workforce will be eligible or will take 
retirement by 2014. VA also reports that by FY 2014, approximately 40.7 
percent of the current workforce will be eligible for (or will take) 
retirement.
    With respect to turnover for VHA nurses, the lowest rates occur in 
the VA Central Office among nurses who perform administrative, policy, 
and management functions. The highest rates occur along the Pacific 
coast and in the Appalachian region along the Atlantic coast. Many RNs 
resign early in their VHA careers. For example, in FY 2006, 16.3 
percent resigned in the first year of employment, compared with VA 
physicians, 13.2 percent of whom departed the VHA in their first year 
of employment. Overall in VHA, 12.9 percent of newly hired personnel 
resign in their first year.
    According to the American Federation of Government Employees, in 
2007, 77 percent of all RN resignations within VA occurred in the first 
5 years of employment, and the average VA-wide cost of turnover is $47 
million per year for nurses. Given the loss of productivity, risks to 
patient care, and waste represented by such early departures from VA 
employment, VA simply cannot afford to ignore the concerns of its 
nurses in the areas of job satisfaction, compensation, and other 
conditions of employment. It appears that the often hostile environment 
consequent to these disagreements diminishes VA as a preferred 
workplace for many of its health care professionals. Likewise, veterans 
who depend on VA and who receive care from VA's physicians, nurses and 
others can be negatively affected by that environment.
    VA has recently given Federal labor organizations some indication 
of additional flexibility in negotiating labor-management issues such 
as some features of compensation, and we are hopeful that this change 
signals a new trend in these key relationships that directly affect 
sick and disabled veterans. As VHA is indeed a unique system wherein 
its employees are driven first and foremost by their commitment to 
serve our Nation's disabled veteran, we hope that VA and Federal labor 
organizations can find a sustained basis for compromise.

    Question 6: In addition to the provisions of H.R. 6123, the TBI 
Improvement Act, please share your insight on additional authorities 
that would be helpful in ensuring better health outcomes for veterans 
with TBI.

    Answer: One additional specific authority that we believe would 
prove helpful to the most severely injured TBI cases and their 
immediate family members would be the provision of off-site long-term 
therapeutic residential facilities that would be near but clearly 
separated from the intensity found in the polytrauma rehabilitation 
centers themselves. DAV testified on this matter before the 
Subcommittee at its July 22, 2010 hearing. We ask that your 
professional staff review our testimony and further consider the merits 
of this proposal, as well as other concerns DAV expressed about VA's 
TBI programs during that particular hearing.

    Question 7: PVA recommends that a broader spectrum of veteran is 
targeted instead of singling out the Qarmat Ali veterans for enrollment 
in H.R. 6127. Do you share PVA's recommendation? Why or why not?

    Answer: Yes. In our written testimony we stated, ``We also ask for 
the Subcommittee's consideration to afford the same eligibility to 
those veterans who were exposed to toxic substances as a result of 
disposing a poisonous mixture of plastics, metals, paints, solvents, 
tires, used medical waste and asbestos insulation in open-air trash 
burn pits in Iraq and Afghanistan. Tests on the burn pits in the war 
zones have shown that the fires released dioxins, benzene and volatile 
organic compounds, including substances known to cause cancer.''

    Question 8: In your testimony, you raised concerns about the 
feasibility of implementing the draft legislation on VHA outreach to 
veterans on VBA benefits. Do you have specific recommendations on ways 
to improve this draft bill so that we can more realistically expect VHA 
to implement the provisions of this bill?

    Answer: Our key concern in implementing the provisions of this bill 
is that correct and consistent information is provided to a veteran 
seeking assistance at VA medical facilities on their claim or filing a 
claim for VA disability compensation, pension, and other ancillary 
benefits.
    We believe serious consideration must be given to a single-point-
of-entry into the Veterans Benefits Administration at VA medical 
facilities to carry out the provisions of this bill. The individual(s) 
located at a VA medical facility charged with assisting veterans in 
this regard should have the necessary tools to discharge his or her 
responsibility by receiving proper training and testing, appropriate 
time if other than a part-time duty, authority, responsibility, and 
accountability.
    Any signage that provides cursory information about submitting a 
claim for compensation, establishing service connection for a 
disability, and contact information (including address, telephone 
number, and Internet Web site address) of the appropriate offices that 
may offer assistance with respect to service-connected disabilities 
should include the single-point of entry at that VA medical facility.

                                 

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                    October 4, 2010

Ralph Ibson
Senior Fellow for Policy
Wounded Warrior Project
1120 G Street, NW, Suite 700
Washington, DC 20005

Dear Mr. Ibson:

    Thank you for your testimony at the U.S. House of Representatives 
Committee on Veterans' Affairs Subcommittee on Health legislative 
hearing on H.R. 3843, H.R. 4041, H.R. 5428, H.R. 5516, H.R. 5543, H.R. 
5641, H.R. 5996, H.R. 6123, H.R. 6127, H.R. 6220, Draft Legislation on 
Homelessness, and Draft Legislation on VA Healthcare Provisions, which 
took place on September 30, 2010.
    Please provide answers to the following questions by Monday, 
November 15, 2010, to Jeff Burdette, Legislative Assistant to the 
Subcommittee on Health.

     1.  Many of the witnesses of this panel emphasized the need to 
balance confidentiality and transparency. In fact, VA explains that it 
is precisely the confidential nature of the quality-assurance program 
that allows providers to report and examine patient safety events 
without fear of recrimination or liability. What specific barriers and 
challenges must VA overcome before they can make quality assurance 
records available to the public without compromising patient 
confidentiality?
     2.  Mr. Ibson, you note that the Federal Recovery Coordinators 
``may need specialized education and training. However it is not clear 
that VA needs legislation to mount such training.'' If not for this 
legislation, what suggestions do you have to encourage VA to enhance 
the training that FRCs receive?
     3.  Some have raised concerns about limiting the bill of rights to 
injured and amputee veterans. What are your thoughts on a bill of 
rights for all veterans which encompasses rights for injured and 
amputee veterans?
     4.  PVA raised concerns with H.R. 5428 ignoring veterans who may 
be in need of special equipment who suffer from a specific disease and 
not a physical injury. Do you share this concern? Why or why not?
     5.  VA explains that H.R. 5543 would ``result in unprecedented 
changes in how the Federal Government operates. It would permit unions 
to bargain over, grieve, and arbitrate a subject--employee 
compensation--that is generally exempted from collective bargaining.'' 
There was unanimous support for this bill by the witnesses on second 
panel. How do you respond to VA's concerns?
     6.  Mr. Ibson, WWP believes that H.R. 5428 does not go far enough 
in ``converting amputees' expectations into reality''. There are 
provisions in this bill that require follow-up action so that the Chief 
Consultant of Prosthetics and Sensory Aids must investigate and address 
the reported complaints and allegations. Doesn't this ensure that the 
bill of rights goes beyond posting a piece of paper at VA medical 
centers? What other changes would you make to translate the bill of 
rights into reality for our injured and amputee veterans?
     7.  VVA raises some caution with H.R. 5516 by stating that they 
hope that the bill ``doesn't do for veterans what was done for active-
duty troops in the all too recent past, who were forced to be 
inoculated against anthrax and smallpox in a panic''. Do you share this 
thought? Why or why not?
     8.  In addition to the provisions of H.R. 6123, the TBI 
Improvement Act, please share your insight on additional authorities 
that would be helpful in ensuring better health outcomes for our 
veterans with TBI.
     9.  PVA recommends that a broader spectrum of veterans is targeted 
instead of singling out the Qarmat Ali veterans for enrollment in H.R. 
6127. Do you share PVA's recommendation? Why or why not?
    10.  In your testimony, you raised concerns about the feasibility 
of implementing the draft legislation on VHA outreach to veterans on 
VBA benefits. Do you have specific recommendations on ways to improve 
this draft bill so that we can more realistically expect VHA to 
implement the provisions of this bill?
    Thank you again for taking the time to answer these questions. The 
Committee looks forward to receiving your answers by November 15, 2010.

            Sincerely,

                                                 MICHAEL H. MICHAUD
                                                           Chairman

                               __________

                         Subcommittee on Health
                    House Veterans Affairs Committee
                September 29, 2010--Legislative Hearing
                        Wounded Warrior Project
                 Responses to Questions for the Record
    Question 1: Many witnesses emphasized the need to balance 
confidentiality and transparency. In fact, VA explains that it is 
precisely the confidential nature of the quality assurance program that 
allows providers to report and examine patient safety events without 
fear of recrimination or liability. What specific barriers and 
challenges must VA overcome before they can make quality assurance 
records available to the public without compromising patient 
confidentiality?

    WWP Response: The issue, in our view, is not solely or even 
principally a matter of ensuring against breaches of patient 
confidentiality. VA is required by law (38 U.S.C. sec. 7311) to conduct 
a quality-assurance program, that is, a comprehensive program to 
monitor and evaluate the quality of health care furnished by the 
Veterans Health Administration. In establishing that requirement, 
Congress adopted a widely accepted principle (reflected in section 5705 
of title 38, protecting the confidentiality of quality-assurance 
records) that in order to evaluate adverse or potentially adverse 
events in health care, discussions must be frank, open, and complete, 
and must be conducted under circumstances that support such 
discussions. It is difficult to imagine that VA could gain the level of 
trust and participation of clinicians needed to operate an effective 
quality assurance program if those records (even redacted) were to 
become readily accessible.

    Question 2: You note that the Federal Recovery Coordinators ``may 
need specialized education and training. However it is not clear that 
VA needs legislation to mount such training.'' If not for this 
legislation, what suggestions do you have to encourage VA to enhance 
the training FRC's receive?

    WWP Response: WWP agrees that by virtue of their responsibilities, 
Federal Recovery Coordinators (FRC's) require specialized skills. It 
has not been our experience, however, that there is any apparent 
systemic deficit in the educational background or experience of FRC's, 
or the training VA provides those selected to carry out these important 
responsibilities.

    Question 3: Some have raised concerns about limiting the bill of 
rights to injured and amputee veterans. What are your thoughts on a 
bill of rights for all veterans which encompasses rights for injured 
and amputee veterans?

    WWP Response: WWP does not find fault with legislation that focuses 
on remedying problems encountered by injured and amputee veterans. Our 
concern regarding H.R. 5428 is with its heavy reliance on a ``bill of 
rights'' which appears likely to fall short of being as effective a 
remedial mechanism as the term ``rights'' suggests. Given our concern 
regarding the limitations of the proposal, we would not recommend 
expanding the bill to provide for a ``bill of rights'' addressing all 
veterans. In addition, VA regulations (at 38 C.F.R. sec. 17.33) already 
establish patients' rights regulations applicable to all VA patients.

    Question 4: PVA raised concerns with H.R. 5428 ignoring veterans 
who may be in need of special equipment who suffer from a specific 
disease and not a physical injury. Do you share this concern?

    WWP response: Given the population it serves, WWP has not 
encountered such problems. But it is understandable that proposing a 
``bill of rights'' as a partial remedy for problems encountered by 
veterans with amputations might spark advocates' concerns regarding 
other disabled veterans who are not covered by such legislation.

    Question 5: WWP believes that H.R. 5428 does not go far enough in 
``converting amputees' expectations into reality.'' There are 
provisions in the bill that require follow-up action so that the Chief 
Consultant of Prosthetics and Sensory Aids must investigate and address 
the reported complaints and allegations. Doesn't this ensure that the 
bill of rights goes beyond posting a piece of paper at VA medical 
centers? What other changes would you make to translate the bill of 
rights into reality for our injured and amputee veterans?

    WWP response: The bill does propose establishment of a mechanism 
for monitoring and complaint-resolution. But, as drafted, the bill 
raises questions regarding the nature and number of complaints that VA 
would actually investigate and address. Specifically, the bill calls 
for investigating and addressing information ``relating to the alleged 
mistreatment of injured and amputee veterans.'' The term 
``mistreatment'' could be read to cover only the most serious kinds of 
allegations, such as patient neglect or abuse. (See ``Elder 
Mistreatment: Abuse, Neglect, and Exploitation in an Aging America,'' 
The National Academy of Sciences, http://www.nap.edu/
openbook.php?isbn=0309084342.) It is not clear from the language that 
the term would apply to a complaint of failure to provide access to a 
practitioner of one's choice or to a second opinion or to comparability 
of benefits with DoD, for example. Since the bill would not appear to 
establish enforceable ``rights'' in law, VA could reasonably conclude 
that its failure to meet veterans' expectations would not amount to 
``mistreatment.''
    WWP recommends that the Committee give consideration to amending 
the bill in a manner that imposes more substantial requirements on VA. 
Rather than directing simply that a ``bill of rights'' be posted, the 
legislation could direct VA to amend its patient rights' regulations to 
establish certain fundamental aspects of prosthetics care as 
substantive, enforceable veterans' rights. So, for example, it would be 
reasonable to direct VA to amend that regulation to provide with 
respect to veterans who have suffered an amputation (1) a right to the 
most appropriate technology, (2) a right to be fully informed of, and 
to participate fully in decisions regarding, all applicable prosthetic 
treatment options; and (3) a right to receive both a primary prosthesis 
and a functional spare. Other issues raised by the bill that are more 
difficult to enforce as ``rights'' might better be addressed in a 
different manner. An amended bill might direct the VA to (1) develop 
and implement a plan (to be submitted to Congress) to improve the level 
of expertise of its prosthetics and orthotics staff, (2) establish and 
implement standards for timeliness of prosthetics and orthotics care; 
and (3) establish and enforce requirements to ensure that veterans 
receive comparable benefits relating to prosthetic and orthotic 
services in transitioning from DoD to VA care. An amended bill could 
also clarify that the proposed complaint resolution process covers 
complaints regarding any of the issues addressed in the bill (vs. 
``mistreatment'').

    Question 6: In addition to the provisions of H.R. 6123, the TBI 
Improvement Act, please share your insight on additional authorities 
that would be helpful in ensuring better health outcomes for veterans 
with TBI.

    WWP Response: While H.R. 6123 would close the gaps in law that 
appear to limit veterans with severe traumatic brain injury from 
getting needed rehabilitative services, Congress could certainly take 
additional steps to foster improved care and better health outcomes for 
these veterans. For example, while numbers of VA facilities have 
received additional staffing, equipment and training to improve TBI 
care, there appears to be a relative dearth of state-of-the-art 
clinical expertise--in VA and nationally--in treating serious 
behavioral-health effects experienced by some who have suffered severe 
TBI. These behavior changes can include impulsivity, impaired judgment, 
inability to control anger, lack of inhibition, etc. Given the profound 
implications these troubling TBI consequences have for the wounded 
warrior and family, there is urgency to closing the knowledge and 
expertise-gap. Scholars have recognized this need, but medicine has yet 
to move in this direction. As discussed in ``The Integration of 
Neurology, Psychiatry, and Neuroscience in the 21st Century'' (American 
Journal of Psychiatry, 159: 695-704, May 2002), there is a clear need 
for more practitioners with extensive experience integrating neurology 
and psychiatry. As its author, Dr. Joseph Martin of Harvard Medical 
School, writes, scientific advances have made it clear that there is no 
scientific basis for the separation of neurology and psychiatry, and 
that it is counterproductive for these fields to continue to follow the 
divergent paths they have taken. Yet, he notes, there are very few 
training programs that foster collaboration and integration. Finally, 
Dr. Martin observes in writing about the role of U.S. medical schools, 
a ``major concern for academic leaders in neurology and psychiatry is 
the paucity of interest among medical students and residents in 
pursuing careers in the clinical neurosciences. . . . At a time when 
neuroscience research promises so much to our understanding of the 
brain in its normal and abnormal conditions, it comes as a shock that 
we have failed to instill more excitement in our students'' to pursue 
residency programs in neurology and psychiatry.
    VA can do more for those veterans struggling with behavioral-health 
changes associated with a severe traumatic brain injury. Through the 
affiliations between its medical centers and major medical schools, VA 
plays a major role in training American physicians. As such, VA is 
ideally situated to help foster the development of clinical-
neuroscience teaching programs--particularly at polytrauma centers--
whose aims would include achieving better outcomes for TBI patients. 
Congress could, and should, provide incentives to spur that needed 
development.

    Question 7: PVA recommends that a broader spectrum of veterans is 
targeted instead of singling out the Qarmat Ali veterans for enrollment 
in H.R. 6127. Do you share PVA's recommendation? Why or why not?

    WWP Response: WWP recommends that given the potential range of 
toxic substances to which veterans might have been exposed in Iraq and 
Afghanistan, rather than legislating on an incident-by-incident basis, 
consideration be given to a systematic approach to addressing toxic 
exposures.

    Question 8: VVA raises some caution with H.R. 5516 by stating that 
they hope that the bill ``doesn't do for veterans what was done for 
active-duty troops in the all too recent past, who were forced to be 
inoculated against anthrax and smallpox in a panic.'' Do you share this 
thought? Why or why not?

    WWP Response: While WWP has no position on H.R. 5516, we do not 
read this legislation as opening a door to forced inoculations, 
particularly in light of the requirement for full and informed patient 
consent in 38 U.S.C. section 7331 and 38 C.F.R. section 17.34.

    Question 9: VA explains that H.R. 5543 would ``result in 
unprecedented changes in how the Federal Government operates. It would 
permit unions to bargain over, grieve, and arbitrate a subject--
employee compensation--that is generally exempted from collective 
bargaining.'' There was unanimous support for this bill by the 
witnesses on the second panel. How do you respond to VA's concerns?

    WWP response: WWP, a participant on the second panel, respectfully 
expressed no position on H.R. 5543 or on a number of other bills on the 
agenda that addressed issues wounded warriors and their families have 
simply not encountered.

                                 

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                    October 4, 2010

Hon. Eric K. Shinseki
Secretary
U.S. Department of Veterans' Affairs
810 Vermont Avenue, NW
Washington, DC 20420

Dear Secretary Shinseki:

    Thank you for the testimony of Robert L. Jesse, Principal Deputy 
Under Secretary for Health, and Walter A. Hall, Assistant General 
Counsel, at the U.S. House of Representatives Committee on Veterans' 
Affairs Subcommittee on Health legislative hearing on H.R. 3843, H.R. 
4041, H.R. 5428, H.R. 5516, H.R. 5543, H.R. 5641, H.R. 5996, H.R. 6123, 
H.R. 6127, H.R. 6220, Draft Legislation on Homelessness, and Draft 
Legislation on VA Healthcare Provisions, which took place on September 
30, 2010.
    Please provide answers to the following questions by Monday, 
November 15, 2010, to Jeff Burdette, Legislative Assistant to the 
Subcommittee on Health.

     1.  In light of recent lapses in certain medical centers using 
dirty reusable medical equipment, why does VA oppose H.R. 3843? What 
steps has VA taken to inform bring transparency to the patient safety 
lapses at certain VA medical centers?
     2.  VA opposes H.R. 4041. How can VA ensure that the current 
training provided to FRCs is evidence-based and will yield positive 
outcomes for our veterans who receive assistance from FRCs?
     3.  DAV identified a number of continuing gaps that exist in the 
FRC program. This includes integration of IT access across VA and DOD, 
manageable caseload, and a multilayer bureaucracy of VA and DOD staff. 
How do you respond to DAV's concerns? What steps has VA taken to 
address these gaps?
     4.  VA has serious concerns with a few of the ``rights'' in H.R. 
5428. This includes the right to select the practitioner that best 
meets the veterans' needs and the right to receive comparable services 
and technology at any VA medical facility. Do you have recommendations 
on ways to modify these ``rights'' so that they are not problematic for 
the VA?
     5.  VA does not support H.R. 5516 because ``clinical indications 
and population size for vaccines vary by vaccine, blanket monitoring of 
performance of all vaccines could be cost prohibitive and may not have 
a substantial positive clinical impact at the patient level''. It is my 
understanding that VA has seen positive health outcomes as a result of 
increased vaccinations for influenza and pneumococcal vaccinations. 
Additionally, a recent article in the New York Times highlighted the 
importance of adult vaccinations explaining that C.D.C. recommends 
adults ages 19 and older receive immunizations against as many as 14 
infectious diseases. In light of this information, why would VA oppose 
efforts to increase and monitor vaccinations among our veterans?
     6.  VA has serious concerns with H.R. 5543 because it would 
subject many discretionary aspects of title 38 compensation to 
collective bargaining. This bill is intended to allow collective 
bargaining over compensation related labor-management disputes such as 
locality pay, overtime pay, shift differential pay, and performance 
pay. I have heard stories of VA nurses who have no recourse if they are 
denied overtime pay, which may negatively impact VA's retention 
efforts. Does VA have administrative solutions for dealing with these 
issues if not through H.R. 5543? Please explain.
     7.  VA explains that H.R. 5543 would ``result in unprecedented 
changes in how the Federal Government operates. It would permit unions 
to bargain over, grieve, and arbitrate a subject--employee 
compensation--that is generally exempted from collective bargaining.'' 
However, it is my understanding that H.R. 5543 makes modest changes by 
allowing VA clinicians the same rights as the rest of Federal employees 
so that they can bargain over the implementation of pay laws and 
regulations. How do you respond to this disconnect?
     8.  I understand that VA is in the process of developing the 
Department's views on H.R. 5641, which would allow veterans to be 
placed in medical foster homes. In the meanwhile, could you comment on 
the number of veterans who currently pay out of pocket to be placed in 
medical foster homes? What is your understanding of the need or demand 
for medical foster homes among our veterans?
     9.  H.R. 5996 addresses the prevention, diagnosis, and treatment 
of veterans with Chronic Obstructive Pulmonary Disease. What treatment 
protocols does VA currently have in place and what tools do VA 
clinicians currently have? What gaps in treatment protocols and tools 
need to be addressed?
    10.  VVA explains that ``there are pharmacological treatments and 
other treatment modalities available in the private sectors that are 
difficult if not virtually impossible to get on the VA formulary.'' How 
do you respond to these concerns?
    11.  Section 4 of the draft legislation on general health care 
matters would provide additional authority beyond simple contracts for 
services at non-VA facilities. Would you explain what additional 
authorities are needed by providing some concrete examples?

    Thank you again for taking the time to answer these questions. The 
Committee looks forward to receiving your answers by November 15, 2010.

            Sincerely,

                                                 MICHAEL H. MICHAUD
                                                           Chairman

                               __________

                        Questions for the Record
                The Honorable Michael Michaud, Chairman
      House Committee on Veterans' Affairs, Subcommittee on Health
                     ``Health Legislative Hearing''
                           September 29, 2010
    Question 1: In light of recent lapses in certain medical centers 
using dirty reusable medical equipment, why does VA oppose H.R. 3843? 
What steps has VA taken to inform, bring transparency to the patient 
safety lapses at certain VA medical centers?

    Response: Had they been in effect, the provisions of H.R. 3843 
would not have prevented a VA medical center from failing to precisely 
follow manufacturers' sterilization or disinfection instructions. VHA 
is openly and candidly identifying the causes for these regrettable 
lapses. Further, where significant events occur, administrative 
investigations are conducted which are subject to the Freedom of 
Information Act, and therefore publicly available. It appears that H.R. 
3843 would supersede the Freedom of Information Act, creating a 
standard for disclosure for VA that is not applied to other agencies or 
entities throughout the government. The impact and interaction of this 
bill with the Freedom of Information Act would need to be further 
explored by all relevant committees of jurisdiction.
    In addition, VA is concerned about the impact of this legislation 
on the willingness of employees to bring forward concerns regarding the 
quality of care provided by VA. VHA's quality assurance programs work 
as well as they do because we strive to maintain a culture where 
employees at all levels feel free, if not obligated, to report even 
potential lapses in quality so fact-finding and remediation can occur. 
We discovered the sterilization and disinfection problems precisely 
because of this culture and specifically because our employees came 
forward with their concerns.
    VHA is opposed to H.R. 3843 because it would repeal almost all of 
the quality assurance and peer review disclosure protections in current 
38 U.S.C. 5705 and require posting of all VHA quality assurance 
documents on the Internet. Confidentiality is critical to the 
protection of Veterans' private information on which quality assurance 
depends. In addition, long experience in clinical quality improvement 
programs has taught the entire medical community that confidentiality 
in reporting and internal fact-finding is critical to establishing a 
culture where errors and close calls are openly identified, 
acknowledged and addressed. All 50 states protect their hospitals and 
health systems from disclosure of quality improvement or peer review 
proceedings through state statutes similar to current 38 U.S.C. 5705 or 
by judicial precedent. The effect of H.R. 3843 would change VHA's 
current culture of openness and potentially diminish error reporting.
    VHA publicly posts\1\ its standards for transparency about its 
clinical lapses. Forthright and open disclosure is required as a 
routine part of medical care. When an individual patient is involved, 
providers disclose directly to their patient. When serious injury or 
death occurs, medical center leadership makes a formal disclosure to 
the patient, his or her personal representative, or designated family 
members and, if requested, their lawyer. When a large number of 
patients are involved, we disclose a medical lapse to all potentially 
affected patients unless the clinical risk is insignificant (defined as 
fewer than 1 in 10,000 patients) and there are no ethical or 
institutional principles which warrant disclosure). If there is a 
question whether we should disclose, we err on the side of Veterans' 
safety and make the disclosure.
---------------------------------------------------------------------------
    \1\ VHA Directive 2008-002, ``Disclosure of Adverse Events to 
Patients,'' http://www1.va.gov/vhapublications/
ViewPublication.asp?pub_ID=1637.
---------------------------------------------------------------------------
    A recent article in the New England Journal of Medicine notes that 
large scale adverse events are not uncommon in the industry. What 
appears to be ``a notable exception'' is VHA's approach to being 
transparent about those mistakes. The article suggests that VHA's 
policy of ``disclosure should be the norm, even when the probability of 
harm is extremely low.'' \2\
---------------------------------------------------------------------------
    \2\ Dudzinski DM, et. al, The Disclosure Dilemma--Large-Scale 
Adverse Events, N Engl J Med 2010; 363:978-986; http://www.nejm.org/
doi/full/10.1056/NEJMhle1003134.
---------------------------------------------------------------------------
    VHA is known as an industry leader in systemic programs that reduce 
the number of medical mistakes that occur such as the issuance of the 
``Hospital Quality Report Card.'' The Hospital Quality Report Card 
provides a snapshot of the quality of care provided at all VA health 
care facilities. The report includes information about waiting times, 
staffing levels, infection rates, surgical volumes, quality measures, 
patient satisfaction, service availability and complexity, 
accreditation status, and patient safety. Repealing the confidentiality 
provisions of 38 U.S.C. 5705 would jeopardize the current culture of 
openness that drives VHA's ability to identify errors and their causes 
and, more importantly, prevent future occurrences.
    VHA is willing to work with the sponsors of H.R. 3843 to identify 
alternatives to the effective repeal of Sec. 5705 while at the same 
time enhancing VHA's ability to make meaningful quality improvement 
information more available to the public.

    Question 2: How can VA ensure that the current training provided to 
FRCs is evidence-based and will yield positive outcomes for our 
Veterans who receive assistance from FRCs?

    Response: The term ``evidence-based'' generally refers to the 
practice of medicine. It involves using evidence to make clinical 
decisions about the care and treatment of an individual patient. The 
Federal Recovery Coordination Program (FRCP) does not provide direct 
medical care or treatment. Instead, Federal Recovery Coordinators 
(FRCs) coordinate the delivery of services and serve as a resource for 
Servicemembers, Veterans and their families.
    Care coordination removes the barriers between organizations and 
systems of care. It is a recognized step in the movement toward a truly 
integrated system. Currently, there is no body of evidence that 
identifies best practices for this approach.
    FRCs are Masters-prepared registered nurses and licensed social 
workers who bring to the position strong educational and practical 
backgrounds. The additional training provided to FRCs is based on the 
knowledge and skills they require to assist clients. This includes in-
depth training on VA, DoD, other governmental benefits, and private 
sector services for this population. FRCs also receive training on 
current medical treatment and management of a variety of medical 
conditions, such as traumatic brain injury, PTSD, spinal cord injury, 
amputee care and rehabilitation, as well as how to access health care 
in the Military or VA health systems and the private sector. FRCP uses 
subject matter experts in delivering this training to the FRCs in a 
variety of ways (quarterly training, on-line educational opportunities, 
conferences, weekly staff meetings, and orientation).
    FRCP recently conducted its first (baseline) satisfaction survey. 
The overall satisfaction score across all clients and caregivers was 79 
percent positive, indicating that most respondents rated the overall 
quality of care and services provided by FRCP as very good. Many of the 
respondents stated they found FRCs to be resourceful, knowledgeable, 
and strong advocates for their clients.

    Question 3: DAV identified a number of continuing gaps that exist 
in the FRC program. This includes integration of IT access across VA 
and DoD, manageable caseload, and a multilayer bureaucracy of VA and 
DoD staff. How do you respond to DAV's concerns? What steps has VA 
taken to address these gaps?

    Response: The integration or interoperability of IT systems across 
VA and DoD is a recognized challenge, involving technological, clinical 
and organizational complexity. To address the need for improved 
information sharing, particularly among case/care management/
coordination programs, FRCP has been a driving force behind an effort 
to develop business requirements for an IT solution. These requirements 
are now completed and ready for identification of a pilot project to 
show feasibility. This project has been included under the Virtual 
Lifetime Electronic Record (VLER) initiative at VA.
    Having an appropriate tool that measures the time impact of an 
injured or ill Servicemember or Veteran enrolled in FRCP is critical 
for determining staffing requirements, appropriate caseloads and 
measuring outcomes. Over time, using an intensity tool should also 
provide a way to document outcomes for each client (if FRCP is 
effective, the intensity of need should decrease with repeated 
measurement). Development of this tool is a high priority for FRCP and 
has the full support of VA. However, it is a complicated task that will 
require time and iterative testing to ensure validity and reliability.
    To coordinate each client's particular needs and goals, the FRCs 
work with military liaisons, members of the Services Wounded Warrior 
Programs, service recovery care coordinators, TRICARE beneficiary 
counseling and assistance coordinators, VA vocational and 
rehabilitation counselors, military and VA facility case managers, VA 
Liaisons, VA specialty care managers, Veterans Health Administration 
(VHA) and VBA OEF/OIF case managers, VBA benefits counselors, and 
others. FRCs understand DoD and VA benefits, as well as access to 
health care. They use this knowledge to assist their clients in 
navigating the various transitions associated with recovery without 
duplicating services.

    Question 4: VA has serious concerns with a few of the ``rights'' in 
H.R. 5428. This includes the right to select the practitioner that best 
meets the Veteran's needs and the right to receive comparable services 
and technology at any VA medical facility. Do you have recommendations 
on ways to modify these ``rights'' so that they are not problematic for 
the VA?

    Response: VHA does not believe rephrasing the proposed rights in 
H.R. 5428 will provide a higher level of flexibility or quality of care 
than is already provided through VA's current processes and oversight 
of care. Veterans are evaluated by a team of qualified practitioners 
who are highly knowledgeable and have access to a complete medical 
history and treatment plan. All VA Orthotic and Prosthetic (O&P) 
Services and more than 600 contracted O&P providers are accredited by 
one of two national accrediting bodies. All amputee Veterans receive 
care at a nationally accredited O&P Service from practitioners that 
meet the requirements of VHA's extensive credentialing and privileging 
program. The Veteran, and as appropriate, their family, is part of the 
decision-making and prescription process when receiving VA amputation 
care services.
    Altering the current process to allow Veterans to self-refer to a 
prosthetist or orthotist poses many risks to our Veterans. Providers 
whose credentials are unknown and not monitored through VA quality 
management programs, and providers who do not have access to the 
Veteran's medical information and cannot provide a team approach to the 
care of the Veteran both pose significant risks. In addition, Veterans 
could incur private medical expenses for which they would be personally 
liable if not eligible for private care at VA expense under 38 U.S.C. 
1703. Finally, although injured and amputee Veterans have needs that 
set them apart from other patients at VA facilities, the basic tenets 
of patient care should not vary based on the condition or injury 
experienced by a Veteran.

    Question 5: VA does not support H.R. 5516 because ``clinical 
indication and population size for vaccines vary by vaccine, blanket 
monitoring of performance of all vaccines could be cost prohibitive and 
may not have a substantial positive clinical impact at the patient 
level.'' It is my understanding that VA has seen positive health 
outcomes as a result of increased vaccinations for influenza and 
pneumococcal vaccinations. Additionally, a recent article in the New 
York Times highlighted the importance of adult vaccinations explaining 
that C.D.C. recommends adults ages 19 and older receive immunizations 
against as many as 14 infectious diseases. In light of this 
information, why would VA oppose efforts to increase and monitor 
vaccinations among our Veterans?

    Response: VA fully supports the provision of all recommended adult 
vaccines to its patients. As noted, VA provides influenza and 
pneumococcal vaccines to a high percentage of Veterans and has seen a 
positive impact on health as a result. Those two vaccines are 
recommended for all (influenza) or a large proportion (pneumococcal) of 
our Veterans. Therefore, setting targets and tracking how well we are 
doing in providing them is critically important.
    Most of the other recommended adult vaccines are recommended for 
smaller subsets of our Veteran population; some vaccines are 
recommended for only a few patients who have specific conditions or 
reasons for getting the vaccines. Setting targets for and tracking the 
delivery of those vaccines is much more difficult because of the 
variability in the indications for the vaccines. For example, the 
varicella (chicken pox) vaccine is recommended for adults but only for 
those who do not already have immunity to varicella (either from 
previous vaccination or from having had the disease). Decisions about 
these non-universally recommended vaccines should be made between 
patients and their providers on a case-by-case basis.

    Question 6: VA has serious concerns with H.R. 5543 because it would 
subject many discretionary aspects of title 38 compensation to 
collective bargaining. This bill is intended to allow collective 
bargaining over compensation related labor-management disputes such as 
locality pay, overtime pay, shift differential pay and performance pay. 
I have heard stories of VA nurses who have no recourse if they were 
denied overtime pay, which may negatively impact retention efforts. 
Does VA have administrative solutions for dealing with these issues if 
not through H.R. 5543? Please explain.

    Response: Title 38 U.S.C. 7422 does not preclude unions or 
employees from seeking redress, including filing a grievance, when VA 
fails to follow its own policies or comply with regulatory or statutory 
obligations regarding employee compensation. In addition, unions have 
the right to request that the Under Secretary for Health provide a 
written determination as to whether a specific issue is properly 
excluded from bargaining or grieving under 38 U.S.C. 7422.
    In connection with proposed legislation concerning section 7422, VA 
and the unions formed a Work Group to work collaboratively to formulate 
recommendations to improve knowledge, and correct misunderstanding, 
misinterpretation, and inconsistent use of section 7422. Both of these 
points are included in Work Group recommendations submitted to the 
Secretary. In addition, VA has an Administrative Grievance Procedure 
which generally permits employees to pursue disputes over perceived 
misapplication of VA compensation statutes and regulations, including 
those that might be covered by section 7422. H.R. 5543 is not necessary 
to enable title 38 employees to pursue such disputes.
    VA's concern with H.R. 5543 is that it is much broader than 
allowing employees a means to resolve labor-management disputes 
involving perceived misapplication of VA compensation statutes and 
regulations. The bill would give title 38 employees and the unions that 
represent them the right to grieve any decision made by the Department 
relating to discretionary pay matters, not just disputes involving 
regulatory or policy-related compensation issues. Title 38 has a number 
of pay systems that have significant discretionary aspects. For 
example, basic pay for physicians and dentists is set by law, but the 
Secretary of Veterans Affairs has discretion to set market pay for 
these positions above established basic rates based on factors such as 
experience, qualifications, complexity of the position and difficulty 
recruiting for the position. Pay for nurses is largely discretionary 
because it is set by locality pay surveys in accordance with the 
locality pay statute and its regulations.
    Further, Congress has granted VA other pay flexibilities involving 
discretion for nurses and certain other health care workers, including 
premium pay, on-call pay, alternate work schedules, special salary 
rates, and recruitment and retention bonuses. If VA was obligated to 
negotiate with unions over discretionary pay, we would not be able to 
implement decisions about discretionary pay until we either reach 
agreements with our unions or until we receive a binding decision from 
the Federal Service Impasses Panel. This could significantly delay our 
ability to hire clinical staff.

    Question 7: VA explains that H.R. 5543 would ``result in 
unprecedented changes in how the Federal Government operates. It would 
permit unions to bargain over, grieve, and arbitrate a subject--
employee compensation--that is generally exempted from collective 
bargaining.'' However, it is my understanding that H.R. 5543 makes 
modest changes by allowing VA clinicians the same rights as the rest of 
Federal employees so they can bargain over the implementation of pay 
laws and regulations. How do you respond to this disconnect?

    Response: In general, Federal employees covered by title 5 pay 
systems do not have the right to bargain or grieve over aspects of 
their compensation. As noted, VA title 38 compensation has significant 
discretionary aspects, in contrast to title 5 pay systems. The pay for 
VA nurses, for example, is almost entirely discretionary because it is 
based upon locality surveys. H.R. 5433 would give title 38 employees 
the right to bargain or grieve over these discretionary aspects of 
compensation. As a result, title 38 employees would be allowed to 
bargain or grieve over significant aspects of their pay, which other 
Federal employees cannot do. For that reason, negotiating over 
compensation on such a large scale would be unprecedented in the 
Federal Government. As discussed above, title 38 employees have the 
same rights as other Federal employees to resolve labor-management 
disputes involving perceived misapplication of compensation statutes 
and regulations.

    Question 8: I understand VA is in the process of developing the 
Department's views on H.R. 5641, which would allow Veterans to be 
placed in medical foster homes. In the meanwhile, could you comment on 
the number of Veterans who currently pay out of pocket to be placed in 
medical foster homes? What is your understanding of the need or demand 
for Medical Foster Homes among our Veterans?

    Response: As of August 30, 2010, there were 274 Veterans residing 
in Medical Foster Homes. All Veterans residing in Medical Foster Homes 
pay out of pocket to live there. Projections through 2019 from the VHA 
demand model indicate that as many as 5,000 Veterans could meet the 
requirements and potentially elect to reside in Medical Foster Homes.

    Question 9: H.R. 5596 addresses the prevention, diagnosis, and 
treatment of Veterans with Chronic Obstructive Pulmonary Disease. What 
treatment protocols does VA currently have in place and what tools do 
VA clinicians currently have? What gaps in treatment protocols and 
tools need to be addressed?

    Response: VHA has many treatment protocols and tools for the 
diagnosis of Chronic Obstructive Pulmonary Disease (COPD). In 2007 VHA 
and DoD published an update for the COPD evidence-based Clinical 
Guideline and similar guidelines, such as the American Medical 
Association COPD Guideline published by the National Quality Forum. The 
VHA/DoD edition of this guidance is one of the most current available. 
The guideline was accompanied by provider ``pocket cards,'' reference 
materials available using online links, and patient education tools. 
VHA also has many tools available for the treatment of COPD, including 
extensive home oxygen guidelines that have proven their utility and 
effectiveness under Joint Commission review.
    Prevention of smoking is critical in patients with COPD. VHA has 
implemented a number of evidence-based national initiatives, including 
adoption of a population-health approach to smoking cessation; 
increased access to nicotine replacement therapy and/or smoking 
cessation medications; elimination of outpatient copayments for smoking 
cessation counseling; clinical practice guidelines; and collaboration 
with mental health and substance use disorder health care providers to 
promote integration of smoking cessation into routine treatment of 
psychiatric populations. VA has metrics regarding screening, 
counseling, and offering of medication support as well as enrollment in 
smoking cessation classes and support groups.
    Historically, the prevalence of smoking and smoking-related 
illnesses has been higher among Veteran patients in the Veterans Health 
Administration (VHA) in comparison to that of the general population. 
Although rates of tobacco use have remained high, smoking cessation 
interventions continued to be greatly underutilized in VHA clinical 
settings just as they have been nationally.
    Moreover, VHA is implementing Patient Aligned Care Teams, expanding 
access to care management for patients suffering from chronic diseases 
such as COPD. A component of this effort will be the development and 
implementation of metrics to trend and drive improvement. We will be 
studying the use of externally developed models and metrics such as the 
Ambulatory Care Sensitive Conditions (ACSC) model for COPD metrics as 
well as internal development of metrics tailored to our Veteran 
population. At this time, there are no identified gaps.

    Question 10: VVA explains that ``there are pharmacological 
treatments and other treatment modalities available in the private 
sector that are difficult if not virtually impossible to get on the VA 
formulary.'' How do you respond to these concerns?

    Response: The VA believes that statement is an inaccurate and 
misleading representation of the VA National Pharmacy program. While it 
is true that not every commercially available drug is listed on the VA 
National Formulary, the same can be said for virtually any formulary in 
use in the United States today. VA is not unique in this regard.
    What is unique about VA's formulary process is that if a VA 
provider determines that a commercially available drug is medically 
necessary, then the commercially available drug will be made available 
via the VA National Formulary process for that individual patient, 
regardless of whether it is a brand or generic drug, whether it is or 
is not listed on the VA National Formulary, or whether it is costly or 
inexpensive. By contrast, in private sector health plans, there are 
numerous examples of drugs that a patient cannot get regardless of the 
medical need.
    The philosophy for VA's formulary management process is an 
unwavering reliance on well-researched, well-documented clinical 
evidence demonstrating that a specific drug can provide an expected, 
cost-effective benefit for the Veteran population. According to an 
analysis of the VA National Formulary (VANF) in 2001, the Institute of 
Medicine (IOM) stated:

       ``The VA National Formulary and formulary system that enable the 
VHA to make quality choices among drugs and negotiate favorable prices 
should be maintained . . . . The VHA should continue to make careful 
choices among drugs, based first on quality considerations but with an 
understanding of cost implications, and should negotiate the best 
prices possible using the leverage of committed use and the ability to 
drive market share.''

    VA's primary motivation in formulary management has always been and 
always will be to ensure highest quality care for Veterans. Economic 
considerations, though important, are secondary compared to safety and 
efficacy. VA has often been criticized for not adding recently approved 
medications to the VANF, or for unduly restricting medications, and has 
been the subject of inquiries and investigations prompted by these 
criticisms by the Institute of Medicine, the Government Accountability 
Office and the Office of the Inspector General. To date, these external 
reviews have only provided suggestions for some minor process 
improvements, concluding that VA's processes were safe and cost-
effective and that formulary decisions were based on sound reviews of 
the medical evidence.

    Questions 11: Section 4 of the draft legislation on general health 
care matters would provide additional authority beyond simple contracts 
for services at non-VA facilities. Would you explain what additional 
authorities are needed by providing some concrete examples?

    Response: 38 U.S.C. 1703, as currently written, provides that fee-
basis arrangements will be accomplished by contracts with non-VA 
facilities. The proposed language in Section 4 of the draft legislation 
would make it clear that VA is able to furnish fee-basis care through 
mechanisms other than contracts, such as an individual authorization 
and other industry standard tools such as provider agreements (similar 
to Center for Medicare and Medicaid (CMS) provider agreements)) for 
authorizing services for veterans. An individual authorization is used 
when services are sporadic in nature where contracting in accordance 
with Federal acquisition law and regulation would be cumbersome and not 
timely. Also, many providers, including many individual and small 
practice groups, are unfamiliar with Federal acquisition regulations 
which could adversely affect their interest in being a provider to VA 
potentially impacting care to Veterans. Further, pricing could be 
determined reasonable by other established rates such as Medicare as 
opposed to competitive acquisitions.

                                 

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                  November 16, 2010

The Honorable Eric K. Shinseki
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

Dear Secretary Shinseki:

    On Wednesday, September 29, 2010, Dr. Robert L. Jesse, Principal 
Deputy Under Secretary for Health, Veterans Health Administration 
testified before the Subcommittee on Health during a legislative 
hearing on a number of bills relating to veterans health care, 
including H.R. 5516 and H.R. 5996.
    As a follow-up to the hearing, I request that Dr. Jesse respond to 
the following questions in written form for the record.
 H.R. 5516--``Access to Appropriate Immunizations for Veterans Act of 
                                 2010''

    1.  The Department's testimony stated that ``. . . blanket 
monitoring of performance of all vaccines could be cost prohibitive and 
may not have a substantial positive clinical impact at the patient 
level.'' However, VA currently has performance measures for influenza 
and pneumococcal vaccines. How has implementing such performance 
measures affected the rates of vaccination and hospitalization for 
these two illnesses? Do you believe that adult immunizations are an 
important way to prevent the spread of disease and are a cost-effective 
way to preserve health?
    2.  A recent New York Times article on adult vaccinations rates 
states that only 7 percent of Americans over age 60 have received the 
herpes zoster vaccine, developed by VA researchers to prevent shingles. 
How many VA patients have received the herpes zoster vaccine? Has VA 
seen a corresponding decline in the number of veteran patients with 
shingles?
    3.  The Department's testimony stated that H.R. 5516 would ``. . . 
limit VA's ability to respond quickly to new research or medical 
findings regarding a vaccine.'' However, the legislation requires VA to 
use the immunization schedule established by the Center for Disease 
Control (CDC) Advisory Committee on Immunization Practices. Is this 
schedule inappropriate for veterans? Does VA believe that H.R. 5516 
would prevent new vaccines from being added to the performance measures 
if the CDC has not adopted them?
    4.  In the Department's statement, it is written that ``VA 
currently conducts ongoing initiatives'' regarding vaccination rates. 
What are these initiatives? How does VA ensure that all veterans have 
access to vaccines and is such data reported? Will VA commit to 
increasing immunization rates?
    5.  VA added the T-dap vaccine to the VA National Formulary as an 
adult booster vaccine. However, in 2007 VA purchased less than 48,000 
doses, enabling the vaccination of less than 1 percent of VA patients. 
How did VA formulate this vaccine strategy? What is the target vaccine 
rate for veterans with this vaccine?
    6.  When VA increased the rate for pneumococcal vaccinations, 
pneumonia hospitalization rates decreased by about 50 percent, a 
savings of about $117 for each vaccine administered. Does VA have any 
estimate on how much money would be saved through preventing future 
hospitalization? Do the costs that VA estimated for this bill include 
any potential savings from diminishing hospitalization rates for 
preventable diseases?

H.R. 5996--To direct the Secretary of Veterans Affairs to improve the 
        prevention, diagnosis, and treatment of veterans with chronic 
        obstructive pulmonary disease.

    1.  Various veteran service organizations (VSOs) testified to the 
need and their support for improving the prevention, diagnosis and 
treatment of veterans with chronic obstructive pulmonary disease 
(COPD). The Paralyzed Veterans of America expressed some concern that 
because this authorization is subject to appropriation, the Secretary 
could choose not to implement the bill if enacted. Can we expect the VA 
to implement this legislation if enacted?
    2.  In their written statement, the Department expressed support 
for the intent of H.R. 5996. How could H.R. 5996 be adjusted to gain 
the support of VA?
    3.  What COPD-related programs currently exist at VA?
    4.  The Department's statement references existing VA authority to 
conduct treatment protocols and further research into COPD. Is VA 
currently developing treatment protocols and related tools to improve 
research programs on COPD, as mandated in H.R. 5996? If so, please 
discuss this work.
    5.  How much of the Veterans Health Administration's budget is 
allocated to COPD-related conditions?
    6.  How did VA estimate the cost of H.R. 5996?

    The attention to these questions by the witness is much appreciated 
and I request that they be returned to the Subcommittee on Health no 
later than close of business Friday, December 17, 2010. If you have any 
further questions, please call (202) 225-3527.

            Sincerely,

                                                      Cliff Stearns
                                                  Republican Member

                               __________

                        Questions for the Record
                      The Honorable Cliff Stearns
      House Committee on Veterans' Affairs, Subcommittee on Health
           ``Health Legislative Hearing'' September 29, 2010
H.R. 5516--``Access to Appropriate Immunizations for Veterans Act of 
        2010''
    Question 1: The Department's testimony stated that ``. . . blanket 
monitoring of performance of all vaccines could be cost prohibitive and 
may not have a substantial positive clinical impact at the patient 
level.'' However, VA currently has performance measures for influenza 
and pneumococcal vaccines. How has implementing such performance 
measures affected the rates of vaccination and hospitalization for 
these two illnesses? Do you believe that adult immunizations are an 
important way to prevent the spread of disease and are a cost-effective 
way to preserve health?

    Response: VHA exceeds other health care providers in the delivery 
of influenza and pneumococcal immunizations (Trivedi A. et al. Medical 
Care. E-pub November 2010). The implementation of performance measures 
for these two immunizations contributed to VHA's high rate of use; 
however, other implementation strategies, including clinical reminders 
for providers, standing orders, immunization campaigns, and wellness 
providers for patients, have also contributed to this success. VHA 
agrees that adult immunizations are an important way to prevent the 
spread of disease and are a cost-effective way to preserve health. Yet, 
most of the adult immunizations other than influenza and pneumococcal 
are recommended for smaller subsets of the Veteran population; some 
vaccines are recommended for only a few patients who have specific 
conditions or reasons for getting the vaccine. Setting targets for and 
tracking the delivery of those vaccines is much more difficult because 
of the variability in the indications for the vaccines.

    Question 2: A recent New York Times article on adult vaccination 
rates states that 7 percent of Americans over age 60 have received the 
herpes zoster vaccine, developed by VA researchers to prevent shingles. 
How many VA patients have received the herpes zoster vaccine? Has VA 
seen a corresponding decline in the number of Veteran patients with 
shingles?

    Response: Data from VHA's Pharmacy Benefits Management shows that a 
total of 193,917 doses of the herpes zoster vaccine have been purchased 
since October 2007. VHA does not uniformly systematically record the 
number of Veterans who have received the vaccine from their non-VA 
providers. Validated data about the incidence or prevalence of shingles 
in VA patients since the vaccine was released are not available.

    Question 3: The Department's testimony stated that H.R. 5516 would 
``. . . limit VA's ability to respond quickly to new research or 
medical findings regarding a vaccine.'' However, the legislation 
requires VA to use the immunization schedule established by the Center 
for Disease Control (CDC) Advisory Committee on Immunization Practices. 
Is this schedule inappropriate for Veterans? Does VA believe that H.R. 
5516 would prevent new vaccines from being added to the performance 
measures if the CDC has not adopted them?

    Response: Overall, VHA supports the immunization schedule 
established by the Advisory Committee on Immunization Practices (ACIP). 
VHA Handbook 1120.05, Coordination and Development of Clinical 
Preventive Services (http://www1.va.gov/vhapublications/
ViewPublication.asp?pub_ID=2095), requires that ``the evidence-based 
recommendations of the . . . ACIP must be included [in VHA Clinical 
Preventive Services Guidance Statements], unless there are reasons to 
differ from these recommendations, such as: existing VHA policy, unique 
characteristics of the VHA population, VHA specific implementation 
issues, or more recent compelling evidence [emphasis added].'' VHA is 
represented as an ex-officio member of the ACIP and several VHA staff 
are members of various ACIP workgroups. So while VHA recognizes ACIP as 
the authoritative source for immunization recommendations for the 
general U.S. population, and participates in the development of its 
recommendations, VHA requires the flexibility to adapt ACIP 
recommendations as needed for its specific population of Veteran 
patients.

    Question 4: In the Department's statement, it is written that ``VA 
currently conducts ongoing initiatives'' regarding vaccination rates. 
What are these initiatives? How does VA ensure that all Veterans have 
access to vaccines and is such data reported? Will VA commit to 
increasing immunization rates?

    Response: VHA promotes immunizations for its Veteran patients by 
providing general information about immunizations on My HealtheVet and 
on the VHA National Center for Health Promotion and Disease Prevention 
Web site (http://www.prevention.va.gov/
Resources_Immunizations_Vaccines_for_Veterans_and _the_Public.asp). 
Veterans who are ``in-person authenticated'' on My HealtheVet receive 
electronic reminders about influenza and pneumococcal immunizations 
when they are due. Every year, the Office of Public Health and 
Environmental Hazards, through its award-winning multidisciplinary 
``Infection: Don't Pass It On'' project, develops an influenza campaign 
that promotes the use of influenza immunization to Veterans and 
employees (http:/www.publichealth.va.gov/flu/index.asp); in addition to 
influenza, campaign materials for pneumococcal immunization are 
provided through this project. Many facilities have clinical reminders 
about immunizations for staff in the electronic medical record, so that 
when patients are seen for appointments, staff are prompted to discuss 
appropriate immunizations with the patients. Nurses, social workers and 
case managers play an important role in promoting use of vaccinations 
with Veterans. Some VA medical centers have arrangements with local 
Veteran Rehabilitation Centers to provide immunizations at the Centers. 
The VHA Office of Rural Health has funded and established over 40 new 
outreach clinics in rural communities and also 4 mobile health units, 
which serve the states of Colorado, Maine, Washington, and West 
Virginia, all of which provide primary care for rural Veterans, 
including adult immunizations.
    VA reports rates of influenza and pneumococcal immunization use, 
compared with non-VA rates, on its Quality of Care Web site, 
www.qualityofcare.va.gov. VA is committed to providing high quality, 
appropriate preventive care, including immunizations, to all its 
Veterans. The VHA National Center for Health Promotion and Disease 
Prevention is developing an interactive public Web site that will allow 
users to search for age-and gender-appropriate recommendations for 
preventive care, including immunizations. Currently, the 
www.prevention.va.gov site has a link to a questionnaire that helps 
people determine which immunizations are recommended for them (http://
www.immunize.org/catg.d/p4036.pdf), based on their individual risk 
factors and health status.

    Question 5: VA added the T-dap vaccine to the VA National Formulary 
as an adult booster vaccine. However, in 2007 VA purchased less than 
48,000 doses, enabling the vaccination of less than 1 percent of VA 
patients. How did VA formulate this vaccine strategy? What is the 
target vaccine rate for Veterans with this vaccine?

    Response: The ACIP recommendation for use of a single dose of T-dap 
in adults ages 19-64 was published in the Morbidity and Mortality 
Weekly Report (MMWR) in December 2006. The recommendation was to 
replace the next booster dose of tetanus and diphtheria toxoids vaccine 
(Td) for adults whose last dose of Td was 10 or more years earlier and 
who had not previously received T-dap. The number of doses needed each 
year is much less than the total number of VA patients and is based on 
an estimate of the number who would be due for the vaccine that year 
and who had not received it outside VA. The vaccine is not FDA-approved 
for use in adults age 65 or older; nearly half of the population served 
by VHA is in that age range. Only recently, at its latest meeting in 
October 2010, the ACIP voted to recommend off-label use for older 
adults. Since 2007, VA has purchased a total of 288,940 doses of T-dap, 
enabling the vaccination of more than 10 percent of VA patients in the 
target age group.

    Question 6: When VA increased the rate for pneumococcal 
vaccinations, pneumonia hospitalization rates decreased by about 50 
percent, a savings of about $117.00 for each vaccine administrated. 
Does VA have any estimate on how much money would be saved through 
preventing future hospitalization rates for preventable diseases?

    Response: The cost-effectiveness estimates for adult vaccinations 
vary by vaccine, depending on the incidence of the vaccine-related 
disease and the cost and effectiveness of the vaccine. While many adult 
vaccines have been shown to be reasonably cost-effective under usual 
circumstances, few are actually cost-saving (unlike childhood 
immunizations, most of which are estimated to be cost-saving). VA has 
not estimated any potential savings from prevention of hospitalizations 
from the increased use of adult immunizations.
H.R. 5996--To direct the Secretary of Veterans Affairs to improve the 
        prevention, diagnosis, and treatment of Veterans with chronic 
        obstructive pulmonary disease.
    Question 1: Various Veterans Service Organizations (VSOs) testified 
to the need and their support for improving the prevention, diagnosis 
and treatment of Veterans with chronic obstructive pulmonary disease 
(COPD). The Paralyzed Veterans of America (PVA) expressed concern that 
because this authorization is subject to appropriations, the Secretary 
could choose not to implement the bill if enacted. Can we expect the VA 
to implement this legislation if enacted?

    Response: VA is committed to the continuous improvement of care to 
our Nation's Veterans. The foundation work related to the 
standardization of diagnosis and care for Veterans suffering from COPD 
has been completed. The results are supported by existing initiatives 
targeting smoking cessation and prevention. Operation of pilot sites as 
prescribed by the bill was not included in the President's budget; 
however, the overall intent of the bill could be met through a 
continued focus on current initiatives.

    Question 2: In their written statement, the Department expressed 
support for the intent of H.R. 5996. How could H.R. 5996 be adjusted to 
gain the support of VA?

    Response: VA would offer full support of this bill if the bill were 
crafted to allow more flexibility with the execution model and plans. 
VA believes it is important to develop pilot programs within VA prior 
to partnering with other agencies. Medicine is ever changing and the 
need to have the flexibility to change with the advances in medicine is 
crucial to success.

    Question 3: What COPD-related programs currently exist at VA?

    Response: COPD care is integrated into the Patient Aligned Care 
Teams (PACT), the primary care system in the Veterans Health 
Administration.
    At the Pharmacy Benefits Management group, a clinical pharmacist 
with experts from the field review current data regarding status of the 
best medical therapy for COPD in addition to other pulmonary diseases.
    Smoking and tobacco use cessation is organized through the Public 
Health Office of the Veterans Health Administration (VHA). Smoking 
continues to be the leading cause of preventable death and disease in 
the United States (US). Quitting smoking is the most important public 
health approach to minimize risk of emphysema and other smoking-related 
illnesses, such as cardiovascular disease, in the aging Veteran 
population. Smoking cessation care is currently provided at every VA 
health care facility nationally, with access to first-line FDA-approved 
smoking cessation medications. VA also has a national performance 
measure that requires that all Veterans seen in outpatient primary care 
and mental health settings be screened yearly for current tobacco use 
and provided with brief counseling and offered assistance in the form 
of medications and additional counseling. The rate of smoking cessation 
care has increased and the prevalence of smoking among Veterans in care 
has decreased from 33 percent in 1999, to 19.7 percent in 2008.

    Question 4: The Department's statement references existing VA 
authority to conduct treatment protocols and further research into 
COPD. Is VA currently developing treatment protocols and related tools 
to improve research programs on COPD, as mandated in H.R. 5996? If so, 
please discuss this work.

    Response: The Department of Veterans Affairs (VA) and The 
Department of Defense (DoD) have developed guidelines for treatment of 
COPD http:// www.healthquality.va.gov/
Chronic_Obstructive_Pulmonary_Disease_COPD.asp.
    These guidelines include algorithms for the management of COPD and 
for the management of acute exacerbations of COPD. The guidelines also 
include tools to facilitate implementation; a pocket card for quick 
reference and a summary in addition to the full guidelines.
    Research Programs--The cooperative studies program (CSP) has as an 
objective to initiate new multi-site clinical trials in chronic 
disease. COPD and its relationship to bacterial infections, 
environmental exposure, and rehabilitation are included in that 
objective's priorities. VA investigators recognize that COPD is an 
important chronic disease. VA and DoD have developed a joint Clinical 
Practice Guideline (CPG) for COPD. This guideline This guideline was 
updated in 2007 based on best practices and available clinical 
research. VA and DoD continue to collaborate on revisions to this CPG.
    VA has funded thirty-five research projects specific to COPD over 
the last 2 years. These projects range from molecular investigation 
through practical application of science in rehabilitating patients 
with COPD.
    VA has over 340 research publications on COPD over the last 3 
years, which demonstrates VA's commitment to research and knowledge 
sharing.
    VA is pleased to announce that Dr. Christine M. Freeman, PhD, has 
been nominated for the Presidential Early Career Award for Scientists 
and Engineers (PECASE) Award for her work on the role of the immune 
system in COPD. Dr. Freeman's work on immunologic mechanisms involved 
in COPD pathogenesis holds great potential that could lead to novel 
treatment approaches for this very common and devastating disease.

    Question 5: How much of the Veterans Health Administration's budget 
is allocated to COPD-related conditions?

    Response: In FY 2010, VA provided Home Respiratory Care to 128,000 
Veterans at a cost of more than $139 million. The VA spends 
approximately $5693 (2004 data)/Veteran with COPD as a primary or 
secondary condition. Approximately, 19 percent of Veterans are 
afflicted with COPD. An estimate of expenditures for COPD for a 
population of about 969,000 Veterans with COPD finds that the VA 
commits $5,516,517,000 (2004 data).

    Question 6: How did VA estimate the cost of H.R. 5996?

    Response: The cost for H.R. 5996 was estimated based on funding a 
person to build the COPD program in each VA medical center and 
resources for a training program which would include two full time 
national coordinators.
    The cost of this bill is estimated to be $25.9 million over 5 
years.