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[110 Senate Hearings]
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S. Hrg. 110-34
THE FISCAL YEAR 2008 BUDGET
FOR VETERANS' PROGRAMS
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
FEBRUARY 13, 2007
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West Larry E. Craig, Idaho, Ranking
Virginia Member
Patty Murray, Washington Arlen Specter, Pennsylvania
Barack Obama, Illinois Richard M. Burr, North Carolina
Bernard Sanders, (I) Vermont Johnny Isakson, Georgia
Sherrod Brown, Ohio Lindsey O. Graham, South Carolina
Jim Webb, Virginia Kay Bailey Hutchison, Texas
Jon Tester, Montana John Ensign, Nevada
William E. Brew, Staff Director
Lupe Wissel, Republican Staff Director
C O N T E N T S
----------
February 13, 2007
SENATORS
Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........ 1
Craig, Hon. Larry E., Ranking Member, U.S. Senator from Idaho.... 3
Charts:
FY 2008 Discretionary Budget Request....................... 7
Quality, Affordable Health Care............................ 8
Transcript excerpt, Hearing on Veterans Health Care
Eligibility Priorities (Part I), held on March 20, 1996,
Senate Committee on Veterans' Affairs...................... 143
Rockefeller, Hon. John D. IV, U.S. Senator from West Virginia.... 9
Murray, Hon. Patty, U.S. Senator from Washington................. 10
Sanders, Hon. Bernard, U.S. Senator from Vermont................. 12
Brown, Hon. Sherrod, U.S. Senator from Ohio...................... 14
Tester, Hon. John, U.S. Senator from Montana..................... 16
Webb, Hon. Jim , U.S. Senator from Virginia...................... 17
WITNESSES
Nicholson, Hon. R. James, Secretary, Department of Veterans
Affairs; accompanied by Michael Kussman, M.D., Acting Under
Secretary for Health; Hon. Daniel L. Cooper, Under Secretary
for Benefits; Hon. William F. Tuerk, Under Secretary for
Memorial Affairs; and Robert J. Henke, Assistant Secretary for
Management..................................................... 18
Prepared statement........................................... 22
Response to written questions submitted by:
Hon. Daniel K. Akaka....................................... 32
Hon. John D. Rockefeller IV................................ 45
Hon. Patty Murray.......................................... 49
Hon. Larry E. Craig........................................ 52
Response to written questions submitted by Hon. Jim Webb to
Hon. Daniel L. Cooper...................................... 62
Blake, Carl, National Legislative Director, Paralyzed Veterans of
America........................................................ 74
Prepared statement........................................... 75
Violante, Joseph A., National Legislative Director, Disabled
American
Veterans....................................................... 78
Prepared statement........................................... 79
Greineder, David G., Deputy National Legislative Director, AMVETS 85
Prepared statement........................................... 86
Cullinan, Dennis M., Director, National Legislative Service,
Veterans of
Foreign Wars of the United States.............................. 89
Prepared statement........................................... 90
Robertson, Steve, Director, National Legislative Commission,
American
Legion......................................................... 96
Prepared statement........................................... 98
Rowan, John, National President, Vietnam Veterans of America..... 110
Prepared statement........................................... 111
Working paper, prepared by Linda Bilmes, John F. Kennedy
School of Government, Harvard University................... 118
APPENDIX
The American Federation of Government Employees, AFL-CIO,
prepared statement............................................. 145
The Friends of VA Medical Care and Health Research, prepared
statement...................................................... 148
Chart, Inflation Adjusted VA Research Appropriations......... 152
FOVA Membership.............................................. 153
The Independent Budget Response to Written Questions Submitted
by:
Hon. Daniel K. Akaka......................................... 154
Hon. Larry E. Craig.......................................... 157
Letters to Hon. Daniel K. Akaka submitted by:
Hon. Frank Q. Nebeker (Ret.), Chief Judge, U.S. Court of
Appeals for Veterans Claims, dated February 12, 2007....... 158
Hon. Daniel Ivers (Ret.), Chief Judge, U.S. Court of Appeals
for Veterans Claims, dated February 13, 2007............... 159
Rear Admiral Philip J. Coady (Ret.), Chairman, Board of
Directors, Lung Cancer Alliance, dated March 22, 2007...... 160
Attachment, Lung Cancer Screening and Early Disease
Management Pilot Program............................... 161
The Independent Budget for Fiscal Year 2008...................... 163
THE FISCAL YEAR 2008 BUDGET FOR VETERANS' PROGRAMS
----------
TUESDAY, FEBRUARY 13, 2007
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 9:30 a.m., in
room SR-418, Russell Senate Office Building, Hon. Daniel K.
Akaka, Chairman of the Committee, presiding.
Present: Senators Akaka, Rockefeller, Murray, Brown,
Tester, Webb, Sanders, and Craig.
OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN,
U.S. SENATOR FROM HAWAII
Chairman Akaka. This hearing will come to order. Aloha, and
welcome to all of you who are here. I look forward to our
dialogue with Secretary Nicholson and other top VA officials,
as well as the representatives of all our Veterans Service
Organizations here with us today.
I also want to say that I am so delighted to be here with
my colleague and friend and former Chairman of this Committee.
We have worked so well together, and I look forward to
continuing that relationship for the benefit of the veterans of
our country. I am so happy to be working with him again.
At the outset, I am pleased that the Administration is
requesting a straightforward increase for VA, without some of
the offsets proposed in prior years. While some see this
proposed budget as good, others see it as inadequate. I believe
that what we need is a much better understanding of some of the
specifics before our Committee goes forward to the Budget
Committee with our views and estimates.
For example, I believe we need to know what the actual
increase is for veterans' health care in the proposed budget.
It appears to me that inflation and automatic cost increases
account for nearly all of the $1.9 billion increase being
requested of Congress. This would leave little funding
available for expansions or improvements to key programs such
as mental health and care for returning servicemembers. I will
address this concern in my questions to VA.
I want you to know that I remain committed to my opposition
to the policy proposals that would impose higher costs on
veterans.
Once again, the Administration is suggesting that we ask
veterans to pay more out of their own pockets if they are not
disabled but still want access to VA care. Let me be clear
about these veterans who would be forced to shoulder these cost
increases. Many of these veterans cannot, in my view, be
characterized as ``higher income.'' These are veterans living
in places like my home State of Hawaii, where the cost of
living is one of the highest in the country, who make as little
as $28,000 a year and would be asked to pay new fees for their
care or their medication.
I have a number of questions about this year's enrollment
fee proposal. Basing the fee upon family income is a different
version than the Administration has proposed in the past. I am
concerned about the lower end of the tier structure, those
working families with a combined income of $50,000 a year, and
how this policy would affect them. A family with two-veteran
wage earners, each taking an average number of medications and
each paying the enrollment fee, would have to pay nearly $3,000
more in out-of-pocket costs if the proposed fees are mandated.
I do not believe this is the way to reward the working families
who have served our country.
On the benefits side of the ledger, VA must be ready to
adjudicate claims in a timely and accurate manner. Should VA
receive claims in excess of the 800,000 that are estimated for
next year, I do not believe the Department will have the
resources to handle the workload. In addition, VA does not have
a history of absorbing the impact of new court decisions
easily, and I am concerned that pending court cases may have an
adverse effect on VA's timeliness and accuracy.
We also know that the ongoing situations in Iraq and
Afghanistan are increasing VA's workload and will continue to
do so for many years to come. The time for VA to hire and train
staff to meet present and future demand for timely adjudication
is now.
I will continue to monitor VA's inventory and staffing
requirements. Our Nation's veterans deserve nothing less than
having their claims rated accurately and in a reasonable amount
of time.
I am committed to working with the Secretary and my
colleagues on both sides of the aisle to ensure that the
Department gets what it truly needs to deliver the highest-
quality benefits and services to those who have served.
I am also deeply committed to working to have all of our
colleagues in Congress recognize the reality that meeting the
needs of veterans is truly part of the ongoing costs of war.
Mr. Secretary, I want to share that, prior to this hearing,
staff asked some questions about the various proposals included
in this budget. The day after the budget roll-out, basic
questions were posed, such as: Would there be a cap on total
drug copayments imposed on veterans? We did not receive this
information. I cannot emphasize enough that answers must be
provided in a more timely way.
Again, I want to say welcome to all of you here today, and,
Mr. Secretary, I want to wish you well. As I told you, we look
forward to working together for a great year and in years to
come for our veterans. We do this on behalf of the Nation's
veterans in the weeks and months ahead, as the Committee works
to put together the best possible budget for veterans' programs
in the coming fiscal year.
Now, I would like to call on our Ranking Member, Senator
Craig, for his statement.
STATEMENT OF HON. LARRY E. CRAIG, RANKING MEMBER,
U.S. SENATOR FROM IDAHO
Senator Craig. Well, Mr. Chairman, thank you very much, and
I think your concluding words are the most important--``the
best possible budget'' we can possibly arrive at for our
veterans.
And, again, let me thank you, Mr. Secretary, for appearing
before the Committee this morning. I know that it has been
difficult to put a 2008 budget together in the absence of a
2007 budget. I think we will have that out for you this week.
But where is the level of spending? And I think that is a
concern. I would say, though, that working with all of my
colleagues on this Committee and the Appropriations Committee
staff, I think--in fact, I believe in an absolute certain way
that you will be pleased with the 2007 budget, as will millions
of veterans who rely on VA's services, because I think this
Congress has been responsive.
Today, you put before us another strong funding
recommendation for the upcoming fiscal year. Within the context
of the total Federal budget request for Fiscal Year 2008,
veterans are again, in my opinion, clear winners. Let me give a
visual demonstration of this fact.
On the chart behind me, you will see that when
discretionary spending increases associated with defense- and
homeland security-related spending are factored out, there is
an $8 billion increase left over for all other Federal agencies
and programs. Of that $8 billion, under the President's plan,
about $3 billion will go to VA. In effect, this will leave
about a 1 percent increase for the rest of Government. As I
said, the President and the Congress continue to make veterans
a priority within the overall Federal budget.
Unfortunately, I have read or heard a number of statements
from some of my colleagues suggesting that this President has
demonstrated a lack of commitment to VA funding. This rhetoric
persists even in the face of a VA budget that has increased 77
percent--let me repeat that--a VA budget that has increased 77
percent under President Bush's watch. Where was the strident
criticism during the late 1990s when, in 2 consecutive years,
actual cuts in VA medical care were proposed by then-President
Clinton? Why now are 10 percent average annual increases
bemoaned as inadequate, but 2 percent increases during the
Clinton years were hailed as an essential to control Federal
spending and reduce the deficit? Frankly, I find that double
standard very troubling.
In the past, I have spoken at length about impending
collisions between VA spending and the spending of other
Federal programs. Well, as the chart demonstrates, the
collision is upon us, except it does not resemble a collision
at all. It, rather, resembles the VA in an 18-wheeler headed
down the Federal road and running over the top of other
agencies in its process.
Now, that is an interesting and probably a colorful
metaphor. It begs the question. Can this pattern be sustained?
That is the question that I and my colleagues will grapple with
as we debate with you, Mr. Secretary and the President, the
President's budget in the months ahead.
One of my favorite sayings is attributed to Benjamin
Franklin. He said, ``The definition of insanity was doing the
same thing over and over but expecting different results.''
Well, it appears that the Administration has heeded Ben
Franklin's wisdom with the Fiscal Year 2008 VA budget in three
key areas, and I commend the President for listening to his
critics on these issues, and I would hope we could shift some
courses. This President has shifted courses.
First, as many already know, it is the sixth year in a row
that some form of increased cost sharing on veterans with
higher incomes and no service-connected disabilities is being
proposed. The Chairman has just mentioned it. Each year, the
proposals were essentially dead upon arrival. We all know that.
There was not a Congressman or a Senator who wanted to support
them. Members of the veterans organizations alike argued that
Priority 7 and 8 veterans were not wealthy and that an
enrollment premium would drive veterans from the system because
they simply could not afford to pay it.
In response, this year the President's budget proposes a
tiered premium that only applies when the income of a non-
service-connected veteran hits $50,000, double the income floor
of previous proposals, and above the median income level in the
United States. The Chairman of the MilConVA Subcommittee of
Appropriations now, she and I had that discussion a year ago
and recommended to the Administration that if they came back to
us with the same proposal, it would go nowhere. They have not.
They have substantially adjusted and changed it.
Second, many complained that the priority proposals forced
one veteran to pay for the health care of another, and that
relying on future premium collections to reduce appropriated
dollars was a risky way to fund a health care system. This
year, the President proposes exactly the opposite. He
recommends that new revenues generated by his proposal be
deposited directly in the Federal Treasury, no tradeoffs, and
not used as an offset against appropriated dollars. In other
words, the President's medical care appropriation request is
not affected by or dependent upon the Congress' action on his
fee proposals.
And, finally, past budgets by both Republican and
Democratic Presidents have been criticized for their use of
unspecified management efficiencies that were driven primarily
by OMB's directives to reduce the need for appropriated
dollars. This budget ends that practice.
Let me talk for a moment, Mr. Chairman, about my own view
of the President's proposals. I know many Senators have come
out once again against the President's premium proposals in
this budget. I, on the other hand, am one that finds these
premiums to be a very reasonable price for access to what is
widely now hailed as the best health care system in America. I
would like to take a minute to go back in time to the late
1990s when the VA first began the transformation from a
hospital system to a health care system. And as we know, those
approaches are very different.
From about 1999 on, the VA started to see hundreds of
thousands of new enrollees every year. Interestingly enough, an
overwhelming proportion of those new enrollees were Medicare-
eligible vets from World War II and the Korean War. In fact,
today over 45 percent of the 5.5 million users of VA's health
care system are Medicare eligible. Many of them signed up for
VA care to get access primarily to one thing: the drug benefit.
Of course, at that time Medicare Part D was not an option
for them. Now it is. As enrollment accelerated, long wait times
began to appear. Using authority given by the Congress to focus
limited resources on the VA's highest priority patients, then-
Secretary Tony Principi closed enrollments to new Priority 8
veterans. As a result of all of this, I find myself in a bit of
a quandary. The VA now provides care to 2.5 million veterans
who have access to Medicare and nearly 550,000 who have TRICARE
coverage and 215,000 who have both TRICARE and Medicare. That
may be well and good, but it probably is not efficient, and it
certainly does not appear fair to those Priority 8s now locked
out of VA with no insurance coverage at all.
I often talk of those Priority 8s who, for purposes of this
discussion, I call the ``Boise Cascaders.'' Now, that may sound
confusing to all of you. These are veterans in their late 40's
and 50's who once worked for Boise Cascade Corporation, home-
based in my State of Idaho, a forest products company.
Unfortunately, the decline in the timber industry in the
country shoved them off the rolls of a large company's health
care plan. They are now working in small businesses--
construction, electrical work, local stores, et cetera--and
they cannot afford health care insurance on their salary, and
their employers do not provide it.
The chart behind me shows what the average cost of an
individual health care insurance premium is in this country
today, and that is $4,242. This is what a Boise Cascader--and
there are many of them across the Nation as our economy adjusts
and changes--is forced into paying.
The President's proposal may be showing us an opportunity
to offer VA health care at an affordable price to those who
cannot offer it to themselves at a time of their need. I cannot
think of anyone with a family income of at least $50,000--and
that is what the new proposal is--and without any other health
care insurance who would not suddenly drop VA health care
because all of a sudden it cost them $21 per month. Now, that
is $21 per month to access the number one health care delivery
system in the country. By anybody's guesstimation, Mr.
Chairman, that is a flat bargain.
Perhaps some with other health insurance would choose not
to pay multiple premiums for multiple plans, and if so, so be
it. I think it is an opportunity for us to take a segment of
America's workforce that is underinsured or uninsured today and
to allow others who have three options--Medicare, TRICARE, and
VA--to determine which of those options they would choose to
access.
So in the end, Mr. Chairman, I believe we have a strong
budget request for VA with thought-provoking proposals. I note
with interest that VA's request for medical care when all
sources of revenue are included even exceeds the recommendation
made by the Independent Budget. And as you know, Mr. Chairman,
the last several years we have always heard that as a
comparative.
I am sure our VSO panel will have more to say on this
point, but I have said before that the care of America's
veterans continues to be a clear funding priority of this
Congress and this President, and I think this budget reflects
it. And within the VA's budget, the needs of our veterans
returning from Iraq and Afghanistan, the disabled, the poor,
are front and center, where they belong.
Mr. Chairman, I have spoken long enough. You have been very
patient. I think these are important issues to make. They will
go on in the debate over the next several months as we work
this budget out. I look forward to hearing from the rest of my
colleagues and the witnesses before the Committee today.
Thank you.
Chairman Akaka. Thank you very much, my colleague, for your
statement.
[The Fiscal Year 2008 Discretionary Budget Request, and the
Quality, Affordable Health Care charts follow:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Let me call for opening statements on Members of this
Committee. I want to welcome the Members of the Committee here,
and we will begin with Senator Jay Rockefeller.
STATEMENT OF HON. JOHN D. ROCKEFELLER IV,
U.S. SENATOR FROM WEST VIRGINIA
Senator Rockefeller. Thank you, Mr. Chairman. I have to go
do an Aviation markup right after my statement, for which I
genuinely apologize. It is a classic case of cross-scheduling,
which always hurts somewhere.
Mr. Secretary, I am very glad that you are here. I wrote a
letter to Jim Altmeyer the other day and mentioned you. And I
am also very aware of what Senator Craig has said most clearly,
and that is that there has been a 77 percent increase since the
President took office. And I will agree that that sounds
dramatic. There is a whole variety of ways of taking that and
breaking it down and seeing it in other ways. But that is not
for the point here.
I think our Members would care to understand that life is
not always what is the percentage of increase but, rather, are
people getting taken care of the way they should be taken care
of? And if you are looking at a budget, obviously everything is
in the realm of possible. But it really should be--in terms of
veterans, it is different from other budget item. Are they
getting the health care they actually need and deserve?
My sense is that this budget does not do that. The
Independent Budget suggests that VA health care needs an
additional $2 billion for fully funded care. The VA has seen an
enormous increase in workloads, and health inflation is real.
But we have to focus on the challenging needs of our veterans
returns from Iraq and Afghanistan, and I would dispute some who
would say that they are getting all that they need.
I visit with them constantly, as I have discussed with
Patty Murray on a number of occasions because I think Patty is
passionate about veterans, and I think she deserves the credit
for restoring $1.3 billion to our veterans' health care budget
last Congress. But, you know, we have got Iraq veterans, we
have got Afghanistan veterans, we have got World War II, Korea,
and Vietnam veterans. They served, all of them, and they all
deserve their benefits.
I worry that the VA continues to propose new fees to either
drive veterans away from VA health care or make them pay more.
One of the previous speakers indicated that we added on an
extra fee in the past. But that was for a new program, for
something called long-term care, which had never existed in the
history of this country before and which was done by Senator
Specter and myself and Lane Evans in the House before some were
even on this Committee. So there was a reason for that fee
increase--a new program, entirely new program. Still it is the
only long-term care program in this country.
I think this year's proposal is even more discouraging
about fees because the budget suggests that enrollment fees go
to the Treasury general revenue. People can try to make that
look good or somehow as a responsible thing to do. I do not
understand that type of thinking.
Whenever I can, which is about every other weekend, I spend
3 to 4 hours in the afternoon usually with returned Afghan and
Iraq veterans. They are young. Sometimes they go back to the
Vietnam War, but not usually. Most of them are wounded. I do
not see them at Walter Reed. I see them in West Virginia. And
so I see them when they are in the course of their VA rehab and
PTSD care along with the rest of it. There is no staff. There
is no press. There are no pencils, no paper. Nothing goes
outside the room. And these have been very, very powerful,
emotional events for me, one after another after another. There
are a lot of cases that come out of that which make me think of
our VA budget.
I think it is really important to be honest about
information, not just percentage increases but what is actually
being done, what do people get, what do they not get. I think
we also need a better process. I am quite pleased that the
joint continuing resolution has a $3.6 billion increase for VA
health care for the rest of this fiscal year. But this increase
is 4 months late. As the Secretary knows only too well, such
delays are hard for VA centers, especially not staffing
decisions.
As I indicated--this is about a quarter of what I wanted to
say--I have to do an Aviation markup and, unfortunately, I have
to Chair it. So I have got to leave, Mr. Chairman, and I
apologize for that. But I just think we have to be very, very
careful when we are talking about veterans, number one, that we
do not get political. Whether President Clinton did or did not
do something is not particularly relevant to me, or whether
President Bush did or did not do something. But the only test
that counts here is: Are they getting the services, the medical
services they need? The deep degree of distress of our veterans
is almost impossible to describe the hurt, and you do not see
it, and you do not get until you have been with them for
several hours. And then somebody starts going really deep in
describing his or her hurt, and then other members who are
there, 12 or 13 gathered around in a circle, they say, ``Stop,
stop, stop. Don't go there. That is too painful for me.''
Now, are we dealing with that? Are we not? Are we dealing
with it adequately? Are we not? I think that is the only
question that counts.
Thank you, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Rockefeller.
Senator Murray?
STATEMENT OF HON. PATTY MURRAY,
U.S. SENATOR FROM WASHINGTON
Senator Murray. Thank you very much, Chairman Akaka,
Senator Craig. I appreciate your holding this very important
hearing on the President's budget proposal for Fiscal Year
2008. I want to thank the Veterans Service Organizations who
are here as well today, who put an awful lot of work into
crafting the Independent Budget, and I think it is very
important we hear what they have to say. So I appreciate them
being here.
I want to welcome back Secretary Nicholson again. Mr.
Secretary, as I said to you privately before we started, thank
you so much for the new CBOC in Northwest Washington, the new
Vet Center in Everett. These are issues we have been working on
for a number of years, and our vets in northwest Washington are
really pleased that someone is finally moving the ball forward.
And I do want to thank you for that publicly.
Mr. Chairman, with our troops fighting overseas and more
veterans being created each and every day, it is critical that
we do everything in our power to make sure that the budget we
provide provides for our veterans. In the past, the VA has been
dramatically wrong in its budget projections, and I think we
all agree we can never let that happen again.
Mr. Secretary, you and I both agree that the VA's health
care system is among the best in the country, once you get in
the door, and that is what concerns many of us. It is the
problem of getting in the door that we have to make sure we are
addressing.
I am very concerned that the budget that we are looking at
closes the VA's door to thousands of our Nation's veterans. It
does, as has been talked about, include new fees and increased
copays that will discourage veterans from accessing the VA, and
it continues to bar Priority 8 veterans from enrolling in the
VA health care system.
I am also very concerned that the VA is still
underestimating the number of veterans from Iraq and
Afghanistan that will seek care in the VA. In Fiscal Year 2006,
the VA underestimated the number of patients it would see by
45,000. For the current fiscal year, 2007, the VA has been
forced to revise its projection up by 100,000 veterans. Now the
VA is projecting that it will see 263,000 Iraq and Afghanistan
vets in 2008, but I am being told by some that the VA should
actually be preparing to care for more than 300,000 returning
veterans. Frankly, I think it is very important that we do not
underestimate this number. We have seen the past failures in
the VA to accurately project the numbers, and I think it is
important that this Committee get it right.
While this budget increases funding for the VA over
previous years, as we have heard, it does barely keep pace with
inflation and other built-in costs, and it falls far short, as
we will hear from the Independent Budget recommendations. This
budget assumes cutbacks in veterans' health care in 2009 and
2010, and I think we need to focus on that, Mr. Chairman,
because we cannot project out the care of some of these
veterans in the short term. We have to make sure they are
covered in the long term, and this budget does not do that.
This budget also assumes a decrease in the number of
inpatient mental health patients. When all signs everywhere
point to an increase in need, when the President has now
proposed a surge of troops to Iraq, when the men and women in
uniform are being deployed for their second and third tours of
duty, and when more and more of our troops are coming home with
PTSD and mental health care needs, I do not understand how the
VA can assume that they will treat fewer patients for inpatient
mental health care.
Mr. Chairman, I think our veterans deserve a better budget
than has been presented to us. They deserve a budget that is
based on real numbers and real needs. We all know too well what
happens when the VA gets shortchanged. It is not bureaucrats in
D.C. that suffer. It is the men and women who have served us so
honorably that pay the biggest price, and I hope that, through
strong oversight of this Committee and your leadership, we will
make sure we are presenting a budget that does reflect the
needs that we have in front of us.
Thank you.
Chairman Akaka. Thank you very much, Senator Murray.
May I call on Senator Bernie Sanders.
STATEMENT OF HON. BERNARD SANDERS,
U.S. SENATOR FROM VERMONT
Senator Sanders. Thank you very much, Mr. Chairman. And,
Mr. Secretary, welcome. Thank you for being here.
Let me begin by concurring with many of the remarks made by
others who have already spoken, and let me just start off by
commenting a little bit on my friend Senator Craig's remarks
about the very significant increase in the last several years.
There are two reasons for that. Number one, as we all know, the
cost of health care is soaring in every area of our lives, so
if nothing else were happening, the cost of health care is
going up. And, number two, we are at war, and more and more of
our soldiers are coming back wounded, and they need care. So I
think those factors have got to be included when we look at the
increased in VA spending. But the issue that we should be
focusing on, as others have said, is-- is the amount of money
that we are spending adequate to take care of the needs of the
men and women who are the veterans of this country?
And I would hope, Mr. Chairman, that there is no
disagreement on this Committee. I know that we have different
political philosophies here, but I would hope that there is no
disagreement that when a man or woman puts his or her life on
the line to defend this country, whether it is a war that I
support or I do not support, that we all agree that when that
person comes home, they are entitled to all of the health care
they need for the rest of their lives; that, in other words,
when the Congress votes to send people to war, that we
understand that the cost of war is not just the tanks and the
bullets, but that the cost of war is that 90-year-old soldier
who may have fought 50 years ago and was hurt, and that we are
not a serious country, a moral country, if we ever turn our
backs on any of those soldiers. I would hope that there would
be agreement on that.
Sadly, for a number of years--and I think it is without
dispute--the budgets that President Bush has sent us have been
totally inadequate, and the evidence is pretty clear, because
in Vermont, and I think all over this country, there are
waiting lists for people to get into the VA. There are staffing
shortages. There are, very clearly, backlogs in terms of the
processing of the claims that veterans bring forward. I do not
think there is a disagreement to that, Mr. Secretary. Maybe you
will speak to that in a moment. But when a veteran puts in a
claim, they should not have to wait 6 months or a year to get
that claim adjudicated. You know as well as I do that there are
veterans who absolutely believe that one of the reasons for
that is maybe they will die, and then the VA will not have to
pay out the claim. I do not want one veteran in the United
States of America to hold that view.
Also, I would concur with the Chairman and others to say
that when people put their lives on the line, we should not be
asking them to pay substantially more--almost double--for
prescription drug fees. We should not be increasing the fees
for people to get into the VA, which, in my view, has the
designed purpose of pushing people out of the VA health care
system altogether. We should be welcoming people into what some
have referred to as one of the great health care systems in the
world, not pushing them out.
We all know--and I want to thank all of the veterans
organizations for the excellent work that they have done, and I
think the Independent Budget that they have given us is a very
important document. It enables us to go forward in assessing
the needs of veterans from the perspective of the veterans
themselves. And I appreciate very much what they have done, and
this year's Independent Budget reveals that the
Administration's proposed budget is about $4 billion short--$4
billion short.
Now, Mr. Chairman, those of us in the Congress know that
there are many competing funding priorities. Four billion
dollars is, in fact, a lot of money, but let's see how within
the Bush budget that $4 billion competes with other needs that
the President has brought forward. And I want everybody to hear
this because this is really what this whole debate is about. It
is about priorities. It is about how strongly we really care
about people who put their lives on the line compared to
others.
In the President's budget, he proposes the elimination of
the estate tax. This tax cut benefits only--the only
beneficiaries of that repeal are the wealthiest two-tenths of 1
percent of the American people; 99.8 percent of Americans do
not benefit one nickel from the repeal of the estate tax.
Eliminating the estate tax will save one family--the Walton
family, who owns Wal-Mart, as we all know--over $32 billion.
Mr. Chairman, one family, the repeal of the estate tax will
benefit $32 billion. And I would like anybody in this room to
tell me that as a Nation we cannot come up with another $4
billion to protect the men and women who have put their lives
on the line defending this country when we can come up with $32
billion for one family. One family. This Nation is the
wealthiest nation in the history of the world. We have the
funds to take care of our veterans.
Mr. Chairman, I have to say that one of the most glaring--
and Senator Craig raised this issue, and maybe we can work
together on this issue--examples of the abandonment of our
veterans is the bar on Category 8 veterans. Since 2003, this
Administration has closed the door to VA enrollment by new
Category 8 veterans. Estimates are that over a million veterans
have been denied access to care as a result.
Now, these are ``wealthy'' veterans. Let us be clear. These
are not the Walton family ``wealthy'' veterans. These are
people who, if they are single, earn $28,000 a year. They
cannot get into the VA anymore. We cannot take care of them,
but if you are the Walton family, we have got $32 billion to
take care of you.
Mr. Chairman, in my view, we should take a very, very hard
look at this budget. In my view, we have got to keep faith with
the 22,000 soldiers who have been wounded in Iraq, the tens and
tens of thousands more who are going to be coming home with
severe post-traumatic stress disorders and other problems.
I should tell you, Mr. Chairman, that my office is now
working on a comprehensive piece of legislation which will
include many of the concerns that the veterans organizations
have. We are going to bring that forward, and we look forward
to support of Members of this Committee. The time is now to get
our priorities right, and included in that is the need to take
care of our veterans.
Thank you very much, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Sanders.
Senator Sherrod Brown?
STATEMENT OF HON. SHERROD BROWN,
U.S. SENATOR FROM OHIO
Senator Brown. Thank you very much, Mr. Chairman.
Secretary Nicholson, thank you, and thank you for your
quick responsiveness to many of us on this Committee. I
appreciate that and your commitment to the Nation's veterans. I
especially echo Senator Murray and her thanks of helping
particularly with CBOCs in Parma, Ohio, and other outpatient
clinics and your work on the consolidation in Cleveland and
what that means especially for psychiatric care and especially
for homeless veterans. Thank you for that.
One hundred and eight years ago, in a tailor shop in the
then small town of Columbus, Ohio, the 13 veterans who recently
returned from the Spanish-American War met and talked about
sharing their memories, talked about their fallen comrades,
talked about issues facing returning veterans coming home,
talked about pensions and the fact there were no pensions, no
real health care for these veterans. In that small tailor shop,
out of that meeting of those 13 veterans came the VFW.
The VFW and so many other veterans organizations, from the
Vietnam Vets to the American Legion to the Disabled American
Vets and so many organizations, are a big reason that we are
here today and a big reason that this Nation has done not
always adequate, but a decent job over the years of taking care
of our veterans.
As this body so often does not go much beyond being a
responsive body, whether it is environmental law, whether it is
the creation of Medicare and Social Security, whether it is
civil rights, or whether it is veterans issues, clearly these
outside organizations, like the VFW and the American Legion and
others, have played such a role in getting this body to do the
right thing. And I thank all the veterans organizations that
have played such a major role in that, especially, as Senator
Craig said, now that the VA really is the best--probably the
best health care system in this country.
But I also concur with Senator Murray in that we simply--
the VA and the President's budget are sorely lacking in what we
really ought to be doing. We know of the problems. We have
heard them stated over and over. A couple of things I wanted to
address, not to go over all the issues that my colleagues--
Senator Sanders and others--talked so well about.
The VA medical care funding still lags behind clearly what
is needed to meet the growing number of veterans. The
Administration proposal is a scant 0.14 percent, one-seventh of
1 percent, more than last year's when adjusted for inflation
and increased patient utilization costs. As Senator Sanders
said, we all share outrage in the VA charging Priority 7 and 8
veterans additional health fees. It is seeking authority, as
was discussed, to redirect $310 million in revenues that would
be generated from these fees to the Department of the Treasury.
Instead of reinvesting those dollars into a VA to help
Secretary Nicholson and the Under Secretaries and the Assistant
Secretaries representing the VA today, instead of helping them
take care of using those funds for less affluent, if you will,
by Senator Sanders' definition, to take care of them, it is
money that goes back into the Treasury that pays, again, for
the tax cuts that Senator Sanders mentioned.
Third, veterans should not have the lengthy waits for
health care and should not be excluded from enrolling for care.
The VA health care system needs to be fully funded and on time
to provide for all veterans seeking care.
Lastly, there was an article in the Miami Herald on Sunday,
I believe, that had a couple of interesting facts and charts
that tell me we have a long way to go, especially on outpatient
mental health care or mental health care generally in the VA.
There is a chart that shows there are--based from 1995 and a
decade later--I will give these to the Secretary and will ask
about them. I, like Senator Rockefeller, have to leave for
other committees, but will come back.
Ten years ago, there were 565,000 patients treated in the
VA mental health system. Today, there are 923,000. That is no
surprise, especially with this war. But, equally importantly,
in 1995, outpatient mental health visits per veteran, 15.1, the
average veteran receiving outpatient mental health treatment
was--they paid 15.1 visits. Ten years later, in 2006, it was 11
visits per patient. I do not understand that. I think probably
the VA is doing some things to discourage people, the fees, the
copays, that kind of thing, to discourage people from coming.
Even more significant, perhaps, is that per patient veteran
costs have come down even before correcting for inflation. In
1995, the VA was spending $3,500 per patient for mental health
care. In 2004--they do not have 2005 or 2006 numbers in this
chart--it was $2,500. So we are spending $1,000 less even
before correcting for inflation, $1,000 less. And to compound
that, some veterans get more visits, obviously, than others,
but that is in part based on which clinics they are assigned to
or they live near. Average number of visits per veteran with
PTSD ranged from 22 in the Hudson Valley Medical Center to a
low of 3.1 in Fargo, North Dakota. That is not a function of--I
cannot believe that is a function of the illness of the veteran
on average. It is more a function of something that the VA is
doing differently or not doing right.
So all of those concerns, Mr. Chairman, we need to look at.
I think that mental health coverage and care for the VA is
improving, but not nearly fast enough. I am not convinced we
are prepared for the next 50 years of mental health problems so
many of our veterans face from this awful war. And I think that
we need assurances and we need real demonstrations from the VA
that they are both aware of that and are taking steps to deal
with it.
I thank the Chairman.
Chairman Akaka. Thank you very much, Senator Brown.
We will hear now from Senator Jon Tester.
STATEMENT OF HON. JON TESTER,
U.S. SENATOR FROM MONTANA
Senator Tester. Thank you, Mr. Chairman. I also want to
thank the Secretary for being here. I very much look forward to
what is said in this Committee meeting. I will make my remarks
very short.
First of all, I want to tell you that everywhere I go, I am
told that in the veterans' facilities you have some of the best
doctors, nurses, and staff that are available. They are doing
an incredible job.
On the other hand, I will also tell you that they are being
burnt out. They are understaffed. And that bothers me,
especially when you have quality people. So that is an issue.
We have been talking to the grassroots folks for nearly 2
years. I mean, literally that has been what I have done since
May of 2005. And I can tell you that not all the people I have
talked to have complaints, but there are enough of them that
have complaints that make me think that there is a problem.
My barber, for example, who is a Korean War vet, is very
happy with the service he gets. He has gotten through the door.
On the other side of the coin, over the last year and a
half to 2 years, I cannot tell you the number of episodes that
I have heard--I have not brought it up, although we did have
some hearings here a couple of weeks ago with veterans about
issues of access and accessibility and the folks that are
trying to get through the door that cannot, that are being
delayed. Several folks told me that they think the delays are
intentional. They think it is because of lack of resources,
money, and they think that the VA is trying to outlive them.
Now, I do not know if that is correct or not, but the truth
is, if it is correct, we should be ashamed. Because as Senator
Sanders said, I think that this is a cost of war that we cannot
overlook, if you take a look at how this country was founded
and why it was founded and what we stand for. And I think we
are on the same page on that.
The health care benefits for veterans, from my perspective,
is not a reward. It is a matter of fulfilling a promise that we
have given our veterans. And I will tell you that. If I did not
think this was an issue, if I did not think there was just a
whole bunch of folks out there that have served this country so
very well on the battlefield and in peacetime that deserve the
benefits, I would not feel so strongly about the fact that this
budget needs to be scrutinized, and it needs to be scrutinized
very strongly. And, quite frankly, I do not think it is
adequate.
If you take a look at the 0.14 percent increase and then
assume the number of veterans--and I am sure you have got
spread sheets that extrapolate this out--from the Iraqi and
Afghanistan war, I think we may be put into a position where
folks cannot get through the door and they cannot get the
access, because I agree with Senator Murray, once they get
through the door, they are getting good health care. But the
matter of fact is, I do not think that all the ones that need
to get through the door are.
So I look forward to your presentation, folks. I appreciate
your being here, and I appreciate being a part of this
Committee.
Chairman Akaka. Thank you very much, Senator Tester.
Senator Jim Webb?
STATEMENT OF HON. JIM WEBB,
U.S. SENATOR FROM VIRGINIA
Senator Webb. Thank you, Mr. Chairman, and I also will
attempt to be brief. We run the risk of having had the hearing
before we have heard the testimony of the people here.
I want to take notice and ask the Secretary and the
veterans group members to take notice of the attendance here
this morning. I think it is a clear indicator of the emphasis
that we on this side of the table put on veterans' issues. And
I, like a number of the new Members on the Committee, actively
sought to be on this Committee. We care deeply about veterans'
issues.
Next month marks the 30th anniversary of when I started
working formally on veterans' issues as a full committee
counsel on the House side. And I have tremendous regard for the
people who have dedicated their careers to working in the
veterans area. I think they are among the most selfless people
in Government. You find so many people who are doing this
absolutely for the right reasons and dedicating their
professional lives to it. And, also, to many people in the
veterans groups themselves who have made themselves
professionals on issues that go directly to veterans' health
care.
I entered the room when the Ranking Republican was making a
comparison, basically defending the current budget process,
talking about why could people be attacking a 10 percent
increase when they were defending a 2 percent increase during
the Clinton years. And I think as my colleague Senator Sanders
pointed out, there are clear reasons for that. The first, is
obviously, we have entered a wartime period. There are
different needs. There is a different pool of veterans coming
in. And at the same time, there has been a breakdown of medical
care in this country nationwide. In the last 6 years, medical
costs in this country have gone up 73 percent, and 36 percent
of that has been right out of people's pockets. So there has
been a natural migration into the VA system.
I was a little puzzled, quite frankly, hearing this comment
about how 45 percent of the veterans who are coming to the VA
are Medicare eligible and have come over basically because of
this prescription drug program and that that might be mitigated
by Medicare D, and perhaps it will. Medicare D is in its own
period of transition. But to say that those people coming into
the system are doing so to the exclusion of people who do not
have medical insurance basically begs the question. If both of
these classes of people are eligible, why shouldn't we be
treating both of them? Somewhere along the line the Government
is going to pay, whether it is Medicare, TRICARE, or the VA.
And the VA system, I am proud to say, as someone who has worked
on and off in it for 30 years, is a wonderfully fine system.
And those who have eligibility ought to be using it.
I would like to say to you, Mr. Secretary, you are aware
that I have strong feelings about the need for those people who
have been serving since 9/11 to get a GI bill that is worthy of
their service. That is something I look forward to discussing
over the coming months. There are a number of other issues that
I have some concerns about, but I would be very anxious to get
into the testimony, Mr. Chairman, and to hear the witnesses.
Thank you very much.
Chairman Akaka. Thank you very much for your statement,
Senator Webb.
All right. We will go into our questions now. Mr.
Secretary, before we get to our questions, I want to invite you
to make your statement or other statements that you have before
the Committee. Again, we welcome you to the Committee.
STATEMENT OF HON. R. JAMES NICHOLSON, SECRETARY,
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY MICHAEL KUSSMAN,
M.D., ACTING UNDER SECRETARY FOR HEALTH; DANIEL L. COOPER,
UNDER SECRETARY FOR
BENEFITS; WILLIAM F. TUERK, UNDER SECRETARY FOR
MEMORIAL AFFAIRS; AND ROBERT J. HENKE, ASSISTANT
SECRETARY FOR MANAGEMENT
Secretary Nicholson. Thank you, Mr. Chairman, Members of
the Committee. Good morning. I do have a written statement I
would like to submit for the record.
Chairman Akaka. It will be included in the record.
Secretary Nicholson. Thank you, Mr. Chairman. I would also
like to introduce my colleagues that are with me here at the
table. I will start at my far left, your right: Under Secretary
for Memorial Affairs, Bill Tuerk. Next to him is the Under
Secretary for Benefits, Admiral Dan Cooper. To my immediate
left is the Acting Under Secretary for Health, Dr. Michael
Kussman. On the far right is the Assistant Secretary for
Information Technology and the Chief Information Officer, Bob
Howard. And on my immediate right is the Assistant Secretary
for Management, and, in effect, the Chief Financial Officer of
the VA, Bob Henke.
Let me preface my remarks by saying that I look forward to
working with the 110th Congress, and particularly our Veterans'
Committee, in a bipartisan, bicameral way of support for our
Nation's veterans. I have heard said and I have said that I
think taking care of our veterans is, in essence, not a
partisan endeavor. It is a patriotic endeavor. And I want to
offer my congratulations to the Committee's newest Members:
Senators Sanders, Brown, Webb, and Tester.
I am here today to discuss the President's 2008 budget
proposal for the Department of Veterans Affairs. The President
is requesting a landmark budget. He is requesting nearly $87
billion to fund our Nation's commitment to America's veterans.
This budget will allow us to expand the three core missions of
the VA, those being: to provide world-class health care; to
provide broad, fair, and timely benefits; and, third, to
provide dignified burials in shrine-like settings for our
Nation's veterans.
This budget will also allow us to continue our progress
toward becoming a national leader in information technology and
data management. I believe that with the right resources in the
hands of the right people, anything and everything is possible
when it comes to caring for America's veterans.
At the VA, we already have the right dedicated people. With
the President's proposed budget, we have the right resources,
too. The $87 billion requested for the VA represents a 77
percent increase in veteran spending since this President took
office on January 20, 2001. Medical care spending is up over 83
percent.
Mr. Chairman, I will outline the major portions of our
proposed budget.
First, Veterans Health Administration. Our total medical
care request is $36.6 billion in authority for our health care.
VA health care is the best anywhere, and that is not just a
boast of a proud Secretary--I am grateful for the complimentary
remarks that have been made here by Members of the Committee. I
would add that medical journals, the national media, and
institutions as respected as the Harvard Medical School just
recently agreed that the VA leads the Nation in health care
delivery, safety, and technology.
During 2008, we expect to treat about 5.8 million patients.
This total is more than 134,000 above the 2007 estimate.
Patients in Priorities 1 through 6--that is, veterans with
service-connected conditions, lower incomes, special health
care needs, and who have had service in Iraq and/or
Afghanistan--will comprise 68 percent of the total patient
population in 2008. They will account for 85 percent of our
health care costs. The number of patients in Priorities 1 to 6
will grow by 3.3 percent from 2007 to 2008.
In 2008, we expect to treat approximately 263,000 veterans
who served in Operation Iraqi Freedom and Operation Enduring
Freedom. This is an increase of 54,000, or 26 percent, above
the number of veterans from these two campaigns that we
anticipate will come to us for health care during this fiscal
year, and an increase of 108,000, or 70 percent, more than the
number that we actually treated in 2006.
Access to this health care--With the resources requested
for medical care in 2008, the Department will be able to
continue our exceptional performance dealing with access to
health care. Ninety-six percent of primary care appointments
and 95 percent of specialty care appointments are scheduled
within 30 days of the desired date by the relevant veteran. We
will minimize the number of new enrollees waiting for their
first appointment to be scheduled. In the last 8 months, we
reduced this number by 94 percent, and we will continue to
place strong emphasis on this effort.
Mental health services--The President's request includes
nearly $3 billion to continue our effort to improve access to
mental health services across the country. Mr. Chairman,
Members of the Committee, the VA is a respected leader in
mental health and PTSD research and care. About 80 percent of
the funds for mental health go to treat seriously mentally ill
veterans, including those suffering from post-traumatic stress
disorder.
Medical research--The President's 2008 budget includes $411
million to support the VA's unparalleled medical and prosthetic
research program. This amount will fund nearly 2,100 high-
priority research projects to expand knowledge in areas most
critical to veterans' particular health care needs, most
notably: research in the areas of mental illness, $49 million;
aging, $42 million; health services delivery improvement, $36
million; cancer research, $35 million; and heart disease
research, $31 million. Nearly 60 percent of our research budget
is devoted to OIF/OEF health care issues.
Polytrauma care--I have traveled to three of our polytrauma
centers, Mr. Chairman, and there is no doubt that these centers
of compassion and competent care are where miracles are
performed every day. In response to the need for such
specialized medical services, the VA has expanded its four
traumatic brain injury centers, which are in Minneapolis, Palo
Alto, Richmond, and Tampa, to a constellation of polytrauma
centers encompassing 17 additional polytrauma centers to make
them more accessible geographically to provide these additional
specialties to treat patients with multiple complex injuries.
Seamless transition--One of the most important features of
the President's 2008 budget request is to ensure that
servicemembers' transition from active duty military status or
mobilized Guard and Reserve to civilian life continues to be as
smooth and seamless as possible. We will not rest until
seriously injured or ill servicemen or women returning from
combat in Iraq or Afghanistan receive the treatment that they
need in a timely way.
Veterans Benefits Administration--Let me speak of veterans
benefits. The VA's primary focus within the Administration of
benefits remains unchanged--delivering timely and accurate
benefits to veterans and their families. Improving the delivery
of compensation and pension benefits has become increasingly
challenging during the last few years. The volume of claims
applications has grown substantially during the last few years
and is now the highest that it has been in 15 years. We
received more than 806,000 individual claims in 2006. That does
not account for the number of issues per claimant. And we
expect this high volume of claims to continue as we are
expecting in the neighborhood of 800,000 claims a year in both
2007 and 2008. However, through a combination of management and
productivity improvements and our 2008 request to add
approximately 450 staff, which is in this budget, we will
improve our performance while maintaining high quality.
We expect to improve the timeliness of processing claims to
145 days in 2008. We will make better use of new technologies
and have more trained people to process and evaluate claims.
With this budget, we project that we can reduce our claims
processing time by 18 percent while maintaining quality.
The National Cemetery Administration--We expect to perform
nearly 105,000 interments in 2008. We are 8.4 percent higher
than the number of interments we performed in 2006. This is
primarily the result of the aging of the World War II and
Korean War veterans population and the opening of new
cemeteries.
The President's 2008 budget request includes $167 million
in operations and maintenance funding to activate six new
national cemeteries and to meet the growing workload at
existing cemeteries by increasing staffing and funding for
contract maintenance, supplies, and equipment.
Capital programs, which is construction and grants to
States--The VA's 2008 request before you includes $1.1 billion
in new budget authority for our capital programs. Our request
includes $727 million for major construction projects, $233
million for minor construction, $85 million in grants for State
extended care facilities, and $32 million in grants to build
State veterans cemeteries. The 2008 request for construction
funding for our health care programs is $750 million. These
resources will be devoted to a continuation of the Capital
Asset Realignment for Enhanced Services, known as CARES,
program.
Over the last 5 years, $3.7 billion in total funding has
been provided for CARES. Within our request for major
construction are resources to continue six medical facility
projects already underway. Those are in Pittsburgh; Denver; Las
Vegas; Orlando; Lee County, Florida; and Syracuse. Funds are
already included for six new national cemeteries in
Bakersfield, California; Birmingham, Alabama; Columbia-
Greenville, South Carolina; Jacksonville, Florida; Southeastern
Pennsylvania; and Sarasota, Florida.
Information technology--VA's 2008 budget request for
information technology is $1.8 billion, which includes the
first phase of our reorganization of IT functions in the
Department and which will establish a new IT management system
in the VA. The major transformation of IT will bring our
program in line with the best practices in the IT industry.
Greater centralization will play a significant role in ensuring
that we fulfill my promise to make the VA the gold standard for
data security within the Federal Government. Toward that end,
our 2008 budget IT request includes almost $70 million for
enhanced cyber security.
Mr. Chairman, I know the Committee shares with me the
concern about VA's ability to secure all our veterans' personal
information. There have been security incidents that are simply
unacceptable, and I have made it a priority to assure our
veterans that we are addressing their concerns. It is not that
these incidents will never occur, but when they do, the VA now
has a process to properly and promptly respond to them.
We are encouraging all our employees to report, including
self-reporting, thefts or other losses of equipment, whether in
the workplace, at home, or on travel, so we can strengthen our
information security procedures through lessons learned, review
personal accountability, and, when appropriate, take
disciplinary actions, including terminations.
Electronic health records--The most critical IT project for
our medical care program is the continued operation and
improvement of the Department's fabled electronic medical
records. I have made it a point for the past year to praise our
electronic health records for their ability to survive
Hurricanes Rita and Katrina. Electronic health records are a
Presidential priority, and VA's electronic health records
system has been recognized nationally for increasing
productivity, quality, and patient safety.
Within this overall initiative, we are requesting $131.9
million for ongoing development and implementation of
HealtheVet-VistA. This is the program to modernize our existing
electronic health records. It will make use of standards that
will enhance the sharing of data within the VA as well as with
other Federal agencies and public and private sector
organizations.
Mr. Chairman, in closing, I want to take this opportunity
to inform you of my plan to create a special advisory committee
on OIF/OEF veterans and their families and to mention a new
initiative to assist returning veterans to connect with their
State and territorial veterans departments, including the
District of Columbia.
First, the OIF/OEF panel. Its membership will include
veterans, spouses, survivors, and parents of combat veterans,
and it will report directly to me. Under its charter, the
committee will focus on ensuring that all men and women with
active military service in Iraq and Afghanistan are
transitioned to the VA in a seamless, informed, hassle-free
manner. The committee will pay particular attention to severely
disabled veterans and their families.
Second, in order to help severely injured servicemembers
receive benefits from their States and territories when they
move from military hospitals to VA medical facilities in their
communities, I announced yesterday, with the 50 State VA
Directors who were in town for a meeting, an expansion of a
collaborative outreach program with the States and territories
and the District of Columbia. It is called the States Benefits
Seamless Transition Program. We just completed a very
successful 4-month pilot with the State of Florida, and I have
expanded the program to all States and territories.
This initiative is a promising extension of the VA's own
transition assistance for those leaving the military service,
and it is an opportunity to partner with the States to make
long-term support possible for our most deserving veterans
throughout the country. There are several States, for example,
that totally waive ad valorem taxes for residential real estate
for those seriously injured veterans.
Mr. Chairman, over the next few weeks and months, as I
travel across the country, I also will be meeting with the
commanders of the several combatant commands to talk to them
about how the VA and the DOD can better work together to care
for our soldiers, sailors, airmen, marines, and coastguardsmen
who are returning from duty overseas. This Friday, I will meet
with Admiral Stavridis, the Commander of the Southern Command,
to brief him on the VA's programs for OIF/OEF troops. In the
coming weeks, I will be meeting with the senior enlisted
advisors and the Reserve chiefs. I also will be extending an
invitation to each service Secretary and service Chief to meet
with me so that we can keep our lines of communication open in
working better for the benefit of all of our transitioning
servicemen and women.
Mr. Chairman, this concludes my remarks. Thank you.
[The prepared statement of Secretary Nicholson follows:]
Prepared Statement of Hon. R. James Nicholson, Secretary,
Department of Veterans Affairs
Mr. Chairman and Members of the Committee, good morning. I am
pleased to be here today to present the President's 2008 budget
proposal for the Department of Veterans Affairs (VA). The request
totals $86.75 billion--$44.98 billion for entitlement programs and
$41.77 billion for discretionary programs. The total request is $37.80
billion, or 77 percent, above the funding level in effect when the
President took office.
The President's requested funding level will allow VA to continue
to improve the delivery of benefits and services to veterans and their
families in three primary areas that are critical to the achievement of
our mission:
<bullet> To provide timely, high-quality health care to a growing
number of patients who count on VA the most--veterans returning from
service in Operation Iraqi Freedom and Operation Enduring Freedom,
veterans with service-connected disabilities, those with lower incomes,
and veterans with special health care needs;
<bullet> To improve the delivery of benefits through the timeliness
and accuracy of claims processing; and
<bullet> To increase veterans' access to a burial option in a
national or state veterans' cemetery.
ensuring a seamless transition from active military
service to civilian life
The President's 2008 budget request provides the resources
necessary to ensure that servicemembers' transition from active duty
military status to civilian life continues to be as smooth and seamless
as possible. We will continue to ensure that every seriously injured or
ill serviceman or woman returning from combat in Operation Iraqi
Freedom and Operation Enduring Freedom receives the treatment they need
in a timely way.
Last week, I announced plans to create a special Advisory Committee
on Operation Iraqi Freedom/Operation Enduring Freedom Veterans and
Families. The panel, with membership including veterans, spouses, and
parents of the latest generation of combat veterans, will report
directly to me. Under its charter, the Committee will focus on the
concerns of all men and women with active military service in Operation
Iraqi Freedom or Operation Enduring Freedom, but will pay particular
attention to severely disabled veterans and their families.
We will expand our ``Coming Home to Work'' initiative to help
disabled servicemembers more easily make the transition from military
service to civilian life. This is a comprehensive intergovernmental and
public-private alliance that will provide separating servicemembers
from Operation Iraqi Freedom and Operation Enduring Freedom with
employment opportunities when they return home from their military
service. This project focuses on making sure servicemembers have access
to existing resources through local and regional job markets,
regardless of where they separate from their military service, where
they return, or the career or education they pursue.
VA launched an ambitious outreach initiative to ensure separating
combat veterans know about the benefits and services available to them.
During 2006, VA conducted over 8,500 briefings attended by more than
393,000 separating servicemembers and returning reservists and National
Guard members. The number of attendees was 20 percent higher in 2006
than it was in 2005 attesting to our improved outreach effort.
Additional pamphlet mailings following separation and briefings
conducted at town hall meetings are sources of important information
for returning National Guard members and reservists. VA has made a
special effort to work with National Guard and Reserve units to reach
transitioning servicemembers at demobilization sites and has trained
recently discharged veterans to serve as National Guard Bureau liaisons
in every state to assist their fellow combat veterans.
Each VA medical center and regional office has a designated point
of contact to coordinate activities locally and to ensure the health
care and benefits needs of returning servicemembers and veterans are
fully met. VA has distributed specific guidance to field staff to make
sure the roles and functions of the points of contact and case managers
are fully understood and that proper coordination of benefits and
services occurs at the local level.
For combat veterans returning from Iraq and Afghanistan, their
contact with VA often begins with priority scheduling for health care,
and for the most seriously wounded, VA counselors visit their bedside
in military wards before separation to assist them with their
disability claims and ensure timely compensation payments when they
leave active duty.
In an effort to assist wounded military members and their families,
VA has placed workers at key military hospitals where severely injured
servicemembers from Iraq and Afghanistan are frequently sent for care.
These include benefit counselors who help servicemembers obtain VA
services as well as social workers who facilitate health care
coordination and discharge planning as servicemembers transition from
military to VA health care. Under this program, VA staff provide
assistance at 10 military treatment facilities around the country,
including Walter Reed Army Medical Center, the National Naval Medical
Center Bethesda, the Naval Medical Center San Diego, and Womack Army
Medical Center at Ft. Bragg.
To further meet the need for specialized medical care for patients
with service in Operation Iraqi Freedom and Operation Enduring Freedom,
VA has expanded its four polytrauma centers in Minneapolis, Palo Alto,
Richmond, and Tampa to encompass additional specialties to treat
patients for multiple complex injuries. Our efforts are being expanded
to 21 polytrauma network sites and clinic support teams around the
country providing state-of-the-art treatment closer to injured
veterans' homes. We have made training mandatory for all physicians and
other key health care personnel on the most current approaches and
treatment protocols for effective care of patients afflicted with brain
injuries. Furthermore, we established a polytrauma call center in
February 2006 to assist the families of our most seriously injured
combat veterans and servicemembers. This call center operates 24 hours
a day, 7 days a week to answer clinical, administrative, and benefit
inquiries from polytrauma patients and family members.
In addition, VA has significantly expanded its counseling and other
medical care services for recently discharged veterans suffering from
mental health disorders, including post-traumatic stress disorder. We
have launched new programs, including dozens of new mental health teams
based in VA medical facilities focused on early identification and
management of stress-related disorders, as well as the recruitment of
about 100 combat veterans as counselors to provide briefings to
transitioning servicemembers regarding military-related readjustment
needs.
medical care
We are requesting $36.6 billion for medical care in 2008, a total
of more than 83 percent higher than the funding available at the
beginning of the Bush Administration. Our total medical care request is
comprised of funding for medical services ($27.2 billion), medical
administration ($3.4 billion), medical facilities ($3.6 billion), and
resources from medical care collections ($2.4 billion).
Legislative Proposals
The President's 2008 budget request identifies three legislative
proposals which ask veterans with comparatively greater means and no
compensable service-connected disabilities to assume a small share of
the cost of their health care.
The first proposal would assess Priority 7 and 8 veterans with an
annual enrollment fee based on their family income:
------------------------------------------------------------------------
Family Income Annual Enrollment
------------------------------------------------------------------------
Fee Under $50,000......................... None
$50,000--$74,999.......................... $250
$75,000--$99,999.......................... $500
$100,000 and above........................ $750
------------------------------------------------------------------------
The second legislative proposal would increase the pharmacy
copayment for Priority 7 and 8 veterans from $8 to $15 for a 30-day
supply of drugs. And the last provision would eliminate the practice of
offsetting or reducing VA first-party copayment debts with collection
recoveries from third-party health plans.
While our budget requests in recent years have included legislative
proposals similar to these, the provisions identified in the
President's 2008 budget are markedly different in that they have no
impact on the resources we are requesting for VA medical care. Our
budget request includes the total funding needed for the Department to
continue to provide veterans with timely, high-quality medical services
that set the national standard of excellence in the health care
industry. Unlike previous budgets, these legislative proposals do not
reduce our discretionary medical care appropriations. Instead, these
three provisions, if enacted, would generate an estimated $2.3 billion
in mandatory receipts to the Treasury from 2008 through 2012.
Workload
During 2008, we expect to treat about 5,819,000 patients. This
total is more than 134,000 (or 2.4 percent) above the 2007 estimate.
Patients in Priorities 1-6--veterans with service-connected conditions,
lower incomes, special health care needs, and service in Iraq or
Afghanistan--will comprise 68 percent of the total patient population
in 2008, but they will account for 85 percent of our health care costs.
The number of patients in Priorities 1-6 will grow by 3.3 percent from
2007 to 2008.
We expect to treat about 263,000 veterans in 2008 who served in
Operation Iraqi Freedom and Operation Enduring Freedom. This is an
increase of 54,000 (or 26 percent) above the number of veterans from
these two campaigns that we anticipate will come to VA for health care
in 2007, and 108,000 (or 70 percent) more than the number we treated in
2006.
Funding Drivers
Our 2008 request for $36.6 billion in support of our medical care
program was largely determined by three key cost drivers in the
actuarial model we use to project veteran enrollment in VA's health
care system as well as the utilization of health care services of those
enrolled:
<bullet> Inflation;
<bullet> Trends in the overall health care industry; and
<bullet> Trends in VA health care.
The impact of the composite rate of inflation of 4.45 percent
within the actuarial model will increase our resource requirements for
acute inpatient and outpatient care by nearly $2.1 billion. This
includes the effect of additional funds ($690 million) needed to meet
higher payroll costs as well as the influence of growing costs ($1.4
billion) for supplies, as measured in part by the Medical Consumer
Price Index. However, inflationary trends have slowed during the last
year.
There are several trends in the U.S. health care industry that
continue to increase the cost of providing medical services. These
trends expand VA's cost of doing business regardless of any changes in
enrollment, number of patients treated, or program initiatives. The two
most significant trends are the rising utilization and intensity of
health care services. In general, patients are using medical care
services more frequently and the intensity of the services they receive
continues to grow. For example, sophisticated diagnostic tests, such as
magnetic resonance imaging (MRI), are now more frequently used either
in place of, or in addition to, less costly diagnostic tools such as x-
rays. As another illustration, advances in cancer screening
technologies have led to earlier diagnosis and prolonged treatment
which may include increased use of costly pharmaceuticals to combat
this disease. These types of medical services have resulted in improved
patient outcomes and higher quality health care. However, they have
also increased the cost of providing care.
The cost of providing timely, high-quality health care to our
Nation's veterans is also growing as a result of several factors that
are unique to VA's health care system. We expect to see changes in the
demographic characteristics of our patient population. Our patients as
a group will be older, will seek care for more complex medical
conditions, and will be more heavily concentrated in the higher cost
priority groups. Furthermore, veterans are submitting disability
compensation claims for an increasing number of medical conditions,
which are also increasing in complexity. This results in the need for
disability compensation medical examinations, the majority of which are
conducted by our Veterans Health Administration, that are more complex,
costly, and time consuming. These projected changes in the case mix of
our patient population and the growing complexity of our disability
claims process will result in greater resource needs.
Quality of Care
The resources we are requesting for VA's medical care program will
allow us to strengthen our position as the Nation's leader in providing
high-quality health care. VA has received numerous accolades from
external organizations documenting the Department's leadership position
in providing world-class health care to veterans. For example, our
record of success in health care delivery is substantiated by the
results of the 2006 American Customer Satisfaction Index (ACSI) survey.
Conducted by the National Quality Research Center at the University of
Michigan Business School, the ACSI survey found that customer
satisfaction with VA's health care system increased last year and was
higher than the private sector for the seventh consecutive year. The
data revealed that inpatients at VA medical centers recorded a
satisfaction level of 84 out of a possible 100 points, or 10 points
higher than the rating for inpatient care provided by the private-
sector health care industry. VA's rating of 82 for outpatient care was
8 points better than the private sector.
Citing VA's leadership role in transforming health care in America,
Harvard University recognized the Department's computerized patient
records system by awarding VA the prestigious ``Innovations in American
Government Award'' in 2006. Our electronic health records have been an
important element in making VA health care the benchmark for 294
measures of disease prevention and treatment in the U.S. The value of
this system was clearly demonstrated when every patient medical record
from the areas devastated by Hurricane Katrina was made available to
all VA health care providers throughout the Nation within 100 hours of
the time the storm made landfall. Veterans were able to quickly resume
their treatments, refill their prescriptions, and get the care they
needed because of the electronic health records system--a real,
functioning health information exchange that has been a proven success
resulting in improved quality of care. It can serve as a model for the
health care industry as the Nation moves forward with the public/
private effort to develop a National Health Information Network.
The Department also received an award from the American Council for
Technology for our collaboration with the Department of Defense on the
Bidirectional Health Information Exchange program. This innovation
permits the secure, real-time exchange of medical record data between
the two departments, thereby avoiding duplicate testing and surgical
procedures. It is an important step forward in making the transition
from active duty to civilian life as smooth and seamless as possible.
In its July 17, 2006, edition, Business Week featured an article
about VA health care titled ``The Best Medical Care in the U.S.'' This
article outlines many of the Department's accomplishments that have
helped us achieve our position as the leading provider of health care
in the country, such as higher quality of care than the private sector,
our nearly perfect rate of prescription accuracy, and the most advanced
computerized medical records system in the Nation. Similar high praise
for VA's health care system was documented in the September 4, 2006,
edition of Time Magazine in an article titled ``How VA Hospitals Became
the Best.'' In addition, a study conducted by Harvard Medical School
concluded that Federal hospitals, including those managed by VA,
provide the best care available for some of the most common life-
threatening illnesses such as congestive heart failure, heart attack,
and pneumonia. Their research results were published in the December
11, 2006, edition of the Annals of Internal Medicine.
These external acknowledgments of the superior quality of VA health
care reinforce the Department's own findings. We use two primary
measures of health care quality--clinical practice guidelines index and
prevention index. These measures focus on the degree to which VA
follows nationally recognized guidelines and standards of care that the
medical literature has proven to be directly linked to improved health
outcomes for patients. Our performance on the clinical practice
guidelines index, which focuses on high-prevalence and high-risk
diseases that have a significant impact on veterans' overall health
status, is expected to grow to 85 percent in 2008, or a 1 percentage
point rise over the level we expect to achieve this year. As an
indicator aimed at primary prevention and early detection
recommendations dealing with immunizations and screenings, the
prevention index will be maintained at our existing high level of
performance of 88 percent.
Access to Care
With the resources requested for medical care in 2008, the
Department will be able to continue our exceptional performance dealing
with access to health care--96 percent of primary care appointments
will be scheduled within 30 days of patients' desired date, and 95
percent of specialty care appointments will be scheduled within 30 days
of patients' desired date. We will minimize the number of new enrollees
waiting for their first appointment to be scheduled. We reduced this
number by 94 percent from May 2006 to January 2007, to a little more
than 1,400, and we will continue to place strong emphasis on lowering,
and then holding, the waiting list to as low a level as possible.
An important component of our overall strategy to improve access
and timeliness of service is the implementation on a national scale of
Advanced Clinic Access, an initiative that promotes the efficient flow
of patients by predicting and anticipating patient needs at the time of
their appointment. This involves assuring that specific medical
equipment is available, arranging for tests that should be completed
either prior to, or at the time of, the patient's visit, and ensuring
all necessary health information is available. This program optimizes
clinical scheduling so that each appointment or inpatient service is
most productive. In addition, this reduces unnecessary appointments,
allowing for relatively greater workload and increased patient-directed
scheduling.
Funding for Major Health Care Programs and Initiatives
Our request includes $4.6 billion for extended care services, 90
percent of which will be devoted to institutional long-term care and 10
percent to non-institutional care. By continuing to enhance veterans'
access to non-institutional long-term care, the Department can provide
extended care services to veterans in a more clinically appropriate
setting, closer to where they live, and in the comfort and familiar
settings of their homes surrounded by their families. This includes
adult day health care, home-based primary care, purchased skilled home
health care, homemaker/home health aide services, home respite and
hospice care, and community residential care. During 2008, we will
increase the number of patients receiving non-institutional long-term
care, as measured by the average daily census, to over 44,000. This
represents a 19.1 percent increase above the level we expect to reach
in 2007 and a 50.3 percent rise over the 2006 average daily census.
The President's request includes nearly $3 billion to continue our
effort to improve access to mental health services across the country.
These funds will help ensure VA provides standardized and equitable
access throughout the Nation to a full continuum of care for veterans
with mental health disorders. The resources will support both inpatient
and outpatient psychiatric treatment programs as well as psychiatric
residential rehabilitation treatment services. We estimate that about
80 percent of the funding for mental health will be for the treatment
of seriously mentally ill veterans, including those suffering from
post-traumatic stress disorder (PTSD). An example of our firm
commitment to provide the best treatment available to help veterans
recover from these mental health conditions is our ongoing outreach to
veterans of Operation Iraqi Freedom and Operation Enduring Freedom, as
well as increased readjustment and PTSD services.
In 2008, we are requesting $752 million to meet the needs of the
263,000 veterans with service in Operation Iraqi Freedom and Operation
Enduring Freedom whom we expect will come to VA for medical care.
Veterans with service in Iraq and Afghanistan continue to account for a
rising proportion of our total veteran patient population. In 2008,
they will comprise 5 percent of all veterans receiving VA health care
compared to the 2006 figure of 3.1 percent. Veterans deployed to combat
zones are entitled to 2 years of eligibility for VA health care
services following their separation from active duty even if they are
not otherwise immediately eligible to enroll for our medical services.
Medical Collections
The Department expects to receive nearly $2.4 billion from medical
collections in 2008, which is $154 million, or 7.0 percent, above our
projected collections for 2007. As a result of increased workload and
process improvements in 2008, we will collect an additional $82 million
from third-party insurance payers and an extra $72 million resulting
from increased pharmacy workload.
We have several initiatives underway to strengthen our collections
processes:
<bullet> The Department has established a private-sector based
business model pilot tailored for our revenue operations to increase
collections and improve our operational performance. The pilot
Consolidated Patient Account Center (CPAC) is addressing all
operational areas contributing to the establishment and management of
patient accounts and related billing and collections processes. The
CPAC currently serves revenue operations for medical centers and
clinics in one of our Veterans Integrated Service Networks, but this
program will be expanded to serve other networks.
<bullet> VA continues to work with the Centers for Medicare and
Medicaid Services contractors to provide a Medicare-equivalent
remittance advice for veterans who are covered by Medicare and are
using VA health care services. We are working to include additional
types of claims that will result in more accurate payments and better
accounting for receivables through use of more reliable data for claims
adjudication.
<bullet> We are conducting a phased implementation of electronic,
real-time outpatient pharmacy claims processing to facilitate faster
receipt of pharmacy payments from insurers.
<bullet> The Department has initiated a campaign that has resulted
in an increasing number of payers now accepting electronic coordination
of benefits claims. This is a major advancement toward a fully
integrated, interoperable electronic claims process.
medical research
The President's 2008 budget includes $411 million to support VA's
medical and prosthetic research program. This amount will fund nearly
2,100 high-priority research projects to expand knowledge in areas
critical to veterans' health care needs, most notably research in the
areas of mental illness ($49 million), aging ($42 million), health
services delivery improvement ($36 million), cancer ($35 million), and
heart disease ($31 million).
VA's medical research program has a long track record of success in
conducting research projects that lead to clinically useful
interventions that improve the health and quality of life for veterans
as well as the general population. Recent examples of VA research
results that are now being applied to clinical care include the
discovery that vaccination against varicella-zoster (the same virus
that causes chickenpox) decreases the incidence and/or severity of
shingles, development of a system that decodes brain waves and
translates them into computer commands that allow quadriplegics to
perform simple tasks like turning on lights and opening e-mail using
only their minds, improvements in the treatment of post-traumatic
stress disorder that significantly reduce trauma nightmares and other
sleep disturbances, and discovery of a drug that significantly improves
mental abilities and behavior of certain schizophrenics.
In addition to VA appropriations, the Department's researchers
compete for and receive funds from other Federal and non-Federal
sources. Funding from external sources is expected to continue to
increase in 2008. Through a combination of VA resources and funds from
outside sources, the total research budget in 2008 will be almost $1.4
billion.
general operating expenses
The Department's 2008 resource request for General Operating
Expenses (GOE) is $1.472 billion. This is $617 million, or 72.2
percent, above the funding level in place when the President took
office. Within this total GOE funding request, $1.198 billion is for
the administration of non-medical benefits by the Veterans Benefits
Administration (VBA) and $274 million will be used to support General
Administration activities.
Compensation and Pensions Workload and Performance Management
VA's primary focus within the administration of non-medical
benefits remains unchanged--delivering timely and accurate benefits to
veterans and their families. Improving the delivery of compensation and
pension benefits has become increasingly challenging during the last
few years due to a steady and sizable increase in workload. The volume
of claims applications has grown substantially during the last few
years and is now the highest it has been in the last 15 years. The
number of claims we received was more than 806,000 in 2006. We expect
this high volume of claims filed to continue, as we are projecting the
receipt of about 800,000 claims a year in both 2007 and 2008.
The number of active duty servicemembers as well as reservists and
National Guard members who have been called to active duty to support
Operation Enduring Freedom and Operation Iraqi Freedom is one of the
key drivers of new claims activity. This has contributed to an increase
in the number of new claims, and we expect this pattern to persist. An
additional reason that the number of compensation and pension claims is
climbing is the Department's commitment to increase outreach. We have
an obligation to extend our reach as far as possible and to spread the
word to veterans about the benefits and services VA stands ready to
provide.
Disability compensation claims from veterans who have previously
filed a claim comprise about 55 percent of the disability claims
received by the Department each year. Many veterans now receiving
compensation suffer from chronic and progressive conditions, such as
diabetes, mental illness, and cardiovascular disease. As these veterans
age and their conditions worsen, we experience additional claims for
increased benefits.
The growing complexity of the claims being filed also contributes
to our workload challenges. For example, the number of original
compensation cases with eight or more disabilities claimed nearly
doubled during the last 4 years, reaching more than 51,000 claims in
2006. Almost one in every four original compensation claims received
last year contained eight or more disability issues. In addition, we
expect to continue to receive a growing number of complex disability
claims resulting from PTSD, environmental and infectious risks,
traumatic brain injuries, complex combat-related injuries, and
complications resulting from diabetes. Each claim now takes more time
and more resources to adjudicate. Additionally, as VA receives and
adjudicates more claims, this results in a larger number of appeals
from veterans and survivors, which also increases workload in other
parts of the Department, including the Board of Veterans' Appeals.
The Veterans Claims Assistance Act of 2000 has significantly
increased both the length and complexity of claims development. VA's
notification and development duties have grown, adding more steps to
the claims process and lengthening the time it takes to develop and
decide a claim. Also, we are now required to review the claims at more
points in the adjudication process.
We will address our ever-growing workload challenges in several
ways. First, we will continue to improve our productivity as measured
by the number of claims processed per staff member, from 98 in 2006 to
101 in 2008. Second, we will continue to move work among regional
offices in order to maximize our resources and enhance our performance.
Third, we will further advance staff training and other efforts to
improve the consistency and quality of claims processing across
regional offices. And fourth, we will ensure our claims processing
staff has easy access to the manuals and other reference material they
need to process claims as efficiently and effectively as possible and
further simplify and clarify benefit regulations.
Through a combination of management/productivity improvements and
an increase in resources in 2008 to support 457 additional staff above
the 2007 level, we will improve our performance in the area most
critical to veterans--the timeliness of processing rating-related
compensation and pension claims. We expect to improve the timeliness of
processing these claims to 145 days in 2008. This level of performance
is 15 days better than our projected timeliness for 2007 and a 32-day
improvement from the average processing time we achieved last year. In
addition, we anticipate that our pending inventory of disability claims
will fall to about 330,000 by the end of 2008, a reduction of more than
40,000 (or 10.9 percent) from the level we project for the end of 2007,
and nearly 49,000 (or 12.9 percent) lower than the inventory at the
close of 2006. At the same time we are improving timeliness, we will
also increase the accuracy of our decisions on claims from 88 percent
in 2006 to 90 percent in 2008.
Education and Vocational Rehabilitation and Employment Performance
With the resources we are requesting in 2008, key program
performance will improve in both the education and vocational
rehabilitation and employment programs. The timeliness of processing
original education claims will improve by 15 days during the next 2
years, falling from 40 days in 2006 to 25 days in 2008. During this
period, the average time it takes to process supplemental claims will
improve from 20 days to just 12 days. These performance improvements
will be achieved despite an increase in workload. The number of
education claims we expect to receive will reach about 1,432,000 in
2008, or 4.8 percent higher than last year. In addition, the
rehabilitation rate for the vocational rehabilitation and employment
program will climb to 75 percent in 2008, a gain of 2 percentage points
over the 2006 performance level. The number of program participants
will rise to about 94,500 in 2008, or 5.3 percent higher than the
number of participants in 2006.
Our 2008 request includes $6.3 million for a Contact Management
Support Center for our education program. These funds will be used
during peak enrollment periods for contract customer service
representatives who will handle all education calls placed through our
toll-free telephone line. We currently receive about 2.5 million phone
inquiries per year. This initiative will allow us to significantly
improve performance for both the blocked call rate and the abandoned
call rate.
The 2008 resource request for VBA includes about $4.3 million to
enhance our educational and vocational counseling provided to disabled
servicemembers through the Disabled Transition Assistance Program.
Funds for this initiative will ensure that briefings are conducted by
experts in the field of vocational rehabilitation, including
contracting for these services in localities where VA professional
staff are not available. The contractors would be trained by VA staff
to ensure consistent, quality information is provided. Also in support
of the vocational rehabilitation and employment program, we are seeking
$1.5 million as part of an ongoing project to retire over 650,000
counseling, evaluation, and rehabilitation folders stored in regional
offices throughout the country. All of these folders pertain to cases
that have been inactive for at least 3 years and retention of these
files poses major space problems.
In addition, our 2008 request includes $2.4 million to continue a
major effort to centralize finance functions throughout VBA, an
initiative that will positively impact operations for all of our
benefits programs. The funds to support this effort will be used to
begin the consolidation and centralization of voucher audit, agent
cashier, purchase card, and payroll operations currently performed by
all regional offices.
national cemetery administration
The President's 2008 budget request includes $166.8 million in
operations and maintenance funding for the National Cemetery
Administration (NCA). These resources will allow us to meet the growing
workload at existing cemeteries by increasing staffing and funding for
contract maintenance, supplies, and equipment. We expect to perform
nearly 105,000 interments in 2008, or 8.4 percent higher than the
number of interments we performed in 2006. The number of developed
acres (over 7,800) that must be maintained in 2008 will be 7.3 percent
greater than last year.
Our budget request includes $3.7 million to prepare for the
activation of interment operations at six new national cemeteries--
Bakersfield, California; Birmingham, Alabama; Columbia-Greenville,
South Carolina; Jacksonville, Florida; southeastern Pennsylvania; and
Sarasota County, Florida. Establishment of these six new national
cemeteries is directed by the National Cemetery Expansion Act of 2003.
The 2008 budget has $9.1 million to address gravesite renovations
as well as headstone and marker realignment. These improvements in the
appearance of our national cemeteries will help us maintain the
cemeteries as shrines dedicated to preserving our Nation's history and
honoring veterans' service and sacrifice.
With the resources requested to support NCA activities, we will
expand access to our burial program by increasing the percent of
veterans served by a burial option within 75 miles of their residence
to 84.6 percent in 2008, which is 4.4 percentage points above our
performance level at the close of 2006. In addition, we will continue
to increase the percent of respondents who rate the quality of service
provided by national cemeteries as excellent to 98 percent in 2008, or
4 percentage points higher than the level of performance we reached
last year.
capital programs (construction and grants to states)
VA's 2008 request includes $1.078 billion in appropriated funding
for our capital programs. Our request includes $727.4 million for major
construction projects, $233.4 million for minor construction, $85
million in grants for the construction of state extended care
facilities, and $32 million in grants for the construction of state
veterans cemeteries.
The 2008 request for construction funding for our health care
programs is $750 million--$570 million for major construction and $180
million for minor construction. All of these resources will be devoted
to continuation of the Capital Asset Realignment for Enhanced Services
(CARES) program, total funding for which comes to $3.7 billion over the
last 5 years. CARES will renovate and modernize VA's health care
infrastructure, provide greater access to high-quality care for more
veterans, closer to where they live, and help resolve patient safety
issues. Within our request for major construction are resources to
continue six medical facility projects already underway:
<bullet> Denver, Colorado ($61.3 million)--parking structure and
energy development for this replacement hospital.
<bullet> Las Vegas, Nevada ($341.4 million)--complete construction
of the hospital, nursing home, and outpatient facilities.
<bullet> Lee County, Florida ($9.9 million)--design of an
outpatient clinic (land acquisition is complete).
<bullet> Orlando, Florida ($35.0 million)--land acquisition for
this replacement hospital.
<bullet> Pittsburgh, Pennsylvania ($40.0 million)--continue
consolidation of a 3-division to a 2-division hospital.
<bullet> Syracuse, New York ($23.8 million)--complete construction
of a spinal cord injury center.
Minor construction is an integral component of our overall capital
program. In support of the medical care and medical research programs,
minor construction funds permit VA to address space and functional
changes to efficiently shift treatment of patients from hospital-based
to outpatient care settings; realign critical services; improve
management of space, including vacant and underutilized space; improve
facility conditions; and undertake other actions critical to CARES
implementation. Our 2008 request for minor construction funds for
medical care and research will provide the resources necessary for us
to address critical needs in improving access to health care, enhancing
patient privacy, strengthening patient safety, enhancing research
capability, correcting seismic deficiencies, facilitating realignments,
increasing capacity for dental services, and improving treatment in
special emphasis programs.
We are requesting $191.8 million in construction funding to support
the Department's burial program--$167.4 million for major construction
and $24.4 million for minor construction. Within the funding we are
requesting for major construction are resources to establish six new
cemeteries mandated by the National Cemetery Expansion Act of 2003. As
previously mentioned, these will be in Bakersfield ($19.5 million),
Birmingham ($18.5 million), Columbia-Greenville ($19.2 million),
Jacksonville ($22.4 million), Sarasota ($27.8 million), and
southeastern Pennsylvania ($29.6 million). The major construction
request in support of our burial program also includes $29.4 million
for a gravesite development project at Fort Sam Houston National
Cemetery.
information technology
VA's 2008 budget request for information technology (IT) is $1.859
billion. This budget reflects the first phase of our reorganization of
IT functions in the Department which will establish a new IT management
structure in VA. The total funding for IT in 2008 includes $555 million
for more than 5,500 staff who have been moved to support operations and
maintenance activities. Prior to 2008, the funding and staff supporting
these IT activities were reflected in other accounts throughout the
Department.
Later in 2007, we will implement the second phase of our IT
reorganization strategy by moving funding and staff devoted to
development projects and activities. As a result of the second stage of
the IT reorganization, the Chief Information Officer will be
responsible for all operations and maintenance as well as development
activities, including oversight of, and accountability for, all IT
resources within VA. This reorganization will make the most efficient
use of our IT resources while improving operational effectiveness,
providing standardization, and eliminating duplication.
This major transformation of IT will bring our program under more
centralized control and will play a significant role in ensuring we
fulfill my promise to make VA the gold standard for data security
within the Federal Government. We have taken very aggressive steps
during the last several months to ensure the safety of veterans'
personal information, including training and educating our employees on
the critical responsibility they have to protect personal and health
information, launching an initiative to expeditiously upgrade all VA
computers with enhanced data security and encryption, entering into an
agreement with an outside firm to provide free data breach analysis
services, initiating any needed background investigations of employees
to ensure consistency with their level of authority and
responsibilities in the Department, and beginning a campaign at all of
our health care facilities to replace old veteran identification cards
with new cards that reduce veterans' vulnerability to identify theft.
These steps are part of our broader commitment to improve our IT and
cyber security policies and procedures.
Within our total IT request of $1.859 billion, $1.304 billion (70
percent) will be for non-payroll costs and $555 million (30 percent)
will be for payroll costs. Of the non-payroll funding, $461 million
will support projects for our medical care and medical research
programs, $66 million will be devoted to projects for our benefits
programs, and $446 million will be needed for IT infrastructure
projects. The remaining $331 million of our non-payroll IT resources in
2008 will fund centrally managed projects, such as VA's cyber security
program, as well as management projects that support department-wide
initiatives and operations like the replacement of our aging financial
management system and the development and implementation of a new human
resources management system.
The most critical IT project for our medical care program is the
continued operation and improvement of the Department's electronic
health record system, a Presidential priority which has been recognized
nationally for increasing productivity, quality, and patient safety.
Within this overall initiative, we are requesting $131.9 million for
ongoing development and implementation of HealtheVet-VistA (Veterans
Health Information Systems and Technology Architecture). This
initiative will incorporate new technology, new or reengineered
applications, and data standardization to improve the sharing of, and
access to, health information, which in turn, will improve the status
of veterans' health through more informed clinical care. This system
will make use of standards accepted by the Secretary of Health and
Human Services that will enhance the sharing of data within VA as well
as with other Federal agencies and public and private sector
organizations. Health data will be stored in a veteran-centric format
replacing the current facility-centric system. The standardized health
information can be easily shared between facilities, making patients'
electronic health records available to them and to all those authorized
to provide care to veterans.
Until HealtheVet-VistA is operational, we need to maintain the
VistA legacy system. This system will remain operational as new
applications are developed and implemented. This approach will mitigate
transition and migration risks associated with the move to the new
architecture. Our budget provides $129.4 million in 2008 for the VistA
legacy system. Funding for the legacy system will decline as we advance
our development and implementation of HealtheVet-VistA.
In veterans benefits programs, we are requesting $31.7 million in
2008 to support our IT systems that ensure compensation and pension
claims are properly processed and tracked, and that payments to
veterans and eligible family members are made on a timely basis. Our
2008 request includes $3.5 million to continue the development of The
Education Expert System. This will replace the existing benefit payment
system with one that will, when fully deployed, receive application and
enrollment information and process that information electronically,
reducing the need for human intervention.
VA is requesting $446 million in 2008 for IT infrastructure
projects to support our health care, benefits, and burial programs
through implementation and ongoing management of a wide array of
technical and administrative support systems. Our request for resources
in 2008 will support investment in five infrastructure projects now
centrally managed by the CIO--computing infrastructure and operations
($181.8 million); network infrastructure and operations ($31.7
million); voice infrastructure and operations ($71.9 million); data and
video infrastructure and operations ($130.8 million); and regional data
centers ($30.0 million).
VA's 2008 request provides $70.1 million for cyber security. This
ongoing initiative involves the development, deployment, and
maintenance of a set of enterprise-wide controls to better secure our
IT architecture in support of all of the Department's program
operations. Our request also includes $35.0 million for the Financial
and Logistics Integrated Technology Enterprise (FLITE) system. FLITE is
being developed to address a long-standing material weakness and will
effectively integrate and standardize financial and logistics data and
processes across all VA offices as well as provide management with
access to timely and accurate financial, logistics, budget, asset, and
related information on VA-wide operations. In addition, we are asking
for $34.1 million for a new state-of-the-art human resource management
system that will result in an electronic employee record and the
capability to produce critical management information in a fraction of
the time it now takes using our antiquated paper-based system.
summary
Our 2008 budget request of $86.75 billion will provide the
resources necessary for VA to:
<bullet> Strengthen our position as the Nation's leader in
providing high-quality health care to a growing patient population,
with an emphasis on those who count on us the most--veterans returning
from service in Operation Iraqi Freedom and Operation Enduring Freedom,
veterans with service-connected disabilities, those with lower incomes,
and veterans with special health care needs;
<bullet> Improve the delivery of benefits through the timeliness
and accuracy of claims processing; and
<bullet> Increase veterans' access to a burial option by opening
new national and state veterans' cemeteries.
I look forward to working with the Members of this Committee to
continue the Department's tradition of providing timely, high-quality
benefits and services to those who have helped defend and preserve
freedom around the world.
______
Response to Written Questions Submitted by Hon. Daniel K. Akaka to
Hon. R. James Nicholson, Secretary, Deparment of Veterans Affairs
Question 1. VA's estimates for the number of OEF/OIF veterans that
will come into the system next year are relatively incremental, at
around 54,000. In the past, VA has underestimated the number of new
veterans seeking VA health care. We also know that some conditions,
such as PTSD, can take some time to manifest themselves in these young
servicemembers, and that in these current conflicts, the average
servicemember will serve more tours than in the past. Can you please
explain the projects that VA will see such a low number of OEF/OIF
veterans next year? In our hearing, you mentioned that you use a very
sophisticated model to reach your projections can you explain this
model?
Response: The Department of Veterans Affairs (VA) has made every
effort to account for the needs of Operation Enduring Freedom/Operation
Iraqi Freedom (OEF/OIF) veterans within the actuarial model. Starting
with the identification of OEF/OIF veterans from a roster provided by
the Department of Defense (DOD) the actuarial model develops
projections based on the actual enrollment and utilization patterns of
OEF/OIF veterans since Fiscal Year (FY) 2002. These projections are
based on the development of separate enrollment, morbidity, and
reliance assumptions for OEF/OIF veterans based on their actual
enrollment and utilization patterns. However, unknowns, such as the
length of the conflict, will impact the services that VA will need to
provide. Therefore, we have included additional investments for OEF/OIF
in the Fiscal Year 2008 budget to ensure that VA is able to care for
all of the health care needs of our returning veterans.
Question 2. VA has indicated that the size of the active duty force
is the best indicator of new claims activity. DOD data shows that there
were nearly 198,000 military separations in 2006. This number does not
include demobilized Guard and Reserve. Trends show that 35 percent of
these veterans will file a claim over the course of their lifetime. For
2006 separation only, that number is over 69,000 for just active duty
forces. What is VA doing to prepare now for this current and future
increase in claims activity?
Response: Special workload reduction initiatives are being
undertaken to meet the demands of pending and future inventory. These
initiatives include an aggressive recruitment program to add more
decisionmakers; employment of rehired annuitants; expanded use of
overtime; expansion of our claims development centers; shifting work
among regional offices to maximize resources and enhance performance;
improving the training for new and existing employees; and working with
DOD to identify opportunities to improve information sharing and
efficiency of claims processing and transition services. The 8,320
direct full time employees (FTE) requested in 2008 for the Compensation
and Pension (C&P) program are essential if VA is to reduce the pending
workload. With a workforce that is sufficiently large, correctly
balanced, and well trained, the Veterans Benefit Administration (VBA)
can successfully meet the needs of our veterans.
Question 3. How many veterans does VA estimate will leave the VA
health care system due to the enrollment fees and increase in the drug
copayment, and how many veterans will be deterred from seeking services
at VA?
Response: VA estimates that approximately 420,000 Priority 8
veterans will choose not to pay the tiered enrollment fee and increased
pharmacy copayment in Fiscal Year 2009. A majority of these veterans
are non-users but approximately 111,000 veteran patients are impacted
by this proposal.
Question 4. Over the past 5 years, VA has made extraordinary
progress in developing new solutions to the medical needs of our aging
veterans population and the growing number of younger veterans with
multiple traumatic injuries. Yet, the research request for Fiscal Year
2008 relies on outside funding sources, and would amount to a cut of $2
million authorized from Fiscal Year 2007. In a similar trend, the
budget requests 3,000 research employees, down by almost 200 from 2006.
Please explain the motivation for these cuts, and the impact they will
have on the impressive research conducted at VA?
Response: VA is committed to increasing the impact of its research
program by ensuring that resources are targeted to the most pressing
needs and spent on the programs that prove to be most effective at
developing new solutions to the medical needs of new and aging
veterans.
VA continues to maintain a workable balance among the competing
needs for research; to evaluate and fund existing programs at
appropriate levels and to fund new projects at a comparable rate as has
happened previously. Strategies include using attrition, transitioning
to shorter durations of awards, and conducting competitive reviews of
research centers. VA is using performance-based criteria to decide
whether to modify, terminate, or expand programs.
Using these strategies, VA research is increasing its focus on the
emerging needs of new veterans, especially those returning from OEF/
OIF, while maintaining a broad research portfolio that addresses the
needs of aging veterans, including chronic diseases and mental health.
It is important to note that, in many cases, the needs of new OEF/OIF
veterans relate to those of aging veterans who served in previous
conflicts. For example, research focused on the combat-related mental
health needs of OEF/OIF veterans is also applicable to the mental
health needs of aging veterans who served in previous deployments.
Similarly, research designed to improve traumatic amputation and
subsequent prosthetics care is also relevant to aging veterans with
diabetes and vascular disease. Accordingly, increases in funding for
OEF/OIF related research does not necessarily come at the expense of
research focused on the aging veteran.
Question 5. How does VA handle OEF/OIF veterans as they enter the
VA system through their 2-year automatic window of eligibility
following separation from service? Are all of them automatically
``enrolled'' in the VA health care system? And how are they prioritized
after their enrollment or entry into the system? Do they automatically
become 7s and 8s?
Response: Combat veterans, including OEF/OIF veterans, who apply
for enrollment within 2 years of their release from active duty are
eligible for placement into Priority Group 6 (unless they are eligible
for placement in a higher Priority Group based on other eligibility
factors).
These combat veterans are eligible for the full medical benefits
package. They are provided hospital care, medical services, nursing
home care, and medications for any illness that may be related to their
combat service during the 2 years after their release from active duty
is provided without charge. Treatment for conditions other than those
clinically determined to be related to their service are subject to
copays.
At the end of their 2-year combat eligibility period, enrolled
combat veterans remain enrolled and are placed into Priority Groups
based upon their income and/or other applicable eligibility factors.
Combat veterans who apply more than 2 years after separation from
active duty are evaluated for enrollment based upon the same
eligibility factors as any other veteran.
Question 6. The proposed budget would maintain the current ban on
enrollment of Priority 8 veterans. How much would it cost to bring
these veterans back into the system? Please take into account the third
party insurance these veterans will bring with them.
Response: Reopening Priority 8 enrollment in Fiscal Year 2008 is
estimated to increase enrollment in Priority 8 by approximately 1.6
million and require an additional $1.7 billion in the budget. VA has
significant concerns that this additional demand will strain VA's
capacity to provide timely, quality care for all enrolled veterans and
will lead to longer waits for care. VA must also consider the impact of
this policy in future years. In 2017, this policy would increase
Priority 8 enrollment by an estimated 2.4 million and would require an
additional $4.8 billion. Over the next 10 years, resumption of Priority
8 enrollment would require an additional $33.3 billion.
Question 7. VA's budget appears not to add $360 million but only
$54 million to implement mental health initiatives to close gaps in
services identified in VA's Mental Health Strategic Plan. Can you
please provide the Committee with a detailed breakdown of how the $306
million will be spent in Fiscal Year 2007 and how the VA proposed to
spend the additional $54 million in Fiscal Year 2008?
Response: The plan for spending the $306 million allocated for the
mental health initiative is included as a spreadsheet. The additional
funds for the Mental Health Initiative for Fiscal Year 2008 will be
fully used to support full year funding for those activities initiated
in Fiscal Year 2007 and prior years.
The following table provides additional information.
----------------------------------------------------------------------------------------------------------------
FY 2007 and FY 2008 Proposed Mental Health Initiative Spend Plan FY 2007 FY 2008 Change
----------------------------------------------------------------------------------------------------------------
Continuation of FY 2005 and FY 2006 Recurring Initiated 166,296,744 166,296,744 0
Activities.....................................................
Primary Care/Mental Health Integration.......................... 38,380,506 55,691,153 17,310,647
Suicide prevention coordinators (156 sites)..................... 8,624,890 16,249,780 7,624,890
Psychosocial Rehabilitation (PSR)............................... 15,138,061 23,587,385 8,449,324
Mental Health Intensive Case Management (MHICM): Rural, multiple 10,185,091 12,345,644 2,160,553
teams, etc.....................................................
Homeless Program Initiatives.................................... 17,556,002 17,342,238 -213,764
Substance Use Disorders......................................... 4,624,702 9,096,072 4,471,370
Mental Health staff in Community Based Outpatient Clinics 15,290,157 21,883,139 6,592,982
(CBOCs)........................................................
Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) 3,490,567 5,102,231 1,611,664
inreach........................................................
Post Traumatic Stress Disorder (PTSD), including Dual Diagnosis 4,979,157 5,115,401 136,244
and Military Sexual Trauma (MST) Resource program..............
Telemental Health............................................... 7,018,000 3,100,000 -3,918,000
EES training.................................................... 600,000 600,000 0
Centers of Excellence........................................... 3,000,000 4,950,000 1,950,000
Gulf Coast market survey........................................ 196,659 0 -196,659
Vet Center staff enhancement.................................... 3,379,923 10,531,046 7,151,123
TBI Transitional Housing........................................ 2,500,000 5,000,000 2,500,000
Other activities including training in evidence based 4,849,541 3,109,167 -1,740,374
psychotherapy..................................................
-----------------------------------------------
Total....................................................... 306,110,000 360,000,000 53,890,000
----------------------------------------------------------------------------------------------------------------
Question 8. I remain concerned that the funding for new mental
health initiatives may be inadequate. VA has been implementing the
Mental Health Strategic Plan since Fiscal Year 2005. Please identify
the initiatives in the plan that have not been fully implemented and
the amounts of funding needed to fully implement each of the remaining
initiatives.
Response: The Veterans Health Administration (VHA) mental health
strategic plan (MHSP) identifies and addresses gaps in services,
disseminates evidence-based programs, and works toward transformation
in the culture of care. While VHA has been working toward
implementation of the MHSP for approximately 2 years, we anticipate
that 5 years or more will be required to achieve the enhancements and
transformations required to fully meet its intended goals.
In terms of initiatives that have not been fully implemented, VA
views the MHSP as a living document that must be modified or
interpreted differently as the needs of eligible veterans change, and
as new opportunities for providing care become available. For example,
VA has learned far more about the needs of veterans from the Global War
on Terrorism (GWOT) since 2003 and 2004 when the strategic plan was
developed. We have also learned from research about new opportunities
for treating veterans with mental illnesses.
Resources to support mental health services have come in the form
of supplementing Veteran Integrated Service Network (VISN)-based
activities funded through veteran's equitable resource allocation
(VERA). Enhancements funded through the mental health initiative are
moving the system rapidly toward implementation of the MHSP. Extending
the funding for the initiative with $306 million in Fiscal Year 2007
and $360 million in Fiscal Year 2008 will contribute to the
transformation of the mental health care system and full implementation
of the MHSP.
Question 9. VA's ability to provide for the security of our
veterans' personal information is still questionable. I understand this
budget contains over $70 million for cyber security. Please explain in
detail how this money will be used. How will this budget prevent future
losses of computer equipment and secure personal information of the
type that is believed to be on the hard drive at the Birmingham VA
Medical Center that was reported lost last month?
Response: The information technology (IT) cyber security program
includes 18 initiatives, as follows:
------------------------------------------------------------------------
Initiative FY 2008
------------------------------------------------------------------------
Cyber Security Management.................................. $28.7M
Certification & Accreditation of IT Systems............ 7.5
Identity Safety and Risk Management.................... 6.0
Policy Development and Maintenance..................... 5.7
Training, Awareness and Education...................... 5.4
FISMA Reporting........................................ 2.3
Security Inspection.................................... 1.8
------------------------------------------------------------------------
Field Security Operations.................................. $41.4M
Enterprise Encryption and Data Protection.............. 7.0
Maintenance/Support Services........................... 6.5
Enterprise Framework................................... 5.5
Antivirus.............................................. 5.4
Vulnerability Assessment and Penetration............... 4.0
Patch Management....................................... 3.4
Encryption............................................. 2.7
Testing................................................ 2.2
Intrusion Prevention................................... 1.9
E-Authentication....................................... 1.9
Media Disposal......................................... 0.5
COOP................................................... 0.4
------------------------------------------------------------------------
Total.............................................. $7O.1OM
------------------------------------------------------------------------
To account for equipment and protect information, VA is:
<bullet> Requiring all VA laptops have security software updated
and unauthorized sensitive information removed through the laptop
``Health Check'' procedure every 90 days.
<bullet> Permitting the use of Federal Information Processing
Standards (FIPS) 140-2 certified encrypted universal serial buses (USB)
thumb drives for VA employees who have justified the need and received
approval to store information on a removable storage device as outlined
in VA Directive 6601, Removable Storage Media.
<bullet> Testing a port security technology to enforce adherence to
the directive that will restrict the transfer of information to
removable storage media and thwart the introduction of malicious code
via USB ports.
<bullet> Establishing levels of standardization and maintaining an
inventory for Blackberry devices, SmartPhones and other mobile devices
(such as personal digital assistants).
<bullet> Implementing Blackberry content protection on devices VA
owns, i.e., if a device is lost, it is password protected and
encrypted.
<bullet> Restricting use of non-government mobile devices within
VA, only allowing them to be used if VA can monitor their use to verify
they are following VA IT security policies.
<bullet> Deploying an encryption solution for SmartPhones and other
mobile devices similar to that of the Blackberry protection.
<bullet> Securing remote access to e-mail and file shares for
employees, contractors, and business partners using government
furnished equipment through the remote enterprise security compliance
update environment (RESCUE), which ensures equipment is encrypted and
has an active host-based firewall, updated antivirus files, and the
most recent security patches mandated for installation.
<bullet> Prohibiting employees, contractors and business partners
from saving information on non-government owned equipment.
<bullet> Testing technology to encrypt network traffic from VistA
mail, computerized patient record system and time and attendance
applications.
<bullet> Automating the distribution of software, patches and
upgrades to servers and workstations via the enterprise security
framework to ensure policy compliance for VA information systems, to
produce compliance reports, and to mitigate risks--in concert with the
VA patch management, intrusion prevention and antivirus initiatives--
propagated by viruses, worms, and other malicious code.
<bullet> Distributing data eraser (a software package for
overwriting sensitive information contained on hard drives) nationwide
to properly sanitize and dispose of equipment.
<bullet> Conducting vulnerability assessments and penetration
testing to identify and quantify risks.
<bullet> Drafting/implementing policies addressing agency
responsibilities to protect laptops and other portable data storage and
communication devices, such as keeping laptops in carry-on luggage, use
of privacy screens when accessing agency information outside the
office, etc.
Question 10. As discussed in the past, I am concerned that VA
cannot always absorb court decisions, anticipated or not, without
falling behind. This year, we already know of a court decision that
could have a significant effect on the workload at VA. What measures
are you taking now to ensure that should the Haas decision not be
overturned, that veterans who are already in the queue, or those who
are now filing their claims, are not burdened by unnecessary delay?
Response: The Haas decision could potentially affect many veterans
who have claims based on herbicide exposure in which the only evidence
of exposure is the receipt of the Vietnam Service Medal or service on a
vessel off the shore of Vietnam, i.e., there is no evidence they served
on land or the inland waterways of Vietnam. In order to be prepared for
adjudication of claims that will be influenced by the decision rendered
by the U.S. Court of Appeals for the Federal Circuit, VA released
instructions in December of 2006 to all regional offices on the correct
process for tracking and controlling claims with Haas issues.
The initiatives that have recently been put in place to address
increased inventory will assist VA in tackling the potential increase
in claims that may stem from Haas. These initiatives include an
aggressive recruitment program to add more decisionmakers, employment
of rehired annuitants, increased use of overtime, expansion of claims
development centers, shifting work among regional offices to maximize
resources and enhance performance, and improved training for all
employees.
Question 11. How is the Department counting injuries that come
about as a result of participation in the Global War on Terror? Are
combat and non-combat injuries categorized differently?
Response: The Office of Public Health and Environmental Hazards
does perform a quarterly review of healthcare use by those OEF/OIF
veterans who have separated from service and present to VA for care.
Since September 2003, DOD Defense Manpower Data Center (DMDC) has
developed an updated file of ``separated'' Afghan and Iraqi combat
troops who have become eligible for VA health care. This roster is used
to check the VA's electronic inpatient and outpatient health records,
in which the standard International Classification of Disease (ICD)-9
diagnostic codes are used to classify health problems, to determine
which OEF/OIF veterans have accessed VA health care. The data available
for this analysis are mainly administrative information and are not
based on a review of each patient record or a confirmation of each
diagnosis. However, every clinical evaluation is captured in VHA's
computerized patient record. Consequently, the data used in this
analysis are excellent for health care planning purposes because the
ICD-9 administrative data reflects the need for health care resources.
VA/DOD social work liaisons located at 10 military treatment
facilities (MTFs) assist with the transfer of seriously injured
servicemembers to the most appropriate VA medical facilities closest to
their home to meet their medical needs. These VA/DOD social work
liaisons categorize the nature of the injury (battle, non-battle or
disease) as part of their documentation and referral to the receiving
VA medical facility. From August 2003 to February 22, 2007, VA/DOD
liaisons received the following referrals:
------------------------------------------------------------------------
Patient Percent of
Military Class of Injury Count Total
------------------------------------------------------------------------
Battle Injury (BI).............................. 1,215 20.3
Non-Battle Injury (NBI)......................... 2,303 38.5
Disease......................................... 1,467 24.6
Unknown......................................... 990 16.6
Total Uniques............................... 5,975 100
------------------------------------------------------------------------
Data Source: MTF2VA Tracking System.
Question 12. What is the justification for moving a claim filed as
a result of the Global War on Terror ahead of an initial claim filed by
a Vietnam veteran?
Response: VA's initiative to provide priority processing of all
OEF/OIF veterans' disability claims will allow all the brave men and
women returning from the OEF/OIF theaters who were not seriously
injured in combat, but who nevertheless have a disability incurred or
aggravated during their military service, to enter the VA system and
begin receiving disability benefits as soon as possible after
separation. We believe this is an important step in assisting them with
their transition to civilian life.
VBA has undertaken several improvement initiatives to reduce the
pending workload and shorten the waiting time for all veterans. We are
hiring more employees and devoting additional resources to claims
processing. Additional overtime funds have been provided to regional
offices, and we are recruiting retired claims processors to return to
work as rehired annuitants. These experienced claims processors will be
tasked with processing claims that have been pending the longest.
Through these initiatives, claims processing for all veterans will be
improved.
Question 13. How was the strategic target for average days to mark
a grave at national cemeteries developed? Now that the National
Cemetery Administration is performing well-above the strategic target,
will the strategic target be adjusted to make the goal higher?
Response: The strategic target for the timeliness (within 60 days
of interment) of marking graves in national cemeteries was originally
set at 90 percent based on a review of performance data and of the
business processes involved with furnishing headstones and markers at
national cemeteries. In Fiscal Year 2002, the National Cemetery
Administration (NCA) collected baseline data showing that 49 percent of
graves in national cemeteries were marked within 60 days of interment.
This level of performance was raised by reengineering business
processes, such as ordering and setting headstones and markers. In
Fiscal Year 2004 and 2005, NCA exceeded this initial strategic target,
marking 94 percent and 95 percent of graves in national cemeteries
within 60 days of interment, respectively. As a result, NCA has
increased the strategic target for this measure to 92 percent.
While NCA's improved performance in this key strategic measure is
due primarily to reengineered business processes, favorable weather
conditions over the past few years, especially during the winter months
in the Northeast and Midwest, have also positively impacted our
performance. External factors beyond NCA's control, such as extreme
weather conditions that impact ground conditions, may cause delays in
the delivery and installation of headstones and markers. Additionally,
some families may choose to delay the ordering of a headstone or marker
for the grave of an individual interred in a national cemetery, which
may impact our ability to mark graves within 60 days of interment.
While national cemetery staff work with families and funeral homes to
ensure the ordering of headstones and markers in a timely manner, we
respect that some families may choose to defer ordering their headstone
or marker until a later date. With these factors in mind, NCA is
currently focused on sustaining our high level of performance in this
area and continuing to achieve and surpass our current strategic
target.
Question 14. Please explain the 310 day change in the Appeals
Resolution Time Strategic Target from last year to this year.
Response: The Board of Veterans Appeals (Board or BVA) appeals
resolution time (ART) is the average length of time it takes the
Department to process an appeal from the date a claimant files a Notice
of Disagreement (NOD) until a case is resolved, including resolution at
a regional office or by issuance of a final, non-remand, decision by
the Board. This Department-wide timeliness measure was adopted in the
late 1990s as a major organizational crosscutting effort to demonstrate
the Board's and VBA's commitment to veterans. We recognize that
appellants are less interested in how long individual stages in the
appeals process take as they are about the length of the entire
process. ART provides appellants, elected officials, Departmental
leadership, VBA and BVA management, and other interested parties a much
more comprehensive and accurate answer to the question, ``How long does
the appeal process take?'' For the reasons that will be discussed
below, the strategic target for the ART for Fiscal Year 2007 was
revised from the longstanding goal of 365 days to 675 days to more
realistically and accurately reflect the actual length of the appeals
process.
The goal established in 1998 was 365 calendar days. However, that
goal has never been met (see chart below). Moreover, this goal was
established before the Veterans Claims Assistance Act (VCAA) was
enacted in November 2000. Prior to that time, VA evaluated claims to
determine whether they were ``well grounded.'' If they were not, VA did
not assist the claimant in the development of his or her claims. The
VCAA, among other things, heightened VA's duty to assist and duty to
notify claimants of the type of evidence needed to substantiate their
claim. This resulted in more steps to the claims process and an
increase in the length of time required to develop claims. In addition,
the U.S. Court of Appeals for Veterans Claims and the U.S. Court of
Appeals for the Federal Circuit have issued a series of precedent
decisions, which required additional action on VA's part. See Holliday
v. Principi, 14 Vet. App. 280 (2001); Quartuccio v. Principi, 16 Vet.
App. 183 (2002); Charles v. Principi, 16 Vet. App. 370 (2002);
Pelegrini v. Principi, 18 Vet. App. 112 (2002); Mayfield v. Nicholson,
444 F.3d 1328 (Fed. Cir. 2006); Dingess/Hartman v. Nicholson, 19 Vet.
App. 473 (2006); Kent v. Nicholson, 20 Vet. App. 1 (2006).
------------------------------------------------------------------------
Strategic
Fiscal Year Target ART Actual ART Target ART
------------------------------------------------------------------------
1999................................ 745 365
2000................................ 682 365
2001................................ 595 365
2002................................ 731 365
2003................................ 633 365
2004................................ 529 365
2005................................ 622 365
2006................................ 657 365
2007................................ 685 670* 675
2008................................ 700 675
------------------------------------------------------------------------
*Thru 1/31/07.
Question 15. The Administration's request projects an increase in
funding for VA health care in Fiscal Year 2008, and cuts in funding in
subsequent years. This projection parallels last year's request which
suggested cuts in immediate out years as well. In the face of steadily
increasing patient workload, an aging veteran population, and steady
inflation in the cost of medical care, what is the rationale for these
projections?
Response: The Administration determines the details of its
appropriations request 1 year at a time. Each year, Office of
Management and Budget (OMB) works with the agencies to develop the
detail estimates for individual programs. OMB's computer model
generates placeholders for, in the case of this year's budget, Fiscal
Year 2009-2012 by account that hit overall targets for defense,
homeland security, international, and other non-security spending, so
that OMB can calculate the deficit path. These projections do not
represent the President's proposed levels for individual accounts and
programs. The Fiscal Year 2009 and subsequent year's requests will be
made in future cycles.
Question 16. The proposed budget shows a transfer of 5,689 Food
Service FTE from the medical facilities to medical services account.
How are these personnel to be distributed amongst the medical services
activities? What is the justification for this change?
Response: This is a technical correction. Under the medical care
three-appropriation structure, which began in 2004, food service
operations were designated under the medical facilities appropriation.
The costs incurred for hospital food service workers, provisions, and
related supplies are for the direct care of patients. Food service
costs are directly related to inpatient workload and, therefore, should
be captured under the medical services appropriation which is
responsible for direct inpatient care. VA requests that beginning in
2008, food service operations be moved to the medical services
appropriation.
Question 17. The proposed budget includes $1.3 billion allocated
for the IT non-pay account. How is this budget line allocated? What
portion of this line will be spent on outside contracts? How many
individual contracts do you expect to make use of, and with how many
individual contractors? How much of this line represents contractor
payroll?
Response: The proposed budget of $1.3 billion is allocated, as
follows (dollars in thousands):
------------------------------------------------------------------------
IT Activities 2008 estimate
------------------------------------------------------------------------
VA IT Infrastructure.................................... $446,139
Veterans Health Care.................................... 461,468
Veterans Benefits Delivery.............................. 65,648
Office of Information and Technology.................... 191,034
Office of Management.................................... 82,572
Human Resources Development............................. 34,140
Other Staff Offices..................................... 22,840
Impact of Continuing Resolution P.L. 109-383............
---------------
Total............................................... $1,303,841
------------------------------------------------------------------------
With respect to the remaining contractor-specific questions, the
volume and detail of data necessary to provide an adequate response
will require an extensive informationgathering effort. As a result, VA
needs significant time to collect this data. However, we expect to be
able to complete the response by June 30, 2007.
Question 18. FISMA compliance accounts for $249 million of the IT
budget. Please explain in detail how these funds will be expended to
improve VA's level of FISMA compliance.
Response: The information technology component of the budget
request includes $231.9 million for compliance with the information
security requirements of Federal Information Security Management Act
(FISMA) compliance.
The Department-level budget of $70.1 million for cyber security
provides an overall framework for development and implementation of the
VA information security program as required by FISMA. This includes a:
<bullet> Cyber security management component that provides the
Department-wide focal point for leadership in information security
policies, procedures, and practices; and
<bullet> Regional field operations component that provides
oversight for a segment of facility information security officers who
are geographically dispersed throughout VA as well as develops and
maintains certain enterprise-wide security controls and measures.
The IT system-level budget, which is $161.8 million spread across
the IT portfolio for implementation, comprises security initiatives
accomplished at the system or facility level to support FISMA
compliance (to include implementation of security controls required by
the National Institute of Standards and Technology). For Fiscal Year
2008, anticipated expenditures are related to re-certification and
accreditation of approximately 560 VA systems; deployment of the VA
personal identify verification system to provide standardized
government identification and access to IT systems for over 350,000 VA
employees and contractors; integration of security into VistA
application development; secure deployment of the VA regional data
centers; remediation of facility security weaknesses; temporary
employee background investigations; field level contingency plan
testing; and system security upgrades.
Question 19. Please provide in detail VA's outreach efforts to the
Guard and Reserve, including specific actions and numbers of
servicemembers contacted, as well as the number of servicemembers
seeking benefits and services.
Response: VHA has made extensive efforts to ensure that information
is available to returning troops about VA services and their
eligibility. Ultimately it is each veteran's decision regarding where
they will seek health care, but VA wants that decision to be based on
ample information about VA and its programs for veterans. VBA, with the
activation and deployment of large numbers of Reserve/Guard members,
has greatly expanded its outreach to this group of veterans as well.
The following is a summary of efforts to reach out and educate veterans
and their families: Transition Assistance Advisors (TAA): The Office of
Seamless Transition has partnered with the National Guard Bureau to
establish 54 TAA, formerly State benefits advisors. A TAA is in every
State and territory. The TAAs are National Guard Bureau staff that work
closely with VA medical centers and Vet Centers in outreach, education,
and referral efforts.
Post Deployment Health Reassessment (PDHRA) Program: VA Medical
Centers (VAMC) and Vet Centers are heavily involved in DOD PDHRA
program for National Guard and Reserve members. PDHRA is an outreach,
education, identification, and referral program. Vet Center staff has
participated in over 300 PDHRA screening events with National Guard and
Reserve units. These screenings have resulted in over 17,125
servicemembers, as of February 2007, being referred to VA for follow-up
care. In addition to providing this follow-up care, VA staff actively
enrolls National Guard and Reserve members in health care.
Army Wounded Warrior (AW2): Recently VA has agreed to host 22 AW2
staff in VAMCs to work with seriously injured soldiers/veterans and
their families. AW2 soldiers have 30 percent or higher disability
ratings from the Army. Over 20 percent of the soldiers/veterans in this
program have a post traumatic stress disorder (PTSD) disability. An AW2
staff will be located in each VISN (with two assigned in VISN 7).
Sixteen of the AW2 staff are currently in place with the remaining six
scheduled to be assigned during 3rd quarter Fiscal Year 2007. The VA/
AW2 partnership is a major step in the outreach initiative that will
help VAMC and Vet Center staff reach out to seriously injured soldiers/
veterans and their families.
Memorandums of Understanding (MOU): The Office of Seamless
Transition is actively working with the Army Reserve and the Marine
Corps to develop MOUs to help promote outreach, education, and
transition assistance.
Vet Center Enhancements: In response to the growing numbers of
veterans returning from combat in OEF/OIF, the Vet Centers have hired
additional staff and opened new centers. In February 2004, 50 GWOT
veterans were hired to augment the Vet Center existing staff. VA
authorized a new 4-person Vet Center in Nashville, Tennessee in
November 2004. An additional 50 GWOT veterans were hired in April 2005
to further enhance services to veterans returning from combat in
Afghanistan and Iraq. VA established two new Vet Centers (Atlanta,
Georgia and Phoenix, Arizona) in April 2006. Since the beginnings of
hostilities in Afghanistan and Iraq, the Vet Centers have seen over
165,000 OEF/OIF veterans, of which over 119,000 were outreach contacts
seen primarily at military demobilization and National Guard and
Reserve sites, usually in group settings.
Vet Center Expansion: In February 2007 a major expansion of the Vet
Center program was announced, with 23 new Vet Centers to be located in
Montgomery, AL; Fayetteville, AR; Modesto, CA; Grand Junction, CO;
Orlando, Fort Myers, and Gainesville, FL; Macon, GA; Manhattan, KS;
Baton Rouge, LA; Cape Cod, MA; Saginaw and Iron Mountain, MI; Berlin,
NH; Las Cruces, NM; Binghamton, Middletown, Nassau County and
Watertown, NY; Toledo, OH; Du Bois, PA; Killeen, TX; and Everett, WA.
Returning Veterans Outreach, Education and Clinical (RVOEC) Teams:
RVOEC teams (funded and monitored through the Office of Mental Health
Services) collaborate with readjustment counseling services and with
State veterans affairs offices to provide information about VA
services. A primary goal of the RVOEC program is to promote awareness
of health issues and health care opportunities and the full spectrum of
VA benefits. Some VAMCs began these outreach activities before RVOEC
teams were funded as local initiatives, and they continue these
services, now using the RVOEC teams as their agents.
The National Center for PTSD: The Center has a number of
informational pamphlets for returning veterans and their families on
their Web site (http://www.ncptsd.va.gov/). The Web site contains the
latest fact sheets and literature on the war in Iraq. Important links
from the site include: The Iraq War Clinician Guide, 2nd Edition, and
two new guides on Returning from the War Zone: A Guide for Military
Personnel and A Guide for Families as well as the VA Operation Enduring
Freedom and Iraqi Freedom Seamless Transition Web site.
Briefings: VA provides briefings on benefits and health care
services specific to Reserve/Guard members at demobilization sites and
during the military pre-separation process as well as at town hall
meetings, family readiness groups, family day activities, reunion and
welcome home events, and during unit drills near the home of returning
Guard/Reservists. Return and deactivation of Reserve/Guard units
presents significant challenges to VA because rotation is irregular and
the servicemembers spend short periods at military installations prior
to release to their Guard or Reserve components. For this reason, VA
continues to refine and adapt traditional outreach efforts to meet the
needs of those who are currently separating from service by focusing at
the local armories or Reserve centers in the months following
deactivation. Benefits briefings such as the transition assistance
program (TAP) workshops and retirement and separation briefings are
available to active duty personnel and also available to Reserve/Guard
members.
Following is a summary of briefings held specifically for Reserve/
Guard members:
Reserve/Guard Briefings
------------------------------------------------------------------------
Fiscal Year Briefings Attendees
------------------------------------------------------------------------
2003.......................................... 821 46,675
2004.......................................... 1,399 88,366
2005.......................................... 1,984 118,658
2006.......................................... 1,298 93,361
2007*......................................... 447 23,389
------------------------------------------------------------------------
*Through 01/31/07
A Summary of VA Benefits for Guard and Reserve Personnel--IB-164:
VA, in cooperation with the Department of Defense (DOD), produced a new
brochure outlining benefits and services available to Guard and Reserve
personnel. Supplies have been mailed to regional offices to support
outreach events and personal interviews. The brochure has also been
provided to Reserve/Guard units to have available for members.
Secretary's Letter: Since May 2005, as part of the Secretary's
Letter Writing Outreach Campaign, over 658,000 letters were mailed to
veterans informing them of VA's wide range of health care benefits and
assistance to aid in their transition from active duty to civilian
life. Based on lists routinely provided by DOD, the Secretary of
Veterans Affairs sends a letter to each returning OEF/OIF veteran,
including Reserve/Guard members, who has separated from the active
duty. Two pamphlets are enclosed with the letter: VA Pamphlet 21-00-1,
A Summary of VA Benefits, and VA IBlO-164, A Summary of VA Benefits for
National Guard and Reserve Personnel.
Veterans Assistance at Discharge System (VADS): The VADS process
generates the mailing of a ``Welcome Home Package'' that includes a
letter from the Secretary, VA Pamphlet 21-00-1, A Summary of VA
Benefits, and VA Form 21-0501, Veterans Benefits Timetable, to all
veterans recently separated or retired from active duty (including
Reserve/Guard members). VADS also sends a 6-month follow up letter with
the same enclosures to these veterans. Through this process,
information letters and materials are also sent about Education and
Life Insurance benefits.
About 181,000 of more than 689,000 GWOT veterans have filed a claim
for disability benefits either prior to or following their GWOT
deployment (approximately 26 percent). This includes survivors' claims
for dependency and indemnity compensation (DIC) and death pension. VA
has processed nearly 2,000 DIC claims for survivors of GWOT
servicemembers who died in service.
Summary counts of C&P benefit activity among veterans deployed
overseas in support of GWOT have been generated. Through this VA/DOD
data match, we are at this point only able to identify deployed GWOT
veterans who have also filed a VA disability claim either prior to or
following their GWOT deployment. Many GWOT veterans had earlier periods
of service, and filed for and received VA disability benefits before
being reactivated. VBA's computer systems do not contain any data that
would allow us to attribute veterans' disabilities to a specific period
of service or deployment.
Question 20. Committee staff have learned that separating
servicemembers in the Benefits Delivery at Discharge Program are not
receiving specialty examinations, except for hearing and psychiatric
cases, and that VBA Regional Office personnel believe that they are
precluded by policy to authorize these examinations. Please explain the
bases for this policy, with specific regard to whether it is based upon
budget implications, and describe your efforts to remedy the problem.
Response: There is no centralized policy that prohibits rating
specialists from ordering specialty or specialist examinations when
needed for servicemembers going through the Benefits Delivery at
Discharge (BDD) process.
We believe that some confusion may exist over the use of the term
``specialty.'' There are differences between general medical
examinations, ``specialty examinations,'' and ``specialist
examinations.'' A specialist examination is an examination conducted by
a clinician who specializes in the particular field. Currently, all
initial psychiatric examinations, and all audiology, dental, and eye
examinations are required to be conducted by a specialist.
A specialty examination is an examination that may be conducted by
a licensed clinician using specific detailed examination worksheets to
elicit the information needed with respect to a specific disability.
For example, it is not necessary in most cases to have a board-
certified orthopedic surgeon or sports medicine physician conduct an
examination of a knee to determine limitation of motion, stability, and
other factors required by the rating schedule. Rather these are routine
examinations that occur in clinical practice throughout public and
private healthcare settings by general practitioners, physicians'
assistants, and nurse practitioners.
A general medical examination is one that is ordered in initial
claims. It is frequently accompanied by specific specialty worksheets
depending on the nature of the conditions claimed.
Question 21. We have seen a dramatic increase in the number of
young veterans requiring long-term care due to combat injuries, such as
traumatic brain and spinal cord injuries. How does the budget address
these additional long-term care demands.
Response: VA has not seen a dramatic increase in the number of OEF/
OIF veterans returning with injuries requiring long term care relative
to the total veteran population receiving long term care services.
However, we have seen that the OEF/OIF veteran requires increasingly
complex long term care. To meet their complex care needs, VA has and
will continue to provide a spectrum of long term care services for
young veterans with combat injuries with the goal of maintaining them
at their highest functional level and as close to home as possible. The
spectrum of services ranges from home and community based care
including home telehealth, respite services, and adult day health care,
to three venues of nursing home care.
VA has rapidly expanded the capacity of its non-institutional home
and community-based services since 1998 while sustaining capacity in
nursing home programs. The Fiscal Year 2008 President's Budget
Submission proposes funding for a 26 percent expansion in home and
community based care services from Fiscal Year 2007 to Fiscal Year
2008. The increase will allow VA to purchase day health and independent
living skills services which are designed to meet the needs of younger
veterans and serve as an alternative to institutional care. In
addition, sufficient capacity exists in the VA, community nursing home,
and State veterans home programs to meet the needs of this population
when short-term or long-term (greater than 90 days) nursing home care
is indicated.
Question 22. How are education and training programs for all VA
employees, specifically those regarding information protection, funded
and administered?
Response: Development of training and awareness programs focused on
information protection are centrally funded through the Enterprise
Cyber Security Program. It provides general security awareness training
for employees and specialized, role-based training for executives,
project/program managers, and field chief information officers (CIO).
Specialized training for Department information security officers
(ISOs) and other IT professionals is centrally developed in a number of
modalities, to include:
<bullet> Web-based, online modules;
<bullet> Training videos;
<bullet> Satellite broadcasts;
<bullet> Annual information security conference;
<bullet> Commercially available training, such as, security
certification classes; and
<bullet> Specialized training focused on new security tools and
technologies under development or being deployed in the enterprise.
We are currently assessing the option of using an Information
System Security Line of Business Shared Service Center as a general
security awareness training provider. This initiative is an E-
Government Line of Business, managed by the Department of Homeland
Security, intending to make Government-wide IT security processes more
efficient.
VA policy requires all staff, including volunteers and contractors,
to participate in an annual awareness session. It is the responsibility
of employees and their supervisors to ensure compliance. Training
metrics are collected annually and reported to Office of Management and
Budget as part of the annual FISMA report. Privacy training, which also
addresses information protection, is handled in a similar manner,
administered through an enterprise privacy program also under the
direction of the VA CIO. Privacy training is required for all employees
annually and is offered in a number of modalities, including
specialized role-based training courses in addition to general
awareness. Privacy officers are provided with specialized training
during the annual information security conference.
Question 23. I have been impressed by the establishment of risk
management and incident response teams, as part of the new information
protection measures VA has implemented. Under which budget line are
these teams funded? Are the team members VA employees or contracted
employees?
Response: As part of the Office of Information and Technology
(OI&T) realignment, and as recommended by IBM, several existing IT
compliance programs have been consolidated into the Office of IT
Oversight and Compliance. This organization is designed to strengthen
and enhance VA's records management, privacy and IT security programs
and practices through a comprehensive program of assessments.
Assessment teams, comprised of VA employees, will conduct analyses
nationwide to measure how well VA facilities comply with legislative,
Federal Government oversight, and VA policies, procedures and
practices. The major objectives of these assessments are to determine
the adequacy of internal controls; validate compliance with laws,
policies and directives; ensure proper safeguards are maintained; and
recommend corrective actions where necessary. This office is currently
funded from multiple line items within the OI&T budget, including the
cyber security and privacy programs.
Question 24. Please provide a breakdown of the Fiscal Year 2008
request for all programs and services for homeless veterans, including
comparisons to the levels as passed in H.J. Res. 20 for Fiscal Year
2007.
Response: The estimate for 2007 and 2008 President's budget request
shows an increase in funding for Fiscal Year 2007 and Fiscal Year 2008:
Homeless Veterans Programs
------------------------------------------------------------------------
2006 2007 2008
------------------------------------------------------------------------
Obligations ($000):
Homeless Veterans $1,448,769 $1,514,096 $1,634,086
Treatment Costs..........
Programs to Assist Homeless
Veterans:
Health Care for Homeless 56,998 59,278 61,649
Vets (HCHV)..............
Homeless Grants & Per Diem 63,621 92,180 107,180
Program..................
Homeless Grants & Per Diem 12,300 12,300
Liaisons.................
Domiciliary Care for 63,592 72,702 75,610
Homeless Veterans........
Compensated Work Therapy/ 19,529 20,310 21,123
Transitional Residence
(CWT/TR) Program.........
Department of Housing & 5,297 5,498 5,718
Urban Development/VA
Supported Housing Program
(HUD-VASH) & Joint HUD/
Health & Human Services/
VA Supported Housing.....
Other..................... 1,248 3,353 3,428
-----------------------------------------
Total................. $210,285 $265,621 $287,008
------------------------------------------------------------------------
The ``other'' category includes a distribution of funds for ``Stand
Downs''; the monitoring and evaluation performed by the North East
Program Evaluation Center (NEPEC); the administration of the
multifamily transitional housing loan guarantee program, and excess
equipment and clothing distributed at ``Stand Downs'' and other
homeless functions.
VA will continue with activation of 11 new homeless domiciliary
residential rehabilitation and treatment programs (DRRTPs). The 11 new
DRRTPs will add over 400 new rehabilitative care beds for homeless
veterans.
VA will also continue the development of transitional housing and
supportive service centers to fill treatment and housing gaps for
homeless veterans in an overall Federal housing continuum. Public Law
107-95 provides VA the authority under the homeless providers grant and
per diem (GPD) program to assist with operational costs as well as
partial capital costs to create and sustain transitional housing and
service programs for homeless veterans. Additionally, VA will continue
to work with grant and per diem recipients to assure high-quality
services and improved outcomes for homeless veterans served in these
supported housing programs and supportive service centers.
In Fiscal Year 2007 and Fiscal Year 2008, VA intends to continue to
work toward building on initiatives that were started in 2005 and
continued in 2006. This includes continued collaboration with other
Federal agencies to address the needs of homeless veterans,
particularly those who are chronically homeless.
Question 25. With regard to the Grant and Per Diem Program and
Special Needs Grants, the proposed budget requests $107 million in
obligations and 2 FTE. Last year, Public Law 109-461 authorized $130
million for the Grant and Per Diem Program, noting that 400,000
veterans will experience homelessness at some point during the course
of the year, that only 25 percent of that number receive assistance
through VA, and that only 150,000 homeless veterans are served by
community-based organizations each year. Please explain why more
funding was not requested for these programs?
Response: VA has supported a significant increase in services for
homeless veterans. VA's Fiscal Year 2008 budget requests an increase of
nearly 77 million dollars between Fiscal Year 2006 and Fiscal Year 2008
funding levels. VA's plans have been both aggressive and thoughtful. VA
has in recent years expanded programs so that there are community
operated programs approved in every state and Puerto Rico, and several
programs on tribal land. On Thursday February 22, 2007, VA published a
series of notices of funding availability (NOFA) in the Federal
Register that will request proposals from community providers to create
1,000 new transitional housing beds under the VA's Homeless Providers
GPD program which represents a 10 percent increase of current capacity
in the number of beds; a funding opportunity to double our services for
special needs programs for homeless women veterans with children, frail
elderly, terminally ill and chronically mentally ill; and to offer
technical assistance to assist community groups be more effective in
securing additional resources.
Question 26. Last year, Congress authorized (in P.L. 109-461)
appropriation of $7 million for Fiscal Year 2007 through Fiscal Year
2011 for Special Needs Grants (women, frail elderly, terminally ill or
chronically mentally ill). What amount has been targeted for Special
Needs Grants in the Fiscal Year 2008 budget?
Response: VA has announced a total of $6 million for current
special needs and an additional $6 million for new special needs
programs. The approximate amount of $12 million will be available
January 2008 thru September 2009 (21-month funding cycle). VA has
announced funding to renew and create new special needs grants.
Question 27. Last year, GAO reported that they estimated a 9,600
bed shortfall would occur in the number of beds available to veterans
seeking to escape homelessness. How does the proposed budget address
this projected need?
Response: VA's current NOFA published February 22, 2007, will add
an additional 1,000 beds. Last year VA awarded funding for an
additional 800 beds. In less than 6 months VA has added and offered
funding to create 1,800 new beds--nearly 20 percent of beds identified
in the 9,600 bed deficit identified in the last community assessment of
need. VA hopes to offer additional funding under VA's Homeless
Providers GPD program.
Question 28. Does the VA budget reflect any plans to expand the
supply of decent and affordable housing for elderly and low-income
veterans?
Response: VA does not have any authority to independently expand
affordable housing for elderly and low-income veterans. VA works
closely with the Department of Housing and Urban Development (HUD) and
other Federal, State, and local entities to promote enhanced housing
opportunities for elderly and low income veterans. Under the Enhanced
Use Lease Program VA has entered into leases with other entities to
create affordable transitional and permanent housing opportunities for
the homeless and elderly. In VA's Enhanced Use Lease Report dated
January 2007, VA has awarded 48 enhanced use leases. A total of 15
projects (37 percent) provide direct service to veterans; 9 projects
provide homeless and transitional housing services, 4 projects are
targeted for senior services, and 2 projects targeted for hospice care
and triage emergency services. The total estimated value of the
enhanced use lease agreements for both the homeless and senior services
is in excess of 20 million with the conservative estimate of 682
affordable housing beds. The number is expected to increase.
Question 29. What has been budgeted for the thousands of vacant
lots that could be used to stimulate the development of affordable
housing for veterans?
Response: VA does not specifically budget for the development of
veterans housing on VA property. However, VA does continually identify
its unneeded assets (land and buildings) and uses its Enhanced-Use
Lease (EUL) authority to out-lease targeted properties and/or buildings
to non-VA entities, who then provide a wide-range of housing
opportunities for veterans. Through this approach, VA has been able
provide homeless, transitional, and affordable housing for veterans. To
date, VA has executed 13 EUL projects and has 9 other EUL projects
under development, which have or will include homeless, transitional or
affordable housing. All aforementioned VA projects offer housing
opportunities to veterans at discounted rates. VA does not currently
have the authority to build and operate affordable housing facilities
on VA property outside of the EUL program.
In addition to the EUL program, properties acquired by VA as the
result of foreclosure of guaranteed loans made to veterans, are offered
for sale to the general public in an effort to recover as much of the
Government's monetary outlay as possible. If there are competing
purchase offers from a veteran and non-veteran for the same dollar
amount, VA gives preference to the veteran's offer. Also, the Loan
Guaranty Program has the authority to sell its foreclosed properties
for up to a 50 percent discount to HUD approved homeless providers who
agree to use these properties primarily to house homeless veterans.
______
Response to Written Questions Submitted by Hon. John D. Rockefeller IV
to Hon. R. James Nicholson, Secretary, Deparment of Veterans Affairs
va health care issues
Question 1. In West Virginia private roundtables with returning
veterans, I hear serious problems about the transition from military to
civilian life. Would VA consider an ombudsman or a specific office so
veterans had a place to seek expeditious action on claims that have
fallen through the bureaucratic cracks?
Response: The Department of Veterans Affairs (VA) has taken
significant measures to expedite the claims process for all Operations
Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans. Each
regional office has designated specific veterans service center
employees to process OEF/OIF claims and an OEF/OIF coordinator to
ensure that OEF/OIF claims are expeditiously processed. Any OEF/OIF
veterans experiencing problems should contact their local regional
office on our nationwide tollfree number 1-800-827-1000. All public
contact employees have been fully trained in this special OEF/OIF
processing initiative and will assure their claims receive priority
handling.
Since the onset of the combat operations in Afghanistan and Iraq,
VA has provided expedited and case-managed services for all seriously
injured OEF/OIF veterans and their families. Last month, the Secretary
of Veterans Affairs announced a new initiative to provide priority
processing of all OEF/OIF veterans' disability claims. This initiative
covers all active duty, National Guard, and Reserve veterans who were
deployed in the OEF/OIF theatres or in support of these combat
operations, as identified by the Department of Defense (DOD).
Each regional office has designated an individual who reports
directly to the director of the regional office to work with National
Guard and Reserve units to obtain service medical records and serve as
the primary point of contact with VA medical centers and contractors to
expedite the scheduling and reports of medical examinations. The
Veterans Benefit Administration (VBA) is also working with the Veterans
Health Administration (VHA) and VA's contract medical examination
provider to develop procedures for expediting VA medical examinations
for all OEF/OIF veterans who served in or in support of OEF/OIF
theatres.
To assist the regional offices in processing OEF/OIF claims, VA has
also designated two development centers and three resource centers as a
special ``Tiger Team.'' The two development centers, located in Roanoke
and Phoenix, will obtain the evidence needed to properly develop the
OEF/OIF claims. The three resource centers, located in Muskogee, San
Diego, and Huntington, will rate OEF/OIF claims for regional offices
with the heaviest workloads.
Question 2. What action will the VA take during this budget cycle
to ensure that the full amount of funding appropriated for mental
health services is used and appropriately targeted?
Response: Appropriated funding for mental health services to VHA
consists of two components. The first component is mental health
funding in the amount of $2.50 billion that will be distributed to the
Veterans Integrated Service Networks (VISN) in fiscal year (FY) 2007
through the Veterans Equitable Resource Allocation (VERA). The second
component is mental health enhancement funding, in the amount of $306
million, to support the implementation of the Comprehensive Mental
Health Strategic Plan.
To ensure that the funds are used efficiently in fiscal year 2007
and fiscal year 2008, VHA has adopted a 2-year planning period and
staggered the implementation of programs during the course of the year
to simultaneously prepare for the fiscal year 2007 and fiscal year 2008
initiatives.
Many of last year's delays were due to difficulties associated with
hiring mental health professionals. In addition, the delay was related
to both program and staff development activities that were necessary to
ensure that funds, when spent, would be used effectively and
efficiently to improve care. This year, to encourage prioritizing
hiring for new positions, VHA has created a performance measure for
VISN leadership to fill these positions. VHA is closely monitoring
recruitment and the resulting changes in clinical productivity. If
there are delays in hiring, VHA will use these funds to augment non-
recurring projects to enhance care and advance implementation of the
Mental Health Strategic Plan.
Question 3. What plan does VA have to support the Vet Centers and
the staff who are dealing with an increasing number of veterans and
families?
Response: VA has addressed the need for Vet Center support in
anticipation of OEF/OIF requirements.
In response to the growing numbers of veterans returning from
combat in OEF/OIF, the Vet Center program has hired additional staff
and opened new Vet Centers. In February 2004, 50 Global War on Terror
(GWOT) veterans were hired to augment existing Vet Center staff. VA
authorized a new 4-person Vet Center in Nashville, TN in November 2004.
An additional 50 GWOT veterans were hired in April 2005 to further
enhance services to veterans returning from combat in Afghanistan and
Iraq. VA established two new Vet Centers (Atlanta, GA and Phoenix, AZ)
in April 2006.
In February 2007, a major expansion of the Vet Center program was
announced. There will be 23 new Vet Centers located in Montgomery, AL;
Fayetteville, AR; Modesto, CA; Grand Junction, CO; Orlando, Fort Myers,
and Gainesville, FL; Macon, GA; Manhattan, KS; Baton Rouge, LA; Cape
Cod, MA; Saginaw and Iron Mountain, MI; Berlin, NH; Las Cruces, NM;
Binghamton, Middletown, Nassau County and Watertown, NY; Toledo, OH; Du
Bois, PA; Killeen, TX; and Everett, WA.
Since the inception of the Vet Center bereavement program in fiscal
year 2004, the families of over 900 military casualties have received
bereavement services. Of these 900 cases, almost 75 percent of the
casualties were from OEF/OIF. Through this program, Vet Centers have
provided approximately 6,500 visits to families at an estimated cost
$600,000. The capacity for an increase in current workload was factored
into the current budget.
Question 4. Does the VA has any plans underway to provide
additional training and support for staff and veterans on the issue of
suicide prevention as suggested by S. 479, the Joshua Omvig Veterans
Suicide Prevention Act?
Response: VHA has formulated a comprehensive strategy for suicide
prevention focusing on the needs of both new veterans from OEF/OIF and
those from prior conflicts.
The specific programs for suicide prevention are based on public
health and clinical models, and activities both within the community
and in VA facilities.
Structural elements of the program include:
<bullet> Designation of March 1, 2007, as the first annual VA
National Suicide Prevention Awareness Day with educational activities
for all staff, clinical and non-clinical at all VAMCs.
<bullet> Designation of two Centers of Excellence focused on
suicide prevention that will provide technical assistance to the system
as a whole.
<bullet> Designation of the Serious Mental Illness Treatment
Research and Evaluation Center (SMITREC) to maintain data on suicide
rates and risk factors, nationally, regionally, and locally, to guide
prevention strategies.
<bullet> Funding for Suicide Prevention Coordinators within each VA
medical center as of April 1, 2007.
<bullet> Creation of a suicide prevention hotline for veterans by
the end of this calendar year.
Public health oriented components of the program, to be accelerated
during the coming year, include:
<bullet> Ongoing messages and education for the community about the
availability of services and the effectiveness of treatment.
<bullet> Continued outreach to returning veterans to support
awareness of VA resources and identification of mental health concerns.
<bullet> Increasing training for those who are in contact with
veterans about the recognition of signs and risk factors for suicide,
and process for helping veterans engage in treatment.
<bullet> Strengthening collaborations with other local, regional,
and national suicide prevention activities.
Clinical components of the program include:
<bullet> Education and training for all VA staff about signs and
risk factors of suicide, and of opportunities to help veterans in need
engage in treatment.
<bullet> Programs organized and directed by the suicide prevention
coordinators to identify veterans at high risk for suicide and to
ensure that the intensity of their clinical monitoring and care are
enhanced.
<bullet> Training for all mental health providers on evidence-based
interventions shown to prevent suicide.
security questions
Question 5. How is the Department of Veterans Affairs (VA)
addressing the protection of Personally Identifiable Information (PII)
as described in the Executive Office of the President, OMB Memorandum
M-06-16?
Response: VA is taking the following actions to address the
protection of PII:
1. Encrypt all data on mobile computers/devices which carry agency
data unless the data is determined to be non-sensitive, in writing, by
your Deputy Secretary or an individual he/she may designate in writing;
By September 15, 2006, the VA encrypted approximately 15,000
laptops. To date, the VA has 18,000+ laptops that are encrypted.
Simultaneously, the Department developed and implemented procedures to
ensure that all laptops have applied updated security policies and
removed all sensitive information that was not authorized to be stored
on the devices. This procedure will continue to occur throughout the
Department routinely and is one measure we have undertaken to protect
information.
The VA Secretary recently approved VA Directive 6600,
Responsibility of Employees and Others Supporting VA in Protecting
Personally Identifiable Information (PII) , and VA Directive 6601,
Removable Storage Media. VA Directive 6601 mandates that VA will only
allow Federal Information Processing Standards (FIPS) 140-2 certified
encrypted universal serial buses (USB) thumb drives to be used within
the Department. In addition, a port security technology is currently
undergoing test and evaluation to enforce adherence to the directive.
This technology will only allow VA authorized removable storage media
to be used; it will restrict the transfer of information to removable
storage media, and will thwart the introduction of malicious code via
USB ports.
The VA is also establishing levels of standardization for
Blackberry devices, SmartPhones and other mobile devices. Older
versions of mobile devices that do not support encryption or content
protection will be retired and replaced with versions of the devices
that can support the VA's IT security policies. The Department has
Implemented Blackberry content protection on a majority of devices VA
owns. IT Memorandum 07-01, Standardization of Blackberry Devices
SmartPhones and other Mobile Devices, also restricts the usage of non-
government mobile devices within VA and only allows them to be used if
the VA can monitor their use to verify that they are following VA IT
Security policies. The VA is also in the process of deploying Trust
Digital which will encrypt SmartPhones.
2. Allow remote access only with two-factor authentication where
one of the factors is provided by a device separate from the computer
gaining access;
The Virtual Private Network (VPN) currently uses the active
directory (AD) infrastructure for VPN authentication. Once connected to
the VA network, access to sensitive data usually requires additional
authentication to the internal resource that hosts the information. The
Network Security Operations Center (NSOC) is in the process of writing
a white paper regarding an interim implementation of two-factor
authentication, pending the rollout of VA's personal identity
verification (PIV) project.
3. Use a ``time-out'' function for remote access and mobile devices
requiring user reauthentication after 30 minutes inactivity;
The ``time-out'' function has been in place since the VPN was
implemented in January 2002. Users are disconnected if their VPN
session is inactive for 30 minutes. If they choose, they may initiate a
new VPN connection which requires them to reauthenticate. In order for
an inactivity timer to be enforced, there must be no traffic generated
over the connection. There are many applications that send out
``heartbeats'' and ``keep-alives'' or that routinely generate traffic
(i.e. Outlook) that prevent a VPN session from being inactive. When
these types of applications are running with VPN, the inactivity timer
cannot be enforced.
4. Log all computer-readable data extracts from databases holding
sensitive information and verify each extract including sensitive data
has been erased within 90 days or its use is still required.
The VA has developed an enterprise level requirements document that
was submitted to the vendor community in March 2007 for a request for
information (RFI). Among the many types of requirements, this document
is intended to address business requirements for protecting
information, such as the mandate from the Office of Management and
Budget (OMB) 06-16 ``to log all computer-readable data extracts
databases holding sensitive information and to verify each extract
including sensitive data has been erased within 90 days.'' In response
to the RFI, the vendor community will provide technology solutions for
VA to research, test, and deploy. Technology to address OMB 06-16 will
result from the RFI. The Department will take immediate action
subsequently to begin test and evaluation of the technology.
Question 6. What specific policy, plans, and funding has the VA put
in place to ensure all of the following OMB M-06-16 requirements are
met and that protection of all personally identifiable information is
secure and cannot be compromised?
Response: Several Departmental policies have been issued from the
Secretary and Deputy Secretary:
SECVA Directives
VA IT Directive 06-2, Safeguarding Confidential and Privacy Act-
Protected Data at Alternative Work Locations, dated June 6, 2006.
Memorandum for the Assistant Secretary for Information and
Technology, Delegation of Authority for Responsibility for Departmental
Information Security, dated June 28, 2006.
Open Letter to VA Contractors and Subcontractors, dated August 10,
2006.
DEPSEC Directives
VA IT Directive 06-1, Data Security-Assessment and Strengthening of
Controls, dated May 24, 2006.
Memorandum to Under Secretaries, Assistant Secretaries, and Other
Key Officials--Access Control and Employee Sensitivity Levels, dated
July 14, 2006.
Memorandum to Under Secretaries, Assistant Secretaries, and Other
Key Officials--Handling and Storing of VA Data by Contractors and
Subcontractors, dated August 10, 2006.
VA IT Directive 06-3, Data Security-Assessment and Strengthening of
Controls, Review of VA Activities that Involve Non-VA employees, dated
August 11, 2006.
VA IT Directive 06-4, Embossing Machines and Miscellaneous Data
Storage Devices, dated September 7, 2006.
VA IT Directive 06-5, Use of Personal Computing Equipment, dated
October 5, 2006.
VA IT Directive 06-6, Safeguarding Removable Media, dated September
29, 2006.
VA IT Directive 6600, Responsibility of Employees and Others
Supporting VA in Protecting Personally Identifiable Information (PI),
dated February 27, 2007.
VA IT Directive 6601, Removable Storage Media, dated February 27,
2007.
The VA NSOC has architected a new remote access environment that
distinguishes VA government furnished equipment (GFE) from non-VA owned
other equipment (OE). GFE equipment is subjected to a variety of
compliance and host integrity checks. One of those checks includes
ensuring the remote device is encrypted prior to allowing full access
to the VA network. Non-encrypted devices will be restricted to a
virtual desktop which does not allow data to be saved on the
unencrypted device. The NSOC is preparing to begin a 60-day pilot of
this solution March 12, 2007. This new architecture will include a 30-
minute inactivity timeout which requires the user to reauthenticate if
they wish to reconnect to the VA network. The solution is also capable
of supporting two-factor authentication.
While the Department is in the process of testing, evaluating,
procuring and deploying at an enterprise level, the technologies that
exist within VA that contribute to Information Protection, a long term
strategy has been developed and is being executed in parallel.
The long term strategy began with the development of an enterprise
information protection requirements document. The existing
infrastructure serves as a baseline for VA's information protection
program and the intent of the requirements document is to fill in the
gaps where information is stored and transmitted, that have yet to be
addressed because VA does not have the technology. The intent of the
RFI is to have the vendor community feed information back to VA with
recommendations on how VA can fill in the information protection gaps
with technical solutions to mitigate the likelihood of unauthorized
disclosure.
VA has already procured the software to encrypt laptops, Blackberry
devices and SmartPhones and will procure FIPS 140-2 certified thumb
drives, as needed. The secure remote access solution, the port security
solution and the secure network transmission technology will be funded
and procured with fiscal year 2007 money if pilot testing proves
successful. Funding has been made available to support all of VA's
information protection initiatives.
Question 6(a). What is the status of ensuring that all data on
portable devices is encrypted before leaving the physical premises of
the VA?
Response: When the Department encrypted the laptops in September
2006, a laptop health check procedure was implemented throughout the
enterprise. The Department developed and implemented procedures to
ensure that all laptops have been encrypted, all security policies are
updated and all unauthorized sensitive information has been removed
from the devices. This procedure occurs routinely throughout the
Department and at a minimum; laptops must be brought into the facility
every 90 days to undergo the health check. In addition, VA IT Directive
6601 mandates that all information stored on a removable storage media
must be stored on a device that employs the National Institute of
Standards and Technology (NIST) (FIPS) 140-2 certified encryption
algorithms.
Question 6(b). What is the status of ensuring that all remotely
accessed data is only available to users who have verified at least 2
factors of authentication, and that access is revoked after 30 minutes
of inactivity?
Response: VA has an enterprise-wide VPN solution. The VPN currently
uses the VA AD infrastructure for VPN authentication which is one-
factor authentication. There is, however, a separate ``authorization''
component to the authentication process. A database that contains
authorized VPN users is maintained by information security officers
(ISOs). If a user is not in the database, they will not be authorized
access to the VA network, even if they possess a valid AD account.
Also, once connected to the VA network, access to sensitive data
usually requires additional authentication to the internal resource
that hosts the information. The NSOC is in the process of writing a
white paper regarding an interim implementation of two-factor
authentication, pending the rollout of the PIV project. All One-VA VPN
users are subject to a 30-minute inactivity timeout.
Question 6(c). Are you successfully enforcing the removal of all
remotely stored data over 90 days old?
Response: For data that is stored on laptops, the information
should be removed during the routine 90 day health check. VA is in the
process of deploying Microsoft Rights Management Services (RMS)
throughout the enterprise. This technology will automate the process of
ensuring information is removed after 90 days of being stored. The
implementation of Microsoft RMS will allow VA to protect information
that has been used and stored remotely. RMS has the ability to set the
duration for how long documents, files and e-mails can exist and then
the document will automatically be destroyed after the duration is
expired. RMS will be fully implemented throughout the enterprise by
July 2007.
Question 6(d). Once all this security is in place, will employees
be able to get their work done remotely--that is, can they access e-
mail, get to files and applications on PCs and servers, and communicate
with coworkers, regardless of location?
Response: Each of the technologies that VA is implementing
contributes to Information Protection and they integrate so that
business operations can continue. E-mail access remotely for employees,
contractors and business partners using GFE will be accomplished
through the use of the GFE VPN solution. The GFE VPN solution will
allow employees to access e-mail and share drives to conduct business.
E-mail for employees, contractors and business partners with OE can be
accomplished through the use of Outlook Web Access (OWA) and a virtual
desktop. The virtual desktop will allow OE employees to access the
intranet and work with files and documents; however, nothing can be
saved on the device. The VA also has a technology undergoing test and
evaluation to encrypt network traffic. This technology will ensure that
the traffic from VistA mail, computerized patient record system (CPRS)
and time and attendance applications are encrypted. The technology can
provide a secure encrypted connection, with secure sockets layer (SSL)
3.0/TLS 1.0, from an external system to the internal server. This
technology, coupled with the use of OWA and secure VPN will enable
employees to conduct business on external devices in a
secure manner.
______
Response to Written Questions Submitted by Hon. Patty Murray
to Hon. R. James Nicholson, Secretary, Deparment of Veterans Affairs
spokane er: shorter hours at va urgent care in spokane
Question 1. Mr. Secretary, this is a second problem with the VA's
emergency room policy. It is very hard for veterans to figure out if
the VA is going to pay for an ER visit or if they're going to get stuck
with the bill. Your new director for emergency medicine, Dr. Gary
Tyndall, told the Syracuse Post Standard--``I've told patients `You
could have died from this.' And the veterans will say, `I'd rather die
than leave my family with a bill that would take 5 years to pay.' ''
Mr. Secretary, if veterans are not going to the ER because they're
worried about sticking their families with massive bills, then it's
clear your policy is broken. I think part of the problem is that the
rules are very confusing. The VA is the ``payer of last resort.'' And
whether or not it pays depends on everything from the miles to the
hospital, the veteran's age, whether its service connected, and the
time of day.
Response: VA is aware that the statutes and regulations for
emergency care can be confusing to veterans and providers. We are
taking the following steps to address these concerns:
<bullet> Providing an emergency care brochure to all local VA
facilities, that is also available on VA's Web site.
<bullet> Developing handbooks explaining Fee program regulations
and policies, which will be made available to the general public on the
VA Web site.
<bullet> Providing training to all VA Fee program staff so they can
better explain the requirements for payment of emergency care. VA's
long term goal is to clarify and simplify all regulations for the Fee
program.
confusing er payment makes veterans hesitant to seek care
Question 2. Mr. Secretary, there is a major concern in the eastern
part of my state about emergency care for veterans. In Spokane, at
least one veteran has died when he sought care at a VA hospital that no
longer offered urgent care after 4:30 p.m. According to the Spokesman
Review, two other families have come forward saying the same thing
happened to their loved ones. Mr. Secretary, that is absolutely
unacceptable. When a veteran is having chest pains, he should not have
to wonder whether the doors to the VA are going to be closed to him or
have to worry about getting stuck with the bill if he goes to a local
hospital. Why did you reduce the hours of urgent care at Spokane VA?
Response: For many years, the Spokane VAMC provided around-the-
clock emergency room care for veterans; however, after a long-term
review of clinic records, it was determined that very few patients
actually used the emergency room after regular business hours. The
review also showed that treatments provided to those patients who did
come in for after-hours services were mostly for minor, non-urgent
conditions that could have safely been taken care of the next business
day.
These findings raised concerns regarding physicians keeping their
skills current with such a low volume of patients presenting for care
with the vast majority having minor ailments. In addition, the facility
determined that resources dedicated to after hours activities should be
realigned to daytime services in order to provide better and faster
care to our patients. This change also allowed the facility to expand
their ability to see as many veterans as needed on a daily basis.
Question 2(a). What are you doing to fix this broken and confusing
emergency room policy?
Response: VHA recognized the importance of establishing clear
emergency room policy and established The Emergency Medicine Field
Advisory Committee, (EMFAC) to actively assess and improve the
provision of emergency care in our facilities. As a result of the
EMFAC's efforts, VHA Directive 2006-051, ``Standards for Nomenclature
and Operations in VHA Facility Emergency Departments,'' dated September
15, 2006, was published. This directive establishes policy ensuring
that emergency departments at VHA facilities remaining open 24 hours a
day delivering high-quality emergency care. It also outlines the
minimum standards that are acceptable for emergency departments that
provide emergency care to our veteran population and the appropriate
designations for units providing unscheduled care to veterans, i.e.,
emergency department and the urgent care clinic. National
implementation of this policy is underway.
Question 2(b). What are you doing to communicate with local
veterans in Spokane so they know the VA does not provide urgent care
after 4:30 p.m.?
Response: Prior to the reduction in urgent care hours (June 2006),
an aggressive communication plan was launched in an effort to educate
veterans, not only about the change in hours, but about where to seek
care in the case of an emergency. The plan included a direct mailing to
23,000 patients, advising them of the change in hours and encouraging
them to go directly to community emergency rooms if emergency care is
needed. Less than a dozen veterans responded to the letter, with most
seeking confirmation that their service connected needs would be paid
by the VA.
Veterans were also informed that, as a result of the change in
hours, Spokane's telephone care program was expanded, and treatment for
urgent or emergent conditions related to their service-connected
condition, or veterans with no other payment source who meet certain
criteria, may be eligible for payment assistance through a VA program.
In addition, a brochure detailing urgent care hours, services and
instructions regarding what to do in the event of an emergency, was
widely distributed to veterans during the time of the change.
In October 2006, a second letter was sent to the same 23,000
patients, reiterating the information contained in the first letter.
The second mailing also included a fact sheet addressing eligibility
questions. In addition, public service announcements were distributed
to media outlets in Spokane and the surrounding area, detailing the
change in hours, clarifying the types of services provided at the
urgent care unit, describing the most common symptoms of a life
threatening emergency, and urging veterans to go to a community
emergency room, regardless of the time of day, should they experience a
health emergency. The telephone line at the Spokane facility also
directs patients that, in case of emergency, they are to ``hang up and
dial 911 immediately.''
walla walla
Mr. Secretary, turning to Walla Walla, Washington--As you know, in
2003 the VA CARES Commission tried to close the facility that 69,000
veterans rely on. I worked with the community and the VA, and I
appreciate you committing to building a new facility in Walla Walla.
The community and I have some questions about the care that will be
provided in that new facility--particularly mental health, long-term
care, and inpatient medical care.
Mental Healthcare
Question 3. As you know, mental health care is not available in the
surrounding community. Can you explain how veterans in Walla Walla will
get mental healthcare under your proposal? Also, how will they get drug
rehabilitation?
Response: The VAMCs in Walla Walla and Spokane will cooperatively
manage inpatient mental health care for the Washington, Oregon and
Idaho counties in their 38 service areas. This will include residential
rehabilitation care for substance abuse and PTSD provided mostly at the
Jonathan M. Wainwright Memorial VAMC in Walla Walla and through
community contracts in Spokane. Inpatient psychiatry will be provided
at the Spokane VAMC in Spokane, Washington and through community
facilities in Lewiston, ID, and Yakima and Tri-Cities, Washington.
Expanded outpatient mental health services will continue to be provided
at the VAMCs, the existing and planned community based outpatient
clinics, and in other locations as determined.
Question 4. Will you continue to provide long-term care at the
Walla Walla facility as long as it's needed, and will you commit to
working with the state to build a state nursing home?
Response: Long term care will be provided at the Walla Walla
facility or the surrounding community as long as it's needed. In
regards to working with the state to build a state nursing home, VISN
20's network director has recently requested that Walla Walla's new
director work with the director of the Washington State Department of
Veterans Affairs to begin the process of establishing a nursing home.
Applications for VA grants to assist in the construction of state
nursing homes for Fiscal Year 2008 must be submitted by August 15,
2007.
Question 4(a). How should vets who need LTC today get it?
Response: There has been no change in the provision of long term
care at the Walla Walla facility at this time.
inpatient care
Question 5. Can you assure me that veterans in Walla Walla will not
lose access to inpatient care as this transformation moves forward?
Response: Veterans with service-connected conditions will continue
to receive acute inpatient care in community facilities close to their
homes. Walla Walla facility staff will ensure that the quality and
accessibility of care are maintained.
Question 6. Mr. Secretary, Washington state is working on getting
its second VA cemetery in the Spokane area. Veterans have long sought a
cemetery in Eastern Washington, so survivors could avoid the 5-hour
drive to the Tahoma National Cemetery near Kent, south of Seattle. Can
you or Under Secretary Tuerk update me on the status of this cemetery?
Response: The staff of the VA State Cemetery Grants Program are
coordinating with the State of Washington Department of Veterans
Affairs to establish a State veterans cemetery in the Spokane area that
will serve approximately 70,000 veterans living in Eastern Washington
and Idaho. Prior to VA approving a pre-application for the grant,
Washington must approve legislation that will authorize the State to
apply for Federal assistance. A study conducted by the State identified
two properties suitable for 39 development as a new cemetery located
approximately 15 to 20 minutes from downtown Spokane. Due to the large
number of veterans in the area, VA State Cemetery Grants Program staff
is working closely with the State of Washington Department of Veterans
Affairs on the preparation of the award request, which would grant
funds to cover 100 percent of the cost of developing and equipping a
State veterans cemetery.
va budget cuts and freezes spending in future years
Question 7. Mr. Secretary, your budget assumes cutbacks in
veterans' healthcare in 2009 and 2010 and a freeze after that. Those
cuts could hit just when large a number of troops are returning home
and need care. Are these phony numbers--created to make it seem like
the President's Budget is balanced?
Response: Out-year estimates in the 2008 budget are based on an OMB
formula that is tied to government-wide deficit reduction targets for
2009 through 2012. Consistent with past practice, VA's medical care
budget for 2009 and beyond will be evaluated on an annual basis. I
fully anticipate that the President's budget in future years will
include sufficient medical care resources to ensure the continued
delivery of timely, high-quality health care for our Nation's veterans.
______
Response to Written Questions Submitted by Hon. Larry E. Craig
to Hon. R. James Nicholson, Secretary, Deparment of Veterans Affairs
compensation and pension program
Question 1. It is clear the Administration has made improving
claims processing a high priority, by requesting over 450 new
Compensation and Pension (C&P) employees. However, VA's productivity
target for FY08--101 claims per direct FTE--is lower than VA has
achieved in prior years and lower than VA expects to achieve this year.
It is also substantially lower than the FY07 goal of 108--a goal that
VA described last year as ``realistic'' given the increasing experience
levels of employees hired during FY05 and FY06.
Question 1(a). What factors account for this reduction in target
performance? With the increasing experience level of previously hired
employees, how can VA justify lowering its productivity goals?
Response: Output per FTE is the number of completed rating-related
claims per C&P direct labor FTE. Table 1 following illustrates the
2004-2006 actual output and the 2007-2008 estimated output. VA's 2008
budget submission adjusted the 2007 output target to 102.8, and the
2008 output target to 101.
Direct Compensation and Pension Rating Productivity Actual and Estimates
----------------------------------------------------------------------------------------------------------------
C&P Direct Completed Output per
FTE Claims FTE
----------------------------------------------------------------------------------------------------------------
2004............................................................... 7,498 703,254 94
2005............................................................... 7,547 788,298 101
2006............................................................... 7,858 774,378 98.5
2007 (projected)................................................... 7,863 808,316 102.8
2008 (projected)................................................... 8,320 840,320 101
----------------------------------------------------------------------------------------------------------------
The primary factors for lowering the rating-related claims output
for 2007 and 2008 are: the large number of new employees added in 2006
and projected to be added in 2007 and 2008; continuing loss of our most
experienced decisionmakers to retirement; increased number and
complexity of claimed disabilities; and changes in law and process.
In recent years, there has been a trend for veterans to claim
multiple disabilities. For 2006, 24 percent of the original
compensation claims contained eight or more service-connected
conditions. The number of claimed conditions increases the number of
variables that must be considered and addressed, therefore making the
claims more complex. VCAA continues to influence the claims process.
VCAA has increased both the length and complexity of claims development
by increasing VA's notification and development duties to assist.
Additionally, VBA continues to expand outreach programs for
separating servicemembers and is devoting resources to priority claims
processing for all returning OEF/OIF veterans. VBA's outreach
initiatives result in more claims.
Beginning in the second quarter of 2006, VSA began an aggressive
recruitment program that has increased our on-board strength by over
580 employees (in addition to replacing all employees who retired or
otherwise left VBA). These new employees require extensive and ongoing
training to become effective. VBA provides on-the-job and comprehensive
centralized national training for all new claims processors. However,
the overall training process takes 2 to 3 years for an entry-level
employee to become fully productive. Approximately 40 percent of our
decisionmakers have less than 3 years of experience in their current
positions. As these employees develop their skills and gain experience,
their output per FTE will increase.
Question 1(b). Given the length of time it takes for new employees
to become fully productive, when would VA expect to see productivity
improvements based on the additional 450 FTE?
Response: The productivity assumptions for the additional 450 FTE
hires are based upon outcomes from recent employment activities and the
current training process. On average, due to the complexities of claims
processing, an entry-level claims processor does not become fully
productive until they have at least 2 years in the position. Based on
that assumption, VBA anticipates some productivity improvements from
the additional 450 Fiscal Year 2008 hires as early as 6 months from the
employment commencement--with full production reached after 2 years in
the position.
Question 2. In 2001, the VA Claims Processing Task Force--Chaired
by Admiral Daniel Cooper--recommended that VA allocate FTE ``to those
Regional Offices that have consistently demonstrated high levels of
quality and productivity in relation to workload and staffing levels.''
If VA's budget proposal is approved, how would VBA allocate the
additional C&P FTE among the regional Offices? Will FTE be allocated
only to high-performing offices?
Response: VBA's staffing policy considers both the number of claims
received at a RO and specific performance factors in determining its
FTE share for the Fiscal Year. FTE is allocated to all offices based on
the number of claims received in order to ensure that staffing levels
are maintained at a sufficient level to allow completion of the C&P
work received each year. However additional FTE is distributed to ROs
who demonstrate high levels of quality and productivity. These
performance factors are reviewed each Fiscal Year and reflect VBA's
strategy to reduce the inventory of pending claims and improve decision
timeliness, decision accuracy, and appeals processing. Therefore,
stations that consistently perform better in these critical areas will
receive additional FTE.
Question 3. In a December 2005 report, the Government
Accountability Office noted that there are wide variations in
performance among the 57 VA regional offices. According to that report,
``VBA and others who have studied claims processing have identified
various options for changing the basic field structure in order to
improve claims processing efficiency, reduce overhead costs, and
improve decision accuracy and consistency, including consolidating
claims processing into fewer than 57 regional offices.'' Would removing
the claims processing function from challenged regional offices and
shifting that work to high-performing stations improve VBA's overall
efficiency? If so, does VA plan to implement any consolidations of this
type during FY08?
Response: VBA continues to explore opportunities to improve claims
processing efficiency and improve decision accuracy and consistency.
The BDD program provides servicemembers with briefings on VA benefits,
assistance with completing forms, and a disability examination before
leaving service. The goal of this program is to deliver benefits within
60 days following discharge. VBA has consolidated the rating aspects of
our BDD initiative, which will bring greater consistency of decisions
on claims filed by newly separated veterans. Additionally, VBA
consolidated claims based on radiation exposure to the Jackson RO.
Claims based on radiation exposure require lengthy and complex evidence
development prior to adjudication; consolidation of these claims to
Jackson will allow quicker development due to specialization of the
staff and a single line of communication to sources of information,
including DOD.
We also established two Development Centers in Phoenix and Roanoke
to assist ROs in obtaining the required evidence and preparing cases
for decision. Pension processing realignment began in 2002 with the
consolidation of pension maintenance work to Philadelphia, St. Paul,
and Milwaukee. Continued consolidation of original pension work to
these centers is currently under consideration. In October 2006, VBA's
C&P Field Realignment Task Force presented its recommendations to the
Under Secretary for Benefits. The Task Force presented three near-term
recommendations currently under consideration: (1) consolidation of
survivor benefit claims processing, (2) restructuring of the oversight
and management of fiduciary activities, and (3) centralization of
telephone activities to call centers.
The Realignment Task Force also presented recommendations to
develop a comprehensive strategic plan for the longer-term
consolidation of additional compensation work. As we explore and
develop additional consolidation opportunities in our compensation
program, we will continue in 2008 to use our resource allocation model
and brokering strategy to redirect workload and resources from our
challenged regional offices to our most productive stations.
Question 4. Given that the level of incoming claims has been
increasing over the past several years and the ongoing conflicts in
Iraq and Afghanistan, what is VA's basis for concluding that incoming
claims in FY08 will remain at the same level as VA expects to receive
in FY07 (800,000 claims)?
Response: In preparing our estimate for Fiscal Year 2008 we
considered a number of factors. Those include the trend in disability
claims over the last 10 years, the size of the active duty force, and
any known or anticipated factors that would affect claims activity. At
the time the budget was prepared, increased troop strengths in
Afghanistan and Iraq were not certain. If the surge in forces in the
combat theaters is drawing from existing active duty and already
planned activation of Guard and Reserve forces, we believe we have
already accounted for them. We did not predict any major changes in
benefit entitlement criteria or new programs that would increase
claims.
Question 5. During FY07 and FY08, how many Rating Veteran Service
Representatives and Veteran Service Representatives will be eligible
for retirement and how many do you anticipate will retire during those
years?
Response: Through 2008, approximately 900 Veterans Service
Representatives and Rating Veterans Service Representatives will be
eligible to retire. We anticipate about 200 retirements each year.
education program
Question 1. I appreciate VA's efforts to find innovative ways to
improve productivity, such as the Contract Management Support Center
initiative. By having year-round contract customer service
representatives handling education calls, how many additional FTE would
this allow the Education Service to allocate to processing and deciding
education claims? What impact would this have on the expected level of
productivity?
Response: It is estimated that the contract management support
center would allow the reallocation of 45 FTE to processing education
claims. This represents 5.8 percent of the 772 direct FTE allocated to
field stations in Fiscal Year 2008, and would be expected to result in
a similar percentage increase in output.
Question 2. It is my understanding that many calls are simple
inquiries about the status of a claim and that VA has been working
toward providing that information online. What is the status of that
effort? Once that information is available online, do you anticipate a
decline in incoming telephone calls?
Response: We are currently working on providing status of claim
information on our GI Bill Web site by allowing individuals to log into
the Web automated verification of enrollment (WAVE) application and
view status of claim information from their electronic claims folder.
Our plan is to have this additional self-service feature available by
July 1, 2007. Right now, if they are currently receiving benefits, they
can view their current award information in WAVE and submit a change of
address, if required.
We are also looking to add additional features so that individuals
can view other benefit information that pertains to their individual
benefit record, such as the amount of their remaining entitlement,
delimiting date and payment information.
We would anticipate a decline in the number of telephone inquiries
that we receive as we add more self-service options on our GI Bill Web
site.
Question 3. With the additional FTE requested for the Education
Service, plus any FTE that would be freed-up by using a contract call
center, will staffing be sufficient to handle the expected level of
incoming claims in FY08 and to reduce any existing backlog?
Response: With the 14 additional FTE requested for the Education
Service, plus the 45 FTE that would be freed-up by using a contract
call center, staffing will be sufficient to handle the expected level
of incoming claims in Fiscal Year 2008, to reduce pending inventory,
and to improve processing timeliness.
vocational rehabilitation and employment program
Question 1. The Administration's FY08 budget proposal includes $4.3
million to enhance the Disabled Transition Assistance Program (DTAP).
Question 1(a). How many DTAP briefings has VA proved each year
since 2001 and how many attendees were at those briefings?
Response: VA did not separately track DTAP briefings prior to
Fiscal Year 2006. A breakout of DTAP briefings and participants during
Fiscal Year 2006 and Fiscal Year 2007 through January as follows:
FY 2006: 1,462 DTAP briefings attended by 28,941 participants.
FY 2007 through January 2007: 493 DTAP briefings attended by 9,407
participants.
Question 1(b). With the expanded resources requested for FY08, how
many DTAP briefings does VA expect to provide and how many attendees
could be accommodated? At how many locations will these DTAP briefings
be conducted?
Response: DOD projects that approximately 200,000 servicemembers
annually will separate from active duty or be demobilized. Of those
separating, approximately 35,000 will receive medical separations.
Currently, DTAP briefings are not mandated or required by all
military services during the pre-separation counseling process or
during medical separation. A review of Department of Army data showed
that about 45 percent of separating servicemembers requested a DTAP
briefing during pre-separation counseling. Extrapolating from that
data, VA anticipates that about 80,000 servicemembers could potentially
request a DTAP briefing. If DOD mandates that DTAP briefings be
provided for all separating servicemembers who request a briefing, then
VA's goal is to provide services to all 80,000.
VA proposes to use the expanded DTAP resources requested for Fiscal
Year 2008 to meet this goal. The more severely injured hospitalized
servicemembers will require one-on-one DTAP. Other servicemembers can
receive DTAP briefings in small groups that encourage discussion and
participation. We estimate that the ideal group size would be 8-12
participants. DOD has more than 300 separation sites, both within and
outside the continental United States. The following groups will be
used to prioritize expenditure of funds and location of DTAP briefings:
Priority Group 1: Hospitalized War-Wounded and Severely Disabled--
These are the most seriously injured servicemembers in jurisdictions
with major military treatment facilities. One-on-one DTAP will be
provided at these locations to the servicemembers and their family
members. Individual and very small group DTAP briefings will also be
provided to servicemembers referred to the Military service's physical
evaluation board (PEB).
Priority Group 2: War-Wounded Requiring Rehabilitation--Injured/ill
servicemembers who are in medical hold or medical holdover status will
be provided individual and group DTAP briefings. Servicemembers in this
group will generally be in their home communities and assigned to
National Guard/Reserve units, community based health care organizations
(CBHCOs), MTFs, or other military separation centers.
Priority Group 3: Hidden War-Wounded: Readjustment and Coming
Home--Injured veterans who have already separated from active duty or
demobilized are also eligible to attend DTAP briefings. These
individuals usually self-identify after sustaining ``hidden wounds''
during combat operations that were not identified until the PDHRA. DTAP
briefings will be provided at National Guard/ Reserve units, MTFs,
military installations, and VA facilities.
Priority Group 4: Other Injured/Ill Servicemembers--Other
servicemembers and military retirees self-identified during DOD's pre-
separation counseling process as requesting or requiring a DTAP
briefing. DTAP briefings will be provided at military duty stations
across the country.
Question 2. The Administration's FY08 budget proposal request 35
additional FTE for the Vocational Rehabilitation and Employment Program
to serve as contracting specialist, to work on the Coming Home to Work
initiative, and to work on the Process Consolidation initiative.
Question 2(a). For the Coming Home to Work initiative, what
specific functions will these employees perform? How do these functions
differ from those performed under the direction of the Veterans'
Employment and Training Service, or other Federal employment programs?
Response: Vocational Rehabilitation and Employment (VR&E) provides
a variety of services to veterans to facilitate their timely return to
civilian employment (educational/vocational testing, counseling,
volunteer and non-paid work experience, job accommodations, adaptive
technology, job seeking assistance, job retention skills, education,
on-the-job training, and all necessary rehabilitative support
services). The goal is for the veteran to obtain and retain suitable
employment consistent with their interests, aptitudes, and abilities.
The coming home to work (CHTW) initiative currently brings these
services to servicemembers on medical hold status at eight major MTFs.
However, the need to provide early VR&E services to VR&E eligible
servicemembers is growing. Through DOD's community based health care
initiative, more and more wounded servicemembers are recovering at
their home of record, and therefore do not receive all of the outreach
efforts available at the MTFs. VA plans to implement CHTW at all 57 ROs
by September 30, 2008, in order to meet the needs of all VR&E eligible
servicemembers that will be medically separated from the military.
Providing VR&E services to servicemembers on medical hold status can
greatly reduce the length of unemployment many disabled veterans face
after separation.
Eight FTE are requested for the CHTW program in the Fiscal Year
2008 budget submission. Those FTE will liaison with military case
managers and VR&E staff, assist servicemembers with the VR&E
application process as needed, and case manage OEF/OIF servicemember
application processing. Each of the eight FTE will cover a geographical
region, providing services to servicemembers at MTFs, CBHCOs, and VA
facilities within their assigned region. Unlike employees of the
veterans employment training service (VETS) and other Federal
initiatives, these FTE will focus specifically on VR&E services.
Question 2(b). For the Process Consolidation initiative, what are
the major milestones of that project and what are the target completion
dates for those milestones?
Response: Milestones for the VR&E process consolidation initiative
are still under development. The goal is to consolidate various VR&E
functions as determined and prioritized by a thorough analysis and a
feasibility assessment. Possible functions subject to consolidation and
centralization include: general eligibility determination processing;
subsistence allowance award processing; contract administration;
purchase card processing; training; and management oversight. The
Fiscal Year 2008 budget submission includes four FTE in support of this
effort.
loan guaranty program
Question 1. If I understand your request, you expect more VA-
guaranteed loans to be made during the 2007 and 2008 period, and more
defaults and foreclosures resulting from rising interest rates and
maturing loans. Despite the workload increase, you request a reduction
in the loan guaranty budget. How will VA maintain quality service to
veterans in the face of a declining budget and increasing workload? If
relying on industry partners is an aspect of the ``do more with less''
strategy, which I applaud, what oversight mechanisms are in place to
ensure that taxpayers and veterans are being well served?
Response: VA will be prepared to ensure that taxpayers and veterans
are well served should the Loan Guaranty program have to deal with a
rise in defaults and foreclosures. A newly redesigned loan servicing
business process and its supporting IT application will, among other
things, allow VA to maintain high quality service to veterans, and
improve VA oversight capability of private sector loan servicers. Under
this new environment, many loan servicing functions are delegated to
private sector loan servicers, and VA will use IT to directly oversee
the work being performed by these servicers on VA's behalf.
The redesigned business environment will be managed through the VA
loan electronic reporting interface (VALERI) application, which is
scheduled for implementation at the end of 2007. Through use of VALERI,
VA will gain significant efficiencies in servicing loans. VALERI will
provide VA the capacity to directly monitor and ensure appropriate
performance of servicers as they service VA loans, and will expedite
VA's ability to intervene on veterans' behalf when necessary.
Question 2. Please provide me with updated statistics on the usage
of ARMs and hybrid-ARMs.
Response: Between 1993 and 1996, VA had the authority to guarantee
adjustable rate mortgages (ARMs). During this period, 139,271 such
loans were made. Since reauthorization of ARMs in 2004, VA has made
1,695 such loans. Since receiving authority to guarantee hybrid
adjustable rate mortgages in 2003, VA has guaranteed 81,319 such loans.
office of general counsel
Question 1. During the past few years, the number of incoming
appeals at the Court of Appeals for Veterans Claims (CAVC) has
increased dramatically. In fact, during the first quarter of FY07 the
CAVC received over 1,500 new cases--the highest level of incoming cases
in CAVC's history. Of the 15 additional FTE requested for the Office of
General Counsel, how many will be allocated to assist in handling cases
pending before the CAVC?
Response: Dependent upon the Office of General Counsel's (OGC)
approved budget and balancing critical hiring needs among all of our
offices, OGC expects to apply 11 of the 15 new FTE to our Veterans
Court Litigation Group, referred to internally as Professional Staff
Group VII (PSG VII).
OGC has closely tracked the significant rise in new cases before
the CAVC. PSG VII represents the Secretary before the CAVC. PSG VII
experienced a 37 percent increase in workload from 2005 to 2006. We
project an additional 57 percent increase from 2006 to 2008. Until
Fiscal Year 2006, PSG VII had six teams comprised of attorneys,
paralegals, and support staff. In Fiscal Year 2006, OGC created a
seventh team within PSG VII to address the rising caseload before the
CAVC. The new team includes one GS-15 supervisory attorney, seven
attorneys (GS-12/13/14), two legal assistants (GS-5/6/7) and one copy
clerk (GS-2/3). Since the Fiscal Year 2006 budget cycle predated the
significant rise in caseload before the CAVC, the new team had not been
identified as a specific initiative in OGC's Fiscal Year 2006 budget.
OGC increased PSG VIl's FTE by 13 from November 2005 to January 2007.
OGC's request for 15 additional FTE is, in part, designed to increase
our budget base to pay for the new PSG VII team established in Fiscal
Year 2006 and restore much-needed payroll funds to fill critical
vacancies in our other offices.
health/it
Question 1. What percentage of returned OEF/OIF servicemembers have
undergone either VA-administered or DOD administered mental health
screenings? Of that percentage, how many have been diagnosed with post-
traumatic stress disorder or other mental health issues?
Response: While VA understands that DOD policy is to screen all
OEF/OIF servicemembers upon return from deployment and again 90-180
days post deployment, only DOD has data on the numbers/percentage
actually screened.
It is VA policy to screen all OEF/OIF veterans who come to VA for
care. As of November 2006, 205,097 (32 percent) of the 631,174
separated OEF/OIF veterans eligible for VA services had sought services
at VAMCs and clinics. Of 205,097, 73,175 (35.7 percent) received a
provisional diagnosis of a mental disorder, and among the 73,175 group,
33,754 (46.1 percent) were given a provisional diagnosis of PTSD.
It should be noted that a provisional diagnosis of PTSD only
indicates that the veteran has responded positively to three of the
four items on the screener for PTSD or that there were other indicators
suggesting a possible diagnosis. It does not mean that the veteran has
been definitively diagnosed with PTSD. Additional evaluation, which may
include testing, is generally required to make a diagnosis of PTSD.
Question 2. Your budget request suggest VA Pharmacy Services will
increase 30 percent from Fiscal Year 2006 to Fiscal Year 2008.
Traditionally, VA has been able to keep its pharmacy cost increases
fairly low. Is VA's ability to hold down its pharmacy costs waning or
is there another explanation for the substantial growth in this budget
line over a 2-year period?
Response: This increase in expenditures is a result of several
factors. VA projects a 9.6 percent increase in use of 30-day
prescriptions from Fiscal Year 2006 to Fiscal Year 2008 due to a slight
increase in enrollment, the aging of the enrollee population, and the
increasing importance of prescription drugs in the medical management
of diseases. It also reflects the continued increase in the cost of
prescription drugs due to inflation and the development of more
expensive drugs. While VA's national formulary, pharmacy management
practices, and contracting efforts are effective in promoting
appropriate use of prescription drugs and containing costs, VA is still
impacted by changing medical practice and inflationary increases in
prescription drug costs.
VA believes this increase in use of drugs and the use of more
expensive drugs will continue. Many chronic care conditions require
multiple drug regiments for a patient to achieve a therapeutic goal.
Question 3. Under current Appropriation law, VA's Medical Care
budget is broken down into three components: Medical Services, Medical
Administration, and Medical Facilities. Health-related Information
Technology expenditures are yet another account. Does this structure in
any way assist VA in better understanding its budget expenditures? Or,
is the three account structure mostly a burden with little benefit?
Please explain your answer with some detail.
Response: The three main accounts are: Medical Services, Medical
Administration, and Medical Facilities. The multiple accounts do not
more accurately reflect VA's medical care expenditures because the
accuracy is achieved by charging expenditures to cost centers which are
associated with the multiple appropriation accounts. The cost centers
are the same ones that existed under the single appropriation
structure. The four accounts significantly increase the complexity of
financial management at each individual medical facility without
improving the accuracy of accounting. The multiple accounts create the
false perception that only the Medical Services account is directly
related to patient care which is not correct. For example, the salary
for physicians and nurses who treat patients are paid from the Medical
Services account, the salary for security guards who protect patients
and staff are paid from the Medical Administration account, and the
cost of utilities to heat and cool the patients are paid from the
Medical Facilities account--all are essential to the delivery of high
quality health care services to our veterans. The Medical Services
account is not the only account directly related to patient care. The
benefits of the multiple account structure do not outweigh the benefits
of the previous single account structure.
Question 4. Your budget suggests that the total number of veterans
in need of mental health care services who will be treated in an
inpatient setting will drop by approximately 1,300 veterans and the
average daily census for this program will drop by 103 veterans. How
much of this drop, if any, is related to reductions in service, bed
numbers, and employee levels? How much of this drop, if any, is related
to changing treatment patterns (i.e., less long-term stays on
psychiatric wards) and new atypical antipsychotics drugs keeping
veterans out of inpatient settings? Please provide a detailed
explanation including--if known--the average age of inpatient
psychiatric patients as well as the average length of stay controlled
for age.
Response: Similar to all other clinical settings, psychiatric care
in VHA has evolved over the past decades from a predominantly inpatient
based system to one that is predominantly clinic based. Since Fiscal
Year 2002, the number of average operating beds for all VHA psychiatric
services has dropped steadily from 7,565 to 7,250, while the occupancy
rate has similarly declined from 72 percent to 60 percent through
November, Fiscal Year 2007. These beds include general psychiatry,
substance abuse, and psychosocial residential rehabilitation treatment
program (PRRTP) beds, but not domiciliary or nursing home beds.
Although there is some drop in beds over this time, there is also a
drop in occupancy rates. Thus, it would appear that the demand for
available beds is diminishing. The occupancy rates demonstrate that
inpatient care beds are not filled, and that there is capacity in the
system as a whole to admit patients in need of hospitalization.
From another perspective, the number of veterans discharged from
VHA psychiatric beds has varied over recent years. It was 56,513 in
Fiscal Year 2003; 57,485 in Fiscal Year 2004; 56,756 in Fiscal Year
2005; and 55,937 in Fiscal Year 2006. While there have been overall
decreases in the number of hospitalizations since Fiscal Year 2004, the
trend since 2003 can best be interpreted by suggesting that the use of
inpatient services fluctuates from year to year. As noted already,
however, the current occupancy rates demonstrate that the system can
accommodate the needs in higher utilization years.
Thus, looking at the past 4 years, it is not clear if the if use of
psychiatric inpatient services has leveled off, or whether there is
still evidence of a persisting but slowed rate of decline. The presence
of substantial numbers of beds that are not occupied on any day argues
strongly against the availability of services, the number of beds, or
the number of employees as being the reason for any decreases in
admissions and discharges. Instead, any decreases in use of inpatient
psychiatric services could be attributed to increases in services such
as mental health intensive case management, psychosocial
rehabilitation, homeless programs, and substance abuse treatment
services.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
While the average age of all veterans hospitalized in VHA
psychiatric settings remains in the mid 50s, there is a shift since
Fiscal Year 2003 from 43 percent in the 45-54 age range to 38 percent,
while the 55-64 age group increased from 20 percent to 29 percent. The
number of veterans over age 65 discharged from psychiatric bed sections
actually decreased from 10.1 percent to 9.4 percent during that period.
The under 35-year-old age groups increased marginally from 6.7 percent
to 8.8 percent.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
The average lengths of stay by age for all psychiatric beds reveals
that veterans stay for shorter periods of time than older veterans.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Question 5. I noticed that the budget for the CHAMPVA program is
growing at incredible rates. By my count, it has gone up several
hundred percent since 2001. What is the primary driver of these large
increases?
Response: The civilian health and medical program VA (CHAMPVA)
provides payment for medical services for the dependents of veterans
rated permanently and totally disabled, or dependents of veterans who
succumb to VA rated service connected conditions. CHAMPVA is comprised
primarily of dependents of World War II, Korean, and Vietnam era
veterans.
The two major drivers causing upward cost pressures include unique
users and medical cost per unique user.
Unique Users--Since 2001 the number of CHAMPVA enrollees increased
by 158 percent; concurrently, the number of enrollees using benefits
increased by 203 percent. The majority of this enrollment growth
occurred with the enactment of Public Law 107-14, which extended
CHAMPVA benefits effective October 1, 2001, to beneficiaries aged 65
years and greater.
Medical Cost per Unique User--This cost driver includes usage
rates, acuity levels, and medical consumer price index (CPI).
<bullet> Usage rates, or the number of enrollees with at least one
paid claim per year, increased 203 percent since 2001. The percentage
of beneficiaries using program benefits in 2001 was approximately 58
percent; this participation rate increased to 68 percent in 2006.
<bullet> The acuity level, based upon the number of annual claims
paid per user, increased from 21.5 claims paid per year in 2001 to 30.2
claims paid per year in 2006, an increase of 40 percent. The annual
cost per user was $2,350 in 2001 and $3,285 in 2006, an overall
increase of 39.8 percent.
<bullet> The annual increase in the cost of medical services, or
the medical CPI, increased 26 percent from 2002 to 2006, an annual rate
of change of about 5.0 percent.
Question 6. I am glad to see that the Department is committed to
completion of construction projects that are already underway, all of
which were authorized by Congress last year as part of a $3 billion
medical construction bill. These are not small price tags, and the
Committee is committed to ensuring that VA's capital assets align with
care needs for optimal access for veterans and efficiency for
taxpayers.
Question 6(a). What is VA doing to control its construction cost?
Are there further sharing and lease opportunities that VA could use to
leverage its resources?
Response: The Department, along with other government agencies and
private sector businesses and individuals, is experiencing a
significant growth in the cost of construction as a result of the
booming construction economy worldwide. The significant demand for
contractors, labor and building materials has produced significant
increases in pricing. This has been further exacerbated by higher
petroleum prices on both petroleum based building products and fuel as
well as construction related impacts of the hurricanes of 2004 and 2005
including Katrina.
In order to position the Department to best deal with this
situation, VA has taken several steps. These include developing a more
detailed market analysis of individual geographic location to ensure
that the best available information is used when establishing the
escalation rates that will be used in the cost estimate. These in
consideration to market timing to the extent practical in order to bid
the project at a time when there is the best opportunity to have the
greatest competition by the contracting community. VA has also began to
employ more extensive preplanning before a project is placed in the
budget to be sure that all issues relating to scope, building systems
and constructability have been identified and their costs recognized.
Question 6(b). Are there further sharing and lease opportunities
that VA could use to leverage its resources?
Response: On December 4, 2006, the Secretary approved a decision
document launching a Site Review Initiative. The intent of this
initiative is to market and decrease the amount of underused VA
property while reinvesting the proceeds into programs and activities at
the Secretary's discretion. The Assistant Secretary for Management will
provide the Secretary with a site assessment by April 2007.
Question 7. Please detail the status of VA's IT organizational
restructuring. Are funds for the restructuring fully budgeted for in
the Fiscal Year 2008 request?
Response: On October 19, 2005, the Secretary approved the concept
of a Federated IT System for the VA and charged the Assistant Secretary
for Information and Technology with the development of a Federated
Model and a follow-on implementation plan. The Federated Model is a
framework that defines the VA Federated IT System by separating IT into
two domains--an Operations and Maintenance Domain that is the
responsibility of the Assistant Secretary for Information and
Technology (VA's Chief Information Officer) and an Application
Development Domain, that is the responsibility of the administrations
and staff offices. The Federated Model was approved by the Secretary on
March 22, 2006.
VA contracted with IBM to recommend the best business practices and
develop processes to manage VA IT capabilities and resources. On
October 1, 2006 over 4,200 employees who worked in IT operations and
maintenance across VA, nationwide, were centralized under the Office of
the Assistant Secretary for Information and Technology.
On October 31, 2006, the Secretary approved the transition of VA IT
management system from the Federated IT System model to a single IT
leadership authority under the Assistant Secretary for Information and
Technology. With this approval, all VA IT employees who worked in the
IT Applications Development Domain, approximately 1,200 employees
nationwide, were detailed to the Office of the Assistant Secretary for
Information and Technology in December 2006.
On February 27, 2007, the Secretary approved a modification to VA
IT management system to implement a process-based organization
structure for the Office of Information and Technology. This
restructuring is an important step for driving IT standardization,
compatibility, interoperability, and fiscal management disciplines
across VA in support of veterans' programs and services.
The resulting construct of this more than 2 year effort is a
centralization of VA IT personnel and financial resources and physical
assets including all IT equipment, all VA data processing centers
nationwide. Any requirements necessary for this restructuring are
included in the Fiscal Year 2008 budget request.
cemeteries
Question 1. What is the status of VA's efforts to fund the needed
cemetery repairs identified in 2002 in the Study on Improvements to
Veterans Cemeteries: Volume 2, The National Shrine Commitment. Please
incorporate in your answer the expected outlay of Nation Shrine
Commitment dollars as part of VA's FY07 appropriations, and expected
outlay under VA's FY08 request.
Response: We are making steady progress completing the repairs
needed to ensure that each national cemetery is maintained as a
national shrine.
The Millennium Act Report to Congress (Volume 2, National Shrine
Commitment), issued in August 2002, provides a comprehensive assessment
of the condition of VA's national cemeteries. This information is used
in NCAs planning process to assist in prioritizing national shrine
projects over a multi-year period.
The report identified the need for 928 repair projects at an
estimated cost of $280 million to ensure a dignified and respectful
setting appropriate for each national cemetery. NCA is using the
information and data provided in the report to plan and accomplish the
repairs needed at each cemetery. Through Fiscal Year 2006, NCA
completed work on 269 projects, and initiated work on additional
projects, with an estimated cost of $99 million.
Repairs to address repair/maintenance needs are addressed in a
variety of ways. Gravesite renovation projects to raise, realign and
clean headstones and markers and to repair sunken graves are addressed
through NCA's operations and maintenance (O/M) account. Infrastructure
improvements to buildings, roads, irrigation systems, and historic
structures are addressed with capital expenditures through the major
and minor construction programs. In addition, cemetery staff is used to
complete some repairs.
In Fiscal Year 2007, NCA plans to spend $16.6 million specifically
for national shrine projects--$9.1 million from O/M and $7.5 million
from minor construction. The 2008 budget includes $11.1 million for
national shrine projects--$9.1 million in the O/M account and $2
million in the minor construction request.
In addition to specific national shrine projects, a commitment to
enhancing the appearance of the national cemeteries underlies all NCA
activities. Over 30 percent of NCA's operating budget is used for
routine tasks such as mowing, trimming, and other maintenance work.
These functions are equally critical to providing enduring memorials to
those we serve.
Our progress in improving the appearance of our national cemeteries
is evidenced in our performance results. In Fiscal Year 2006, 97
percent of respondents rated the appearance of our national cemeteries
as excellent. Our target for Fiscal Year 2007 and 2008 is 99 percent.
NCA has also established an organizational assessment and
improvement (OAI) program to ensure regular and consistent assessment
of performance against established standards. Each national cemetery
will be evaluated through site visits conducted on a cyclical basis. A
total of 47 national cemeteries have been reviewed under OAI since the
program's inception in 2004. In addition, NCA has developed additional
performance metrics that will be used to improve the appearance of its
national cemeteries. Baseline data was collected in 2004 for three new
performance measures designed to assess the condition of individual
gravesites, including the cleanliness and proper alignment of
headstones and markers. With this baseline data, NCA has identified the
gap between current performance and the strategic goal for each
measure.
Funds available in Fiscal Year 2007 and included in the 2008 budget
request will allow us to continue work toward improving the appearance
of our national cemeteries. This is a multi-year effort, and VA is
committed to ensuring that a dignified and respectful setting for each
national cemetery is achieved. Future budget requests tied specifically
to the shrine commitment will be prioritized within the context of
Departmental priorities. For example, critical gravesite expansion
projects require our immediate focus in order to keep existing
cemeteries open and to ensure continued service to our nation's
veterans and their families.
Response to Written Questions Submitted by Hon. Jim Webb to Hon. Daniel
L. Cooper, Under Secretary for Benefits, Department of Veterans Affairs
Question 1. Provide the current inventory of pending rating-related
claims:
Response: VBA defines the claims processing workload as the number
of liability claims requiring a rating decision. The chart below shows
rating-related workload by type of claim.* As of April 7, 2007, 406,660
claims were pending.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
*Rating-related workload by type of claim:
Original Disability Compensation--128,030
Reopened Disability Compensation--233,249
Original DIC and Disability Pension--20,163
Reopened Disability Pension--15,243
Future Exams/Hospitalization Reviews--9,975
Question 2. Utilization of Benefits. I would be curious if you
could get us something just in terms of utilization of the VA system,
writ large. What are we going to estimate in terms of how many people
are going to take advantage of one or another benefit in the VA system,
whether it is home loans or compensation, pension, education benefits?
Response. VA does not have access to date that would allow us to
compile this information for the entire veteran population. We are
working with DOD to obtain inforamtion that will allow us to compile
data on benefits usage for veterans of the Global War on Terrorism
(GWOT). The Information we currently have available is provided in the
table below. We are continuing to work to expand and refinethis data.
Because many GWOT veterans had earlier periods of service, the benefits
activity identified in the table could have occurred either prior to or
subsequent to their GWOT deployment (or both).
Total Living GWOT Population--686,306
(Based on DOD separations through November 2006)
------------------------------------------------------------------------
GWOT Veterans (percent)
------------------------------------------------------------------------
Veterans with disability claims decisions-- 21.7
148,891 (data through 12/06.
Veterans who accessed the VR&E program-- 1.7
12,168 (data through 12/06).
Veterans awarded TSGLI benefits--1,569 0.2
(data through 01/24/07).
Veterans who have obtained a VA home loan-- 22.5
154,377 (data through 01/31/07).
------------------------------------------------------------------------
Note: Percentages reflect unique veterans within that business line
only.
We can provide the estimated number of servicemembers, veterans,a
nd survivors that will receive or use VA benefits in FY 2007 and FY
2008.
------------------------------------------------------------------------
Beneficiaries 2007 Estimate 2008 Estimate
------------------------------------------------------------------------
Veterans Receiving Disability 2.7 million....... 2.9 million
Compensation.
Survivors Receiving DIC......... 330,000........... 340,000
Veterans and Survivors Receiving 523,000........... 512,000
Receiving Pension.
Veterans who will access the 92,000............ 94,000
VR&E program.
Veterans who will obtain a VA 180,000........... 180,000
Home Loan.
Serviemembers, Veterans, and 7 million......... 6.9 million
Survivors Covered by VA Life
Insurance.
------------------------------------------------------------------------
Chairman Akaka. Thank you very much, Mr. Secretary.
At this time the Chairman calls for a very brief recess
that will be at least 5 minutes, maybe a little bit more.
Thank you.
[Recess.]
Chairman Akaka. The Committee will come to order.
Mr. Secretary, before I start my questions, I want to
commend you on your final remarks about extending yourself to
the families of veterans and also your outreach program for the
severely injured and for your meeting with the combatant
commanders. I think this will be of great benefit to our
veterans.
Mr. Secretary, I note that it is certainly true that VA has
received significant budget increases during this
Administration's tenure, as you testified and as others have
mentioned. It is also true that these increases are a result of
both Administration proposals and actions by the Congress, and
my simple question to you is: Do you agree with that statement?
Secretary Nicholson. I think that both the President and
the Congress have been very supportive of the VA, yes, sir.
Chairman Akaka. Well, thank you. I want you to know that
this Committee works well together, in a bipartisan manner, to
help our veterans.
Mr. Secretary, I would like to expand on what I touched on
in my opening statement, regarding the actual level of funding
requested for health care. As I said, when you take into
account the $2 billion in what the budget calls ``health care
industry trends''--increases due to inflation and other
factors--there does not seem to be any funding left for the top
priorities. I am talking about mental health improvements and
ensuring that the needs of returning war veterans are met.
My question to you is: How can VA both cover inflation and
other costs and still make the improvements that we all know
are needed?
Secretary Nicholson. Thank you, Mr. Chairman.
Mr. Chairman, we are requesting a 10.3 percent increase for
health care in the budget, 2007 to 2008, and believe that with
the pay increase that would be anticipated in that and
inflation, there would still be above that a 3.6 percent
increase in the Health Administration. That is after adjusting
for inflation, after adjusting for the pay increase.
Chairman Akaka. Dr. Kussman, I note that inpatient care in
various settings is facing a big cut in this budget. You expect
to have fewer patients in rehab and psychiatric units as well
as in residential facilities. I do not believe that these cuts
are being driven by good medical practice. I understand clearly
that outpatient care is the best approach in some cases, but we
must, however, own up to the fact that this war is resulting in
some young veterans who will need substantial inpatient
treatment. Just last week, a family wrote to me about their son
who died in a VA facility from a drug overdose after spending
only 2 weeks in an inpatient unit.
Can you please explain why VA should be losing beds now?
Secretary Nicholson. Well, you touched on it, Mr. Chairman.
The paradigm for VA health care in general is for more
outpatient care. That is, as some of the statistics were cited,
a great frequency of visits to a facility. But we also are
using far more of the technology of our times--telemedicine,
telehealth, we are doing teletherapy. So there is an increasing
usage of those technology.
But I could tell you, Mr. Chairman, that we have the
capacity and that no veteran who is in need of acute mental
health care is turned away. They are admitted.
Chairman Akaka. Mr. Secretary, I would like to ask for
specifics on the enrollment fee proposal this year. In my
statement, I mentioned the new out-of-pocket costs for working
families. In creating this year's version of the enrollment
fee, what attention was given to families with dependents,
families with two veteran wage earners, and other similar
situations?
Secretary Nicholson. There was a lot of discussion given to
these policy proposals which have been proposed in some form
for six years. I have testified now for the third time on this
concept, and I will tell you that I support it. I support it on
a practical basis, and I support it on an equitable basis.
What we are talking about here are veterans who have no
service-connected disability, no diminution as a result of
their service, which is the whole theory behind the VA. If
someone has suffered physically or mentally as a result of
their service, they are to be compensated by a grateful
country. These people have not had that experience, and they
have income.
We have looked at and reflected on the experiences of the
previous years, where you all here in the Congress have not
been very supportive of this. And so we discussed a progressive
system where people making less than $50,000 would not be asked
to pay this modest enrollment fee. Again, keep in mind, if you
would, sir, and Members of the Committee, no one with any
service-connected disability pays this under this proposal.
Second, there is an equity argument because if you are a
person who served in the military for 30 years or 35 years and
take off the uniform and go into the TRICARE health care
system, you pay an enrollment fee, and you pay a copay. We can
debate that. I think it is fair to say they are modest. But
they are more than what is being asked here.
In an environment of somewhat finite resources, if you want
to assume that the resources are finite, then we have to make
priorities, which we do, and try to direct resources toward
those who need us the most. That is the policy behind this.
Chairman Akaka. Let me ask in particular, if there were two
veterans who were married to each other with a combined income
of $50,000 a year would each be assessed the fee?
Secretary Nicholson. Yes, they would, Mr. Chairman. If they
were both patients in our system, yes.
Chairman Akaka. Thank you.
Now, I will call on our Ranking Member for his questions.
Senator Craig. Thank you very much, Mr. Chairman.
Mr. Secretary, I apologize for having to step out to
another hearing to give testimony, and I do appreciate your
presence and that of your staff and associates here today.
Your budget talks about focusing aggressively on reducing
waiting times for current patients, specifically targeting
those patients who are waiting the longest for care. Certainly,
it makes sense to all of us that that happens, and we have
worked on that progressively over time.
Can you talk a little about who is now waiting the longest
for care? Is it a function of individual facilities that
struggle to deliver timely care? Or is it certain specific
services, such as neurology or orthopedics? In other words,
what are the drivers in the time here? What are the drivers in
the waiting time involved?
Secretary Nicholson. Thank you, Senator. Let me again
repeat the good news part of this, which I think is
significant, in that 95 percent of all people who want an
appointment of any kind get it within 30 days, and 96 percent
get an appointment within 60 days.
There are some of these specialties that do have to wait
longer, among which are dermatology and ophthalmology. The
primary reasons for that are our resources in those specialties
and our ability to be able to hire and retain doctors in the
numbers that we need.
We have been assisted by you in recent legislation where we
can incentivize them into the VA, and we are doing that. That
is helping. But that is the main part of that.
Senator Craig. And all of these categories are non-
emergency type settings. Is that correct?
Secretary Nicholson. Yes, sir. There is no veteran who is
in need of, as they say, emergent or emergency care that does
not get it immediately. If we cannot provide it, he or she is
taken to a local facility.
Senator Craig. It was interesting that you would mention
dermatology. My wife will probably crucify me for bringing her
into this. She in a routine way scheduled a meeting with her
dermatologist about a month ago, and it occurred last week. In
the civilian landscape, non-emergency type routine access to
health care oftentimes takes that long, depending on where you
are in the delivery system and all of that kind of thing. I
find it fascinating that you would mention that.
Ten years ago, Mr. Secretary, every Member of this
Committee signed a budget letter stating that VA entitlement
spending did not show spiraling growth patterns. We concluded
that VA entitlement programs were--and this is the quote from
the letter--``not among the chief factors in looming Federal
deficits.'' VA entitlement spending has since jumped by nearly
100 percent. As our bipartisan letter then put it, ``I am
worried that we have entered into a pattern of unsustained
growth.''
What are the causes of the growth in VA entitlement
spending? And is this growth expected to continue at its
present rate?
Secretary Nicholson. The causes, Senator Craig, are
multiple. One of those is very active, aggressive outreach by
the VA, and it takes several forms. We have now over 140 VA
benefit counselors embedded in military units throughout the
world who are there to counsel and educate and make aware those
people who have a separation from the service coming up. And we
have people at all the major points of embarkation, people
redeploying back from the combat zone.
We have traveling groups of outreach counselors who go out
and set up displays at Veterans Service Organization events.
Two weeks ago, I was in San Antonio for the dedication of the
Center for the Intrepid, and we had a major outreach, a static
display with staff for the many veterans there to become more
aware of what they are entitled to. And they are entitled to
substantial benefits, depending, of course, on their situation.
Then there is the corresponding fact that more and more of
them are coming in, as I said, in absolute numbers. In 2006, we
had 806,000 individuals come in and make a claim.
The other thing that is happening is the demographics of
veterans--some of us are older. Fifty percent of our veterans
are over 60, 45 percent of our veterans are over 65, and they
begin to have more ailments from their experiences or arthritis
and different things. So that is an individual claim, each of
those, individual clinic visits, individual adjudications. And
the underlying philosophy that is imparted to the VA in this
system is to grant a claim if you can and deny only if you
must.
And so the system, I think, is quite beneficial and people
are coming in in ever increasing numbers.
Senator Craig. Thank you.
Thank you, Mr. Chairman. My time is up.
Chairman Akaka. Thank you very much, Senator Craig.
Senator Murray?
Senator Murray. Thank you, Mr. Chairman.
I wanted to follow up on the Chairman's line of questioning
on the need for inpatient mental health care, because I, too,
was really disconcerted to see the budget request projecting
fewer veterans needing inpatient mental health care. I
understand the philosophy of trying to do more and more
outpatient, reach more people that way, but it just seems to
me, when one in three Iraq war veterans are estimated now to be
seeking mental health care, many of our servicemembers are now
on their second or third, some even fourth deployments. We are
hearing about the intensity on the ground and what our men and
women are facing and the consequences when they return home,
and the President now sending up to 48,000 more troops. It just
seems to me that we are going to need more inpatient
psychiatric services, not less. And I want to hear your
rationale on that.
But, you know, you made a comment that struck me because
you said no veteran has been denied inpatient health care,
mental health care, yet we heard about a highly publicized case
of an Iraq war veteran with two Purple Hearts named Jonathan
Schulze, who tragically took his own life, and the press
reports were that he had asked for help from the VA twice and
was told he was 26th on the waiting list. We have heard about
cases in Minnesota as well as--or he was from Minnesota, but
also a case in Illinois and in Iowa.
It just seems to me when you have that many red flags
going, you cannot just arbitrarily say no one is being denied
care. And, you know, I think we have to say there are red flags
out there. We need to find out what is going on.
So I would ask you two questions: We are hearing about
these cases that say veterans are being denied care when they
ask for it. And, second, how can you predict a lower demand for
inpatient psychiatric services in your budget when we know
there are going to be increasing consequences as the years
progress?
Secretary Nicholson. Thank you, Senator Murray. Those are
several important questions, and I like having the opportunity
to respond.
First, our budget for psychiatric inpatient care is
actually up. I am looking at it. We are asking for $1.6
billion----
Senator Murray. Right. Your budget request has increased,
but you are projecting that fewer veterans will need inpatient
health care.
Secretary Nicholson. Well, let me give you the capacity
figures. You know, what we have anticipated our needs to be is
what we should request from you the money to fill.
In our capacity for mental health, we are currently being
utilized at 70 percent, and for polytraumatic care in our
polytrauma centers, it is 80 percent. So we have, in the case
of mental health in general, a 30 percent capacity available;
in the case of polytraumatic capacity, we have 20 percent
available.
Let me also address--you raised the point----
Senator Murray. Are you talking nationwide 20 percent
available? Because if those facilities are not where our
veterans are, it does not make any difference. They are not
going to travel 5,000 miles to get inpatient care.
Secretary Nicholson. We have 154 inpatient facilities
around the country and almost 1,000 other points of access for
veterans to come in to be screened, to be referred.
I want to address the other point that you raised to the
extent that I can, and I am limited by the privacy regulations
because the family has not given us a waiver to discuss this.
But the case that you mentioned from Minnesota, which comes up
often, that veteran was seen by our facilities in Minnesota 46
times. That is about all I can say.
Senator Murray. OK. I understand extenuating circumstances
in all cases, but it is not an isolated case. We are hearing
about cases elsewhere.
But my question to you is: Do you really think that we are
going to see fewer veterans needing access to inpatient mental
health care?
Secretary Nicholson. Well, we are projecting that we are
going to see somewhat fewer of those cases in this time frame.
Senator Murray. Well, my time is up, and I want to ask
another quick question. But, Mr. Chairman, I think we have to
be careful not just to project numbers on the hopes of keeping
the budget down, but really looking at what we are going to
need to pay for because of inpatient care. And as you have
stated and as I referred to, we do have, you know, many
veterans who are in their second, third, possibly fourth tour.
We have 48,000 additional troops being sent, and we are seeing
a third of our veterans seeking mental health care. So I hope
we look very carefully at those numbers as we put our budget
together.
But let me ask one other question really quickly in my
time. I wanted to ask you about shorter hours at our urgent
care in Spokane--I am going to submit that for the record--
because we have a serious concern about that facility closing
at 4:30 in the afternoon. We have one if not more cases of
veterans who have died because they have shown up shortly after
the facility closed, and there is a huge problem with how
veterans perceive their care if they do not go to the VA
facility not being paid for. That is an issue I want to address
with you on another occasion.
But I also wanted to ask you about these increased user
fees and copays because, as you know, I oppose that. I believe
that anybody that we ask to serve us should not be given an
additional cost to get their health care. That is not what they
were told. But I am disturbed that in the proposal this year
that you asked to put that money from fees, should it ever be
collected, back into the general budget rather than into the VA
health care. And it seems to me what that simply is saying to
our veterans is we are asking you to balance the Federal budget
now. And I find that even worse than the suggestion that they
should pay copays, and I wanted to ask you why you have changed
that policy and why you are suggesting that in this budget.
Secretary Nicholson. Well, the reason for that, Senator
Murray, is that if you will recall other discussions that we
have had about this, the revenue that was assumed in the budget
was used to apply for the needs on the application side of the
budget. So having an experience where it has not been approved
and then having a gap, instead of doing that, we did not assume
it. This budget, if you approve it without those measures, will
still have the money that we need.
Senator Murray. So basically we can balance the budget if
we charge our veterans fees. I just find that incom----
Secretary Nicholson. No, no. I am not being artful in
trying to explain it. If you deny it, there will be no gap in
this budget where you have to find it somewhere else.
Senator Murray. For the VA.
Secretary Nicholson. Right.
Senator Murray. I know my time is up, Mr. Chairman. Thank
you.
Chairman Akaka. Thank you very much, Senator Murray. Let me
tell you that we have a second round of questions for this
panel, and then we will have our next panel.
At this time, Senator Jim Webb.
Senator Webb. Thank you, Mr. Chairman. May I ask a
procedural request? Our colleague, Senator Tester, had to leave
in order to preside, and he asked that I ask a question on his
behalf. I would request that the clock be reset once I have
asked the question on his behalf.
[Laughter.]
Chairman Akaka. Senator Webb, granted.
Senator Webb. Thank you, Mr. Chairman.
Mr. Secretary, the question that Senator Tester wanted to
get an answer to regards the growth in the claims and the
indication that it has now gone from 500,000 to over 800,000.
And he had had a number of constituent contacts that indicated
that a lot of the claims that are going forward had been kicked
back for more information and this sort of thing. And so his
question was, ``What percentage of this claim backlog involves
recycled or incomplete claims? And if you do not have that
today, could we please have that?''
Secretary Nicholson. Thank you, Senator Webb. I do not
think we have that, and we will get that. I can ask Admiral
Cooper, the Under Secretary for Benefits, if he would like to
expand.
Admiral Cooper. Yes, sir. We have a very specific process
established by law as to how to process a claim, and no claims
are sent back to the individual. We do go to them and tell them
specifically what we require in order to properly adjudicate
their claims. We also state precisely what VA will do to
properly obtain the information. Once we get all the
information in and make the decision, then they will
occasionally appeal that decision. The appeal process is a
separate process. Appeals are not counted as part of the
approximately 400,000 claims that we have pending today.
Senator Webb. So when you say 400,000, you are talking all
of those are initial claims?
Admiral Cooper. All of those are initial, but the term
``initial'' requires explanation. They are either original,
that is, the person has come in for the first time, or they are
reopened, which means that the person having had a claim
adjudicated previously, now comes in because his or her
condition has deteriorated or the veteran claims service
connection for another condition that has not been claimed
before.
Senator Webb. Or new information----
Admiral Cooper. Or they have new information----
Senator Webb. Could you get us some sort of a breakdown so
we could understand that?
Admiral Cooper. Of course.
Senator Webb. Thank you.
Mr. Chairman, if we could now reset the clock, I will do my
best to ask a few on my own time.
I was struck by a number here, a percentage here--I am just
trying to get my data points as I join the Committee--that says
out of the 198,000 military separations in 2006, trends show
that 35 percent will file a claim over the course of their
lifetime. I am assuming that means some sort of a compensation
claim. What I am curious about is what percentage are we
estimating a vet is going to use a benefit, because I recall
even from the Vietnam GI bill alone it was about a two-thirds
participation rate.
Secretary Nicholson. I will review the top line, Senator,
and then if Admiral Cooper wants to come in. If you think of
the veteran population as a whole in the country today, it is
about a little over 24 million: 7.8 million of them are
enrolled in our health care system; 5.6 million present
themselves every year for medical treatment. But that is on the
average of 10.1 times, which means that we see over 1 million
people a week in the health care system. On the claims side,
about 35 percent of those that we----
Senator Webb. So we are defining a claim as a claim for
compensation?
Secretary Nicholson. Yes, sir.
Senator Webb. Purely. OK. I just wanted to make that clear.
I would be curious if you could get us something just in terms
of the utilization of the VA system, writ large. What are we
going to estimate in terms of how many people are going to take
advantage of one or another benefit in the VA system, whether
it is home loans or compensation, pension, educational
benefits? I would venture that number is well in excess of----
Admiral Cooper. I do not have that information now, but let
me get back to you in writing.
Senator Webb. OK. Great. Thank you.
As I mentioned in my opening statement, I am very desirous
of ensuring that these people who have been serving since 9/11
get an educational benefit that is worthy of the service that
they have given. I think we are all aware that the Montgomery
GI Bill, which is a good GI bill, a good peacetime GI bill, has
its limitations. I am wondering if you would agree that the
post-9/11 veterans should receive a better educational reward
than that which they are now getting.
Secretary Nicholson. Well, you recognize, Senator, that I
am here as a representative of the Administration, and what you
are talking about is a major policy implication with
significant cost ramifications which have not been scored.
We will, if you ask, analyze that and give you the benefit
of our judgment in concert with the Administration, whom we
represent and, as you know, I think, is very supportive of
veterans and appreciates the importance of education and what
the GI bill has meant to veterans and to our country, which I
certainly support as well.
Senator Webb. On a personal level, I assume that I am
hearing that on a personal level you probably would agree with
that, or are you comfortable in saying----
Secretary Nicholson. I have to qualify my answer, but I
will tell you, coming from a family that had to get through
college--all seven of our kids in my family went to college by
hook and by crook, and I was lucky I got to go to the Military
Academy. And knowing what education means in this country, I
have some concern about our Reserve and National Guard and
whether they are being equitably benefited because of their
service, their active-duty service now in this war, I think
that is a legitimate thing to be looking at.
Senator Webb. Did the Administration support the
legislation that allowed attorney representation in VA claims?
I was not here when----
Secretary Nicholson. It did not.
Senator Webb. It did not?
Secretary Nicholson. No, sir.
Senator Webb. Do you have any indication of how this new
concept has affected the increase or decrease in caseload?
Secretary Nicholson. Well, no. The answer is no, but we are
working on that. It is now the law, and we are charged with
implementing it and coming up with the standards for the
attorneys, the system, to look out for the interests of the
veterans in this case to see that they are well and fairly
represented and that the compensation is a fair system. It is
not yet in effect, but we are looking at it.
I think part of your question, if I hear it right, is what
effect is this going to have on waiting times on this system.
Senator Webb. Yes.
Secretary Nicholson. And I will tell you that I think it is
going to have an effect of stretching them out. I mean, I
cannot help reflecting I grew up in this little town of 99
people that had one country lawyer that used to play pinochle
every afternoon at the one tavern, and then a young lawyer
moved in, and then they were both busy.
[Laughter.]
Secretary Nicholson. So this is going to have an effect on
waiting times, I think there is no question.
Senator Webb. I would agree with your concern in that area,
quite frankly. I have watched the quality of the national
service officers over the years, people who have become
specialists in Title 38. And it is worrisome if we were to go
to a system where a veteran would feel compelled to have to
obtain an attorney rather than the free services that have been
available, unless that attorney were willing to do it on a pro
bono basis, as I have on many occasions, by the way. That is
something that I look forward to look at, and I hope there is
some kind of a tracking system established where we might get
into the timing and those sorts of things and be able to
evaluate.
Thank you, Mr. Chairman. My time is up.
Chairman Akaka. Thank you very much, Senator Webb. We will
begin a second round here.
Admiral Cooper, in your personal or professional view, and
without regard to the present situation, how long should a
veteran or dependent have to wait to have their claim decided?
Admiral Cooper. The goal that we have--and I honestly
believe we can get there--is 145 days, predicated on all the
laws that are now in place. As you know, the Veterans Claims
Assistance Act of 2000 did extend processing time by
establishing many specific things that VA is required to do,
all for the benefit of the veteran, all for the right reason.
But that did extend the process.
As I look at it and try to analyze how we can best reduce
the time to the shortest time possible, I find that 145 days--
perhaps 140 days eventually--that is probably, realistically,
the best we can achieve on average. We will be able to do some
claims, very fast assuming we get all the information
immediately. But, on average, I think 145 days is about the
best we can do.
Secretary Nicholson. Mr. Chairman, could I just add an
important footnote to that.
Chairman Akaka. Mr. Secretary.
Secretary Nicholson. For clarity, a claim, when it is
finally decided, is paid from the time it was initiated. So
during that pendency period, if it is given, it is given
retroactive back to the time it was filed.
Chairman Akaka. Thank you for that explanation.
Dr. Kussman, in your personal or professional opinion,
should someone seeking a primary care appointment have to wait
30 days to get an appointment? Or in your answer, please give
me examples of other health care systems that use such an
extended period for a primary care appointment.
Dr. Kussman. Thank you, Mr. Chairman. As was already
mentioned, anybody who has an urgent or emergent issue can be
seen right away by walking into one of our clinics or one of
our emergency rooms. So if anybody really needs to be seen
right away--the issue of the 30 days is for stable, chronic,
longitudinal care for the patient that we have been seeing
regularly in our clinics.
Chairman Akaka. Thank you.
Mr. Secretary, I notice that VA's estimated number of OEF
and OIF veterans that will come into the system next year is
relatively incremental at around 54,000. We know that in the
past, VA has underestimated the number of new veterans seeking
VA health care. We also know that some conditions such as PTSD
can take some time to manifest themselves in these young
servicemembers, and that in these current conflicts, the
average servicemember will serve more tours than in the past.
Can you please explain the projection that VA will see such
a low number of OEF and OIF veterans next year?
Secretary Nicholson. Well, Mr. Chairman, we use a very
sophisticated model. The model, as you will recall--I know you
do--for the 2005 budget year did not hit it because it was
based on 2003 actual data, and it did not incorporate the
effects of the war into it.
Since that time, that model in the overall patient demand
that we have is almost uncanny in its accuracy--less than half
of 1 percent off. So we use that. We use it for 85 percent of
our predictive capacity. It does not predict certain things
like long-term care, dental, and CHAMPA. So we have to apply
some judgment into that. But we are quite confident in that
estimate that we have for 2008, which is 263,000. And the
funding for it, as you will note, we have asked for nearly
double that of 2006.
Chairman Akaka. Thank you very much, Mr. Secretary. My time
has expired.
Senator Craig?
Senator Craig. Mr. Chairman, I will be brief. We have
another panel, and I would like to hear from them before I have
to rush out around the noon hour.
There are questions I will submit for the record for the
Secretary and his colleagues to answer.
I would only make this observation, Mr. Secretary. Last
year, the VA stated that the training of veterans service
officers, that once trained by the VA, could help expedite
claims. And while you are an attorney and I am not, I cannot
imagine that well-trained attorneys in the law could not help
expedite claims also. Or is there something about the degree
itself that deters them from expediting----
[Laughter.]
Senator Craig [continuing].--while VSOs trained by VA can,
in fact, expedite claims processes? Now, you must defend your
fellow attorneys. I understand that.
Secretary Nicholson. I am a recovering attorney, Senator.
[Laughter.]
Senator Craig. I see.
Secretary Nicholson. But I would tend to repeat my story of
Struble, Iowa, and rest my case. The veterans service officers
that work on these cases, they are really doing it--they have
no financial interest in it. They do not have a clock that is
running. It is not dependent on their livelihood. I think they
have a more detached view, but in most cases a very competent
and committed view. And attorneys--I mean, attorneys are
trained to be thorough. If they are not thorough, because they
are held to a higher standard, could be held to be negligent,
so they do not tend to leave many stones unturned, or they are
not too much on an expedition. And I think common sense for me
suggests that it will just take longer.
Senator Craig. Well, I thank you for that. I visited with
the judges down at the court. Thoroughness is part of a problem
in why claims are rejected at that level, and thoroughness is
something that is important to carry the process through. That
is why I felt that the policy of the Civil War era should be
put to bed once and for all on behalf of our veterans.
Having said that, Mr. Chairman, I thank you all of you for
being here today and look forward to working with you in the
coming year.
Chairman Akaka. Thank you very much, Senator Craig, for
your remarks.
Mr. Secretary, before we switch panels, I want to let you
know that we will be sending post-hearing questions over to you
beginning this afternoon, and others may follow in the next few
days. And questions from Members will be submitted for the
record for your response.
Mr. Secretary, I have two requests. First, please send
replies to individual questions as soon as they are ready--you
do not have to wait until the packages are completed. Second, I
would greatly appreciate your prompt attention to the questions
as well. Having VA's answers will be extremely helpful as we
move forward with our work on the VA budget, and that is the
reason for my request.
Last year, we did not receive our responses until summer,
and that is simply too late. We want to work together with you
on the budget.
Mr. Secretary, I want to thank you and your staff for your
responses. We have heard good things in your statements and
look forward to working with you to even make it better as we
move along here in the budget process.
So thank you again, and we wish you well.
Secretary Nicholson. Thank you, Mr. Chairman.
Chairman Akaka. At this time I would like to call up the
second panel.
We have in our next panel Carl Blake, National Legislative
Director, Paralyzed Veterans of America; Joseph Violante,
National Legislative Director, Disabled American Veterans;
David Greineder, Deputy National Legislative Director, AMVETS;
and Dennis M. Cullinan, Director, National Legislative Service,
Veterans of Foreign Wars. We also have Steve Robertson,
Director, National Legislative Commission, American Legion; and
John Rowan, National President, Vietnam Veterans of America.
We welcome all of you to this Committee hearing, and we
would like you to begin your testimony in the order that I
called your names. First will be Carl Blake.
STATEMENT OF CARL BLAKE, NATIONAL LEGISLATIVE DIRECTOR,
PARALYZED VETERANS OF AMERICA
Mr. Blake. Thank you, Mr. Chairman.
Mr. Chairman, Senator Craig, on behalf of the four co-
authors of the Independent Budget, I would like to thank you
for the opportunity to present our views today regarding the
veterans' health care budget for Fiscal Year 2008. Before I
begin, I would just like to mention that in the spirit of
openness and cooperation, the IBVSOs invited all of the
Committee staff members as well as all of the legislative
assistants for the Members of the Committee to attend a
briefing the week before the President's budget was released to
discuss the recommendations of the Independent Budget in
advance and to go into some detail about how we develop our
budget recommendations, realizing that we have nothing really
to hide and ultimately our only interest is to ensure that
veterans have the best quality health care and benefits
available to them.
It is unfortunate, even as we testify today, that the
appropriations bill has still not been completed for the
Department of Veterans Affairs, as well as other Federal
agencies. Despite the positive outlook in H.J. Res. 20, the VA
has been placed in a critical situation where it is forced to
cannibalize other accounts in order to continue to provide
health care services to veterans. This is jeopardizing not only
the health care system, but the actual health care of veterans.
For Fiscal Year 2008, the Administration has requested
$34.2 billion for veterans health care, a $1.9 billion increase
over the levels established in H.J. Res. 20. Although we
recognize this is another step forward, it still falls short of
the recommendations of the IB. For Fiscal Year 2008, the IB
recommends approximately $36.3 billion, an increase of $4
billion over the Fiscal Year 2007 appropriation level, yet to
be enacted, and approximately $2.1 billion over the
Administration's request.
For Fiscal Year 2008, the IB recommends approximately $29
billion for medical services. Our medical services
recommendation includes $26.3 billion for current services,
$1.4 billion for the increase in patient workload, $105 million
for additional FTEs, and approximately $1.1 billion for policy
initiatives. For medical administration, the IB recommends
approximately $3.4 billion, and, finally, for medical
facilities the IB recommends approximately $4 billion.
This recommendation also includes an additional $250
million above the Fiscal Year 2008 baseline in order to begin
addressing the non-recurring maintenance needs of the VA.
Although the IB health care recommendation does not include
additional money to provide for the health care needs of
Category 8 veterans being denied enrollment into the system, we
believe that adequate resources should be provided to overturn
this policy. The VA estimates that more than 1.5 million
Category 8 veterans will have been denied enrollment in the VA
health care system by Fiscal Year 2008. Assuming a utilization
rate of 20 percent in order to reopen the system, the IB
estimates that VA will require approximately $366 million in
discretionary funding.
Although not proposed to have a direct impact on veterans'
health care, we are deeply disappointed that the Administration
has chosen to once again recommend an increase in prescription
drug copayments and an indexed enrollment fee. Although the VA
does not overtly explain the impact of these proposals, similar
proposals in the past have estimated that nearly 200,000
veterans will leave the system, and more than 1 million
veterans will choose not to enroll.
It is astounding that the Administration would continue to
recommend policies that would push veterans away from the best
health care system in America. Congress has soundly rejected
these proposals in the past, and we call on you to do so once
again.
For medical and prosthetic research, the Independent Budget
is recommending $480 million. This represents a $66 million
increase over the Fiscal Year 2007 level established in H.J.
Res. 20 and is $69 million over the Administration's request
for Fiscal Year 2008. We are very concerned that the medical
and prosthetic research account continues to face a virtual
flat line in its funding level. Research is a vital part of
veterans' health care and an essential mission for our national
health care system.
In closing, to address the problem of adequate resources
provided in a timely manner, the Independent Budget has once
again proposed funding for veterans' health care be removed
from the discretionary budget process and be made mandatory.
The budget and appropriations process over the last number of
years, and particularly this year, demonstrates conclusively
how the VA labors under the uncertainty of not only knowing how
much money it is going to get, but when it is going to get it.
In the end, it is easy to forget that the people who are
ultimately affected by the wrangling over the budget during
this process are the men and women who have served and
sacrificed so much in defense of this country.
Mr. Chairman, Senator Craig, I would like to thank you
again for the opportunity to testify, and I would be happy to
answer any questions that you might have.
[The prepared statement of Mr. Blake follows:]
Prepared Statement of Carl Blake, National Legislative Director,
Paralyzed Veterans of America
Mr. Chairman and Members of the Committee, as one of the four co-
authors of The Independent Budget, Paralyzed Veterans of America (PVA)
is pleased to present the views of The Independent Budget regarding the
funding requirements for the Department of Veterans Affairs (VA) health
care system for Fiscal Year 2008.
PVA, along with AMVETS, Disabled American Veterans, and the
Veterans of Foreign Wars, is proud to come before you this year marking
the beginning of the third decade of The Independent Budget, a
comprehensive budget and policy document that represents the true
funding needs of the Department of Veterans Affairs. The Independent
Budget uses commonly accepted estimates of inflation, health care costs
and health care demand to reach its recommended levels. This year, the
document is endorsed by 53 Veterans Service Organizations, and medical
and health care advocacy groups.
Last year proved to be a unique year for reasons very different
from 2005. The VA faced a tremendous budgetary shortfall during Fiscal
Year 2005 that was subsequently addressed through supplemental
appropriations and additional funds added to the Fiscal Year 2006
appropriations. For Fiscal Year 2007, the Administration submitted a
budget request that nearly matched the recommendations of The
Independent Budget. These actions simply validated the recommendations
of The Independent Budget once again.
Unfortunately, even as we testify today, Congress has yet to
complete the appropriations bill more than one-third of the way through
the current fiscal year. Despite the positive outlook for funding as
outlined in H.J. Res. 20, the Fiscal Year 2007 Continuing Resolution,
the VA has been placed in a critical situation where it is forced to
ration care and place freezes on hiring of much needed medical staff.
Waiting times have also continued to increase. Furthermore, the VA has
had to cannibalize other accounts in order to continue to provide
medical services, jeopardizing not only the VA health care system but
the actual health care of veterans. It is unconscionable that Congress
has allowed partisan politics and political wrangling to trump the
needs of the men and women who have served and continue to serve in
harm's way.
For Fiscal Year 2008, the Administration has requested $34.2
billion for veterans' health care, a $1.9 billion increase over the
levels established in H.J. Res. 20, the continuing resolution for
Fiscal Year 2007. Although we recognize this as another step forward,
it still falls well short of the recommendations of The Independent
Budget. For Fiscal Year 2008, The Independent Budget recommends
approximately $36.3 billion, an increase of $4.0 billion over the
Fiscal Year 2007 appropriation level yet to be enacted and
approximately $2.1 billion over the Administration's request.
The medical care appropriation includes three separate accounts--
Medical Services, Medical Administration, and Medical Facilities--that
comprise the total VA health-care funding level. For Fiscal Year 2008,
The Independent Budget recommends approximately $29.0 billion for
Medical Services. Our Medical Services recommendation includes the
following recommendations:
(Dollars in Thousands)
------------------------------------------------------------------------
------------------------------------------------------------------------
Current Services Estimate............................... $26,302,464
Increase in Patient Workload............................ 1,446,636
Increase in Full-time Employees......................... 105,120
Policy Initiatives...................................... 1,125,000
---------------
Total fiscal year 2008 Medical Services............. $28,979,220
------------------------------------------------------------------------
In order to develop our current services estimate, we used
the Obligations by Object in the President's Budget to set the
framework for our recommendation. We believe this method allows
us to apply more accurate inflation rates to specific accounts
within the overall account. Our inflation rates are based on 5-
year averages of different inflation categories from the
Consumer Price Index-All Urban Consumers (CPI-U) published by
the Bureau of Labor Statistics every month.
Our increase in patient workload is based on a 5.5 percent
increase in workload. This projected increase reflects the
historical trend in the workload increase over the last 5
years. The policy initiatives include $500 million for
improvement of mental health services, $325 million for funding
the fourth mission (an amount that nearly matches current VA
expenditures for emergency preparedness and homeland security
as outlined in the 2007 Mid-Session Review), and $300 million
to support centralized prosthetics funding.
For Medical Administration, The Independent Budget
recommends approximately $3.4 billion. Finally, for Medical
Facilities, The Independent Budget recommends approximately
$4.0 billion. This recommendation includes an additional $250
million above the Fiscal Year 2008 baseline in order to begin
to address the non-recurring maintenance needs of the VA.
Although The Independent Budget health-care recommendation
does not include additional money to provide for the health-
care needs of Category 8 veterans now being denied enrollment
into the system, we believe that adequate resources should be
provided to overturn this policy decision. VA estimates that
more than 1.5 million Category 8 veterans will have been denied
enrollment in the VA health-care system by Fiscal Year 2008.
Assuming a utilization rate of 20 percent, in order to reopen
the system to these deserving veterans, The Independent Budget
estimates that VA will require approximately $366 million. The
Independent Budget Veterans Service Organizations (IBVSO)
believe the system should be reopened to these veterans and
that this money should be appropriated in addition to our
Medical Care recommendation.
Although not proposed to have a direct impact on veterans'
health care, we are deeply disappointed that the Administration
chose to once again recommend an increase in prescription drug
copayments from $8 to $15 and an indexed enrollment fee based
on veterans' incomes. These proposals will simply add
additional financial strain to many veterans, including PVA
members and other veterans with catastrophic disabilities.
Although the VA does not overtly explain the impact of these
proposals, similar proposals in the past have estimated that
nearly 200,000 veterans will leave the system and more than
1,000,000 veterans will choose not to enroll. It is astounding
that this Administration would continue to recommend policies
that would push veterans away from the best health care system
in the world. Congress has soundly rejected these proposals in
the past and we call on you to do so once again.
For Medical and Prosthetic Research, The Independent Budget
is recommending $480 million. This represents a $66 million
increase over the Fiscal Year 2007 appropriated level
established in the continuing resolution and $69 million over
the Administration's request for Fiscal Year 2008. We are very
concerned that the Medical and Prosthetic Research account
continues to face a virtual flatline in its funding level.
Research is a vital part of veterans' health care, and an
essential mission for our national health care system. VA
research has been grossly underfunded in comparison to the
growth rate of other Federal research initiatives. We call on
Congress to finally correct this oversight.
The Independent Budget recommendation also recognizes a
significant difference in our recommended amount of $1.34
billion for Information Technology versus the Administration's
recommended level of $1.90 billion. However, when compared to
the account structure that The Independent Budget utilizes, the
Administration's recommendation amounts to approximately $1.30
billion. The Administration's request also includes
approximately $555 million in transfers from all three accounts
in Medical Care as well as the Veterans Benefits Administration
and the National Cemetery Administration. Unfortunately, these
transfers are only partially defined in the Administration's
budget justification documents. Given the fact that the
veterans' service organizations have been largely excluded from
the discussion of how the Information Technology reorganization
would take place and the fact that little or no explanation was
provided in last year's budget submission, our Information
Technology recommendation reflects what information was
available to us and the funding levels that Congress deemed
appropriate from last year. We certainly could not have
foreseen the VA's plan to shift additional personnel and
related operations expenses.
Finally, we remain concerned that the Major and Minor
Construction accounts continue to be underfunded. Although the
Administration's request includes a fair increase in Major
Construction from the expected appropriations level of $399
million to $727 million, it still does not go far enough to
address the significant infrastructure needs of the VA.
Furthermore, the actual portion of the Major Construction
account that will be devoted to Veterans Health Administration
infrastructure is only approximately $560 million. We also
believe that the Minor Construction request of approximately
$233 million does little to help the VA offset the rising tide
of necessary infrastructure upgrades. Without the necessary
funding to address minor construction needs, these projects
will become major construction problems in short order. For
Fiscal Year 2008, The Independent Budget recommends
approximately $1.6 billion for Major Construction and $541
million for Minor Construction.
In closing, to address the problem of adequate resources
provided in a timely manner, The Independent Budget has
proposed that funding for veterans' health care be removed from
the discretionary budget process and made mandatory. The budget
and appropriations process over the last number of years
demonstrates conclusively how the VA labors under the
uncertainty of not only how much money it is going to get, but,
equally important, when it is going to get it. No Secretary of
Veterans Affairs, no VA hospital director, and no doctor
running an outpatient clinic knows how to plan and even provide
care on a daily basis without the knowledge that the dollars
needed to operate those programs are going to be available when
they need them.
Making veterans health care funding mandatory would not
create a new entitlement, rather, it would change the manner of
health care funding, removing the VA from the vagaries of the
appropriations process. Until this proposal becomes law,
however, Congress and the Administration must ensure that VA is
fully funded through the current process. We look forward to
working with this Committee in order to begin the process of
moving a bill through the House, and the Senate, as soon as
possible.
In the end, it is easy to forget, that the people who are
ultimately affected by wrangling over the budget are the men
and women who have served and sacrificed so much for this
Nation. We hope that you will consider these men and women when
you develop your budget views and estimates, and we ask that
you join us in adopting the recommendations of The Independent
Budget.
This concludes my testimony. I will be happy to answer any
questions you may have.
Chairman Akaka. Thank you very much, Mr. Blake.
I want our witnesses to know that your full statements will
be included in the record.
Mr. Violante?
STATEMENT OF JOSEPH A. VIOLANTE, NATIONAL LEGISLATIVE DIRECTOR,
DISABLED AMERICAN VETERANS
Mr. Violante. Thank you, Mr. Chairman, Members of the
Committee. I am pleased to appear before you on behalf of
Disabled American Veterans to summarize our recommendations for
Fiscal Year 2008. As mentioned in my written statement, my
testimony focuses primarily on the Department of Veterans
Affairs benefit programs.
To improve administration of VA's benefit programs, the IB
recommends Congress provide the Veterans Benefits
Administration with total funding of $1.9 billion in Fiscal
Year 2008. Included in our funding recommendations are new
resources needed for additional VBA staffing, training
programs, and information technologies to correspond with a
more effective and efficient benefit delivery system. Mr.
Chairman, a core mission of the VA is to provide timely
financial disability compensation, dependency and indemnity
compensation, and disability pension benefits to veterans and
their family members and survivors. VA disability benefits are
critical to veterans and their families. We believe meeting the
needs of disabled veterans should always be a top priority of
the Federal Government.
Mr. Chairman, the backlog is unquestionably growing. Rather
than making headway and overcoming the chronic claims backlog
and subsequent protracted delays in disposition of claims, VA
actually has lost ground on the problem.
We believe that adequate staffing levels are essential to
any meaningful strategy to get claims processing and backlogs
under control. The IB recommends 10,675 employees for
Compensation and Pension.
Mr. Chairman, in addition to boosting its staffing, we
believe VBA must continue to upgrade its information technology
infrastructure and revise its training tools to stay abreast of
modern business practices to maintain efficiency and to meet
increasing workload demands. The IB, therefore, recommends that
Congress provide $115.4 million for VBA initiatives in Fiscal
Year 2008.
To meet its ongoing workload demands and to implement the
important initiatives that the VA Vocational Rehabilitation and
Employment Task Force recommended, VR&E needs increased
staffing. The task force recommended creation and training of
200 new staff position for this purpose. With its increased
reliance on contract services, VR&E also needs approximately 50
additional FTEE for management and oversight of contract
counselors and employment service providers.
VA has been striving to provide more timely and efficient
service to its claimants for education benefits. VBA must
increase staffing in its Educational Service to 1,033
employees.
The benefit programs are effective for their intended
purposes only to the extent that VBA can deliver benefits to
entitled veterans and dependents in a timely fashion. Congress
must make adjustments to benefit programs from time to time to
address increases in the cost of living and other needed
improvements. We invite your attention to our written statement
and the Independent Budget itself for details on those issues.
Mr. Chairman, my final concern today is a serious one to
the DAV, and also some of our sister organizations. The DAV
believes that each veteran who is awarded compensation is
entitled to the full payment and that no disabled veteran
should be forced to obtain a private attorney to secure an
accurate and humane disability rating from VA. Last year,
Congress passed Public Law 109-461, which opened the claims
process to attorneys.
We at DAV do not believe private attorneys will ease
resolution of veterans' claims--and I think the Secretary
agreed with that--reduce the claims backlog, nor get these
claims resolved on an expeditious basis--the historical intent
of Congress. We have been advised by professionals in VBA that
adding attorneys to the claims process will only complicate,
lengthen, and make resolution of veterans' disability claims
more difficult. How such a contentious new direction will
actually help sick disabled veterans is beyond our ability to
comprehend.
Mr. Chairman, thank you for inviting DAV and the other
member organizations of the Independent Budget to testify
before the Senate today. I would be happy to answer any
questions your Members may have.
[The prepared statement of Mr. Violante follows:]
Prepared Statement of Joseph A. Violante, National Legislative
Director, Disabled American Veterans
Mr. Chairman and Members of the Committee:
I am pleased to have this opportunity to appear before you on
behalf of the Disabled American Veterans (DAV), one of four national
veterans organizations that create the annual Independent Budget (IB)
for veterans programs, to summarize our recommendations for Fiscal Year
(FY) 2008.
As you know Mr. Chairman, the IB is a budget and policy document
that sets forth the collective views of DAV, AMVETS, Paralyzed Veterans
of America (PVA), and Veterans of Foreign Wars of the United States
(VFW). Each organization accepts principal responsibility for
production of a major component of our Independent Budget, but it is a
budget and policy document on which we all agree. Reflecting that
division of responsibility, my testimony focuses primarily on the
variety of Department of Veterans Affairs' (VA) benefits programs
available to veterans.
In preparing this 21st Independent Budget, the four partners draw
upon our extensive experience with veterans' programs, our firsthand
knowledge of the needs of America's veterans, and the information
gained from continuous monitoring of workloads and demands upon, as
well as the performance of, the veterans benefits and services system.
As a consequence, this Committee has acted favorably on many of our
recommendations to improve services to veterans and their families. We
ask that you give our recommendations full and serious consideration
again this year.
the veterans benefits administration is still understaffed
and overwhelmed
To improve administration of VA's benefits programs, the IB
recommends Congress provide the Veterans Benefits Administration (VBA)
$752 million in additional funding in Fiscal Year 2008 compared to the
existing Fiscal Year 2007 funding level (assumed at the time of
submission of this statement to be that level approved for VBA by the
other Body in H. J. Res. 20, the Continuing Resolution for Fiscal Year
2007, now pending consideration by the Senate). These additional funds,
which would raise total funding for VBA to $1.9 billion in Fiscal Year
2008, will provide the means to support a workable long-term strategy
for improvement in claims processing and more adequate staffing for the
discretionary programs under the jurisdiction of VBA. Included in our
funding recommendation are new resources needed for additional VBA
staff, training programs and information technologies to correspond
with a more effective and efficient benefits delivery system. In total,
if Congress accepts our recommendations for necessary funding increases
to the General Operating Funds account, these new funds would bring new
capabilities to VBA to better serve disabled veterans.
Mr. Chairman, a core mission of VA is to provide financial
disability compensation, dependency and indemnity compensation, and
disability pension benefits to veterans and their dependent family
members and survivors. These payments are intended by law to relieve
economic effects of disability (and death) upon veterans, and to
compensate their families for loss. For those payments to effectively
fulfill their intended purposes, VA should deliver them promptly and
based on sound adjudications. The ability of disabled veterans to feed,
clothe, and provide shelter for themselves and their families often
depends on VA benefits. Also, the need for financial support among
disabled veterans can be urgent. While awaiting action by VA on their
pending claims, they and their families must suffer hardships;
protracted delays can lead to privation and even bankruptcy and
homelessness. Some veterans have died while their claims for VA
disability compensation or pension were unresolved for years at VA. In
sum, VA disability benefits are critical to veterans and their
families, Mr. Chairman. We believe meeting the needs of disabled
veterans should always be a top priority of the Federal Government.
diversion from the real problem
Recently VA has adopted a tactic of diverting public attention away
from the growing claims backlog it holds by demonstrating great speed
and efficiency in adjudicating the claims of soldiers and Marines who
were severely wounded in the current conflicts in Iraq and Afghanistan.
While VA is crowing that it is breaking all records in awarding these
new veterans their rightful benefits, hundreds of thousands of claims
from older veterans of prior conflicts and military service during
earlier periods lie dormant, awaiting a vague future resolution. While
we applaud VA's efforts to help new veterans, VA continues to fail
older veterans every day that the backlog grows.
Mr. Chairman, the backlog is unquestionably growing. Rather than
making headway and overcoming the chronic claims backlog and consequent
protracted delays in disposition of its claims, VA actually has lost
ground on that problem. In fact, looking retrospectively over the past
6 years, the backlog of claims has moved from the December 2000 total
of 363,412, to the January 13, 2007 level of 606,239, a more than 80
percent increase during a period when three VA Secretaries of both
political parties have stated publicly on multiple occasions that
reducing this backlog was their highest management priority. We also
note that during this same period as these promises were being made in
public, VBA staffing has essentially remained flat at about 9,000 full-
time employee equivalents (FTEE). As late as 1 week ago,
representatives of our organizations heard senior VA officials brief us
on the President's Fiscal Year 2008 budget, with what we could only
call ``hopeful thinking'' that the backlog will be brought under
control, but without disclosing any particular plan to fulfill that
hope. It will not occur with the level of resources requested by the
Administration.
We believe that adequate staffing is essential to any meaningful
strategy to get claims processing and backlogs under control. The IB
recommends 10,675 FTEE for Compensation and Pension Service (C&P).
During Fiscal Year 2004 and Fiscal Year 2005, the total number of
compensation, pension, and burial claims received in C&P Service
increased by 9 percent, from 735,275 at the beginning of Fiscal Year
2003 to 801,960 at the end of Fiscal Year 2005. This represents an
average annual growth rate in claims of 4.5 percent. During this same
period, the number of pending claims requiring rating decisions
increased by more than 33 percent. As the VA Under Secretary for
Benefits has stated, ``[c]laims that require a disability rating
determination are the primary workload component because they are the
most difficult, time consuming, and resource intensive.'' With an aging
veteran population and escalating U.S. military operations in Iraq and
Afghanistan, we have no reason to believe that growth rate will
decline. With a 9 percent increase over the Fiscal Year 2005 number of
claims in 2006, VA should be expecting 874,136 claims in C&P Service in
Fiscal Year 2007. Moreover, legislation requiring VA to invite veterans
in six States to request review of past claims decisions and to require
VA to conduct outreach to invite new claims from other veterans in
these States will add substantially to the growing workload. Much of
this new workload carried over into Fiscal Year 2007. Also, the
Secretary's recent announcement of a special VA outreach effort to
ensure non-service connected disability pensioners become aware of
their potential eligibility for Aid and Attendance and Housebound
benefits is sure to add even more claims to the existing backlog. While
we appreciate such outreach efforts, as well as efforts to correct past
injustices that may have occurred in particular States, VBA has a co-
equal responsibility to ensure it maintains a system capable of
managing workload growth. We have not seen that system at work.
In its budget submission for Fiscal Year 2007, VBA projected
production based on an output of 109 claims per direct program FTEE. We
have long argued that VA's production requirements do not allow for
thorough development and careful consideration of disability claims,
resulting in compromised decisions, higher error and appeal rates, and
even more overload on the system. In addition to recommending staffing
levels more commensurate with the workload, we have maintained that VA
should invest more in training adjudicators and that it should hold
them accountable for higher standards of accuracy. In response to
survey questions from VA's Office of Inspector General, nearly half of
the VBA adjudicators responding admitted that many claims are decided
without adequate record development. They saw an incongruity between
their objectives of making legally correct and factually substantiated
decisions, with management objectives of maximizing output to meet
production standards and reduce backlogs. Nearly half reported that it
is generally, or very difficult, to meet production standards without
compromising quality. Fifty-seven percent reported difficulty meeting
production standards as they attempt to assure they have sufficient
evidence for rating each case and thoroughly reviewing the evidence.
Most attributed VA's inability to make timely and high quality
decisions to insufficient staff. Also they indicated that adjudicator
training had not been a high priority in VBA.
To allow for more time to be invested in training, we believe it
prudent to recommend staffing levels based on an output of 100 cases
per year for each direct program FTEE. With an estimated 930,000
incoming claims in Fiscal Year 2007, that effort would require 9,300
direct program FTEE in Fiscal Year 2008. With support FTEE added, this
would require C&P to be authorized 10,675 total FTEE for Fiscal Year
2008.
Instead of requesting the additional funds and personnel needed to
accomplish better results over the past 5 years, the Administration
sought, and Congress provided, fewer VBA resources. Recent budgets have
requested actual reductions in full-time employees--the workforce that
processes claims. Any reductions in VBA staffing would be clearly at
odds with the realities of VBA's growing workload and its own well-
established adjudication procedures. Adjudication of veterans' claims
is a labor-intensive and ``hands on'' system of personal
decisionmaking, with lifelong consequences for disabled veterans. These
management and political decisions to cut funding and reduce staffs
have contributed to a diminished VA's quality of claims processing and
to VA's loss of ground against its backlog. During Congressional
hearings, VA is routinely forced to defend VBA budgets that it knows to
be inadequate to the task at hand. The priorities and goals of the
immediate stagnation are at odds with the need for a long-term strategy
to fulfill VBA's mission and confirm the Nation's moral obligation to
disabled veterans.
Historically, many underlying causes have acted in concert to bring
on this seemingly intractable problem. These include poor management,
misdirected goals, lack of focus or the wrong focus on cosmetic fixes,
poor planning and execution, and outright denial of the existence of
the problem--rather than the development and execution of real
strategic measures. These dynamics have been thoroughly detailed in
several studies and reviews of the continuing problem, but they persist
without remedy. While the problem has been exacerbated by lack of
action, the IBVSOs believe most of the causes can be directly or
indirectly traced to availability of resources. The problem was
primarily triggered and is now perpetuated by chronic and insufficient
resources.
unmet needs in information technology
Mr. Chairman, in addition to boosting its staffing, we believe VBA
must continue to upgrade its information technology infrastructure and
revise its training tools to stay abreast of modern business practices,
to maintain efficiency, and to meet increasing workload demands. In
recent years, however, Congress has actually reduced funding for such
VBA initiatives. With restored investments in its initiatives, VBA
could complement staffing increases for higher workloads with a support
infrastructure designed to increase operational effectiveness. VBA
could resume an adequate pace in its development and deployment of
information technology solutions, as well as upgrade and enhance
training systems, to improve operations and service delivery. Some of
these initiatives for priority funding are:
Replacement of the antiquated and inadequate Benefits Delivery Network
(BDN) with VETSNET for C&P, The Education Expert System (TEES)
for Education Service, and Corporate WINRS (CWINRS) for VR&E
VETSNET serves to integrate several subsystems into one nationwide
information system for claims development and adjudication and payment
administration. TEES serves to provide for electronic transmission of
applications and enrollment documentation along with automated expert
processing. CWINRS is a case management and information system allowing
for more efficient award processing and sharing of information
nationwide.
Continued development and enhancement of data-centric benefits
integration with ``Virtual VA'' and modification of The Imaging
Management System (TIMS), which serve to replace paper-based
records with electronic files for acquiring, storing, and
processing claims data
Virtual VA supports pension maintenance activities at three Pension
Maintenance Centers. Further enhancement would allow for the entire
claims and award process to be accomplished electronically.
TIMS is the Education Service's system for electronic education
claims files, storage of imaged documents, and workflow management.
This initiative is to modify and enhance TIMS to make it fully
interactive to allow for fully automated claims and award processing by
Education Service and VR&E nationwide.
Upgrading and enhancement of training systems
VA's Training and Performance Support Systems (TPSS) is a
multimedia, multi-method training tool that applies Instructional
Systems Development (ISD) methodology to train and support employee
performance of job tasks. These TPSS applications require technical
updating to incorporate changes in laws, regulations, procedures, and
benefit programs. In addition to regular software upgrades, a help desk
for users is needed to make TPSS work effectively.
VBA initiated its ``Skills Certification'' instrument in 2004. This
tool aids VBA in assessing the knowledge base of Veterans Service
Representatives. VBA intends to develop additional skills certification
modules to test Rating Veterans Service Representatives, Decision
Review Officers, Field Examiners, Pension Maintenance Center employees,
and Education Veterans Claims Examiners.
Accelerated implementation of Virtual Information Centers (VICs)
By providing veterans regionalized telephone contact access from
multiple offices within specified geographic locations, VA achieves
greater efficiency and improved customer service. Accelerated
deployment of VICs will more timely accomplish this beneficial effect.
Congress has reduced funding for VBA initiatives every year since
2001, from $82 million in Fiscal Year 2001 to $23 million in Fiscal
Year 2006. The IB calls for restoration of funding for this purpose to
the 2001 level, with a 5 percent adjustment for each year to cover
inflation and increased demands upon the system. The IB therefore
recommends that Congress provide $115.4 million for VBA initiatives in
Fiscal Year 2008.
The record should show we made many of these same recommendations
last year, but unfortunately they did not attract supportive
appropriations. The lack of funding for these existing VBA priorities
manifests in reinforcing the existing backlogs and failing to serve
disabled veterans.
To meet its ongoing workload demands and to implement the important
new initiatives the VA Vocational Rehabilitation and Employment Task
Force recommended, VR&E needs increased staffing. As a part of its
strategy to enhance accountability and efficiency, the Task Force
recommended creation and training of 200 new staff positions for this
purpose. Other new initiatives recommended by the Task Force also
require an investment of personnel resources. With its increased
reliance on contract services, VR&E also needs approximately 50
additional FTE for management and oversight of contract counselors and
employment service providers.
VA has been striving to provide more timely and efficient service
to its claimants for education benefits. Though the workload (number of
applications and recurring certifications, etc.) increased by 11
percent during Fiscal Year 2004 and Fiscal Year 2005, direct program
FTEE were reduced from 708 at the end of Fiscal Year 2003 to 675 at the
end of Fiscal Year 2005. Based on experience during Fiscal Year 2004
and Fiscal Year 2005, it is very conservatively estimated that the
workload will increase by 5.5 percent in Fiscal Year 2008. VA must
increase staffing to meet the existing and added workload, or service
to veterans seeking educational benefits will decline. Based on the
number of direct program FTEE at the end of Fiscal Year 2003 in
relation to the workload at that time, VBA must increase direct program
staffing in its Education Service in Fiscal Year 2008 to 873 FTEE, 149
more direct program FTEE than authorized for Fiscal Year 2006. With the
addition of the 160 support FTEE as currently authorized, Education
Service should be provided 1,033 total FTEE for Fiscal Year 2008.
The benefit programs are effective for their intended purposes only
to the extent VBA can deliver benefits to entitled veterans and
dependents in a timely fashion. However, in addition to ensuring that
VBA has the resources necessary to accomplish its mission in that
manner, Congress must also make adjustments to the programs from time
to time to address increases in the cost of living and needed
improvements. We invite your attention to the IB itself for the details
of those issues, but the following summarizes a number of
recommendations to adjust rates and improve the benefit programs
administered by VBA:
<bullet> Cost-of-living adjustments for compensation, specially
adapted housing grants, and automobile grants, with provisions for
automatic annual increases in the housing and automobile grants based
on increases in the cost of living.
<bullet> A presumption of service connection for hearing loss and
tinnitus for combat veterans and veterans who had military duties
involving high levels of noise exposure who suffer from tinnitus or
hearing loss of a type typically related to noise exposure or acoustic
trauma.
<bullet> Removal of the provision that makes persons who first
entered service before June 30, 1985, ineligible for the Montgomery GI
Bill, along with other improvements to the program.
<bullet> No increase in, and eventual repeal of, funding fees for
VA home loan guaranty.
<bullet> Increase in the maximum coverage and adjustment of the
premium rates for Service-Disabled Veterans' Life Insurance.
<bullet> Increase in the maximum coverage available on policies of
Veterans' Mortgage Life Insurance.
<bullet> Legislation to restore protections for veterans' benefits
against awards to third parties in divorce actions.
<bullet> Legislation to increase Dependency and Indemnity
Compensation for certain survivors of veterans, and to no longer offset
DIC with Survivor Benefit Plan payments
We hope the Committee will review these recommendations and give
them consideration for inclusion in your legislative plans for 2007 and
will support their funding in the eventual Congressional Budget
Resolution for Veterans Benefits and Services for Fiscal Year 2008.
the federal appeals court for veterans claims
Another important component of our system of veterans' benefits is
the right to appeal VA's benefits decisions to an independent court.
The IB includes recommendations to improve the processes of judicial
review in veterans' benefits matters. Again, we invite the Committee's
attention to the IB for the details of these recommendations. In
addition, the IB recommends that Congress enact legislation to
authorize and fund construction of a courthouse and justice center for
the United States Court of Appeals for Veterans Claims.
a related and urgent concern: assured funding for va medical care
A continuing major concern of this Independent Budget is gaining
and keeping adequate funding for veterans medical care. Because the
Administration typically seeks funding substantially below the amount
necessary to maintain health care services for veterans and because
discretionary appropriations have continually fallen short of what is
needed, the IB supports legislation to fund VA medical care under a
mandatory account or an assured formula to obviate the political
wrangling we have observed every year for the past twelve fiscal years,
and now including this year as well. Pending his return to duties in
the Senate, Senator Tim Johnson of South Dakota has committed to the
veterans service organization community his pledge to again introduce a
bill this year that would resolve VA health care's chronic funding
shortages. Mr. Chairman, as soon as practicable, we urge you to
schedule a legislative hearing on this bill, and we ask for an
opportunity to testify on its merits.
the importance of national guard and reserve
Benefits Mr. Chairman, the decade-long trend of the Nation's
increasing reliance on National Guard, Air National Guard, and the
Reserve forces of the Army, Navy and Marine Corps, Air Force and Coast
Guard, for national security and disaster call-ups at home, and for
peacekeeping and combat deployments overseas, bears no sign of
abatement. Our reliance on Guard and Reserve forces has grown since the
pre-Persian Gulf War era, and this trend continues even though both
Reserve and active duty force levels remain far below their cold war
peak.
Since September 11, 2001, over 410,000 individuals who serve in
National Guard and Reserve forces have been mobilized for a variety of
military, police and security actions. Increasing demands on these
serving members impose significant and repeated family separations and
create additional uncertainties and interruptions in their civilian
career opportunities. Furthermore, Guard and Reserve recruiting,
retention, morale and readiness are already at considerable risk. The
Nation cannot afford to promote the perception that we undervalue the
great sacrifices and level of commitment being demanded from the Guard
and Reserve community.
Various incentive, service and benefit programs designed a half
century ago for a far different Guard and Reserve philosophy and
mission are no longer adequate to address demands on today's Guard and
Reserve forces. Accordingly, we believe steps must be taken by Congress
to upgrade National Guard and Reserve benefits and support programs to
a level commensurate with the sacrifices being made by these patriotic
volunteers. Such enhancements should provide Guard and Reserve
personnel a level of benefits comparable to their active duty
counterparts and provide one means to ease the tremendous stresses now
being imposed on Guard and Reserve members and their families, and to
bring the relevance of these benefits into 21st century application.
With concern about the current missions of the Guard and Reserve
forces, Congress must take necessary action to upgrade and modernize
Guard and Reserve benefits, to include more comprehensive health care,
equivalent Montgomery G.I. Bill educational benefits, and full
eligibility for the VA Home Loan guaranty program.
Mr. Chairman, the members of the serving Guard and Reserve forces
are now ``veterans'' for purposes of the benefits and services
authorized under Title 38, United States Code. However, the Code was
fashioned over the past 65 years primarily to address the needs of the
``citizen soldier,'' an individual who either enlisted in war or was
conscripted, served the minimum enlistment or period required, then
returned to civilian life as a veteran. The current generation of Guard
and Reserve members present very different needs as a consequence of
their service, and the kind and variety of service we demand of them as
a Nation. We ask the Senate to closely examine the needs of Guard and
Reserve members now serving and to consider measures to provide them
with effective benefits and services of a grateful government.
attorneys in va claims
Mr. Chairman, my final concern today is a serious one of DAV and
also of some of our sister organizations, but in deference to some that
take an alternate view, it is not a major issue in the Independent
Budget. As directed by law, VA has a duty to assist veterans in
developing and presenting their claims for disability. Congress
established the Federal Court discussed above to hear disputes that
arise after VA adjudicates those claims, and veterans possess the right
by law to appeal their disagreements with decisions and to redress
their grievances to a unique Board of Veterans Appeals. That self-
checking, unique, system exists because national veterans
organizations, including the IBVSOs, have insisted historically that
veterans' war injuries and other service-related health problems be
dealt with in a humane manner, and without friction or rancor to the
greatest extent practicable. Despite the problems we encounter in VBA
decisionmaking and operations as related above, we believe that design
works, although not as well as intended. The question before the Senate
is resources to empower those mechanisms to work better and additional
oversight to ensure it works as intended.
The DAV believes that each veteran who is awarded compensation is
entitled to full payment, and that no disabled veteran should be forced
to obtain a private attorney to secure an accurate and humane
disability rating from VA. Nevertheless, against the advice of the DAV
and others, last year in Public Law 109-461 Congress authorized private
attorneys and agents to engage for pay in veterans' disability claims
representation duties, opening the way for significantly altering the
foundations of the disability claims adjudication system--a system that
has been in place since the founding of the Nation. We at DAV continue
to believe this was an unwise action and ask for its repeal.
Mr. Chairman, on adoption of a motion by Representative Stevenson
Archer of Maryland, on December 22, 1813, the House of Representatives
established the predecessor to its current Committee on Veterans
Affairs, for the following stated purpose: ``to take into consideration
all such petitions, and matters, or things, touching military pensions,
and, also claims and demands originating in the Revolutionary War, or
arising therefrom, as shall be presented, or shall or may come in
question, and be referred to them by the House; and to report their
opinion thereupon together with such propositions for relief therein,
as to them shall seem expedient.'' [Emphasis added.] What this history
demonstrates, Mr. Chairman, is that almost 200 years ago Congress, then
playing a primitive executive role, intended to provide disabled
Revolutionary veterans their rightful relief--and with expediency.
While throughout our history that goal has never flagged, your 21st
century injection of private attorneys into that non-adversarial
process may serve to change it now.
We at DAV do not believe private attorneys will ease resolution of
veterans' claims, reduce the claims backlog, nor get these claims
resolved on an expedient basis--the historical intent of Congress. We
have been advised by professionals in VBA that your adding attorneys to
the claims system will only complicate, lengthen and make more
fractious the resolution of veterans' disability claims. As an
organization that furnishes 260 National Service Officers to aid
veterans with their claims, we believe our own work at DAV will be
compromised and made much more expensive once private lawyers enter in.
How such an inevitably contentious new direction will actually help
sick and disabled veterans receive their just compensation, pension and
survivor benefits, we cannot foretell, but we know it will not be easy.
We ask the Committee to take legislative action to repeal this measure
at the earliest date possible.
Mr. Chairman, thank you for inviting DAV and other member
organizations of the Independent Budget to testify before the Senate
today. I will be happy to answer any of your or other Members'
questions concerning these issues.
Chairman Akaka. Thank you very much, Mr. Violante.
Mr. Greineder?
STATEMENT OF DAVID G. GREINEDER, DEPUTY NATIONAL LEGISLATIVE
DIRECTOR, AMVETS
Mr. Greineder. Thank you. Mr. Chairman, Mr. Craig, Members
of the Committee, thank you for inviting AMVETS to this
important hearing on VA's budget request for Fiscal Year 2008.
As a co-author of the Independent Budget, AMVETS is pleased to
give you our best estimates on the resources necessary to carry
out the responsibilities of the National Cemetery
Administration.
The Administration requests approximately $167 million in
discretionary funding for operations and maintenance of the
NCA, $167.4 million for major construction, $24.4 million for
minor construction, as well as $32 million for the State
Cemetery Grants program. The members of the Independent Budget
recommend Congress provide $218.3 million for the operational
requirements of NCA, a figure that includes our National Shrine
Initiative. In total, our funding recommendation represents a
$51.5 million increase over the Administration's request.
The national cemetery system continues to be seriously
challenged. Adequate resources and developed acreage must keep
pace with the increasing workload. The NCA expects to perform
nearly 105,000 interments in 2008, an 8.4 percent increase
since 2006. By 2009, annual interments are expected to reach
117,000.
Congress also needs to address the need for gravesite
renovation and upkeep. Though there has been noteworthy
progress made over the years, the NCA is still struggling to
remove decades of blemishes and scars from military burial
grounds across the country. Congress has approved funding in
recent years aimed to restore the appearance of national
cemeteries, but, frankly, more needs to be done. Therefore, we
recommend Congress establish a 5-year, $250 million National
Shrine Initiative to restore and improve the condition and
character of NCA cemeteries. We recommend $50 million in Fiscal
Year 2008 to begin this important initiative. By enacting a 5-
year program with dedicated funds and an ambitious schedule,
the national cemetery system can fully serve all veterans and
their families with the utmost dignity, respect, and
compassion.
For funding the State Cemetery Grants Program, the
Independent Budget recommends $37 million for Fiscal Year 2008.
The State Cemetery Grants Program is an important component of
the NCA. It has greatly assisted States to increase burial
services to veterans, especially those living in less densely
populated areas not currently served by a national veterans
cemetery.
Many States have difficulty meeting the ``170,000 veterans
within 75 miles'' requirement from national cemeteries, which
is why the State grant program is so important. Since 1978, the
VA has more than doubled the acreage available and accommodated
more than a 100 percent increase in their burials through these
grants.
The Independent Budget also strongly recommends that
Congress review a series of burial benefits that have eroded in
value over the years. While these benefits were never intended
to cover the full cost of burial, they now pay for just 6
percent of what they covered in 1973. Our recommended increase
is modest and will restore the allowance to its original
proportion of burial expense, about 22 percent, and will tell
veterans that their sacrifice is given the appreciation that is
so well deserved.
The NCA honors veterans with a final resting place that
commemorates their service to this Nation. More than 2.7
million soldiers who died in every war and conflict are honored
by burial in a national cemetery. Our national cemeteries are
more than a final resting place. They are hallowed ground to
those who died in our defense and a memorial to those who
served.
Mr. Chairman, this concludes my statement. Thank you again.
[The prepared statement of Mr. Greineder follows:]
Prepared Statement of David G. Greineder,
Deputy National Legislative Director, AMVETS
Chairman Akaka, Ranking Member Craig, and Members of the Committee:
AMVETS is honored to join our fellow Veterans Service Organizations
and partners at this important hearing on the Department of Veterans
Affairs budget request for Fiscal Year 2008. My name is David G.
Greineder, Deputy National Legislative Director of AMVETS, and I am
pleased to provide you with our best estimates on the resources
necessary to carry out a responsible budget for VA.
AMVETS testifies before you as a co-author of The Independent
Budget. This is the 21st year AMVETS, the Disabled American Veterans,
the Paralyzed Veterans of America, and the Veterans of Foreign Wars
have pooled their resources together to produce a unique document, one
that has stood the test of time.
The IB, as it has come to be called, is our blueprint for building
the kind of programs veterans deserve. Indeed, we are proud that over
60 veteran, military, and medical service organizations endorse these
recommendations. In whole, these recommendations provide decisionmakers
with a rational, rigorous, and sound review of the budget required to
support authorized programs for our Nation's veterans.
In developing this document, we believe in certain guiding
principles. Veterans should not have to wait for benefits to which they
are entitled. Veterans must be ensured access to high-quality medical
care. Specialized care must remain the focus of VA. Veterans must be
guaranteed timely access to the full continuum of health care services,
including long-term care. And, veterans must be assured burial in a
state or national cemetery in every state.
Today, I will specifically address the National Cemetery
Administration (NCA); however, I would like to briefly comment on the
Administration's budget request coming out of the Office of Management
and Budget (OMB) just 3 days ago.
Everyone knows that the VA healthcare system is the best in the
country, and responsible for great advances in medical science. VHA is
uniquely qualified to care for veterans' needs because of its highly
specialized experience in treating service-connected ailments. The
delivery care system can provide a wide array of specialized services
to veterans like those with spinal cord injuries and blindness. This
type of care is very expensive and would be almost impossible for
veterans to obtain outside of VA.
Because veterans depend so much on VA and its services, AMVETS
believes it is absolutely critical that the VA healthcare system be
fully funded. It is important our Nation keep its promise to care for
the veterans who made so many sacrifices to ensure the freedom of so
many. With the expected increase in the number of veterans, a need to
increase VA health care spending should be an immediate priority this
year. We must remain insistent about funding the needs of the system,
and the recruitment and retention of vital health care professionals,
especially registered nurses. Chronic under funding has led to
rationing of care through reduced services, lengthy delays in
appointments, higher copayments and, in too many cases, sick and
disabled veterans being turned away from treatment.
Looking at the Administration's budget released last Monday, The
Independent Budget recommends Congress provide $36.3 billion to fund VA
medical care for Fiscal Year 2008. We ask you to recognize that the VA
healthcare system can only bring quality health care if it receives
adequate and timely funding.
The best way to ensure VA has access to adequate and timely
resources is through mandatory, or assured, funding. I would like to
clearly state that AMVETS along with its Independent Budget partners
strongly supports shifting VA healthcare funding from discretionary
funding to mandatory. We recommend this action because the current
discretionary system is not working. Moving to mandatory funding would
give certainty to healthcare services. VA facilities would not have to
deal with the uncertainty of discretionary funding, which has been
inconsistent and inadequate for far too long. Most importantly,
mandatory funding would provide a comprehensive and permanent solution
to the current funding problem.
the national cemetery administration
The Independent Budget acknowledges the dedicated and committed NCA
staff who continue to provide the highest quality of service to
veterans and their families despite funding shortfalls, aging
equipment, and increasing workload. The devoted staff provides aid and
comfort to hurting veterans' families in a very difficult time, and we
thank them for their consolation.
The NCA currently maintains more than 2.7 million gravesites at 124
national cemeteries in 39 states and Puerto Rico. At the end of 2007,
66 cemeteries will be open to all interments; 16 will accept only
cremated remains and family members of those already interred; and 43
will only perform interments of family members in the same gravesite as
a previously deceased family member.
VA estimates that about 27 million veterans are alive today. They
include veterans from World War I, World War II, the Korean War, the
Vietnam War, the Gulf War, the conflicts in Afghanistan and Iraq, and
the Global War on Terrorism, as well as peacetime veterans. With the
anticipated opening of the new national cemeteries, annual interments
are projected to increase from approximately 102,000 in 2006 to 117,000
in 2009. It is expected that one in every six of these veterans will
request burial in a national cemetery.
The NCA is responsible for five primary missions:
(1) To inter, upon request, the remains of eligible veterans and
family members and to permanently maintain gravesites;
(2) To mark graves of eligible persons in national, state, or
private cemeteries upon appropriate application;
(3) To administer the state grant program in the establishment,
expansion, or improvement of state veterans cemeteries;
(4) To award a Presidential certificate and furnish a United States
flag to deceased veterans; and
(5) to maintain national cemeteries as national shrines sacred to
the honor and memory of those interred or memorialized.
NCA Budget Request
The Administration requests $166.8 million for the NCA for Fiscal
Year 2008. The members of The Independent Budget recommend that
Congress provide $218.3 million and 30 FTE for the operational
requirements of NCA, the National Shrine Initiative, and the backlog of
repairs. We recommend your support for a budget consistent with NCA's
growing demands and in concert with the respect due every man and woman
who wears the uniform of the United States Armed Forces.
The national cemetery system continues to be seriously challenged.
Though there has been progress made over the years, the NCA is still
struggling to remove decades of blemishes and scars from military
burial grounds across the country. Visitors to many national cemeteries
are likely to encounter sunken graves, misaligned and dirty grave
markers, deteriorating roads, spotty turf and other patches of decay
that have been accumulating for decades. If the NCA is to continue its
commitment to ensure national cemeteries remain dignified and
respectful settings that honor deceased veterans and give evidence of
the Nation's gratitude for their military service, there must be a
comprehensive effort to greatly improve the condition, function, and
appearance of all our national cemeteries.
In accordance with ``An Independent Study on Improvements to
Veterans Cemeteries,'' which was submitted to Congress in 2002, The
Independent Budget again recommends Congress establish a 5-year, $250
million ``National Shrine Initiative'' to restore and improve the
condition and character of NCA cemeteries as part of the FY 2008
operations budget.
It should be noted that the NCA has done an outstanding job thus
far in improving the appearance of our national cemeteries, but we have
a long way to go to get us where we need to be. By enacting a 5-year
program with dedicated funds and an ambitious schedule, the national
cemetery system can fully serve all veterans and their families with
the utmost dignity, respect, and compassion.
the state cemetery grants program
The State Cemetery Grants Program (SCGP) complements the NCA
mission to establish gravesites for veterans in those areas where the
NCA cannot fully respond to the burial needs of veterans. Several
incentives are in place to assist states in this effort. For example,
the NCA can provide up to 100 percent of the development cost for an
approved cemetery project, including design, construction, and
administration. In addition, new equipment, such as mowers and
backhoes, can be provided for new cemeteries. Since 1978, the
Department of Veterans Affairs has more than doubled acreage available
and accommodated more than a 100 percent increase in burials through
this program.
To help provide reasonable access to burial options for veterans
and their eligible family members, The Independent Budget recommends
$37 million for the SCGP for Fiscal Year 2008. The availability of this
funding will help states establish, expand, and improve state-owned
veterans' cemeteries.
Many states have difficulties meeting the requirements needed to
build a national cemetery in their respective state. The large land
areas and spread out population in these areas make it difficult to
meet the ``170,000 veterans within 75 miles'' national veterans
cemetery requirement. Recognizing these challenges, VA has implemented
several incentives to assist states in establishing a veterans
cemetery. For example, the NCA can provide up to 100 percent of the
development cost for an approved cemetery project, including design,
construction, and administration.
Burial Benefits
There has been serious erosion in the value of the burial allowance
benefits over the years. While these benefits were never intended to
cover the full costs of burial, they now pay for only a small fraction
of what they covered in 1973, when the Federal Government first started
paying burial benefits for our veterans.
In 2001, the plot allowance was increased for the first time in
more than 28 years, to $300 from $150, which covers approximately 6
percent of funeral costs. The Independent Budget recommends increasing
the plot allowance from $300 to $745, an amount proportionally equal to
the benefit paid in 1973.
In the 108th Congress, the burial allowance for service-connected
deaths was increased from $500 to $2,000. Prior to this adjustment, the
allowance had been untouched since 1988. The Independent Budget
recommends increasing the service-connected burial benefit from $2,000
to $4,100, bringing it back up to its original proportionate level of
burial costs.
The non-service-connected burial allowance was last adjusted in
1978, and also covers just 6 percent of funeral costs. The Independent
Budget recommends increasing the non-service-connected burial benefit
from $300 to $1,270.
The NCA honors veterans with a final resting place that
commemorates their service to this Nation. More than 2.7 million
soldiers who died in every war and conflict are honored by burial in a
VA national cemetery. Each Memorial Day and Veterans Day we honor the
last full measure of devotion they gave for this country. Our national
cemeteries are more than the final resting place of honor for our
veterans, they are hallowed ground to those who died in our defense,
and a memorial to those who survived.
Mr. Chairman, this concludes my testimony. I thank you again for
the privilege to present our views, and I would be pleased to answer
any questions you might have.
Chairman Akaka. Thank you very much, Mr. Greineder.
And now Mr. Cullinan.
STATEMENT OF DENNIS M. CULLINAN, DIRECTOR, NATIONAL LEGISLATIVE
SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED STATES
Mr. Cullinan. Thank you very much, Chairman Akaka, Senator
Craig, distinguished Members of the Committee. It is certainly
a pleasure to be here today on behalf of the men and women of
the Veterans of Foreign Wars and the constituent members of the
Independent Budget to discuss our recommendations on
construction.
The Department of Veterans Affairs construction budget for
the past few years has been dominated by the CARES process.
Throughout CARES, the IBVSOs were greatly concerned with the
underfunding of the construction budget. Congress and the
Administration did devote many resources to VA's
infrastructure, preferring to wait for final results of CARES--
sorry--I meant to say, did not devote any resources to VA's
infrastructure.
In passing Independent Budgets, we warned against this,
pointing out that there were a number of legitimate
construction needs identified by local managers of VA
facilities. A number of facilities were authorized, but funding
was never appropriated with the ongoing CARES being used as the
primary excuse. Within this context, and while generally
appreciative of a good budget recommendation by the
Administration, we must point out that the Fiscal Year 2008
budget for the construction portion is far from adequate.
Chairman Akaka, you have our written statement. I will just
now highlight some of our major concerns in this context.
In putting our construction recommendations together, we
have our own in-house expertise, but we far from rely upon that
alone. We also consult people outside of the VSO community. We
look at things like the Pricewaterhouse study. The Presidential
Task Force on VA has been a terrific source of information with
respect to coming up with our calculations, our percentile
adjustments on VA construction.
When we are looking at the shape of VA facilities, we look
at VA's own Facility Condition Assessment document as best we
can lay our hands on it to come up with projections on that.
We can tell you that Pricewaterhouse among others have
pointed out that VA does not recapitalize its physical plant
quickly enough. The Presidential Task Force, for example,
recommends a recapitalization rate of 5 to 8 percent. I believe
that at this time VA only recapitalizes--keeps up its
infrastructure at a rate of about half of a percent, which
would mean an average VA facility would have to last about 155
years.
For the medical portion of the construction budget, the IB
recommends a 4 percent recapitalization rate. Well, that is
about $1.4 billion. To emphasize this, we point to the fact
that in 2004, then-Secretary Principi said before the House
Veterans' Affairs Committee that major construction for VA
under CARES would have to be at $1 billion a year for 5 years
to keep up. In 2004, the VA got about $750 million for this
purpose, and in subsequent years it was only about $.5 billion
a year. So it is far below what was needed.
With respect to major construction for medical care, this
year the President's budget only asks for about $5.11 million
for medical care, and it is far below what we are asking for,
as I just mentioned the amount of $1.4 billion, which is
actually a rather modest request.
Lastly, we would point to the fact that the 2007 capital
plan, that would only fund 8 of the partially funded projects
out of the top list of 20. Furthermore, in the 2008 capital
plan, again, the President's budget recommendation is only $511
million. This would only fund 6 projects of the 12 partially
funded that, as I just mentioned, are receiving some funding.
Six others are not funded at all. And in that Capital Asset
Plan, with respect to scored projects, those projects which
have some sort of priority of attention, none of 27 is funded.
So, in short, there is no funding for new projects in the 2008
budget. We find that to be highly problematic.
I will touch briefly on minor construction. The Capital
Plan illuminates some 300 projects. The IB calls for $450
million to address these--again, a modest request. We point to
the fact that the Administration's budget for this purpose
would only be about $180 million, again, for VHA.
Another point here, in the initial planning document of
CARES, it was there indicated that VA should have $2 billion
under minor construction alone. Again, it is clear that we are
falling behind in this capacity.
Mr. Blake earlier talked about non-recurring maintenance.
Again, this is a very serious concern. Industry standard, this
should occur at about a rate of 2 to 4 percent per year or $800
million to $1.6 billion. The VA's own Capital Asset Management
Plan indicates $800 million to $1.6 billion a year in keeping
with that calculation. Again, the Administration's budget only
calls for about $573 million, falling far short.
There are other things I would like to touch on, Mr.
Chairman, but I see the red light blinking. Thank you very
much.
[The prepared statement of Mr. Cullinan follows:]
Statement of Dennis M. Cullinan, Director, National Legislative
Service, Veterans of Foreign Wars of the United States
On behalf of the 2.4 million men and women of the Veterans of
Foreign Wars of the United States (VFW), this Nation's largest combat
veterans' organization, I would like to thank you for the opportunity
to testify today on the Fiscal Year 2008 budget for the Department of
Veterans Affairs (VA).
The VA construction budget has, for the past few years, been
dominated by the Capital Asset Realignment for Enhanced Services
(CARES) process.
CARES is a system-wide, data-driven assessment of VA's capital
infrastructure. It aimed to identify the needs of veterans to aid in
the planning of future and realignment of current VA facilities to most
efficiently meet those needs. It was not just a one-time evaluation but
also the creation of a process and framework to continue to determine
veterans' future requirements.
Throughout the entire CARES process, The Independent Budget
Veterans Service Organizations (IBVSOs) were highly supportive, as long
as VA emphasized the ``ES''--enhanced services--portion of the acronym.
<bullet> 2001--CARES pilot study in Network 12 (Chicago, Illinois;
Wisconsin; and Upper Michigan) completed.
<bullet> 2002--Phase II of CARES began in all other networks of VA
individually, to be compiled in the Draft National CARES Plan.
<bullet> 2003--August: Draft National CARES Plan submitted to CARES
Commission to review and gather public input.
<bullet> 2004--February: VA Secretary receives CARES Commission
recommendations.
<bullet> 2004--May: VA Secretary announces his decision on CARES,
but calls for additional ``CARES Business Plan Studies'' at 18 sites
throughout the country.
These CARES Business Plan Studies are available on VA's CARES Web
site, www.va.gov/cares. As of December 2006, only ten of these studies
have been completed, despite VA's stated June 2006 deadline. The IBVSOs
look forward to the final results so that implementation of these
important plans can go forward.
The IBVSOs believe that all decisions on CARES should be consistent
with the CARES Decision document and its established priorities, or
with the findings of the CARES Review Commission that largely confirmed
those priorities. Proposed changes or deviation from the plan should
undergo the same rigorous data validation as the original projects.
CARES was intended to be an apolitical, data-driven process that
looked out for the best interest of veterans throughout the entire
system. We are certainly pleased that the Secretary and Members of
Congress are interested in the future of VA capital facilities, but we
urge all involved to maintain consistency with the apolitical process
that, as agreed to by all parties--stakeholders included--would provide
the best way to determine future VA infrastructure needs to
sufficiently care for all veterans. This was the hallmark of the CARES
plan.
Throughout the CARES process, the IBVSOs were greatly concerned
with the underfunding of the construction budget. Congress and the
Administration did not devote many resources to VA's infrastructure,
preferring to wait for the final results of CARES. In past Independent
Budgets we warned against this, pointing out that there were a number
of legitimate construction needs identified by the local manager of VA
facilities. A number of facilities were authorized, including House
passage of the ``Veterans Hospital Emergency Repair Act,'' but funding
was never appropriated, with the ongoing CARES review being used as the
primary excuse.
At the time, the IBVSOs argued that a de facto moratorium on
construction was unnecessary because of our conviction that a number of
these projects needed to go forward and that they would be fully
justified in any future plans produced through CARES. Despite this
reasonable argument, funding never came, and VA lost progress on
hundreds of millions of dollars that otherwise would have been invested
to meet the system's critical infrastructure needs.
The IBVSOs continue to believe that this deferral of all major VA
construction projects was poor policy. In the five-plus years the
process took, construction and maintenance improvements lagged far
beyond what the system truly needed. With CARES nearly complete,
funding has not yet been proposed by the Administration nor approved by
Congress to address the very large project backlog that has grown.
We note this year that both Veterans' Committees have considered
legislation that would authorize resumption of VA major medical
facility construction projects, but with the breakdown of the
appropriations process, these projects died with the end of the 109th
Congress.
In July 2004, VA Secretary Anthony Principi testified before the
Health Subcommittee of the House Committee on Veterans' Affairs. In his
testimony, he noted that CARES ``reflects a need for additional
investments of approximately $1 billion per year for the next 5 years
to modernize VA's medical infrastructure and enhance veterans' access
to care.'' Since that statement, however, the amount actually
appropriated by Congress for VA major medical facility construction has
fallen far short of that goal; in Fiscal Year 2007, the Administration
recommended a paltry $399 million for major construction.
After that 5-year de facto moratorium and without additional
funding coming forth, VA facilities have an even greater need than they
did at the start of the CARES process. Accordingly, we urge the
Administration and the Congress to live up to the Secretary's words by
making a steady investment in VA's capital infrastructure to bring the
system up to date with the needs of 21st century veterans.
For major construction, the IBVSOs recommend $1.602 billion in
funding. This includes funding for the projects on VA's priority list,
advanced planning, and for construction costs for a number of new
national cemeteries in accordance with the NCA strategic plan.
------------------------------------------------------------------------
Funding (dollars
Category in thousands)
------------------------------------------------------------------------
CARES................................................. 1,400,000
Master Planning....................................... 20,000
Advanced Planning..................................... 45,000
Asbestos.............................................. 5,000
Claims Analyses....................................... 3,000
Judgment Fund......................................... 2,000
Hazardous Waste....................................... 2,000
National Cemetery Administration...................... 95,000
Staff Offices......................................... 5,000
Historic Preservation................................. 25,000
-----------------
Total............................................. $1,602,000
------------------------------------------------------------------------
For minor construction, the IBVSOs recommend a total of
$541 million, the bulk of which will go toward the more than
100 minor construction projects identified by VA in its 5-year
capital plan in Fiscal Year 2008.
------------------------------------------------------------------------
Funding (dollars
Category in thousands)
------------------------------------------------------------------------
CARES/Non-CARES....................................... 450,000
National Cemetery Administration...................... 40,000
Veterans Benefits Administration...................... 35,000
Staff................................................. 6,000
Advanced Planning..................................... 10,000
-----------------
Total............................................. $541,000
------------------------------------------------------------------------
Department of Veterans Affairs (VA) does not have adequate provisions
to protect against deterioration and declining capital asset
value.
The last decade of underfunded construction budgets has led to a
reduction in the recapitalization of VA's facilities. Recapitalization
is necessary to protect the value of VA's capital assets by renewing
the physical infrastructure to ensure safe and fully functional
facilities. Failure to adequately invest in the system will result in
its deterioration, creating even greater costs down the road.
As in past years, we continue to cite the Final Report of the
President's Task Force to Improve Health Care Delivery for our Nation's
veterans (PTF). The PTF noted that in the period from 1996-2001, VA's
recapitalization rate was 0.64 percent, which corresponds to an assumed
building life of 155 years. When maintenance and restoration are
factored into VA's major construction budget, VA annually invests less
than 2 percent of plant replacement value in the system. The PTF
observed that a minimum of 5 to 8 percent per year is necessary to
maintain a healthy infrastructure and that failure to adequately fund
could lead to unsafe, dysfunctional settings.
Congress and the Administration must ensure that there are adequate
funds for major and minor construction so that VA can properly reinvest
in its capital assets to protect their value and ensure that health
care can be provided in safe and functional facilities long into the
future.
The deterioration of many Department of Veterans Affairs (VA)
properties requires increased spending on nonrecurring
maintenance.
A Pricewaterhouse study looked at VA facilities management and
recommended that VA spend at least 2 to 4 percent of its plant
replacement value on upkeep. Nonrecurring maintenance (NRM) consists of
small projects that are essential to the proper maintenance and to the
preservation of the life span of VA's facilities. Examples of these
projects include maintenance to roofs, replacement of windows, and
upgrades to the mechanical or electrical systems.
Each year, VA grades each medical center, creating a facility
condition assessment (FCA). These FCAs give a letter grade to various
systems at each facility and assign a cost estimate associated with
repairs or replacement. The latest FCAs have identified $4.9 billion
worth of necessary repairs in projects with a letter grade of ``D'' or
``F.'' F's must be taken care of immediately, and D's are in need of
serious repairs or represent pieces of equipment reaching the end of
their usable life. Most of these projects would be reparable using NRM
funds.
Another concern with NRM is with how it is allocated. NRM is under
the Medical Care account and is distributed to various VISNs through
the Veterans Equitable Resource Allocation (VERA) process. While this
does move the money toward the areas with the highest demand for health
care, it tends to move money away from facilities with the oldest
capital structures, which generally need the most maintenance. It also
could increase the tendency of some facilities to use maintenance money
to address shortfalls in medical care funding.
VA should spend $1.6 billion on NRM to make up for the lack of
proper funding in previous years and to keep VA on the right track with
maintenance for the future.
VA must also resist the temptation to dip into NRM funding for
health-care needs, as this could lead to far greater expenses down the
road.
Veterans and staff continue to occupy buildings known to be at
extremely high risk because of seismic deficiencies.
The Independent Budget Veterans Service Organizations (IBVSOs)
continue to be concerned with the seismic safety of the Department of
Veterans Affairs (VA) facilities. The July 2006 Seismic Design
Requirements report noted the existence of 73 critical VA facilities
that, based on FEMA definitions, are at a ``moderately high'' or
greater risk of seismic incident. Twenty-four of these have been deemed
``very high'' risk, the highest standard.
To address the safety of veterans and employees, VA includes
seismic corrections in its annual list of projects to Congress. In
conjunction with the Capital Asset Realignment for Enhanced Services
process, progress is being made on eight of these facilities. More is
needed, and, accordingly, funding will need to increase.
For efficiency, most seismic correction projects should also
include patient care enhancements as part of their total scope. Seismic
correction typically includes lengthy and widespread disruption to
hospital operations; it would be prudent to make medical care
improvements at the same time to minimize disruptions in the future.
While this approach is the most practical for the delivery of health
care and services as well as for cost-effectiveness, it also results in
higher upfront project costs, which would require an increase in the
construction budget.
Congress must appropriate adequate construction funding to correct
these critical seismic deficiencies.
VA should schedule facility improvement projects concurrently with
seismic corrections.
Each Department of Veterans Affairs (VA) medical center needs to
develop a detailed master plan.
This year's construction budget should include at least $20 million
to fund architectural master plans. Without these plans, the Capital
Asset Realignment for Enhanced Services (CARES) medical benefits will
be jeopardized by hasty and short-sighted construction planning.
The Independent Budget Veterans Service Organizations believe that
each VA medical center should develop a facility master plan to serve
as a clear roadmap to where the facility is going in the future. It
should be an inclusive document that includes multiple projects for the
future in a cohesive strategy.
In many cases, VA plans construction in a reactive manner. Projects
are funded first and then fitted onto the site. Each project is planned
individually and not necessarily with respect to other ongoing projects
or ones planned for the future. It is essential that each medical
center has a plan that looks at the big picture to efficiently utilize
space and funding. If all projects are not simultaneously planned, for
example, the first project may be built in the best site for the second
project. Master plans would prevent short-sighted construction that
restricts, rather than expands, future options.
Every new project in the master plan is a step in achieving the
long-range CARES objectives. These plans must be developed so that all
future projects can be prioritized, coordinated and phased. They are
essential to efficiently use resources, but also to minimize disruption
to VA patients and employees. Medical priorities, for example, must be
adjusted for construction sequencing. If infrastructure changes must
precede new construction, master plans will identify this so that
schedules and budgets can be adjusted. Careful phasing is essential to
avoid disrupting the delivery of medical care, and the correct planning
of such will ensure that cost estimates of this phased-construction
approach will be more accurate.
There may be cases, too, where master planning will challenge the
original CARES decisions, whether due to changing demand, unidentified
need, or other cause. If CARES, for example, calls for the use of
renovated space for a relocated program and a more comprehensive
examination as part of a master plan later indicates that the site is
impractical, different options should be considered. Master plans will
help to correct and update invalid planning assumptions.
VA must be mindful that some CARES plans involve projects
constructed at more than one medical center. Master plans, as a result,
most coordinate the priorities of both medical centers. Construction of
a new SCI facility, for example, might be a high priority for the
``gaining'' facility, but a lower priority for the ``donor'' facility.
It may be best to fund and plan the two actions together, even though
they are split between two different facilities.
Another essential role of master planning is its use to account for
three critical programs that VA left out of the initial CARES process:
long-term care, severe mental illness, and domiciliary care. Because
these were omitted, there is a strong need for a comprehensive plan,
and a full facility master plan will help serve as a blueprint for each
facility's needs in these essential areas.
VA must ensure that each medical center develops and continues to
work on long-range master plans to validate strategic planning
decisions, prepare accurate budgets, and implement efficient
construction that minimizes wasted expenses and disruptions to patient
care.
Congress must appropriate $20 million to allow each VA medical
facility to develop architectural master plans to serve as roadmaps for
the future.
Each facility master plan should address long-term care, including
plans for those with severe mental illness, and domiciliary care
programs, which were omitted from the CARES process.
VA must develop a format for these master plans so that there is
standardization throughout the system, even though planning work will
be performed by local contractors in each Veterans Integrated Service
Network.
The Department of Veterans Affairs (VA) must develop a strategic plan
for the infrastructure needs of these important programs.
The initial Capital Asset Realignment for Enhanced Services (CARES)
plan did not take long-term care or the mental health considerations of
veterans into account when making recommendations. We were pleased that
the CARES Review Commission recognized the need for proper accounting
of these critical components of care in VA's future infrastructure
planning. However, we continue to await VA's development of a long-term
care strategic plan to meet the needs of aging veterans. The Commission
recommended that VA ``develop a strategic plan for long-term care that
includes policies and strategies for the delivery of care in
domiciliary, residential treatment facilities and nursing homes, and
for older seriously mentally ill veterans.''
Moreover, the Commission recommended that the plan include
strategies for maximizing the use of state veterans' homes, locating
domiciliary units as close to patient populations as feasible and
identifying freestanding nursing homes as an acceptable care model. In
absence of that plan, VA will be unable to determine its future capital
investment strategy for long-term care.
VA must take a proactive approach to ensure that the infrastructure and
support networks needed by veterans will be there for them in
the future.
We also concur with the CARES Commission's recommendations that VA
take action to ensure consistent availability of mental health services
across the system to include mental health care at community-based
clinics along with the appropriate infrastructure to match demand for
these specialized services. This is important in light of the growing
demand for these types of services, especially among those returning
from overseas in the wars in Iraq and Afghanistan.
VA must develop a long-term care strategic plan to account for the
needs of aging veterans now and into the future. This should include
care options for older veterans with serious mental illnesses.
VA must also develop plans to provide for the infrastructure needs
associated with mental health care services, especially with the
unprecedented current need for these services, and the likely
tremendous long-term need of our returning servicemembers.
The Department of Veterans Affairs (VA) must not use empty space
inappropriately.
Studies have suggested that the VA medical system has extensive
amounts of empty space that can be reused for medical services. It has
also been suggested that unused space at one medical center may help
address a deficiency that exists at another location. Although the
space inventories are accurate, the assumption regarding the
feasibility of using this space is not.
Medical facility planning is complex. It requires intricate design
relationships for function, but also because of the demanding
requirements of certain types of medical equipment. Because of this,
medical facility space is rarely interchangeable, and if it is, it is
usually at a prohibitive cost. Unoccupied rooms on the eighth floor,
for example, cannot be used to offset a deficiency of space in the
second floor surgery ward. Medical space has a very critical need for
inter- and intradepartmental adjacencies that must be maintained for
efficient and hygienic patient care.
When a department expands or moves, these demands create a domino
effect of everything around it, and these secondary impacts greatly
increase construction expense and they can disrupt patient care.
Some features of a medical facility are permanent. Floor-to-floor
heights, column spacing, light, and structural floor loading cannot be
altered. Different aspects of medical care have different requirements
based upon these permanent characteristics. Laboratory or clinical
spacing cannot be interchanged with ward space because of the needs of
different column spacing and perimeter configuration. Patient wards
require access to natural light and column grids that are compatible
with room-style layouts. Labs should have long structural bays and
function best without windows. When renovating empty space, if the area
is not suited to its planned purpose, it will create unnecessary
expenses and be much less efficient.
Renovating old space rather than constructing new space creates
only a marginal cost savings. Renovations of a specific space typically
cost 85 percent of what a similar, new space would. When you factor in
the aforementioned domino or secondary costs, the renovation can end up
costing more and produce a less satisfactory result. Renovations are
sometimes appropriate to achieve those critical functional adjacencies,
but it is rarely economical.
Many older VA medical centers that were rapidly built in the 1940s
and 1950s to treat a growing veteran population are simply unable to be
renovated for more modern needs. Most of these Bradley-style buildings
were designed before the widespread use of air conditioning and the
floor-to-floor heights are very low. Accordingly, it's impossible to
retrofit them for modern mechanical systems. They also have long,
narrow wings radiating from a small central core, which is an
inefficient way of laying out rooms for modern use. This central core,
too, has only a few small elevator shafts, complicating the vertical
distribution of modern services.
Another important problem with this unused space is its location.
Much of it is not located in a prime location; otherwise it would have
been previously renovated or demolished for new construction. This
space is typically located in outlying buildings or on upper floor
levels and is unsuitable for modern use.
VA should develop a plan for addressing its excess space in non-
historic properties that are not suitable for medical or support
functions due to their permanent characteristics or locations.
The Department of Veterans Affairs (VA) must continue to develop and
revise facility design guides for spinal cord injury/spinal
cord disorders.
With the largest health-care system in the U.S., VA has an
advantage in its ability do develop, evaluate, and refine the design
and operation of its many facilities. Every new clinic's design can
benefit from lessons learned from the construction and operation of
previous clinics. VA also has the unique opportunity to learn from
medical staff, engineers, and from its users--veterans and their
families--as to what their needs are, allowing them to generate
improvements to future designs.
As part of this, VA provides design guides for certain types of
facilities that provide care to veterans. These guides are rough tools
used by the designer, clinician, staff, and management during the
design process. These design guides, which are viewable on the
Facilities Management Web page, cover a variety of types of care.
These design guides, due to modernization of equipment and lessons
learned at other facilities, should be revised regularly. Some of the
design guides have not been updated in over a decade, despite the
massive transition of the VA health-care system from an inpatient-based
system. The Independent Budget Veterans Service Organizations (IBVSOs)
understand that VA intends to regularly update these guides, and we
would urge that increased funding be allocated to the Advanced Planning
Fund to revise and update these essential guides.
As in past years, the IBVSOs would note the need for guides for
long-term care at spinal cord injury/dysfunction (SCI/D) centers. It is
important that these guides be separate from the guides that call for
acute care as the needs of the two are dramatically different.
These facilities must be less institutional in their character with
a more homelike environment. Rooms and communal space should be
designed to accommodate patients who will be living at these facilities
for a long time. They must include simple ideas that would improve the
daily life of these patients. Corridor length should be limited. They
should include wide areas with windows to create tranquil places or
areas to gather. Centers should have courtyard areas where the climate
is temperate and indoor solariums where it is not. We believe that a
complete guideline for these facilities would also include a discussion
of design philosophies that emphasize the quality of life of these
patients, and not just the specific criteria for each space. Because
the type of care these patients need is unique, it is essential that
this type of design guidance is available to contracted architects.
VA must revise and update their design guides on a regular basis.
VA should develop a long-term care design guide for SCI/D centers
to accommodate the special needs of these unique patients.
The Department of Veterans Affairs' extensive inventory of historic
structures must be protected and preserved.
VA has an extensive inventory of historic structures, which
highlight America's long tradition of providing care to veterans. These
buildings and facilities enhance our understanding of the lives of
those who have worn the uniform, and who helped to develop this great
Nation. Of the approximately 2,000 historic structures, many are
neglected and deteriorate year after year because of a lack of funding.
These structures should be stabilized, protected, and preserved because
of their importance.
Most of these facilities are not suitable for modern patient care,
and, as a result, a preservation strategy was not included in the
Capital Asset Realignment for Enhanced Services process. As a first
step in addressing its responsibility to preserve and protect these
buildings, VA must develop a comprehensive program for these historic
properties.
VA must make an inventory of these properties, classifying their
physical condition and their potential for adaptive reuse. Medical
centers, local governments, nonprofit organizations or private sector
businesses could potentially find a use for these important structures
that would preserve them into the future.
The Independent Budget Veterans Service Organizations recommend
that VA establish partnerships with other Federal departments, such as
the Department of the Interior, and with private organizations, such as
the National Trust for Historic Preservation. Their expertise would be
helpful in creating this new program.
As part of its adaptive reuse program, VA must ensure that
facilities that are leased or sold are maintained properly for
preservation's sake. VA's legal responsibilities could, for example, be
addressed through easements on property elements, such as building
exteriors or grounds. We would point to the partnership between the
Department of the Army and the National Trust for Historic Preservation
as an example of how VA could successfully manage its historic
properties.
P.L. 108-422, the Veterans Health Programs Improvement Act,
authorized historic preservation as one of the uses of a new capital
assets fund that receives funding from the sale or lease of VA
property. We applaud its passage, and encourage its use.
VA must begin a comprehensive program to preserve and protect its
inventory of historic properties.
We thank you for allowing us to testify today, and we would be
happy to answer any questions that you or the Committee may have.
Chairman Akaka. Thank you. Thank you very much for your
testimony.
Mr. Robertson?
STATEMENT OF STEVE ROBERTSON, DIRECTOR, NATIONAL LEGISLATIVE
COMMISSION, AMERICAN LEGION
Mr. Robertson. Thank you, Mr. Chairman, for the invitation.
I would like to submit also for the record my official opening
remarks, and instead I would like to talk more to the issues
that were addressed at the initial panel.
The comment about change, I have been here 19 years working
in the legislative arena, and in that 19 years, there has been
a lot of change. When I first came here, the biggest complaint
I got from legionnaires around the country was the quality of
care in the VA system. Now, people are trying to get into the
system, and that is their biggest complaint. The quality of
care is superb, and it is well documented. But a lot of the
changes we have made have been good changes. Senator Craig, the
only thing that I have not seen change is the way we go about
funding the system, and that is driving me insane. I will give
you an example: third-party collections.
You know, when eligibility reform was passed in 1996, it
was a good idea. It opened the system and made it easier to get
the quality of care, the right place, the right type of care.
It moved to an outpatient system where we were being proactive
rather than reactive to treating patients, and we looked at
ways to fund this. And at the time of eligibility reform, we
really thought we were going to get Medicare reimbursements. We
thought we would be reimbursed by all the insurance companies
that participated. We even thought that the veterans that did
not have insurance would be able to pay some toward the health
care that they got.
But, unfortunately, what we wound up with was a third-party
collection goal that is very rarely achieved and is deducted
from the appropriations. So, I mean, yes, we made a good
change, but it turned around biting us. When you have a
shortage in third-party collections, that is a real shortage.
The issue of this enrollment fee--and I hear terms being
switched around, calling it a ``premium'' or ``enrollment''
fee--what it is, is a user fee. You are paying to be able to
use the system. And, unfortunately, there are service-connected
veterans that are in Priority Groups 7 and 8, and at the
rollout, I asked a specific question: ``Would the 0 percent
service-connected non-compensable be required to pay the
enrollment fee?'' And the answer was yes. And I would encourage
the Committee to write that question and get it in black and
white from the Secretary so we have it documented for the
record.
Medicare-eligible people that pay Part A, Part B, and Part
D would also have to pay the Government once again to access
the system that many of them were in the Greatest Generation
that saved the country. And you are going to require them to
pay this extra fee to the Government.
Then you have got other people that have other insurance,
TRICARE, TRICARE for Life, FEHBP. If they want to come to the
VA, ``the best health care system in the country,'' you are
going to tack on whatever amount of money that they are going
to have to pay as an additional user fee for a system that they
are entitled to have.
You also have veterans that file a claim, a disability
claim, and they are waiting on that claim to be decided. They
may also be Priority Group 8s or 7s, and you are, again, asking
them to pay while you are waiting for their claim to be
finalized.
Then you have recently separated veterans that did not
serve in OEF/OIF. They may not even be able to enroll because
they did not go overseas.
The one thing I learned about the military is once you
raise your hand and say, ``I will serve this country,'' from
that point on you do not have another decision in the military
except when you are ready to leave. So where you get assigned
is not your choice. It is the Government's choice. But yet
these veterans, even though their honorable military service
may have occurred in a missile field in North Dakota, they are
being denied access to a system that they should have access
to.
The increased number of claims, Senator Craig, that you
asked about, that is kind of a self-induced thing because now
we have said that the only way you can enroll in the system is
if you are service-connected or economically indigent. So it is
an incentive for people to file a claim so that they can
qualify to go to the system that was there for them from the
very beginning.
There is also a lot of people who are facing up to
disabilities that they previously had ignored. They were doing
the John Wayne thing, you know: ``I fought the war. I won. I
will go home now.'' But now whatever medical condition is
manifested to where they need to have access to the system.
There are also court decisions that drive claims to be
reprocessed through that had originally been denied, but
because of medical research, whatever, those claims now are
valid. So they were denied initial access, and that is why they
are refiling their claim, because it is the right thing to do.
Mr. Chairman, I got to tell you, you have got a tough act
to follow in Senator Craig. In my 19 years, I don't remember a
Chairman holding as many hearings as Senator Craig held as
Chairman. So you have got a tough act to follow. But you have
got the staff and the people around you to make it work.
Senator Craig. I am here to help him. There will be more.
[Laughter.]
Mr. Robertson. Thank you, Mr. Chairman. That concludes my
remarks.
[The prepared statement of Mr. Robertson follows:]
Prepared Statement of Steve Robertson, Director,
National Legislative Commission, American Legion
Mr. Chairman and Members of the Committee:
I thank you for this opportunity to present the views of its 2.7
million members on the President's Fiscal Year 2008 budget request.
The President's Fiscal Year 2008 budget request is designed to
allow VA to address its three highest priorities:
<bullet> Provide timely, high-quality health care to veterans who
need VA the most--those with service-connected disabilities, lower
incomes, special health care needs, and service in Operation Iraqi
Freedom and Operation Enduring Freedom.
<bullet> Address the significant increase in claims for
compensation and pension.
<bullet> Ensure the burial needs of veterans and their eligible
family members are met, and maintain veterans' cemeteries as national
shrines.
The American Legion will continue to work with the Secretary,
Congress and the entire veterans' community to ensure that VA is indeed
capable of providing the highest quality health care services ``. . .
for him who shall have borne the battle and for his widow and his
orphan.'' In 1996, Eligibility Reform was enacted to reopen the VA
health care system to all eligible veterans within existing
appropriations. Therefore, the challenge faced is to make sure no
veteran in need of health care is ever turned away from a VA medical
care facility as a result of budgetary shortfalls.
There is no question that all service-connected disabled veterans
and economically disadvantaged veterans must receive timely access to
quality health care; however, their comrades-in-arms should also
receive their earned benefit--enrollment in the VA health care delivery
system. Rather than supporting legislative proposals designed to drive
veterans from the world's best health care delivery system, The
American Legion will continue to advocate new revenue streams to allow
any veteran to receive VA health care.
Equally as important, The American Legion remains steadfastly in
support of achieving timely adjudication of VA disability claims and
pensions. As a nation at war, the expectation of an increase in the
number of new disability claims is apparent. The newest generation of
wartime veterans rightly deserve timely adjudication of their claims.
Again, the Secretary, Congress and the veterans' community must work
toward meaningful solutions to the ever-increasing backlog of veterans'
disability claims. Increased funding and additional staffing is a solid
first step toward change.
The American Legion fully supports the goals of the National
Cemetery Administration. The addition of new national cemeteries and
state veterans' cemeteries is critical in meeting the growing need.
With that in mind, The American Legion offers the following
budgetary recommendations for selected discretionary programs within
the Department of Veterans Affairs for Fiscal Year 2008:
----------------------------------------------------------------------------------------------------------------
President's
Program FY06 Funding Request Legion's Request
----------------------------------------------------------------------------------------------------------------
Medical Care.............................................. $30.8 billion 36.6 billion 38.4 billion
Medical Services.......................................... 22.1 billion 27.2 billion 29 billion
Medical Administration.................................... 3.4 billion 3.4 billion 3.4 billion
Medical Facilities........................................ 3.3 billion 3.6 billion 3.6 billion
Medical Care Collections.................................. (2 billion) (2.4 billion) 2.4 billion*
Medical and Prosthetics Research.......................... 412 million 411 million 472 million
Construction:
Major..................................................... 1.6 billion 727 million 1.3 billion
Minor..................................................... 233 million 233 million 279 million
State Extended Care Facilities Grant Program.............. 85 million 85 million 250 million
State Veterans' Cemetery Grants Program................... 32 million 32 million 42 million
National Cemetery Administration.......................... 149 million 166 million 178 million
General Administration.................................... 294 million 274 million 300 million
Information Technology.................................... 1.2 billion 1.9 billion 1.9 billion
----------------------------------------------------------------------------------------------------------------
*Third-party reimbursements should supplement rather than offset discretionary funding.
medical care
The Department of Veterans Affairs' standing as the Nation's leader
in providing safe, high-quality health care in the health care industry
(both public and private) is well documented. Now VA is also recognized
internationally as the benchmark for health care services:
<bullet> December 2004, RAND investigators found that VA
outperforms all other sectors of the U.S. health care industry across a
spectrum of 294 measures of quality in disease prevention and
treatment;
<bullet> In an article published in the Washington Monthly (Jan./
Feb. 2005) ``The Best Care Anywhere'' featured the VA health care
system;
<bullet> In the prestigious Journal of the American Medical
Association (May 18, 2005) noted that VA's health care system has ``. .
. quickly emerged as a bright star in the constellation of safety
practice, with system-wide implementation of safe practices, training
programs and the establishment of four patient-safety research
centers.'';
<bullet> The U.S. News and World Report (July 18, 2005) issue
included a special report on the best hospitals in the country titled
``Military Might--Today's VA Hospitals Are Models of Top-Notch Care''
highlighting the transformation of VA health care;
<bullet> The Washington Post (Aug. 22, 2005) ran a front-page
article titled ``Revamped Veterans' Health Care Now a Model''
spotlights VA health care accomplishments;
<bullet> In 2006, VA received the highly coveted and prestigious
``Innovations in American Government'' Award from Harvard's Kennedy
School of Government for its advanced electronic health records and
performance measurement system; and
<bullet> Recently, in January 2007, the medical journal Neurology
wrote: ``The VA has achieved remarkable improvements in patient care
and health outcomes, and is a cost-effective and efficient
organization.''
Although VA is considered a national resource, the Secretary of
Veterans Affairs continues to prohibit the enrollment of any new
Priority Group 8 veterans, even if they are Medicare-eligible or have
private insurance coverage. This prohibition is not based on their
honorable military service, but rather on limited resources provided to
the VA medical care system. For 2 years following receiving an
honorable discharge, veterans from Operations Enduring Freedom and
Iraqi Freedom are able to receive health care through VA, but many of
their fellow veterans and those of other armed conflicts may very well
be denied enrollment due to limited existing appropriations. This is
truly a national tragedy.
As the Global War on Terrorism continues, fiscal resources for VA
will continue to be stretched to their limits and veterans will
continue to go to their elected officials requesting additional money
to sustain a viable VA capable of caring for all veterans, not just the
most severely wounded or economically disadvantaged. VA is often the
first experience veterans have with the Federal Government after
leaving the military. This Nation's veterans have never let this
country down; Congress and VA should do its best to not let veterans
down.
The President's budget request for Fiscal Year 2008 calls for
Medical Care funding to be $36.6 billion, which is about $1.8 billion
less than The American Legion's recommendation of $38.4 billion. The
major difference is the President's budget requests continues to offset
the discretionary appropriations by its Medical Care Collection Fund's
goal ($2.4 billion), whereas The American Legion considers this
collection as a supplement since it is for the treatment of nonservice-
connected medical conditions.
Medical Services
The President's budget request assumes the enrollment of new
Priority Group 8 veterans will remain suspended. The American Legion
strongly recommends reconsidering this ``lockout'' of eligible
veterans, especially for those veterans who are Medicare-eligible,
military retirees enrolled in TRICARE or TRICARE for Life, or have
private health care coverage. Successful seamless transition from
military service should not be penalized, but rather encouraged. This
prohibition sends the wrong message to recently separated veterans. No
eligible veteran should be ``locked out'' of the VA health care
delivery system.
The VA health care system enjoys a glowing reputation as the best
health care delivery system in the country, so why ``lock out'' any
eligible veteran, especially those that have the means to reimburse VA
for services received? New revenue streams from third-party
reimbursements and copayments can supplement the ``existing
appropriations,'' but sound fiscal management initiatives are required
to enhance third-party collections of reasonable charges.
In Fiscal Year 2008, VA expects to treat 5.8 million patients (an
increase of 2.4 percent). According to the President's budget request,
VA will treat over 125,000 more Priority 1-6 veterans in 2008
representing a 3.3 percent increase over the number of these priority
veterans treated in 2007. Priority 7 and 8 veterans are projected to
decrease by over 15,000 or 1.1 percent from 2007 to 2008. However, VA
will provide medical care to non-veterans; this population is expected
to increase by over 24,000 patients or 4.8 percent over this same time
period. In 2008, VA anticipates treating 263,000 Operation Iraqi
Freedom (OIF) and Operation Enduring Freedom (OEF) veterans, an
increase of 54,000 patients, or 25.8 percent, over the 2007 level.
The American Legion supports the President's mental health
initiative to provide $360 million to deliver mental health and
substance abuse care to eligible veterans in need of treatment of
seriously mental illness, to include post-traumatic stress disorder.
The American Legion remains opposed to the concept of charging an
enrollment fee for an earned benefit. Although the President's new
proposal is a tiered approach targeted at Priority Groups 7 and 8
veterans currently enrolled, the proposal does not provide improved
health care coverage, but rather creates a fiscal burden for the 1.4
million Priority Groups 7 and 8 patients. This initiative clearly
projects further reductions in the number of Priority Groups 7 and 8
veterans leaving the system for other health care alternatives. This
proposed vehicle for gleaning of veterans would apply to both service-
connected disabled veterans as well as nonservice-connected disabled
veterans in Priority Groups 7 and 8.
The American Legion also remains opposed to the President's
proposed increase in VA pharmacy copays from the current $8 to $15 for
enrolled Priority Groups 7 and 8 veterans. This proposal would nearly
double current pharmacy costs to this select group of veterans.
The American Legion recommends $29 billion for Medical Services,
$1.8 billion more than the President's budget request of $27.2 billion.
Medical Administration
The President's budget request of $3.4 billion is a slight increase
in Fiscal Year 2006 funding level. VA plans to transfer 3,721 full-time
equivalents from Medical Administration to Information Technology in
Fiscal Year 2008. The American Legion applauds the President
recommending this level of funding.
Medical Facilities
The President's budget request of $3.6 billion is about $234
million more than the Fiscal Year 2006 funding level. The American
Legion agrees with this recommendation to maintain VA existing
infrastructure of 4,900 buildings and over 15,700 acres. In Fiscal Year
2008, VA will transfer 5,689 full-time equivalents from Medical
Facilities to Medical Services. It has been determined that the costs
incurred for hospital food service workers, provisions and related
supplies are for the direct care of patients which Medical Services is
responsible for providing.
Medical Care Collection Fund (MCCF)
The Balanced Budget Act of 1997, Public Law 105-33, established the
VA Medical Care Collections Fund (MCCF), requiring that amounts
collected or recovered from third-party payers after June 30, 1997 be
deposited into this fund. The MCCF is a depository for collections from
third-party insurance, outpatient prescription copayments and other
medical charges and user fees. The funds collected may only be used for
providing VA medical care and services and for VA expenses for
identification, billing, auditing and collection of amounts owed the
Federal Government. The American Legion supported legislation to allow
VA to bill, collect, and reinvest third-party reimbursements and
copayments; however, The American Legion adamantly opposes the scoring
of MCCF as an offset to the annual discretionary appropriations since
the majority of the collected funds come from the treatment of
nonservice-connected medical conditions. Historically, these collection
goals far exceed VA's ability to collect accounts receivable.
In Fiscal Year 2006, VA collected nearly $2 billion, a significant
increase over the $540 million collected in Fiscal Year 2001. VA's
ability to capture these funds is critical to its ability to provide
quality and timely care to veterans. Miscalculations of VA required
funding levels results in real budgetary shortfall. Seeking annual
emergency supplemental is not the most cost-effective means of funding
the Nation's model health care delivery system.
Government Accountability Office (GAO) reports have described
continuing problems in VHA's ability to capture insurance data in a
timely and correct manner and raised concerns about VHA's ability to
maximize its third-party collections. At three medical centers visited,
GAO found an inability to verify insurance, accepting partial payment
as full, inconsistent compliance with collections follow-up,
insufficient documentation by VA physicians, insufficient automation
and a shortage of qualified billing coders were key deficiencies
contributing to the shortfalls. VA should implement all available
remedies to maximize its collections of accounts receivable.
The American Legion opposes offsetting annual VA discretionary
funding by the arbitrarily set MCCF goal, especially since VA is
prohibited from collecting any third-party reimbursements from the
Nation's largest federally mandated, health insurer--Medicare.
Medicare Reimbursement
As do most American workers, veterans pay into the Medicare system
without choice throughout their working lives, including active-duty. A
portion of each earned dollar is allocated to the Medicare Trust Fund
and although veterans must pay into the Medicare system, VA is
prohibited from collecting any Medicare reimbursements for the
treatment of allowable, nonservice-connected medical conditions. This
prohibition constitutes a multi-billion dollar annual subsidy to the
Medicare Trust Fund. The American Legion does not agree with this
policy and supports Medicare reimbursement for VHA for the treatment of
allowable, nonservice-connected medical conditions of allowable
enrolled Medicare-eligible veterans.
As a minimum, VA should receive credit for saving the Centers for
Medicare and Medicaid Services billions of dollars in annual mandatory
appropriations.
medical and prothestics research
The American Legion believes that VA's focus in research should
remain on understanding and improving treatment for conditions that are
unique to veterans. The Global War on Terrorism is predicted to last at
least two more decades. Servicemembers are surviving catastrophically
disabling blast injuries in Iraq, Afghanistan and elsewhere due to the
superior armor they are wearing in the combat theater and the timely
access to quality triage. The unique injuries sustained by the new
generation of veterans clearly demands particular attention. There have
been reported problems of VA not having the state-of-the-art
prostheses, like DOD, and that the fitting of the prostheses for women
has presented a problems due to their smaller stature.
In addition, The American Legion supports adequate funding for
other VA research activities, including basic biomedical research as
well as bench-to-bedside projects. Congress and the Administration
should encourage acceleration in the development and initiation of
needed research on conditions that significantly affect veterans--such
as prostate cancer, addictive disorders, trauma and wound healing,
post-traumatic stress disorder, rehabilitation, and others jointly with
DOD, the National Institutes of Health (NIH), other Federal agencies,
and academic institutions.
The American Legion recommends $472 million for Medical and
Prosthetics Research in Fiscal Year 2008, $61 million more than the
President's budget request of $411 million.
construction
Major Construction
Over the past several years, Congress has kept a tight hold on the
purse strings that control the funding needs for the construction
program within VA. The hold out, presumably, is the development of a
coherent national plan that will define the infrastructure VA will need
in the decades to come. VA has developed that plan and it is CARES. The
CARES process identified more than 100 major construction projects in
37 states, the District of Columbia, and Puerto Rico. Construction
projects are categorized as major if the estimated cost is over $7
million. Now that VA has a plan to deliver health care through the year
2022, it is up to Congress to provide adequate funds. The CARES plan
calls for, among other things, the construction of new hospitals in
Orlando and Las Vegas and replacement facilities in Louisville and
Denver for a total cost estimate of well over $1 billion alone for
these four facilities. VA has not had this type of progressive
construction agenda in decades. Major construction money can be
significant and proper utilization of funds must be well planned out.
The American Legion is pleased to see six medical facility projects
(Pittsburgh, Denver, Orlando, Las Vegas, Syracuse, and Lee County, FL)
included in this budget request.
In addition to the cost of the proposed new facilities are the many
construction issues that are virtually ``put on hold'' for the past
several years due to inadequate funding and the moratorium placed on
construction spending by the CARES process. One of the most glaring
shortfalls is the neglect of the buildings sorely in need of seismic
correction. This is an issue of safety. Hurricane Katrina taught a very
real lesson on the unacceptable consequences of procrastination. The
delivery of health care in unsafe buildings cannot be tolerated and
funds must be allocated to not only construct the new facilities, but
also to pay for much-needed upgrades at existing facilities. Gambling
with the lives of veterans, their families and VA employees is
absolutely unacceptable.
The American Legion believes that VA has effectively shepherded the
CARES process to its current state by developing the blueprint for the
future delivery of VA health care--it is now time for Congress to do
the same and adequately fund the implementation of this comprehensive
and crucial undertaking.
The American Legion recommends $1.3 billion for Major Construction
in Fiscal Year 2008, $573 million more than the President's budget
request of $727 million to fund more pending ``life-safety'' projects.
Minor Construction
VA's minor construction program has suffered significant neglect
over the past several years as well. The requirement to maintain the
infrastructure of VA's buildings is no small task. Because the
buildings are old, renovations, relocations and expansions are quite
common. When combined with the added cost of the CARES program
recommendations, it is easy to see that a major increase over the
previous funding level is crucial and well overdue.
The American Legion recommends $279 million for Minor Construction
in Fiscal Year 2008, $46 million more than the President's budget
request of $233 million to address more CARES proposal minor
construction projects.
capital asset realignment for enhanced services (cares)
In March 1999, GAO published a report on VA's need to improve
capital asset planning and budgeting. GAO estimated that over the next
few years, VA could spend one of every four of its health care dollars
operating, maintaining, and improving capital assets at its national
major delivery locations, including 4,700 buildings and 18,000 acres of
land nationwide.
Recommendations stemming from the report included the development
of asset-restructuring plans for all markets to guide future investment
decisionmaking, among other initiatives. VA's answer to GAO and
Congress was the initiation and development of the Capital Asset
Realignment for Enhanced Services (CARES) program.
The CARES initiative is a blueprint for the future of VHA--a fluid,
work in progress, in constant need of reassessment. In May 2004, the
long awaited final CARES decision was released. The decision directed
VHA to conduct 18 feasibility studies at those health care delivery
sites where final decisions could not be made due to inaccurate and
incomplete information. VHA contracted PricewaterhouseCoopers (PwC) to
develop a broad range of viable options and, in turn, develop business
plans based on a limited number of selected options. To help develop
those options and to ensure stakeholder input, then-VA Secretary
Principi constituted the Local Advisory Panels (LAPs), which are made
up of local stakeholders. The final decision on which business plan
option will be implemented for each site lies with the Secretary of
Veterans Affairs.
The American Legion is dismayed over the slow progress in the LAP
process and the CARES initiative overall. Both Stage I and Stage II of
the process include two scheduled LAP meetings at each of the sites
being studied with the whole process concluding on or about February
2006.
It wasn't until April 2006, after nearly a 7-month hiatus, that
Secretary Nicholson announced the continuation of the services at Big
Spring, Texas, and like all the other sites, has only been through
Stage I. Seven months of silence is no way to reassure the veterans'
community that the process is alive and well. The American Legion
continues to express concern over the apparent short-circuiting of the
LAPs and the silencing of the stakeholders. The American Legion intends
to hold accountable those who are entrusted to provide the best health
care services to the most deserving population--the Nation's veterans.
Upon conclusion of the initial CARES process, then-Secretary
Principi called for a ``billion dollars a year for the next 7 years''
to implement CARES. The American Legion continues to support that
recommendation and encourages VA and Congress to ``move out'' with
focused intent.
state extended care facility grants program
Since 1984, nearly all planning for VA inpatient nursing home care
has revolved around State Veterans' Homes and contracts with public and
private nursing homes. The reason for this is obvious; VA paid a per
diem of $59.48 for each veteran it placed in State Veterans' Homes,
compared to the $354 VA pays to maintain a veteran for 1 day in its own
nursing home care units.
Under the provisions of title 38, United States Code, VA is
authorized to make payments to states to assist in the construction and
maintenance of State Veterans' Homes. Today, there are 109 State
Veterans' Homes in 47 states with over 23,000 beds providing nursing
home, hospital, and domiciliary care. Grants for Construction of State
Extended Care Facilities provide funding for 65 percent of the total
cost of building new veterans homes. Recognizing the growing long-term
health care needs of older veterans, it is essential that the State
Veterans' Home Program be maintained as a viable and important
alternative health care provider to the VA system. The American Legion
opposes any attempts to place moratoria on new State Veterans' Home
construction grants. State authorizing legislation has been enacted and
state funds have been committed. The West Los Angeles State Veterans'
Home, alone, is a $125 million project. Delaying this and other
projects could result in cost overruns from increasing building
materials costs and may result in states deciding to cancel these much
needed facilities.
The American Legion supports:
<bullet> Increasing the amount of authorized per diem payments to
50 percent for nursing home and domiciliary care provided to veterans
in State Veterans' Homes;
<bullet> The provision of prescription drugs and over-the-counter
medications to State Veterans' Homes Aid and Attendance patients along
with the payment of authorized per diem to State Veterans' Homes; and
<bullet> Allowing for full reimbursement of nursing home care to 70
percent service-connected veterans or higher, if the veteran resides in
a State Veterans' Home.
The American Legion recommends $250 million for the State Extended
Care Facility Construction Grants Program in Fiscal Year 2008, $165
million more than the President's budget request. This additional
funding will address more pending life-safety projects and new
construction projects.
state cemetery grants program
The State Veterans' Cemetery Grant Program is not intended to
replace National Cemeteries, but to complement them. Grants for state-
owned and operated cemeteries can be used to establish, expand and
improve on existing cemeteries. States are planning to open 24 new
state veterans' cemeteries between 2007 and 2012. There are 60
operational cemeteries and two more under construction. Since NCA
concentrates its construction resources on large metropolitan areas, it
is unlikely that new national cemeteries will be constructed in all
states. Therefore, individual states are encouraged to pursue
applications for the State Cemetery Grants Program. Fiscal commitment
from the state is essential to keep the operation of the cemetery on
track. NCA estimates it takes about $300,000 a year to operate a state
cemetery.
The American Legion recommends $42 million for the State Cemetery
Grants Program in Fiscal Year 2008, $10 million more than the
President's budget request.
national cemetery administration
The mission of the National Cemetery Administration is to honor
veterans with final resting places in national shrines and with lasting
tributes that commemorate their service to this Nation. The National
Cemetery Administration's vision is to serve all veterans and their
families with the utmost dignity, respect, and compassion. Every
national cemetery should be a place that inspires visitors to
understand and appreciate the service and sacrifice of this Nation's
veterans.
National Cemetery Expansion
The American Legion supported P.L. 108-109, the National Cemetery
Expansion Act of 2003, authorizing VA to establish new national
cemeteries to serve veterans in the areas of: Bakersfield, Calif.;
Birmingham, Ala.; Jacksonville, Fla.; Sarasota County, Fla.;
southeastern Pennsylvania; and Columbia-Greenville, S.C. All six areas
have veterans' populations exceeding 170,000, which is the threshold VA
has established for new national cemeteries. By 2009, all six new
national cemeteries should be open to serve veterans in these areas.
There are approximately 24 million veterans alive today. Nearly
688,000 veteran deaths are estimated to occur in 2008. The total number
of graves maintained by VA is expected to increase from 2.8 million in
2006 to just over 3.2 million by 2012. The VA expects that at least 12
percent of these veterans will request burial in a national cemetery.
Considering the growing costs of burial services and the excellent
quality of service the NCA is providing, The American Legion foresees
that this percentage will be much greater. By 2012, four more national
cemeteries are expected to exhaust their supply of available,
unassigned gravesites.
Congress must provide sufficient major construction appropriations
to permit NCA to accomplish its stated goal of ensuring that burial in
a national or state cemetery is a realistic option by locating
cemeteries within 75 miles of 90 percent of eligible veterans.
National Shrine Commitment
Maintaining cemeteries as National Shrines is one of NCA's top
priorities. This commitment involves raising, realigning and cleaning
headstones and markers to renovate gravesites. The work that has been
done so far has been outstanding; however, adequate funding is key to
maintaining this very important commitment. The American Legion
supports NCA's goal of completing the National Shrine Commitment within
5 years. This commitment includes the establishment of standards of
appearance for national cemeteries that are equal to the standards of
the finest cemeteries in the world. Operations, maintenance and
renovation funding must be increased to reflect the true requirements
of the NCA to fulfill this commitment.
The American Legion recommends $178 million for the National
Cemetery Administration in Fiscal Year 2008, $12 million more than the
President's budget request.
information technology
The data theft that occurred in May of last year serves as a
monumental wake up call to the Nation. VA can no longer ignore IT
security. The recovery of the laptop is indeed cause for optimism;
however, we must not discount the possibility that every name on that
list could still be subject to possible identity theft. The complete
overhaul of VA IT is only in its beginning stages. Meanwhile, there are
still unresolved security breaches within VA including the most recent
theft of a laptop from a VA contractor. How many computers need to be
stolen before veterans get some real assurances from the Federal
Government that their information is not only safe, but that safeguards
will be in place to help protect them against identity theft? The
American Legion once again calls on VA and the Administration to keep
its promise to veterans and provide free credit monitoring for 1 year.
The American Legion is hopeful that the steps VA takes to strengthen
its IT security will renew the confidence and trust of veterans who
depend on VA for the benefits they have earned.
Funding for the IT overhaul should not be paid for with money from
other VA programs. This would in essence make veterans pay for VA's
gross negligence in the matter. The American Legion hopes that Congress
will not attempt to fix this problem on the backs of America's veterans
and from scarce fiscal resources provided to the VA health care
delivery.
VA has shown it can be a leader in the areas of care and service.
Its accomplishments, from providing high quality medical care to
leading the world in the development of electronic records, are
indicators that VA can also be the Nation's leader in IT security.
The American Legion believes that there should be a complete review
of IT security governmentwide. VA isn't the only agency within the
government that needs to overhaul its IT security protocol. The
American Legion would urge Congress to exercise its oversight authority
and review each Federal agency to ensure that the personal information
of all Americans is secure.
The American Legion agrees with the President's budget request for
$1.9 billion for Information Technology in Fiscal Year 2008.
va's long-term care mission
Historically, VA's Long-Term Care (LTC) has been the subject of
discussion and legislation for nearly two decades. In a landmark July
1984 study, Caring for the Older Veteran, it was predicted that a wave
of elderly veterans had the potential to overwhelm VA's long-term care
capacity. Further, the recommendations of the Federal Advisory
Committee on the Future of Long-Term Care in its 1998 report VA Long-
Term Care at the Crossroads, made recommendations that serve as the
foundation for VA's national strategy to revitalize and reengineer
long-term care services. It is now 2006 and that wave of veterans has
arrived.
Additionally, Public Law 106-117, the Millennium Act, enacted in
November 1999, required VA to continue to ensure 1998 levels of
extended care services (defined as VA nursing home care, VA
domiciliary, VA home-based primary care, and VA adult day health care)
in its facilities. Yet, VA has continually failed to maintain the 1998
bed levels mandated by law.
VA's inability to adequately address the long-term care problem
facing the agency was most notable during the CARES process. The
planning for the long-term care mission, one of the major services VA
provides to veterans, was not even addressed in the CARES initiative.
That CARES initiative is touted as the most comprehensive analysis of
VA's health care infrastructure that has ever been conducted.
Incredibly, despite 20 years of forewarning, the CARES Commission
report to the VA Secretary states that VA has yet to develop a long-
term care strategic plan with well-articulated policies that address
the issues of access and integrated planning for the long-term care of
seriously mentally ill veterans. The Commission also reported that VA
had not yet developed a consistent rationale for the placement of long-
term care units. It was not for the lack of prior studies that VA has
never had a coordinated long-term care strategy. The Secretary's CARES
decision agreed with the Commission and directed VHA to develop a
strategic plan, taking into consideration all of the complexities
involved in providing such care across the VA system.
The American Legion supports the publishing and implementation of a
long-term care strategic plan that addresses the rising long-term care
needs of America's veterans. We are, however, disappointed that it has
now been over 2 years since the CARES decision and no plan has been
published.
It is vital that VA meet the long-term care requirements of the
Millennium Health Care Act and we urge this Committee to support
adequate funding for VA to meet the long-term care needs of America's
Veterans. The American Legion supports the President's $4.6 billion
funding recommendation for Fiscal Year 2008.
homeless veterans
VA has estimated that there are at least 250,000 homeless veterans
in America and approximately 500,000 experience homelessness in a given
year. Most homeless veterans are single men; however, the number of
single women with children has drastically increased within the last
few years. Homeless female veterans tend to be younger, are more likely
to be married, and are less likely to be employed. They are also more
likely to suffer from serious psychiatric illness.
Approximately 40 percent of homeless veterans suffer from mental
illness and 80 percent have alcohol or other drug abuse problems. It
cannot go unnoticed that the increase in homeless veterans coincides
with the underfunding of VA health care, which resulted in the
downsizing of inpatient mental health capabilities in VA hospitals
across the country. Since 1996, VA has closed 64 percent of its
psychiatric beds and 90 percent of its substance abuse beds. It is no
surprise that many of these displaced patients end up in jail, or on
the streets. The American Legion applauds VA's recent plan to restore a
good portion of this capacity. The American Legion believes there
should be a focus on the prevention of homelessness, not just measures
to respond to it. Preventing it is the most important step to ending
it.
The American Legion has a vision to assist in ending homelessness
among veterans by ensuring services are available to respond to
veterans and their families in need before they experience
homelessness. Toward that objective, The American Legion in partnership
with the National Coalition for Homeless Veterans created a Homeless
Veterans Task Force. The mission of the Task Force is to develop and
implement solutions to end homelessness among veterans through
collaborating with government agencies, homeless providers and other
Veterans Service Organizations. In the last 2 years, 16 homeless
veterans workshops were conducted during The American Legion National
Leadership Conferences, National Convention and Mid-Winter Conferences.
Currently, there are 51 Homeless Veterans Chairpersons within The
American Legion who act as liaison to Federal, state and community
homeless agencies and monitor fundraising, volunteerism, advocacy and
homeless prevention activities within participating American Legion
Departments.
The current Administration has vowed to end the scourge of
homelessness within 10 years. The clock is running on this commitment,
yet words far exceed deeds. While less than 9 percent of the Nation's
population are veterans, 34 percent of the Nation's homeless are
veterans and of those 75 percent are wartime veterans.
Homelessness in America is a travesty, and veterans' homelessness
is disgraceful. Left unattended and forgotten, these men and women, who
once proudly wore the uniforms of this Nation's Armed Forces and
defended her shores, are now wandering her streets in desperate need of
medical and psychiatric attention and financial support. While there
have been great strides in ending homelessness among America's
veterans, there is much more that needs to be done. We must not forget
them. The American Legion supports funding that will lead to the goal
of ending homelessness in the next 10 years.
Homeless Providers Grant and Per Diem Program Reauthorization
In 1992, VA was given authority to establish the Homeless Providers
Grant and Per Diem Program under the Homeless Veterans Comprehensive
Service Programs Act of 1992, P.L. 102-590. The Grant and Per Diem
Program is offered annually (as funding permits) by the VA to fund
community agencies providing service to homeless veterans.
The American Legion strongly supports changing the Grant and Per
Diem Program to be funded on a 5-year period instead of annually and a
funding level increased to the $200 million level annually.
veterans benefits administration (vba)
The VA has a statutory responsibility to ensure the welfare of the
Nation's veterans, their families, and survivors. Providing quality
decisions in a timely manner has been, and will continue to be, one of
the VA's most difficult challenges.
Workload and Claims Backlog
There are approximately 3.5 million veterans and beneficiaries
currently receiving VA compensation and pension benefits. In 2006, VA
added almost 250,000 new beneficiaries to the compensation and pension
rolls. VA anticipates receiving about 800,000 claims a year in 2007 and
2008. The current staffing levels do not enable VA to reduce the
pending claims inventory and provide timely service to veterans;
therefore, the President is requesting an increase of 457 full-time
equivalents compensation and pension personnel. The productivity of the
additional staff will increase throughout 2008 and in subsequent years
as these new employees receive training and gain experience. VA
believes the additional staffing will enable VBA to improve claims
processing timeliness, reduce appeals workload, improve appeals
processing timeliness, and enhance services to veterans returning from
the Global War on Terrorism.
The increasing complexity of VA claims adjudication continues to be
a major challenge for VA rating specialists. Since judicial review of
veterans' claims was enacted in 1988, the remand rate of those cases
appealed to the United States Court of Appeals for Veterans Claims
(CAVC) has, historically, been about 50 percent. In a series of
precedent-setting decisions by the CAVC and the United States Court of
Appeals for the Federal Circuit, a number of longstanding VA policies
and regulations have been invalidated because they were not consistent
with statute. These court decisions immediately added thousands of
cases to regional office workloads, since they require the review and
reworking of tens of thousands of completed and pending claims.
As of August 19, 2006, there were more than 389,000 rating cases
pending in the VBA system. Of these, 92,047 (23.6 percent) have been
pending for more than 180 days. According to the VA, the appeals rate
has also increased from a historical rate of about 7 percent of all
rating decisions being appealed to a current rate that fluctuates from
11 to 14 percent. This equates to more than 152,000 appeals currently
pending at VA regional offices, with more than 132,000 requiring some
type of further adjudicative action.
Staffing
Whether complex or simple, VA regional offices are expected to
consistently develop and adjudicate veterans' and survivors' claims in
a fair, legally proper, and timely manner. The adequacy of regional
office staffing has as much to do with the actual number of personnel
as it does with the level of training and competency of the
adjudication staff. VBA has lost much of its institutional knowledge
base over the past 4 years, due to the retirement of many of its 30-
plus year employees. As a result, staffing at most regional offices is
made up largely of trainees with less than 5 years of experience. Over
this same period, as regional office workload demands escalated, these
trainees have been put into production units as soon as they completed
their initial training.
Concern over adequate staffing in VBA to handle its demanding
workload was addressed by VA's Office of the Inspector General (IG) in
a report released in May 2005 (Report No. 05-00765-137, dated May 19,
2005). The IG specifically recommended, ``in view of growing demand,
the need for quality and timely decisions, and the ongoing training
requirements, reevaluate human resources and ensure that the VBA field
organization is adequately staffed and equipped to meet mission
requirements.'' The Under Secretary for Benefits has conceded that the
number of personnel has decreased over the last few years. And the
congressionally mandated Veterans' Disability Benefits Commission is
also closely looking at the adequacy of current staffing levels.
It is an extreme disservice to veterans, not to mention
unrealistic, to expect VA to continue to process an ever increasing
workload, while maintaining quality and timeliness, with less staff.
Our current wartime situation provides an excellent opportunity for VA
to actively seek out returning veterans from Operations Enduring
Freedom and Iraqi Freedom, especially those with service-connected
disabilities, for employment opportunities within VBA. To ensure VA and
VBA are meeting their responsibilities, The American Legion strongly
urges Congress to scrutinize VBA's budget requests more closely. Given
current and projected future workload demands, regional offices clearly
will need more rather than fewer personnel and The American Legion is
ready to support additional staffing. However, VBA must be required to
provide better justification for the resources it says are needed to
carry out its mission and, in particular, how it intends to improve the
level of adjudicator training, job competency, and quality assurance.
gi bill education benefits
Over 96 percent of recruits currently sign up for the MGIB and pay
$1,200 out of their first year's pay to guarantee eligibility. However,
only one-half of these military personnel use any of the current
Montgomery GI Bill benefits. We believe this is directly related to the
fact that current GI Bill benefits have not kept pace with the
increasing cost of education. Costs for attending the average 4-year
public institution as a commuter student during the 1999-2000 academic
year was nearly $9,000. On October 1, 2005, the basic monthly rate of
reimbursement under MGIB was raised to $1,034 per month for a
successful 4-year enlistment and $840 for an individual whose initial
active-duty obligation was less than 3 years. The current educational
assistance allowance for persons training full-time under the MGIB
Selected Reserve is $297 per month.
The Servicemen's Readjustment Act of 1944, P.L. 78-346, the
original GI Bill, provided millions of members of the Armed Forces an
opportunity to seek higher education. Many of these individuals may not
have been afforded this opportunity without the generous provisions of
that Act. Consequently, these former servicemembers made a substantial
contribution not only to their own careers, but also to the economic
well being of the country. Of the 15.6 million veterans eligible, 7.8
million took advantage of the educational and training provisions of
the original GI Bill. Between 1944 and 1956, when the original GI Bill
ended, the total educational cost of the World War II bill was $14.5
billion. The Department of Labor estimates that the government actually
made a profit because veterans who had graduated from college generally
earned higher salaries and, therefore, paid more taxes.
Today, a similar concept applies. The educational benefits provided
to members of the Armed Forces must be sufficiently generous to have an
impact. The individuals who use MGIB educational benefits are not only
improving their career potential, but also making a greater
contribution to their community, state, and Nation.
The American Legion recommends the 110th Congress make the
following improvements to the current MGIB:
<bullet> The dollar amount of the entitlement should be indexed to
the average cost of a college education including tuition, fees,
textbooks, and other supplies for a commuter student at an accredited
university, college, or trade school for which they qualify;
<bullet> The educational cost index should be reviewed and adjusted
annually;
<bullet> A monthly tax-free subsistence allowance indexed for
inflation must be part of the educational assistance package;
<bullet> Enrollment in the MGIB shall be automatic upon enlistment;
however, benefits will not be awarded unless eligibility criteria have
been met;
<bullet> The current military payroll deduction ($1,200)
requirement for enrollment in MGIB must be terminated;
<bullet> If a veteran enrolled in the MGIB acquired educational
loans prior to enlisting in the Armed Forces, MGIB benefits may be used
to repay those loans;
<bullet> If a veteran enrolled in MGIB becomes eligible for
training and rehabilitation under Chapter 31, of title 38, United
States Code, the veteran shall not receive less educational benefits
than otherwise eligible to receive under MGIB;
<bullet> Separating servicemembers and veterans seeking a license,
credential, or to start their own business must be able to use MGIB
educational benefits to pay for the cost of taking any written or
practical test or other measuring device;
<bullet> Eligible veterans shall have an unlimited number of years
after discharge to utilize MGIB educational benefits;
<bullet> Eligible veterans should have the right to transfer their
earned benefits to their spouse and dependents; and
<bullet> Eligible members of the Select Reserves, who qualify for
MGIB educational benefits shall receive not more than half of the
tuition assistance and subsistence allowance payable under the MGIB and
have up to 5 years after their date of separation to use MGIB
educational benefits.
vocational rehabilitation and employment service (vr&e)
The mission of the VR&E program is to help qualified, service-
disabled veterans achieve independence in daily living and, to the
maximum extent feasible, obtain and maintain suitable employment. The
American Legion fully supports these goals. As a nation at war, there
continues to be an increasing need for VR&E services to assist
Operations Iraqi Freedom and Enduring Freedom veterans in reintegrating
into independent living, achieving the highest possible quality of
life, and securing meaningful employment. To meet America's obligation
to these specific veterans, VA leadership must focus on marked
improvements in case management, vocational counseling, and--most
importantly--job placement.
The successful rehabilitation of our severely disabled veterans is
determined by the coordinated efforts of every Federal agency (DOD, VA,
DOL, OPM, HUD etc.) involved in the seamless transition from the
battlefield to the civilian workplace. Timely access to quality health
care services, favorable physical rehabilitation, vocational training,
and job placement play a critical role in the ``seamless transition''
of each and every veteran, as well as his or her family.
Administration of VR&E and its programs is a responsibility of the
Veterans Benefits Administration (VBA). Providing effective employment
programs through VR&E must become a priority. Until recently, VR&E's
primary focus has been providing veterans with skills training, rather
than providing assistance in obtaining meaningful employment. Clearly,
any employability plan that doesn't achieve the ultimate objective--a
job--is falling short of actually helping those veterans seeking
assistance in transitioning into the civilian workforce.
Vocational counseling also plays a vital role in identifying
barriers to employment and matching veterans' transferable job skills
with those career opportunities available for fully qualified
candidates. Becoming fully qualified becomes the next logical objective
toward successful transition.
Veterans Preference in Federal hiring plays an important role in
guiding veterans to career possibilities within the Federal Government
and must be preserved. There are scores of employment opportunities
within the Federal Government that educated, well-trained, and
motivated veterans can fill--given a fair and equitable chance to
compete. Working together, all Federal agencies should identify those
vocational fields, especially those with high turnover rates, suitable
for VR&E applicants. Career fields like information technology, claims
adjudications, debt collection, etc., offer employment opportunities
and challenges for career-oriented applicants that also create career
opportunities outside the Federal Government.
GAO has also cited exceptionally high workloads for a limited
number of staff members at VR&E offices. This increased workload
hinders the staff's ability to effectively assist individual veterans
with identifying employment opportunities. In April 2005, the average
caseload of a typical VR&E counselor approached 160 veterans. The
American Legion is pleased that an additional number of 150 full-time
equivalents will be hired and we applaud the President's budget request
for $159.5 million in Fiscal Year 2008. It is vital that Congress
approve this request to adequately address the expected increase of
veterans needing assistance.
home loan guaranty program
VA's Home Loan Guaranty program has been in effect since 1944 and
has afforded nearly 17 million veterans the opportunity to purchase
homes. The Home Loan programs offer veterans a centralized, affordable
and accessible method of purchasing homes in return for their service
to this Nation. The program has been so successful over the past years
that not only has the program paid for itself but has also shown a
profit in recent years. The American Legion believes that it is unfair
for veterans to pay high funding fees of 2 to 3 percent, which can add
approximate $3,000 to $11,000 for a first-time buyer. The VA funding
fee was initially enacted to defray the costs of the VA guaranteed home
loan program. The current funding fee paid to VA to defray the cost of
the home loan has had a negative effect on many veterans who choose not
to participate in this highly beneficial program. Therefore, The
American Legion strongly recommends that the VA funding fee on home
loans be reduced or eliminated for all veterans whether active duty,
reservist, or National Guard.
Specially Adapted Housing
The American Legion believes that with the increasing numbers of
disabled veterans returning from Iraq and Afghanistan, the need for
specially adapted housing is paramount. Therefore, The American Legion
strongly recommends that the current $50,000 grant for specially
adapted housing be increased to $55,000 and special home adaptations be
increased from $10,000 to $12,300. Specially adapted housing grants are
available for the installation of wheelchair ramps, chair lifts,
modifications to kitchens and bathrooms and other adaptations to homes
for veterans who cannot move about without the use of wheelchairs,
canes or braces or who are blind and suffer the loss or loss of use of
one lower extremity. Special home adaptation grants are available for
veterans who are legally blind or have lost the use of both hands.
summary
Mr. Chairman and Members of the Committee, The American Legion
appreciates the strong relationship we have developed with this
Committee. With increasing military commitments worldwide, it is
important that we work together to ensure that the services and
programs offered through VA are available to the new generation of
American servicemembers who will soon return home. You have the power
to ensure that their sacrifices are indeed honored with the thanks of a
grateful Nation.
The American Legion is fully committed to working with each of you
to ensure that America's veterans receive the entitlements they have
earned. Whether it is improved accessibility to health care, timely
adjudication of disability claims, improved educational benefits or
employment services, each and every aspect of these programs touches
veterans from every generation. Together we can ensure that these
programs remain productive, viable options for the men and women who
have chosen to answer the Nation's call to arms.
Thank you for allowing me the opportunity to appear before you
today.
Chairman Akaka. Thank you very much for your testimony, Mr.
Robertson.
Mr. Rowan?
STATEMENT OF JOHN ROWAN, NATIONAL PRESIDENT, VIETNAM VETERANS
OF AMERICA
Mr. Rowan. Good afternoon. Chairman Akaka and Senator Craig
and Senator Brown, thank you for allowing the Veterans Service
Organizations to testify this morning on the VA budget, giving
us access at the beginning of this process.
While we tend to agree with the IB folks about a lot of
their numbers, we believe that they are still a little low. We
actually think that we need another $6.9 billion rather than $4
billion, and we have a chart that we have broken out much of
that dollars and cents, which we have put in as part of our
testimony. One of the biggest chunks is almost $2 million and
change to cover these so-called management deficiencies, which
were really staff deficiencies, that the VISNs made do with
what they could and basically cut staff to fit the budget that
they got.
I would also ask the Senate if they could allow us to put
into the record as part of our testimony the study by Ms. Linda
Bilmes from Harvard Kennedy School of Government on ``Soldiers
Returning from Iraq and Afghanistan: The Long-Term Costs of
Providing Veterans Medical Care and Disability Benefits,'' a
study that she had done, which is pretty enlightening.
Chairman Akaka. That study will be included in the record.
Mr. Rowan. Thank you, sir.
As I said, we believe that there is a whole host of reasons
why we think this needs more money into this budget that has
been proposed, not the least of which is what we think is an
undercount in both numbers of new veterans coming into the
system and old veterans coming into the system, many for the
first time. As I testified last year before this Committee, we
believe that Vietnam veterans in particular are coming down
with many Agent Orange-related illnesses that they are entitled
to get compensation and health care for that are now
manifesting themselves today--the whole diabetic problem, the
whole problem with prostate cancer, lung cancer, all kinds of
other conditions, which in and of themselves must drive up the
need for medical care by veterans in the VA system. And,
unfortunately, it is very expensive care and often
multidisciplinary care, as was pointed out earlier in the
Secretary's testimony.
When we file a claim today, a veteran often is not filing a
single claim. They are filing multiple claims with multiple
issues, either secondary conditions attached to the original
condition or multiple different conditions. And so the 800,000
claims we talk about being submitted is really God knows how
many actual issues of health care. And what the impact is on
the VA health care system has got to be substantial.
So, again, we would like to see a breakdown also of how
many people who have been put aside that are no longer eligible
for the system and really who they are, this whole dollar-and-
cents thing is throwing around it. I doubt very much if there
is any $200,000 income family or income veteran running to get
to the VA in reality. It has got to be a very small number. And
Senator Craig mentioned earlier how the significant percentage
of the veterans in the system that are eligible for Medicare
only seems to me another reason why we ought to get the
Medicare money back into the VA system. I would venture to say
that many of those people are also service-connected disabled
veterans who are entitled to health care no matter what. So it
will be really interesting to see a more in-depth analysis of
all of that.
There were some other issues raised. Senator Murray raised
the whole issue about inpatient PTSD programs. There are VISNs
in this country that do not have inpatient programs in their
VISN, and so we see a lot of time veterans traveling far
distances to get inpatient care. Having come from New York, I
know that Batavia has an excellent inpatient care program that
I know of from dealing with the people in their alumni
association who take care of them after they have gone through
the program, dealing with veterans from all across this country
who come to that facility because it is well known and does a
very good job. And they have just opened a new women's
facility, which is going to be real interesting to see what
happens with that, with, unfortunately, the significant number
of women now in the system.
As we wind down, I would also echo what Steve said about
the zeros. The zero percenters, one must remember, may have
been 100 percenters at one time, and the classic example of
that is the prostate cancer person. You get a Vietnam vet who
has got prostate cancer gets 100 percent while they are
diagnosed with prostate cancer. If they are lucky enough to go
through a treatment that takes care of their cancer, they are
dropped down to zero. But as everybody will tell you, they need
to come back regularly for significant care and review to make
sure that their cancer does not come back somewhere else.
Thank you.
[The prepared statement of Mr. Rowan follows:]
Prepared Statement of John Rowan, National President,
Vietnam Veterans of America
Chairman Akaka, Ranking Member Craig and distinguished Members of
the Committee, on behalf of all of our officers, Board of Directors,
and members, I thank you for giving Vietnam Veterans of America (VVA)
the opportunity to testify today regarding the President's Fiscal Year
2008 budget request for the Department of Veterans Affairs. I am
pleased to welcome so many new and returning Members onto the Committee
this year. VVA looks forward to working with all of you to address the
needs of the unique system created to serve our Nation's veterans.
Mr. Chairman, several years ago, Vietnam Veterans of America
developed a White Paper in support of the need for assured funding for
the veterans health care system, which I know you have read and shared
with others. I also know you have been a long-time supporter of
legislation to achieve assured funding. You have always understood the
need for such a mechanism to correct the problems in the current system
of funding. As we have this discussion in regard to the FY 2008 budget
for VA, the readily apparent need for this legislation has never been
more pressing. We look forward to working with you to ensure its
enactment.
VVA does wish to recognize that this year's request from the
President for the VA Budget, while lacking in many other respects, is
relatively free of ``budget gimmicks'' that have so plagued discussions
in the past. VVA believes that this is due to the strong efforts of
Secretary Nicholson in doing battle to strip out the favorite
``gimcrackery'' of that permanent staff over at the Office of
Management and Budget (OMB). VVA commends the Secretary of Veterans
Affairs in this regard for seeking to have an honestly presented budget
proposal.
veterans health administration
VVA is recommending an increase of $6.9 billion to the expected
Fiscal Year 2007 appropriation for the medical care business line. We
recognize that the budget recommendation VVA is making this year is
extraordinary, but with troops in the field, years of underfunding of
health care organizational capacity, renovation of an archaic and
dilapidated infrastructure, updating capital equipment, and several
cohorts of war veterans reaching ages of peak health care utilization,
these are extraordinary times. It's past time to meet these needs.
In contrast to what is clearly needed, we believe the
Administration's Fiscal Year 2008 request for $2 billion more than the
expected 2007 appropriation in the continuing resolution is inadequate.
Unfortunately, we still are unsure of the bottom line for Fiscal Year
2007. While we certainly appreciate that the Congress is planning to
restore funding for veterans health care in the continuing resolution
(and it is essential that it does so to ensure the Department's ability
to meet ongoing obligations), the fact that VA is still uncertain about
the amount of funding it will receive a third of the way through the
fiscal year does, virtually in and of itself, make the case for assured
funding.
The $2 billion increase the Administration has requested for
medical care may almost keep pace with inflation, but it will not allow
VA to enhance its health care or mental health care services for
returning veterans, restore diminished staff in key disciplines like
clinicians needed to care for Hepatitis C, restore needed long-term
care programs for aging veterans, or allow working-class veterans to
return to their health care system. VVA's recommendation does
accommodate these goals, in addition to restoring eligibility to
veterans exposed to Agent Orange for the care of their related
conditions.
I need not tell you about the many successes of the Department of
Veterans Affairs in recent years. The Veterans Service Organizations
are often seen as critics of the Department, but while it's true that
we sometimes take exception to its policy decisions we are, in fact,
also its most stalwart champions. Over the last decade the Veterans
Health Administration (VHA) at VA has taken steps to become a higher
quality, more accessible health care system. It has demonstrated great
efficiency by almost doubling the number of veterans it treats while
holding per capita costs relatively constant. It has developed hundreds
of Community Based Outreach Clinics (CBOCs). VHA has received many
prestigious awards for excellence and innovation. While VVA remains
extremely concerned about recent breaches that compromised veterans'
personal data, VVA appreciates the fact that VA has put together a
computerized system of medical records that sets the standard for
modern health care delivery. These achievements are to be celebrated.
Yet, these advances have not come without a cost. For years, the
veterans' health care system has been falling behind in meeting the
health care needs of some veterans. At the beginning of 2003, the
former Secretary of Veterans Affairs made the decision to bar so-called
Priority 8 veterans from enrolling. In most cases, these veterans are
not the well-to-do--they are working-class veterans or veterans living
on fixed incomes as little as $28,000 a year. It's not uncommon to hear
about such veterans choosing between getting their prescription drug
orders filled and paying their utility bills. The decision to bar these
veterans is still standing, and it is still troubling to thoughtful
Americans.
In addition to the current bar on health care enrollment, in recent
years VA has sent Congress a budget that requires more cost-sharing
from veterans, and eliminates options for their care--particularly
long-term care. We appreciate that VA's proposal this year has not
presumed enactment of some of the cost-sharing legislative proposals
Congress has opposed in the past. This may allow Congress more leeway
to augment its request in concrete ways rather than merely filling
deficits left by the Administration presuming that revenues and savings
from these unpopular initiatives will be realized.
Congress is to be commended for turning back many legislative
requests for enrollment fees and outpatient cost increases, which would
have jeopardized hundreds of thousands of veterans' access to health
care. Hard-fought Congressional add-ons, such as the $3.6 billion for
Fiscal Year 2007 currently being debated as part of the continuing
resolution, have kept the system afloat. The budget recommended by VVA
in addition to the enactment of some assured funding mechanism will
enable a robust health care system to meet the needs of all eligible
veterans--now and in the future.
medical services
For medical services for Fiscal Year 2008, VVA recommends $34.5
billion, including collections. This is approximately $5 billion more
than the Administration's request. VVA is making its budget
recommendations based on re-opening access to the millions of veterans
disenfranchised by the Department's policy decision of early 2003 that
was supposed to be ``temporary.'' The former ranking member of the
House Veterans' Affairs Committee, Lane Evans, discovered that a
quarter-million Priority 8 veterans had applied for care in Fiscal Year
2005. Similar numbers of veterans have likely applied in each of the
years since their enrollment was barred. Our budget allows 1.5 million
new Priority 7 and 8 veterans to enroll for care in their health care
system. While this may sound like too great a lift for the system, use
rates for Priority 7 and 8 veterans are much lower than for other
priority groups. Based on our estimates, it may yield only an 8 percent
increase in demand at a cost of about $1.5 billion to the system for
additional personnel, supplies and facilities.
The budget axe has fallen hard on long-term care programs in VA.
About a decade ago, there was a major policy shift throughout the
health care industry, including with VA, which encouraged programs to
deliver as much care as possible outside of beds. In many cases this
has been a productive policy. Veterans value the convenience of using
nearby community clinics for primary care needs, for example.
However, the change took a great toll on the neuro-psychiatric and
long-term care programs that housed and cared for thousands of
veterans, often keeping them institutionalized for years. Instead of
developing the significant community and outpatient infrastructures
that would have been necessary to adequately replace the care for these
most vulnerable veterans, the resources were largely diverted to other
purposes.
Where have these vets gone? The fiscally challenged Medicaid
program supports many of those who need long-term care, adding an
additional burden to the states. State homes play an important role in
remaining the only VA-sponsored setting that provides ongoing, rather
than rehabilitative or restorative, long-term care. VA's mental health
programs--some of the finest in the Nation--as well as significant
advances in pharmaceutical therapies continue to serve and allow many
veterans to recover. However, what are in fact increasing waiting times
for mental health programs and the lack of treatment options often
contribute to incarceration and homelessness for the most vulnerable of
these veterans. Sadly, we hear increasing numbers of stories of
veterans of Iraq and Afghanistan whose inability to deal with
readjustment post-deployment have lead them to the streets or even
suicide.
Mr. Chairman, Vietnam Veterans of America's founding principle is:
``Never again will one generation of veterans abandon another.'' This
is why we are imploring this Committee to ensure that VA has the
imperative and the resources to bolster the mental health programs that
should be readily available to serve our young veterans from Iraq and
Afghanistan. Experts from within the Department of Defense estimate
that as many as 17 percent of those who serve in Iraq will have issues
requiring them to seek post-deployment mental health services and
recent studies have shown that four out of five of the veterans who may
need post-deployment care are not properly referred to such care. There
is good reason to believe that even the rates forecast by DOD may be
too low.
VA has not made enough progress in preparing for the needs of
troops returning from Iraq and Afghanistan--particularly in the area of
mental health care. Its own internal champions--the Committee on Care
of the Seriously Mentally Ill and the Advisory Committee on Post-
Traumatic Stress Disorder, for example--have expressed doubts about
VA's mental health care capacity to serve these newest vets. As
recently as last March, VHA's Undersecretary for Health Policy
Coordination told one commission that mental health services were not
available everywhere, and that waiting times often rendered some
services ``virtually inaccessible.'' The doubts about capacity to serve
new veterans have reverberated in reports done by the Government
Accountability Office (GAO). In addition, one recent working paper by
Linda Bilmes of the John F. Kennedy School of Government at Harvard
University estimates that in a ``moderate'' scenario in 2008 VA will
require $1.8 billion to treat the veterans returning from Iraq and
Afghanistan--much of this funding would be used to augment mental
health care to properly serve these veterans. VA has projected that
approximately 260,000 Global War on Terrorism (GWOT) veterans will use
the VA health care system in FY 2008. VVA and others believe that well
more than 300,000 ``new'' veterans will use the VHA system in FY 2008.
A further reason that VA has underestimated the need for medical
services is that they continue to use the same formula that they use
for CARES, which is a civilian-based model. Mr. Chairman, VVA has
testified many times that the VHA must be a ``veterans' health care
system'' and not a general health care system that happens to see
veterans if the VHA is to properly and adequately address the needs of
veterans, particularly veterans who are sick or injured in military
service. The model VA uses was designed for middle-class people who can
afford HMOs or other such programs. It projects only one to three
``presentations'' (things wrong with) patients as opposed to the five
to seven that is the average at VHA for veterans. Obviously, one using
the VA model will continually underestimate overall resources needed to
care for the veterans who come to the system by using this civilian
formula. Further, VHA has been consistent in underestimating the number
of GWOT returnees who will seek services from the system in each of the
last 4 years. VVA has corrected these errors in our projections.
In addition to the funds VVA is recommending elsewhere, we
specifically recommend an increase of an additional billion dollars to
assist VA in meeting the long-term care and mental health care needs of
all veterans. These funds should be used to develop or augment with
permanent staff at VA Vet Centers (Readjustment Counseling Service, or
RCS), as well as PTSD teams and substance use disorder programs at VA
Medical Centers and CBOCs, which will be sought after as more troops
(including demobilized National Guard members and Reservists) return
from ongoing deployments. In addition, VA should be augmenting its
nursing home beds and community resources for long-term care,
particularly at the State veterans' homes.
To assist in developing these programs and augmenting all areas of
veterans' care, VVA recommends funding to accommodate the staff-to-
patient ratio VA had in place before VA had dismantled so much of its
neuro-psychiatric and long-term care infrastructure. This would allow
VA to better ensure timely access to care and services. Studies have
shown that inadequate staffing--particularly of nurses involved in
direct care--is correlated with poorer health care outcomes in all
medical disciplines. To allow the staffing ratios that prevailed in
1998 for its current user population, VA would have to add more than
20,000 direct-care employees--MDs and nurses--at a cost of about $2.2
billion.
The $2.2 billion funding for the staff shortfalls identified by VVA
closely corresponds to the funding from unspecified ``management
efficiencies'' VA has had to shoulder throughout this Administration.
It is important to realize that the effect of leaving these funding
deficiencies unfulfilled is cumulative. That is, each year VA is forced
to live with a greater hole in its budget. GAO has joined VSOs and
Congress in questioning the extent to which VA has been able to
identify and realize the so-called savings created by such proposed
efficiencies. VA officials have advised GAO that the efficiencies
identified in at least two recent budget proposals--FY 2003 and FY
2004--were developed to allow VA to meet its budget guidance rather
than by detailed plans for achieving such savings (GAO-06-359R). In
other words, the savings were justified only by the need to meet the
Administration's ``bottom line.'' I hope Congress agrees that this is
no way to fund our veterans' health care system.
Finally, VVA believes Congress did a grave injustice to Vietnam-era
veterans. For decades, veterans exposed to Agent Orange and other
herbicides containing dioxin had been granted health care for
conditions that were presumed to be due to this exposure. This special
eligibility expired at the end of 2005 and, despite our request,
Congress did not reauthorize it. Had Congress simply reauthorized
existing authority, VA would have realized no new costs. Now we have
heard that the Congressional Budget Office estimates that it will cost
more than $300 million to restore this eligibility. Why this
eligibility was allowed to expire seems more a matter of dollars than
sense to VVA, given the ever-mounting body of research that clearly
points to conditions such as diabetes being linked to dioxin exposure.
However, the pressing issue now is to reinstate veterans with these
conditions for the higher priority access to services that they
deserve.
medical facilities
For medical facilities for Fiscal Year 2008, VVA recommends $5.1
billion. This is approximately $1.5 billion more than the
Administration's request for Fiscal Year 2008. Maintenance of the
health care system's infrastructure and equipment purchases are often
overlooked as Congress and the Administration attempt to correct more
glaring problems with patient care. In FY 2006, in just one example,
within its medical facilities account VA anticipated spending $145
million on equipment, yet only spent about $81 million. (The rest of
the funds went just to meet costs to keep the facilities open and
operating.) However, these projects can only be neglected for so long
before they compromise patient care, and employee safety in addition to
risking the loss of outside accreditation. The remainder of the funding
was apparently shifted to other more immediate priority areas (i.e.,
keeping facilities operating in the short run).
VA undertook an intensive process known as CARES (Capital Asset
Realignment to Enhance Services) to ``right-size'' its infrastructure,
culminating in a May 2004 policy decision that identified approximately
$6 billion in construction projects. While for the reasons noted above
the VA has consistently underestimated future needs by using a fatally
flawed formula, thus far Congress and the Administration have only
committed $3.7 billion of this all too conservative needed funding.
We believe the CARES estimate to be extremely conservative given
that the models projecting health care utilization for most services
were based on use patterns in generally healthy managed care
populations rather than veterans and that the patient population base
did not include readmitting Priority 8 veterans, or significant
casualties from the current deployments. Notwithstanding our concerns
about the methods used in CARES, very few of the projects VA agrees are
needed have been funded since this time. Non-recurring maintenance and
capital equipment budgets have also been grievously neglected as
administrators have sought to shore up their operating funds.
In a system in which so much of the infrastructure would be deemed
obsolete by the private sector (in a 1999 report GAO found that more
than 60 percent of its buildings were more than 25 years old), this has
and may again lead to serious trouble. We are recommending that
Congress provide an additional $1.5 billion to the medical facilities
account to allow them to begin to address the system's current needs.
We also believe that Congress should fully fund the major and minor
construction accounts to allow for the remaining CARES proposals to be
properly addressed by funding these accounts with a minimum of
remaining $2.3 billion.
medical and prosthetic
Research For medical and prosthetic research for Fiscal Year 2008,
VVA recommends $460 million. This is approximately $50 million more
than the Administration's request for Fiscal Year 2008. VA research has
a long and distinguished portfolio as an integral part of the veterans'
health care system. Its funding serves as a means to attract top
medical schools into valued affiliations and allows VA to attract
distinguished academics to its direct-care and teaching missions.
VA's research program is distinct from that of the National
Institutes of Health because it was created to respond to the unique
medical needs of veterans. In this regard, it should seek to fund
veterans' pressing needs for breakthroughs in addressing environmental
hazard exposures, post-deployment mental health, traumatic brain
injury, long-term care service delivery, and prosthetics to meet the
multiple needs of the latest generation of combat-wounded veterans.
Further, VVA brings to your attention that VA Medical and
Prosthetic Research is not currently funding a single study on Agent
Orange or other herbicides used in Vietnam, despite the fact that more
than 300,000 veterans are now service-connected disabled as a direct
result of such exposure in that war. VVA submits that this is
unacceptable.
Mr. Chairman, finally I urge this Committee to at long last urge
your colleagues on the Appropriations Committee to use the power of the
purse to compel VA to obey the law (Public Law 106-419) and conduct the
long-delayed National Vietnam Veterans Longitudinal Study. VVA ask that
you specifically request report language in the Appropriations bill for
Military Construction, Veterans Affairs, and Related Agencies that
compels VA to advise the Appropriators and the Authorizers as to how VA
plans to complete this study properly within 2 years, as a
comprehensive mortality and morbidity study.
assured funding for veterans' health care
Once this Congress provides a budget that shores up VA medical
services and facilities, it will need to assure that VA continues to be
funded at a level that allows it to provide high-quality health care
services to the veterans that need them. That is where enactment of
assured funding will come in. Once enacted, an assured funding
mechanism will ensure that, at a minimum, annual appropriations cover
the cost of inflation and growth in the number of veterans using VA
health care. It will allow VA administrators some predictability in
both how much funding it will receive and when it will be received,
resulting in higher quality and ultimately more cost-effective care for
our veterans.
veterans benefits administration
The Veterans Benefits Administration (VBA) is in even more acute
need of additional resources and enhanced accountability measures now
than it was a year ago. VVA recommends an additional 400 over and above
the roughly 470 new staff members that are requested in the President's
proposed budget for all of VBA.
compensation & pension
VVA recommends adding one hundred staff members above the level
requested by the President for the Compensation & Pension Service (C&P)
specifically to be trained as adjudicators. Further, VVA strongly
recommends adding an additional $60 million specifically earmarked for
additional training for all of those who touch a veteran's claim,
institution of a competency-based examination that is reviewed by an
outside body that shall be used in a verification process for all of
the VA personnel, veteran service organization personnel, attorneys,
county and state employees, and any others who might presume to at any
point touch a veteran's claim.
vocational rehabilitation
VVA recommends that you seek to add an additional 300 specially
trained vocational rehabilitation specialists to work with returning
servicemembers who are disabled to ensure their placement into jobs or
training that will directly lead to meaningful employment at a living
wage. It is clear that the system funded through the Department of
Labor simply is failing these fine young men and women when they need
assistance most in rebuilding their lives.
VVA has always held that the ability to obtain and sustain
meaningful employment at a living wage is the absolute central event of
the readjustment process. Adding additional resources and much greater
accountability to the VA Vocational Rehabilitation process is
absolutely essential if we as a Nation are to meet our obligation to
these Americans who have served their country so well, and have already
sacrificed so much.
accountability at va
So much of what VVA and the Congress on both sides of the aisle
find wrong or disturbing at the VA revolves around the general and all-
pervasive issue of little or no accountability, or imprecise fixing of
authority commensurate with accountability mechanisms that are
meaningful (and vice versa) in all parts of the VA.
Within the past year, VA has finally made significant progress in
meeting the minimum goal of at least 3 percent of all contracts and 3
percent of all subcontracts being let to service-disabled veteran
business owners. Secretary Nicholson and Deputy Secretary Mansfield are
to be commended on setting the pace for the Federal Government. It is
instructive in this discussion, however, that the action directed by
the Secretary to put achievement or substantial real progress toward
meeting or exceeding the 3 percent minimum into the performance
evaluation of each Director of the 21 Veterans Integrated Service
Networks (VISNs) was a key element enabling VA to be the first large
agency to reach the goal mandated by law. Some 85 percent of all VA
procurement is through VHA, primarily through the VISNs is the key
factor in this achievement.
All people (particularly people with a great deal of responsibility
who work long hours) care about what they feel they have to care about.
Putting it in the performance evaluations means that those managers who
ignore a requirement do not get an outstanding or superior rating, and
hence no bonus. VVA, and now the VA in at least this one instance, has
always found that it is amazing how reasonable almost all people can be
when you have their full attention.
There is no excuse for the dissembling and lack of accountability
in so much of what happens at the VA. It can be cleaned up and done
right the first time, it there is the political will to hold people
accountable for doing their job properly.
Lastly, there is no excuse for the continuation of the practice of
VHA to ``lose'' tens of millions (sometimes hundreds of millions) of
taxpayer dollars that are appropriated to VHA for specific purposes,
whether that purpose be to restore organizational capacity to deliver
mental health services, particularly for PTSD and other combat trauma
wounds, or to conduct outreach to GWOT veterans as well as demobilized
National Guard and Reserve returnees from war zone deployments. There
is a consistent pattern of VA, particularly VHA, to either really not
know what happened to large sums of money given to them for specific
reasons, or they are not telling the truth to the Congress and the
public. In either case, it is unacceptable and cannot be tolerated any
longer.
In the proposed budget submittal, VVA struggled with accounting for
the dollars footnoted in the President's submittal as ``Adjusted for
IT.'' We could not find an accurate accounting. When we asked, it turns
out that no one that we have spoken to, including VA officials, can
fully explain at least $200 million-plus of this ``adjustment'' either.
And this is before they get their hands on the dollars. VVA urges this
Committee and your colleagues on Appropriations to make this the year
that this sloppy nonsense and dissembling is stopped once and for all.
Accountability will only come about when Congress absolutely demands
that these folks be fully accountable for performance, and for
accounting for each and every taxpayer dollar.
Thank you again, Mr. Chairman. We look forward to working with you
and this distinguished Committee to obtain an excellent budget for VA
in FY 2008, and to ensure the next generation of veterans' well-being
by enacting assured funding. I will be happy to answer any questions
you and your colleagues may have.
[The working paper prepared by Linda Bilmes of the John F. Kennedy
School of Government, Harvard University, follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
My questions are for all of our witnesses. What are your
views on VA's capacity to provide needed rehabilitation, case
management, and community reintegration services for veterans
with traumatic brain injuries and to help their families as
caregivers? How can VA improve services to veterans with
traumatic brain injuries and their families to help them
recover and lead full, productive lives?
I'd like to call on Mr. Blake first.
Mr. Blake. Well, Senator Akaka, what I would say first is,
I believe the VA is doing a great job already of doing their
best to address the needs of particularly the veterans with
traumatic brain injury. I think that has probably established
itself, along with PTSD, as being at the forefront of
conditions being experienced by the OIF/OEF veterans.
Being a user of the VA Medical Center in Richmond, I see
what they do there, and I think that it is yeoman's work what
they do there. They do a lot with a lot less than any other
system outside of the VA would probably be able to handle.
I would say that right now the best thing that could be
done for the VA would be to complete appropriations work for
their current year because all we are doing is putting them in
a bind where even the most important services, which I would
consider TBI and a lot of the specialized services to be, are
also being strapped to the limits because they cannot hire new
staff; they have even had to cut staff in a lot of cases
because it is just not there. And for us to continue to expect
the VA to provide these much needed services under the
situation it is in is just unacceptable.
Chairman Akaka. Mr. Violante?
Mr. Violante. Thank you, Mr. Chairman. I am not sure VA has
the capacity. I mean, this seems to be the disability from this
war, and, unfortunately, the range of severity is almost
negligible in some individuals to totally severe in others. And
I think VA needs to focus a lot more resources, number one, on
identifying individuals that have been exposed to IEDs, whether
that be minor exposure or whatever, because we are going to see
a lot more of these individuals probably coming forward with
disabilities in the future. So I think VA definitely needs more
resources focused on this area.
Chairman Akaka. Mr. Greineder?
Mr. Greineder. Thank you, Mr. Chairman. I would agree with
my colleagues here at the table. I think VA has done a
tremendous job on TBI issues and mental health issues. And I
would say that, you know, to get VA the timely funding so they
can cover their staff shortages and cover their needs in that
area, as well as the funding area.
Chairman Akaka. Mr. Cullinan?
Mr. Cullinan. Thank you, Mr. Chairman. I would agree that
VA to this point is doing a terrific job with respect to
dealing with these issues. I certainly have to associate myself
with Mr. Blake's remarks, though, that it is very important to
get them the money on time. They simply cannot keep on doing
this without getting enough money on time.
The other thing, things like TBI and certain force injuries
are uncharted medical and scientific ground, so the area of
research really has to be looked at. We have to identify those
individuals, and we have to be able to find out what the things
are that are going to beset these individuals as well, and how
they can be addressed. So the research is key.
Chairman Akaka. Mr. Robertson?
Mr. Robertson. Yes, sir. It is very interesting, I was
talking to a psychiatrist about this very subject, and he was
telling me that most of the TBI injuries, the family members
are the ones that are seeing the difference in their conduct
and their behavior, and it is the families that are referring
them into the hospitals.
I am thinking that maybe we have to do a lot more outreach
of educating the family members and spouses, whether it is a
video to show them what signs they should be looking for or the
kinds of conducts or symptoms traditionally associated with
this kind of injury.
The other thing is the separation physicals. I think it is
just absolutely critical that when they separate these kids
that have been in theater, they ask them specifically: Were you
around IEDs? Were you involved in an automobile accident where
your Humvee rolled over? Anything that could be documented to
show that there was a head injury, because most of these, as
you well know, there are no marks left behind. It is kind of
like being shot with a bullet made of ice that melts and the
evidence is gone, but the results are still pretty traumatic.
Chairman Akaka. Mr. Rowan?
Mr. Rowan. Yes, sir. I would concur with my colleagues,
particularly Steve's point. I had dinner with some people from
Walter Reed recently, and one of the people there was a young
lady who had gotten banged up in Afghanistan. And she got sent
back to Germany and everything seemed fine, except she then had
a massive stroke that put her in a wheelchair. So that point
really comes home about following up with them.
Also, we do a terrible job in families. I mean, one of the
problems the VA has is we have never figured out what to do
with families in any issues--PTSD, physical injury, whatever.
And, I mean, I can only say thank God for Fisher Houses in
dealing with the folks that are sitting in these places. And, I
do not know, maybe we need to work on an appeal in the private
sector to develop more Fisher Houses next to the VAs as well as
next to Walter Reed and Brooks Army Medical Center and other
places like that. But we need to do something.
Chairman Akaka. Well, I thank you very much for your
responses. Before I call on Senator Craig, I just want to tell
you that we both want to have joint sessions with VSOs here in
Congress. And I want you to know that it is going to come back,
and we look forward to that.
Senator Craig?
Senator Craig. Mr. Chairman, thank you very much. One
question and then one comment.
First and foremost, let me tell you that the Independent
Budget serves a very valuable role in our assessment of and
evaluation of the Administration and the VA's budget, and its
presentation and your involvement in it is not taken lightly.
The President's request for medical care exceeds the
Independent Budget recommendations when $2.3 billion in
expected collections are factored in. Your organizations,
however, do not factor in the expected collections and instead
seek full funding from appropriated dollars alone. You do not
all have to answer that, but, Carl, possibly you and others
could explain why you don't factor in the expected dollars now
that we have a very real track record in the budget as to what
those collections are.
Mr. Blake. Well, Senator Craig, this point was also
addressed when we had our meetings with your staff, and I think
it is a good point, and it is one of those things where the
historical trends in the past have borne out that the VA was
really incapable of meeting its collections estimates. And I
would be lying if I did not say that it is something that the
further down the line we go, the more we will have to kind of
re-evaluate it as the VA proves whether it is able to actually
do it.
The problem still remains. Although they may collect, let's
just say, for instance, 90 percent of their collection
estimates this year, there is no guarantee that next year they
will not turn right around once again and collect 40 percent or
35 percent. So there is too much risk, I believe, in laying too
much on funding the VA health care system in estimates where
there is far too much variation in how much collections VA is
actually going to recognize.
Senator Craig. OK.
Mr. Robertson. Since the American Legion is not part of the
IB, I will not have an answer from the Legion's perspective. We
have always seen this as treatment for people other than the
service connected, the ones where Title 38 says ``the Secretary
shall provide . . .'' That usually covers Priority Groups 1
through 6. And then it says, ``The Secretary may provide . .
.'' and that is the 7s and 8s.
So we have always had the mindset that when the
discretionary appropriation is made, it is really made for the
1s through the 6s, and that the 7s and 8s, when eligibility
reform was established, every veteran that registered that was
a 7 and 8 had to agree to allow third-party collections and
copayments. So they agreed to bring money into the system.
Where the breakdown has taken place is, number one, the vast
majority of our enrollees that are 7s and 8s are Medicare
eligible, and VA is prohibited by law from billing Medicare.
That is one.
The other one is that if you have an insurance company that
says, ``If you go outside the PPO of our network of doctors,
then it is on you.'' And in that situation, when we send the
bill to them, they send it back and say, ``I am sorry. They
went outside the network. We do not have to pay you anything.''
So I was very pleased to see that VA has worked with Medicare
in developing a reasonable charge formula, I guess, that is
consistent with what Medicare uses when they start sending
these bills out to more insurance companies. So, hopefully,
more insurance companies will start looking at that and say,
``Yes, that is an acceptable charge,'' and go ahead and pay it.
But throughout the history of the third-party collections,
they have never, ever, ever met their goal. And when you are
short of money and that is part of your discretionary
appropriations, that means it impacts directly at the health
care facility.
Senator Craig. Well, thank you all, and the reason I say
that, we cannot ignore the obvious, and the obvious is the
record. The VA brought in $1.7 billion in collections in 2004,
$1.89 billion in 2005, $2 billion in 2006, and is on the pace
to collect $2.2 billion this year.
I think it is reasonably safe to assume they are going to
meet that target of $2.3 billion, and what I find us doing is
ignoring one mighty big slush fund--a $2.3 billion slush fund
sitting out in VA.
Now, I hope you are not blinded by your pursuit of a
totally funded entitlement program by ignoring the opportunity
of reasonable revenue.
Mr. Robertson. May I please respond?
Senator Craig. Well, no.
[Laughter.]
Senator Craig. Let me make one other observation, Steve.
Mr. Robertson. I will write you a letter.
Senator Craig. Please do. Now, I am serious about this.
Mr. Robertson. I am, too.
Senator Craig. It is worthy of an open discussion as to
what we are all about here because of the obvious increased
demands for veterans' appropriate and necessary funding. Also,
you know, I am allowed to change my mind on occasion, but when
I do, it usually makes headlines. I, therefore, appreciate your
ability to change your minds. But let me put into the record,
Mr. Chairman, testimony from the DAV in 1996, which means
somebody changed their mind, and it says here--and this is the
representative of the DAV at that time saying to the then-
Chairman: ``But everybody else who comes to the system''--and
we are talking about the new priorities--``Mr. Chairman, is
going to have to pay their own way as they would in any other
system, through either copayments, deductibles, or private
insurance. So if there is an assumption on the cost of this
bill being predicated upon all these new veterans coming into
the system and not paying for their care, then it is a faulty
assumption and one that drives the cost up.'' That was 1996.
Frankly, almost every veterans organization has changed their
mind.
Now, having said that, I think what is also important, the
DAV goes on to say, ``In the Independent Budget DAV proposes,
along with AMVETS, PVA, and VFW, that the Secretary have the
discretion to treat these parties at their own expense. We do
not request that they be entitled to VA medical care. We
believe it would be in the best interest of the veterans and
the VA to allow these parties to use VA care at their own
expense.'' That was then. This is now. And in that stretch of
time, we have seen a phenomenal growth in this budget, and
appropriately so. None of us deny that.
We have explained this before. You have explained it
before. I am not criticizing. But I do believe, Mr. Chairman,
it is important to let the record show there has been a
significant shift in attitude about funding and funding
priorities at a time when money is no less difficult to come by
as it relates to providing our veterans with appropriate
service. That is why, Steve, I wanted to go on and complete
this. I am running fast to catch up with myself to get to
another meeting, and, gentlemen, I would never deny you access
to the record to express why you have changed and why you see
it as necessary to change the position that was held then by
your organizations and what is held today.
Thank you, Mr. Chairman.
[Hearing transcript excerpt follows:]
Hearing Transcript Excerpt, Veterans Health Care Eligibility Priorities
(Part I), Held on March 20, 1996, Senate Committee on Veterans' Affairs
Chairman Simpson. Which veterans should receive free medical care
from the Federal Government and what services should they receive?
Mr. Gorman (DAV). I think the premise today that you would build a
system on really was the premise it was built on when it was first
enacted, and that is to take care of the wartime disabled veteran . . .
we believe as an organization of service-connected veterans that that's
who the system should treat primarily.
Mr. Vitikacs (The American Legion). I certainly would concur that
service disabled veterans are the primary constituents of the VA
medical care system. I think that if we were newly creating a VA system
today, we would also support the current eligibility where veterans
unable to defray the cost of their own health care would be given
consideration.
Mr. Currieo (VFW). I believe anyone who in the service of their
country was injured or disabled in any way that needs medical treatment
once they leave that military service, if they were injured and
disabled in the line of duty, which doesn't necessarily mean combat, it
could be training accidents, should be entitled to some type of health
care once they leave the service without any expense to themselves.
Mr. Mansfield (PVA). I think, in response to some of the questions,
what PVA is looking for is we think that service-connected veterans,
catastrophically disabled veterans, veterans with limited income are
those that ought to be the focus of VA providing health care. Other
veterans with funding streams to be retained by the VA are what we're
talking about in additional care.
Chairman Simpson. If you say expanded and improved VA health
benefits won't open the floodgates, then are you saying to us that
veterans will not seek free care? If so, why not?
Mr. Gorman (DAV). Although all these veterans may be eligible for
care, and they are all eligible for care now, our proposal does not in
any way stipulate or even imply that their care would not be paid for
by somebody. The service-connected veteran and the Category A veteran
as defined in the bill would continue to be provided care with
appropriated dollars, as it should be. . . . But everybody else who
comes to the system, Mr. Chairman, is going to have to pay their own
way, as they would in any other system, through either copayments,
deductibles, or private insurance. So if there's an assumption on the
cost of this bill being predicated upon all these new veterans coming
into the system and not paying for their care, then it is a faulty
assumption and one that drives the cost up.
Mr. Vitikacs (The American Legion). The American Legion has never,
and will never, advocate the VA be a charity system. . . . In addition
to VA achieving greater efficiencies and reducing redundancies within
the VIS networks and to right-size the system through mission changes,
we believe that the way to arrive at budget neutrality is through
developing new revenue sources into the system. . . .
Senator Rockefeller (post-hearing Question For the Record). To what
extent do you think it is important that access to VA care be provided
to (a) Higher income veterans with no service-connected disabilities?
(b) Dependents of veterans?
Mr. Gorman (DAV). In the Independent Budget, DAV proposes, along
with AMVETS, PVA, and VFW, that the Secretary have the discretion to
treat these parties at their own expense. We do not request that they
be entitled to VA medical care. We believe it would be in the best
interest of veterans and VA to allow these parties to use VA care at
their own expense.
Mr. Vitikacs (The American Legion). The American Legion believes
that higher income nonservice-connected veterans and certain dependents
of eligible veterans should be permitted access to the VA health care
system by paying premiums, copayments and deductibles. These additional
revenue streams would help to ensure the long-term viability of the VA
health care system. . . The normal appropriations process would ensure
funding for Category A veterans and the conversion of VA to a market-
based, managed care system would attract other paying customers.
Chairman Akaka. Thank you very much. Your words and your
statement is now part of the record, Senator Craig.
We will submit the rest of the questions that Committee
Members have to you for the record.
I want to thank you all for your responses. We look forward
to working with you on veterans' issues this year. The hearing
on the Fiscal Year 2008 Budget for Veterans' Programs is now
adjourned.
[Whereupon, at 12:30 p.m., the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of the American Federation
of Government Employees, AFL-CIO
introduction
The American Federation of Government Employees, AFL-CIO, which
represents more than 600,000 Federal employees who serve the American
people across the Nation and around the world, including roughly
150,000 employees in the Department of Veterans Affairs (VA), is
honored to submit a statement regarding the VA's Fiscal Year (FY) 2008
budget.
AFGE commends Chairman Akaka for his leadership in securing
adequate funding for veterans in the face of VA's unpredictable budget
process. It is time to give veterans more predictability through an
assured funding process. As Chairman Akaka so eloquently stated last
month, ``VA must not be seen simply as another department or agency
coming hat in hand to seek funding.'' The evidence of a broken funding
process is overwhelming: a $3 billion shortfall 2 years ago, hiring
freezes, hospitals operating in the red, and 400,000 pending benefit
claims last year, while this year, the VA is operating on its twelfth
continuing resolution in thirteen years.
AFGE members see first hand both the costs of war and the costs of
a discretionary VA funding formula. Chronic underfunding and financial
uncertainty cause tremendous wear and tear on VA services and the
employees who provide them. Our members who work in the Veterans Health
Administration (VHA) and Veterans Benefits Administration (VBA) express
growing anxiety, sometimes bordering on desperation over the lack of
resources, staffing and training they need to do their jobs. Many VBA
employees who process the claims of service-connected veterans were
themselves once on the receiving end of the claims process. Many social
workers in VHA providing PTSD treatment bring their own valuable
veteran's perspective to their jobs. The large numbers of veterans in
low wage VA jobs who launder hospital bed linens and clear the snow on
hospital grounds take particular pride in meeting the needs of fellow
veterans. In short, AFGE speaks for employees and veterans in calling
for a strong and predictable VA budget because we too believe that
shortchanging veterans is unacceptable.
need for more oversight
Adequate funding goes hand in hand with adequate oversight.
Congress and the public must be able to determine whether these
precious dollars are being spent cost effectively and in the best
interests of veterans. Unfortunately, there is far too little
transparency in VA spending at the present time. As the Government
Accountability Office (GAO) has found, the VA does a poor job of budget
forecasting, relying on incorrect assumptions. In the first quarter of
Fiscal Year 2006, VHA treated nearly 34,000 more returning OIF and OEF
veterans than it had predicted it would treat for the entire year. The
VA does not adequately track how many health care dollars are spent on
illegal cost comparison studies, according to another GAO study.
Finally, last year, GAO found that millions of dollars budgeted for
mental health strategic initiatives had not been spent.
Stronger reporting requirements for VA spending are badly needed.
It appears that the VA has suffered no consequences for filing several
years of incomplete reports on contracting out that are required by
Federal law (38 U.S.C. Sec. 305). It also appears that the quarterly
reports required by the Fiscal Year 2006 VA appropriations law have not
provided much of a vehicle for oversight. For example, those quarterly
reports should help track the movement of funds between the three
medical care categories. Yet, AFGE members continue to report
``borrowing'' between medical accounts. Along the same lines, the
proposed budget does not adequately explain why 5,689 food service jobs
suddenly fit better in Medical Services than Medical Facilities.
AFGE also urges the Committee to conduct oversight of other problem
spending areas. First, it is very difficult to determine how much VHA
spends on direct patient care FTEs as compared to supervisory and
administrative FTEs. We are especially concerned about the enormous
growth in VISN budgets. One of the original goals of the VISN
reorganization was to reduce the need for management positions, and
each VISN was expected to have 8 to 10 FTEs. Yet currently, total VISN
employment is nearly three times that amount (638 FTEs). Seven of the
23 VISNs have 30 or more employees. AFGE also encourages more oversight
of VHA dollars spent on bonuses.
the president's fiscal year 2008 budget proposal
As proud and longtime supporters of the Independent Budget (IB),
AFGE's overall concern with the President's budget proposal is that the
proposed funding levels for VHA and VBA fall short of the IB's
recommendations, which forecasts veterans' needs using sound,
systematic methodology. We also concur with the IB's recommendation to
restore eligibility to Category 8 veterans. AFGE rejects doubling of
copays, new user fees or any other policies that shift costs to
moderate income veterans and shrink deficits by pushing veterans away.
Despite the Administration's contentions, this proposed budget is
not gimmick-free. Even though drug copays and user fees are not part of
this year's medical care budget, the Administration acknowledges that
these dollars could affect its 2009 appropriations request. Another
familiar gimmick is to follow a strong first year budget with a
decrease in funding over the next 4 years; according to the Center for
Budget and Policy Priorities, veterans' health care would undergo large
cuts between 2008 and 2012.
Fee Basis Care
One of the most harmful byproducts of underfunding is excessive
reliance on contract care. Federal law and good policy dictate that fee
basis care should be provided to veterans in limited circumstances.
AFGE is concerned that the proposed Fiscal Year 2008 budget continues a
dangerous trend toward increased reliance on fee basis care, in lieu of
hiring more VA medical professionals and timely construction of new
hospitals and clinics. The number of outpatient medical fee basis
visits estimated for Fiscal Year 2008 represents a 27 percent increase
in 3 years. Veterans deserve a better explanation of VA's growing
reliance on fee basis care, in the face of constant accolades in the
medical community about the quality of VA health care. AFGE also has
concerns about the potential of VA's newest fee basis initiative,
Project HERO, to waste scarce medical dollars by increased use of
contract care.
Long Term Care
The Administration has once again failed to propose adequate
funding for institutional long term care. There are insufficient
resources in the community to shift large numbers of aging and disabled
veterans to noninstitutional care. Some veterans must remain in
institutional care and need beds that are currently in short supply. In
addition, AFGE questions estimates in the proposed budget that predict
declines in operating levels for rehabilitative, psychiatric, nursing
home and domiciliary care.
VBA
The proposed priority system for processing OIF and OEF claims
leaves many unanswered questions. Admiral Cooper's assurance at the
budget briefing that this new system will ``hopefully'' not impact
other veterans already facing long delays in claims processing is not
enough. VBA needs to hire enough staff to process all benefit claims in
a timely manner. Specific legislation should be required to impose any
priority system in VBA.
The proposed budget does not contain adequate justification for its
request for dollars to conduct new contracting out pilot projects for
medical exams to determine service-connected disabilities and income
matching. AFGE strongly encourages this Committee to inquire as to
whether it is in veterans' interests to contract out this work, and
whether doing so violates competition requirements in the OMB A-76
Circular and 2006 Transportation-Treasury Appropriations law.
The proposed increase in staff for the processing of disability
claims is a step in the right direction. However, the proposed decrease
in staff for the Pension Maintenance Centers is definitely a step in
the wrong direction. Currently, the Pension Maintenance Centers have
too few authorizers to review cases, while adjudicators are pressured
to give claims a limited review to meet production standards. If VBA
proceeds with plans to shift the processing of original pension claims
from the Regional Offices to the Pension Maintenance Centers,
additional staff will be needed.
reports from the front lines
The following examples illustrate how underfunding and financial
uncertainly adversely impact the delivery of health care to veterans:
Nurses
<bullet> Pay: Despite widely recognized problems with recruitment
and retention, RNs in every VISN report problems with the locality pay
process established by 2000 nurse legislation. Managers often refuse to
provide locality pay increases even after conducting surveys, claiming
lack of funds. The result is a worsening of the current nurse
recruitment and retention problem and fewer nurses at veterans'
bedsides.
<bullet> Contract Nurses: Turning to contract nurses as a stopgap
solution wastes scarce dollars and impacts quality. AFGE commends
Chairman Akaka and Senator Salazar for requesting a GAO study of the
growing VA practice of using contract nurses to address nursing
shortages resulting from budget-driven hiring freezes.
<bullet> Floating: Another frequently used stopgap solution that
hurts patient care is requiring nurses to rotate between two or more
short-staffed clinics.
<bullet> Mandatory Overtime: Despite provisions in 2004 legislation
to reduce mandatory nurse overtime, hospitals continue to rely on
mandatory overtime to address staffing shortages.
<bullet> Patient Safety Equipment: AFGE urges this Committee to
ensure that all VA medical facilities have the funds to purchase
patient lifting equipment that reduce nurse back injuries and patient
tears.
Physicians and Dentists
In every VISN, physicians and dentists report difficulty getting
adequate market pay increases and performance pay awards, despite clear
language in 2004 physicians pay legislation. Facility directors have
contended that they lack the funds to increase pay and give awards,
even before they convened any panels to set market pay or conducted
evaluations of individual physician performance. Management also cries
``budget'' in refusing to reimburse physicians for continuing medical
education, again despite clear language in Title 38 entitling full-time
physicians to up to $1,000 per year.
On call physicians are routinely scheduled for weekend rounds and
are not provided any compensation time for weekend work. Primary care
panel sizes are at maximum levels regardless of the complexity of
various cases. Physicians with heavy workloads must also cover large
patient loads of other doctors on leave as there are no additional
physicians available.
The results of these ill-advised policies are widespread shortages
of specialty physicians throughout the VA, and shorthanded primary care
clinics with enormous patient caseloads.
Delays in Diagnostic Testing
Short staffing causes significant delays in medical testing.
According to recent report from a VISN 20 facility, veterans there face
significant delays in obtaining sleep studies because the sleep clinic
lacks adequate staff to review the results. As a result, it takes 5 to
6 months to get reports read (over double the wait time a year ago).
The facility is also experiencing extensive delays in getting the
results of bone density studies because the Imaging Department has only
one part-time employee to read the scans.
Mental Health
Due to a chronic shortage of psychiatrists in many facilities, new
veterans entering the VA health care system must wait several months to
see a psychiatrist. While there has been an increase in hiring of new
social workers, the level is still below that of 10 years ago. Heavier
caseloads prevent social workers from spending more time with patients
and providing other support such as visiting patients at homeless
shelters.
conclusion
AFGE greatly appreciates the opportunity to submit our views and
recommendations to the Senate Committee on Veterans Affairs. We look
forward to working with Chairman Akaka and Ranking Member Craig to
ensure that the VA budget adequately meets the needs of our veterans in
Fiscal Year 2008 and beyond. We believe assured funding and increased
oversight are essential to meeting that goal.
______
Prepared Statement of the Friends of VA Medical Care
and Health Research
On behalf of the Friends of VA Medical Care and Health Research
(FOVA), thank you for your continued support of the Department of
Veterans Affairs (VA) Medical and Prosthetic Research Program. FOVA is
a coalition of over 80 national academic, medical and scientific
societies; voluntary health and patient advocacy groups; and Veterans
Service Organizations committed to ensuring high-quality health care
for our Nation's veterans. The FOVA organizations greatly appreciate
this opportunity to submit testimony on the President's proposed Fiscal
Year (FY) 2008 budget for the VA research program. For Fiscal Year
2008, FOVA recommends an appropriation of $480 million for VA Medical
and Prosthetic Research and an additional $45 million for research
facilities upgrades to be appropriated through the VA Minor
Construction account.
FOVA recognizes the significant budgetary pressures this committee
bears and thanks both the House and Senate Committees on Veterans
Affairs for their Fiscal Year 2007 views and estimates with regard to
the VA Medical and Prosthetic Research program. The committees'
recommended increases in VA research funding of between $28 million and
$51.5 million over the President's Fiscal Year 2007 budget request for
the VA research program affirm your ongoing support for improving the
health of our Nation's veterans. FOVA also thanks Senators Akaka and
Craig for their strong leadership of this committee and for leading
efforts in the Senate to encourage the Senate Committee on
Appropriations to appropriately fund the VA research program. FOVA
looks forward to working with you to develop views and estimates for
Fiscal Year 2008 that reflect this same commitment to medical research
for the benefit of veterans and, ultimately, all Americans.
va medical and prosthetic research is necessary for superior
veterans health care
Recent stagnate funding has jeopardized the national leadership
status of the VA research program. Significant growth in the annual VA
research appropriation is necessary to continue to achieve
breakthroughs in health care for the current population of veterans and
to develop new means for addressing the health care needs of the
Nation's new veterans.
For Fiscal Year 2008, the Bush Administration has yet again
recommended a budget that cuts funding for the VA research program.
When biomedical inflation is considered--the Biomedical Research and
Development Price Index for Fiscal Year 2008 is projected at 3.7
percent--the research program will be cut even more significantly than
the $1 million in current dollars. Just to keep pace with the previous
year's spending, an additional $15 million, for a total of $427
million, is required.
FOVA's $480 million recommendation for VA research funding
represents an inflation adjustment for the program against the Fiscal
Year 2003 baseline. Unfortunately, this recommendation does not even
address the additional funding needed to address emerging needs for
more research on posttraumatic stress disorder (PTSD), long-term
treatment and rehabilitation of veterans with polytraumatic blast
injuries, and genomic medicine.
The VA Medical and Prosthetic Research program has been one of the
Nation's premier research endeavors. The program has a strong history
of success as illustrated by the following examples of VA
accomplishments:
<bullet> Developed effective therapies for tuberculosis.
<bullet> Invented the implantable cardiac pacemaker, helping many
patients prevent potentially life-threatening complications from
irregular heartbeats.
<bullet> Performed the first successful liver transplants.
<bullet> Developed the nicotine patch.
<bullet> Found that an implantable insulin pump offers better blood
sugar control, weight control, and quality of life for adult-onset
diabetes than multiple daily injections.
<bullet> Identified a gene associated with a major risk for
schizophrenia.
<bullet> Launched the first treatment trials for Gulf War Veterans'
Illnesses, focusing on antibiotics and exercise.
<bullet> Began the first clinical trial under the Tri-National
Research Initiative to determine the optimal antiretroviral therapy for
HN infection.
<bullet> Launched the largest-ever clinical trial of psychotherapy
to treat PTSD.
<bullet> Demonstrated the effectiveness of a new vaccine for
shingles, a painful skin and nerve infection that affects older adults.
<bullet> Discovered--via a 15-year study of 5,000 individuals--that
secondhand smoke exposure increases the risk of developing glucose
intolerance, the precursor to diabetes.
VA strives for improvements in treatments for conditions with a
prevalence among veterans greater than in the general population,
including: diabetes, substance abuse, mental illnesses, heart diseases,
and prostate cancer. The VA research program also focuses its efforts
on service connected conditions, including spinal cord injury,
paralysis, amputation, and sensory disorders.
VA is equally obliged to develop better responses to the grievous
conditions suffered by veterans of Operation Iraqi Freedom (OIF) and
Operation Enduring Freedom (OEF), such as extensive bums, multiple
amputations, compression injuries, and mental stress disorders.
Additional increases are also necessary for continued support of new
initiatives in neurotraumas, including head and cervical spine
injuries; wound and pressure sore care; pre- and post-deployment health
issues with a particular focus on post-traumatic stress disorder; and
the development of improved prosthetics and strategies for
rehabilitation from polytraumatic injuries. These returning OIF and OEF
veterans have high expectations for returning to their active
lifestyles and combat.
The seamless mental and physical reintegration of these soldiers is
a challenge, but the VA Medical and Prosthetic Research Program can and
will address these needs. However, without appropriate funding, VA will
be ill-equipped to address the needs of the returning veteran
population while also researching treatments for diseases that affect
veterans throughout the course of their lives and for which they will
seek treatment from VA medical facilities.
To address these long-term needs, VA has a distinct opportunity to
recreate its health care system and provide progressive and cutting
edge care for veterans through genomic medicine. Innovations in genomic
medicine will allow the VA to track genetic susceptibility for disease
and develop preventative measures; predict response to medication; and
modify drugs and treatment to match an individual's unique genetic
structure. VA is the obvious choice to undertake substantial research
in genomic medicine as the largest integrated health care system in the
world with an advanced and industry-leading electronic health record
and a dedicated population for sustained research, ethical review, and
standard processing.
While advances in genomic medicine show promise in aiding the
discovery of new, personalized treatments for diseases prevalent among
many veterans seeking treatment at VA hospitals, there is also evidence
that genomic medicine will greatly help in the treatment and
rehabilitation of returning OIF/OEF veterans. For instance, research
can target the human genome for insight into individual capacity for
the healing of wounds. Additional studies have considered the
differences between genes that aid in healing and genes that cause
inflammation and its sideeffects. Advancements in this field can
drastically influence the treatment of injured soldiers and may play a
large role in the long-term treatment of surgical patients and
amputees.
The VA genomic medicine project will require sustained increases in
funding for the VA research program over the next decade, at least. A
VA pilot program for banking genetic information that involves 20,000
individuals and 30,000 specimens (with the capacity to hold 100,000
specimens) provides estimates that approximately $1,000 will be
necessary to conduct genetic analyses of each specimen. The potential
advances that can be achieved with regard to PTSD and veteran-related
diseases rely on an expansion of tissue banking as the crucial
information generating step that will inform future ongoing research
and the development of new treatments.
va research facilities must be updated to meet
scientific opportunities
State-of-the-art research requires state-of-the-art technology,
equipment, and facilities in addition to highly qualified and committed
scientists. Modem research cannot be conducted in facilities that more
closely resemble high school science labs than university-class spaces.
Modern facilities also help VA recruit and retain the best and
brightest clinician scientists. In recent years, funding for the VA
Minor Construction Program has failed to provide the resources needed
to maintain, upgrade, and replace aging research facilities. Many VA
facilities have run out of adequate research space, and ventilation,
electrical supply, and plumbing appear frequently on lists of needed
upgrades along with space reconfiguration. Under the current system,
research must compete with other facility needs for basic
infrastructure and physical plant improvements which are funded through
the minor construction appropriation.
FOVA appreciates the inclusion within the House-passed Military
Quality of Life and Veterans' Affairs and Related Agencies Fiscal Year
2007 appropriations bill of an additional $12 million to address
research facility infrastructure deficiencies. The House Committee on
Appropriations also gave attention to this problem in the House Report
accompanying the Fiscal Year 2006 appropriations bill (P.L. 109-114),
which expressed concern that equipment and facilities to support the
research program may be lacking and that some mechanism is necessary to
ensure VA's research facilities remain competitive. The report noted
that more resources may be required to ensure that research facilities
are properly maintained to support VA's research mission. To assess
VA's research facility needs, Congress directed VA to conduct a
comprehensive review of its research facilities and report to Congress
on the deficiencies found, along with suggestions for correction.
Unfortunately, in its Fiscal Year 2008 budget submission, VA stated
that this review, already underway for the past year, will take an
additional 3 years to complete.
Meanwhile, in May, 2004, Secretary of Veterans Affairs Anthony J.
Principi approved the Capital Asset Realignment for Enhanced Services
(CARES) Commission report that called for implementation of the VA
Undersecretary of Health's Draft National CARES Plan. The CARES Plan
recommended at least $87 million to renovate existing research space.
FOVA believes this estimate should be sufficient justification for an
increase in the minor construction program to begin a significant
modernization program. However, based on pre-2004 assessments of VA
research facilities, FOVA believes a complete assessment of research
infrastructure needs will likely require a facilities improvement
investment of more than $300 million across the 75 VA medical centers
that conduct significant amounts of VA funded research. The urgency of
VA funding for facilities is more heightened now than ever given the
difficulties facing many affiliated non-profit research corporations,
which have historically contributed to the modernization of VA research
facilities.
FOVA believes Congress should establish and appropriate a funding
stream specifically for research facilities using the VA assessment
resulting from the Fiscal Year 2006 report language. In the meantime,
to ensure that funding is adequate to meet both immediate and long-term
needs, FOVA recommends an annual appropriation of $45 million in the
minor construction budget dedicated to research facilities
improvements. This appropriation is a critical interim step to ensure
VA can continue to conduct state-of-the-art research.
the integrity of va's intramural, peer-review system
must be preserved
As a perquisite for membership, all FOVA organizations agree not to
pursue earmarks or designated amounts for specific areas of research in
the annual appropriation for the VA research program. The coalition
urges you to take a similar stance in regard to Fiscal Year 2008
funding for VA research for the following reasons:
<bullet> The VA research program is exclusively intramural. Only VA
employees holding at least a five-eighths salaried appointment are
eligible to receive VA research awards originating from the VA research
appropriation. Compromising this principle by designating funds to
institutions or investigators outside of the VA undermines an extremely
effective tool for recruiting and retaining the highly qualified
clinician-investigators who provide quality care to veterans, focus
their research on conditions prevalent in the veteran population, and
educate future clinicians to care for veterans .
<bullet> VA has well-established and highly refined policies and
procedures for peer review and national management of the entire VA
research portfolio. Peer review of proposals ensures that VA's limited
resources support the most meritorious research. Additionally,
centralized VA administration provides coordination of VA's national
research priorities, aids in moving new discoveries into clinical
practice, and instills confidence in overall oversight of VA research,
including human subject protections, while preventing costly
duplication of effort and infrastructure. Earmarks have the potential
to circumvent or undercut the scientific integrity of this process,
thereby funding less than meritorious research.
<bullet> VA research encompasses a wide range of types of research.
Designating amounts for specific areas of research minimizes VA's
ability to fund ongoing programs in other areas and forces VA to delay
or even cancel plans for new initiatives. Biomedical research inflation
alone, estimated at 3.8 percent for Fiscal Year 2005, 3.5 percent for
Fiscal Year 2006, and 3.7 percent for Fiscal Year 2007, has reduced the
purchasing power of the R&D appropriation by $44.9 million over just 3
years. In the absence of commensurate increases, VA is unable to
sustain important research on diabetes, hepatitis C, heart diseases,
stroke and substance abuse, or address emerging needs for more research
on post traumatic stress disorder and long-term treatment and
rehabilitation of polytraumatic blast injuries. While Congress
certainly should provide direction to assist VA in setting its research
priorities, earmarked funding exacerbates ongoing resource allocation
shortages.
va medical and prosthetic research will thrive
with your support
With its modest research funding, the VA Medical and Prosthetic
Research Program has yielded the important scientific discoveries
outlined above, competed successfully for over $1 billion annually in
funding from other governmental research programs as well as the
private sector, produced multiple Nobel Laureates and recipients of
other major research recognitions, and added over 2,900 papers annually
to the scientific literature. However, VA's modest funding has also
required that scientific awards be capped at $125,000 annually, a level
significantly lower than the average award amount for the National
Institutes of Health, for example. The $125,000 cap is also lower than
the cap on funding from earlier in this decade, a tradeoff VA
leadership has had to make to continue funding the same number of
grants it has historically supported. Modest funding has also limited
the capacity of the VA career development program and forced VA to cut
funding to important program areas including aging, degenerative
diseases of bones and joints, infectious diseases, and kidney
disorders.
Congresses' strong past support for the VA research program has
been encouraging. FOVA believes the crises and opportunities facing VA
research necessitate a significant boost in Federal funding for the
program. With such funding, VA can maintain its leadership role in
developing resources to address the immediate health care needs of
veterans emerging from OIF/OEF as well as the long-term needs of these
veterans and those who served the country in the 20th century.
Again, FOVA appreciates the opportunity to present our views to the
Committee. While research challenges facing our Nation's veterans are
significant, if given the resources, we are confident the expertise and
commitment of the physician-scientists working in the VA system will
meet the challenge.
[The Inflation Adjusted VA Research Appropriations chart follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
aFOVA Membership
Administrators of Internal Medicine
Alliance for Academic Internal Medicine
Alliance for Aging Research
American Academy of Child and Adolescent Psychiatry
American Academy of Neurology
American Academy of Orthopaedic Surgeons
American Association for the Study of Liver Diseases
American Association of Anatomists
American Association of Colleges of Nursing
American Association of Colleges of Osteopathic Medicine
American Association of Colleges of Pharmacy
American Association of Spinal Cord Injury Nurses
American Association of Spinal Cord Injury Psychologists and Social
Workers
American College of Chest Physicians
American College of Clinical Pharmacology
American College of Physicians
American College of Rheumatology
American Dental Education Association
American Federation for Medical Research
American Gastroenterological Association
American Geriatrics Society
American Heart Association
American Hospital Association
American Lung Association
American Military Retirees Association
American Occupational Therapy Association
American Optometric Association
American Osteopathic Association
American Paraplegia Society
American Physiological Society
American Podiatric Medical Association
American Psychiatric Association
American Psychological Association
American Society for Bone and Mineral Research
American Society for Pharmacology and Experimental Therapeutics
American Society of Hematology
American Society of Nephrology
American Thoracic Society
Association for Assessment and Accreditation of Laboratory
Animal Care International
Association for Research in Vision and Ophthalmology
Association of Academic Health Centers
Association of American Medical Colleges
Association of Professors of Medicine
Association of Program Directors in Internal Medicine
Association of Schools and Colleges of Optometry
Association of Specialty Professors
Association of VA Chiefs of Medicine
Association of VA Nurse Anesthetists
Blinded Veterans Association
Blue Star Mothers of America
Clerkship Directors in Internal Medicine
Coalition for Health Services Research
Digestive Disease National Coalition
Federation of American Societies for Experimental Biology
Gerontological Society of America
Gold Star Wives
Hepatitis Foundation International
International Foundation for Functional Gastroenterological
Disorders
Juvenile Diabetes Research Foundation International
Legion of Valor of the USA, Inc.
Medical Device Manufacturers Association
Medicine-Pediatrics Program Directors Association
Military Officers Association of America
National Alliance on Mental Illness
National Association for the Advancement of Orthotics and
Prosthetics
National Association for Uniformed Services
National Association of VA Dermatologists
National Association of VA Physicians and Dentists
National Association of Veterans' Research and Education
Foundations
National Mental Health Association
Nurses Organization of Veterans Affairs
Osteogenesis Imperfecta Foundation
Paralyzed Veterans of America
Paralyzed Veterans of America Spinal Cord Research Foundation
Partnership Foundation for Optometric Education
Society for Investigative Dermatology
Society for Neuroscience
Society for Women's Health Research
Society of General Internal Medicine
Spinal Cord Research Foundation
The Endocrine Society
United Spinal Association
Veterans Affairs Physician Assistant Association
Veterans of the Vietnam War and the Veterans Coalition
Vietnam Veterans of America
______
The Independent Budget Response to Written Questions
Submitted by Hon. Daniel K. Akaka, Chairman, U.S. Senator from Hawaii
Question 1. I would like your comments on VA's proposed enrollment
fee and increase in the prescription drug copayment for Priority 7 and
8 veterans-both of which the Administration has repeatedly proposed.
What are the implications of these policies? How many veterans do you
estimate would be drive out of the system?
Answer. Although the Administration's proposal will not have direct
impact on veterans' health care funding, we are deeply disappointed
that the Administration chose to once again recommend an increase in
prescription drug copayments from $8 to $15 and an indexed enrollment
fee based on veterans' incomes. These proposals will simply add
additional financial strain to many veterans, including veterans with
catastrophic disabilities. Although the VA does not overtly explain the
impact of these proposals, similar proposals in the past have estimated
that nearly 200,000 veterans will leave the system and more than
1,000,000 veterans will choose not to enroll.
It is astounding that this Administration would continue to
recommend policies that would push veterans away from the best health
care system in the world. The Independent Budget contends that veterans
should not have to pay an additional price to utilize the VA health
care system, when that price was already paid through their service.
Furthermore, it is not appropriate to compare the VA system and these
new proposed fees to the TRICARE system and the fees that enrolled
retirees pay. TRICARE serves as an insurance program both for the
retiree and his or her family. A veteran's family has only limited
access to the VA health care system. We appreciate the fact that
Congress has soundly rejected these proposals in the past and we hope
that you will do so once again.
Question 2. How long should a veteran or dependent have to wait to
have his or her claim decided?
Answer. While the IB does not make recommendations regarding a
specific amount of time considered reasonable for a veteran to await a
claims decision, we appreciate Chairman Akaka's question and effort to
establish a benchmark for the Department of Veterans Affairs (VA) to
strive for in claims processing times. The IB does not normally make
such recommendations because we believe the VA should continually
strive to increase efficiency, though its primary focus should be on
producing accurate decisions that must not be appealed. Not
withstanding this position, the IB would be pleased with the progress
made if VA were able to attain the goals it has already established for
itself. In 2001, the Secretary of Veterans Affairs' Claims Processing
Task Force goal was to reduce the waiting period by fifty percent.
According to the VA Web site, the average processing time then was 202
days, so the goal was to reduce it to 101 days. The Veterans' Claims
Assistance Act of 2000 and other factors have impacted that goal and
the VA's new goal is to reduce claims processsing time to 145 days.
Clearly, disabled veterans should have to wait as little as possible to
receive benefits to which they are entitled, but a 145-day waiting
period would certainly be preferable to the length of time that is
currently required. Again, while efficiency is important, the FY 2008
IB emphasizes that VA's main focus should be on quality rather than
quantity.
Question 3. As you know, improved cooperation between VA and DOD to
achieve a seamless transition between the two Departments for
separating servicemembers is one of my top priorities. I was glad to
see The Independent Budget's recommendation that VA and DOD ensure that
servicemembers have a seamless transition from military to civilian
life. Please share your thoughts on what the Departments can do to
improve on their performance and reach this goal.
Answer. The Independent Budget Veterans Service Organizations
(IBVSO) believe that regardless of who is responsible for addressing
weaknesses in the process, seamless transition is a responsibility that
both agencies must bear equally. Time and again, progress has been
stymied by a combination of a lack of leadership priority and
oversight, bureaucratic inertia, and technological backwardness. It is
disconcerting comparing the current state of the seamless transition
process to the potential extraordinary accomplishments of which the DOD
and VA are capable. We recommend greater vigilance from Congress in its
oversight responsibilities on issues hampering the seamless transition
of servicemembers, possibly through an informal workgroup for point
specific issues regarding strategic goals in the Joint Strategic Plan
approved by the VA-DOD Joint Executive Committee. Additionally, we
recommend joint committee hearings with the Senate Committee on Armed
Services for greater transparency and oversight of the VA-DOD Joint
Executive Council activities including the implementation of the Joint
Strategic Plan.
Issues regarding fundamental components of the process remain to
which we address recommendations including the development of
electronic medical records that are interoperable and bidirectional,
allowing for two-way electronic exchange of computable health
information; occupational and environmental exposure data; and, an
electronic Discharge Document (DD) 214. At a minimum, this would allow
VA to expedite the process and give the servicemember faster access to
health care and benefits. In addition, implementing a mandatory single
separation physical as a prerequisite of promptly completing the
military separation process would address many issues in the
transitioning of benefits and services for servicemembers entering
civilian life. Although the physical examinations of demobilizing
reservists have improved in recent years, there are still a number of
soldiers who ``opt out'' of the physical examinations, even when
encouraged by medical personnel to obtain them. Finally, we recommend
additional funding for the Army Wounded Warrior Program and Marine for
Life programs to allow for appropriate expansion of these programs to
address the needs of more seriously disabled soldiers and Marines. With
a high number of severely injured servicemembers returning from Iraq
and Afghanistan, it is essential that Congress and the Administration
support and enhance these successful programs.
Question 4. Given that VBA continues to fall behind in workload
pending versus workload completed, what are some immediate steps that
can be taken to give some relief to veterans who are waiting to have
their claims adjudicated?
Answer. The IB appreciates the Chairman's innovative perspective
with regard to providing benefits to disabled veterans as quickly as
possible. Clearly, doing so would require some degree of certainty that
such veterans will be eligible for service-connected benefits.
Otherwise, such a grant would merely create an overpayment and
indebtedness to the Government for veterans whose claim is denied. The
VA already utilizes authority to grant immediate benefits via
``memorandum ratings'' to veterans, such as those severely injured in
combat, who will unquestionably be entitled to at least twenty percent
service connected disability compensation. The memorandum rating is a
temporary rating that is for the purpose of establishing entitlement to
Vocational Rehabilitation and Employment (VR&E). With entitlement to
VR&E established, disabled veterans can begin their lengthy transition
into the civilian job market and lifestyle.
Perhaps this process could be used as a template to deliver
additional benefits to disabled veterans awaiting their final rating
decisions. Most importantly, VA should have sufficient resources to
enable it to make timely claims decisions. This would take into
consideration the irreducible amount of time required for responses to
requests for information, including turnaround time for mailing; the
minimum number of days in queue to maintain minimum inventory necessary
for having work on hand, maintaining even production; and, reasonable
task times.
Question 5. The Department of Veterans Affairs Personnel
Enhancement Act of 2004 was intended to reform the pay and performance
system used by VA for hiring and retaining its physicians and dentists.
Now that we are in the first full year of implementation, can you give
us a sense of how well VA has implemented this legislation and if it is
truly assisting VA in recruiting and retaining the best and brightest
physicians?
Answer. We do not detect any notable change in VA's pace or methods
for recruiting physician staff that we can attribute to enactment of
Public Law 108-445. We are confident that VA managers of health care
want to obtain the ``best and brightest'' in physicians and all staff
who care for veterans, but we cannot verify that result with any
objective data that can be linked to passage of the Act. We are
concerned about whether VA's stated support for its passage, provided
by the Under Secretary for Health at a hearing before your House
counterpart on October 23, 2003, has been fulfilled. The Under
Secretary testified as follows:
``Also, a national shortage of many physician specialties critical
to our health care mission further affects our ability to fill key
vacancies. In these shortage specialties, VA total compensation lags
behind private or academic sectors by as much as 67 percent. If we are
to maintain our tertiary care capability and our capacity to offer a
full range of health care services to veterans, including those now
serving in far away parts of the world, we must be able to offer
competitive salaries. For several specialties, we are losing staff
faster than we can hire them. In some critical specialties, our
turnover rate exceeds 25 percent a year. Many facilities are not
actively recruiting, as Mr. Rodriguez pointed out, to fill some key
vacancies because they simply cannot find viable candidates at current
VA salary rates. It is estimated that there are over 900 such positions
nationwide for physician specialties. Non-competitive pay and benefits
are also reflected in dramatic increases in our scarce specialty, fee
basis, and contractual expenditures. These expenditures, which are
necessitated when we cannot hire physicians, have risen from $180
million a year in 1995 to over $850 million a year last year.
Additionally, we increasingly must hire non-U.S. citizens under the
VA's J-1 visa waiver authority, and international medical graduates now
constitute almost 30 percent of our entire VA physician workforce. The
problems with the current system are clear. Special pay rates are fixed
in statute so that over time, their values are eroded by inflation, and
VA pay falls behind the market. We now pay the maximum authorized
amounts for some scarce specialists, and have no discretion under
existing statute to pay more to retain these mission critical
employees.''
The premise in Congressional passage of the bill was that these
numbers (of vacancies in specialty physicians, and the costs for
contracting for scarce medical specialists) would both fall. The
overall indication was that the Veterans Health Administration would
position itself--using this authority--to make itself a more attractive
employment opportunity for specialists, and that specialists would
respond.
One of the requirements of the Act is that VA submits a report to
the Committee 18 months post enactment, reporting its effects on
recruitment and retention. We hope VA will address at least some of
these questions in providing that report to the Committee.
In monitoring implementation of this legislation, we were disturbed
at VA's exclusionary approach to developing compensation panels,
setting parameters for market pay and establishment of performance pay
incentives. We have learned that VA would not allow outside
consultation with labor organizations representing VA physicians on any
of these matters, despite the stated intention of your Committee that
VA physicians be consulted in establishing these policies. Also,
funding shortages in VA facilities essentially negated the promise of
significant performance pay being made available to fulfill the
purposes of the Act. In a number of networks, local management was
given the option of setting arbitrary caps on performance pay that were
imposed universally and preventing any significant rewards for
outstanding performance, while VA physicians working within the
performance plans were penalized if they failed to meet those expected
levels of productivity. We understand that the American Federation of
Government Employees was refused in its effort under the Freedom of
Information Act to obtain statistical information from VA dealing with
the establishment of compensation panels, the policies governing that
work, and of salary ranges those panels set, even though it is
difficult for us to understand the claimed ``sensitive'' nature of this
information.
For all these reasons, The Independent Budget Veterans Service
Organizations are concerned about the status of VA physician pay as a
consequence of enactment of Public Law 108-445, and we hope the
Committee will use its oversight authority to closely monitor VA
actions.
______
The Independent Budget Response to Written Questions Submitted
by Hon. Larry E. Craig, Ranking Member, U.S. Senator from Idaho
Question 1. The IB's recommendation of 9,300 direct FTE for the
C&P service appears to be based on an assumption that VA will receive
over 870,000 claims in Fiscal Year 2008 plus an additional 56,000
claims based on the six state outreach that occurred in 2006. VA, on
the other hand, has estimated that it will receive 800,000 total claims
in Fiscal Year 2008 and is not projecting any additional work in Fiscal
Year 2008 based on the six state outreach, which ultimately generated
only 8,000 additional claims.
Using the IB's math of 100 claims per FTE, if VA's projection of
800,000 claims is accurate, wouldn't the 8,300 direct FTE requested by
the Administration be more than adequate?
Response. Yes, if VA's projection that it will receive 800,000
claims is accurate, 8,300 FTE would be adequate based on the IB
recommendation of 100 claims per FTE. However, the IB is confident that
its projection of more than 870,000 future claims receipts is more
precise. The disability claims workload from returning war veterans and
veterans of previous periods has steadily increased since 2000. During
both Fiscal Year 2005 and Fiscal Year 2006, the total number of
compensation, pension, and burial claims increased by an average annual
rate of 4.5 percent. During this same period, the number of pending
claims increased by a total of more than 33 percent. With an aging
veterans population and ongoing hostilities in Iraq and Afghanistan, it
is reasonable to expect a continuation of inclined rates. Assuming the
annual percentage rate of growth remains the same as in preceding
years, VA can expect 874,136 claims for C&P in Fiscal Year 2007.
However, the VA perspective is that a slight decrease in the number of
claims receipts will occur during 2007 and 2008. This prediction is
somewhat troubling, considering that the VA funding shortfall that
occurred in 2005 was attributed to error in estimating the number of
future claims receipts.
Question 2. You recommend a 63 percent increase for the Veterans
Benefits Administration, an increase of $737 million. I see that you
propose $115 million for information technology initiatives, but it
would appear that what remains is far too high to account for the extra
staffing you propose (assuming an average cost of $85,000 for one FTE
according to VA's budget documents) and for general inflationary
increases.
Please explain how you arrived at your recommended increase for
VBA.
Response. The Independent Budget recommendations for the Veterans
Benefits Administration for Fiscal Year 2008 are significantly higher
than the previous year primarily because our baseline from which we
began our calculations was significantly higher than what appears to be
the appropriated level in H.J. Res. 20. We do not believe that the
current services level (appropriated level) adequately addressed the
true needs and problems facing VBA. In fact, we believe that this level
was wholly inadequate. The Fiscal Year 2007 appropriated level only
allows the VA to barely keep its head above water. It does nothing to
actually allow the VBA to reduce the backlog that it is dealing with.
Not only that, the backlog is actually growing. It makes no sense to
say that the Fiscal Year 2007 appropriated level is sufficient as a
baseline to determine what will be needed to address the claims
workload next year. The Independent Budget's Fiscal Year 2008
recommendations reflect what we believe it will take for the VBA to
meet the needs of current and future veterans and actually start making
progress on the claims backlog, and not just get by, as has been the
case for many years. That accounts for the largest difference in our
recommendations. The Independent Budget believes that the current
baseline does not provide the VBA with a reasonable starting point to
address the rapidly growing claims backlog.
From that starting point, the bulk of the increase in our
recommendation comes from an increase in the compensation and pension
(C&P) line item. Based on our calculations, inflationary increases
total approximately $105 million over the Fiscal Year 2007 projected
appropriation. Our compensation and pension recommendation also
includes nearly $143 million for additional FTEE. This is derived from
our estimated C&P average salary and benefits of approximately $100,000
for an additional 1,375 new FTEE. Finally, as you mention, our C&P
increase includes the $115 million for the information technology
initiatives. This accounts for our total increase in C&P over what we
believe the available amounts will be from the appropriations bill.
The remaining increase in VBA is through inflationary increases to
the primary accounts and modest increases in FTEE for Vocational
Rehabilitation and Education.
Question 3. The Independent Budget proposes a $500 million
initiative to expand mental health services, with a specific emphasis
on PTSD care.
Please discuss briefly with us what you see as VA's shortcomings in
mental health treatment and what you see the $500 million increase in
services doing to fill the gaps your organizations have identified.
Response. As reported in the Fiscal Year 2008 Independent Budget,
we are generally pleased with the direction VA has taken and the
progress it has made with respect to implementing the National Mental
Health Strategic Plan (MHSP). However, we assert that gaps remain in
mental health services that still need to be addressed. The additional
funding that we recommended is not intended to be earmarked for
specific mental health programs, but instead is meant to boost the VA's
efforts to adapt to the emerging and often unique needs of the newest
generation of combat service personnel while continuing to address the
chronic and acute needs of older veterans. We view this funding as
necessary above the projected current services amounts that the VA will
devote to the mental health care needs of these men and women.
Some additional insight on this issue from the perspective of The
Independent Budget is necessary. In November 2006, the Government
Accountability Office (GAO) issued a report on resources allocated for
VA's MHSP initiatives. The GAO found that VA did not allocate all of
the funding it planned in Fiscal Year 2005 for new mental health
initiatives to address identified gaps in mental health services.
Additionally, the GAO reported that the VA Central Office did not
inform Veterans Integrated Service Network (VISN) and medical center
officials that certain funds were to be used for these specific mental
health initiatives, and therefore it is likely some funds went for
other health care priorities. It is unacceptable that funding
priorities that were clearly outlined were not properly managed,
particularly at the VISN and lower levels.
Furthermore, VA has intensified its outreach efforts to Operation
Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans and reports
that the relatively high rates of health care utilization among this
group reflect the fact that these veterans have ready access to VA
health care, which is available without charge for 2 years following
separation from service for problems related to their wartime service.
With increased outreach, internal mental health screening efforts now
underway and expanded access to health care for OEF/OIF veterans, we
are concerned that VA continues to underestimate the numbers of these
veterans who will be seen for various mental health problems in VA
facilities. This in itself could result in a shortfall in funding
necessary to meet the demand. Additionally, VA has not yet developed an
appropriate screening tool or treatment plan for veterans with mild
traumatic brain injury (TBI). VA mental health providers believe they
are ill-prepared to properly access, diagnosis and treat these types of
patients in a multi-disciplinary manner, and that a strategic TBI plan
should be developed and implemented immediately.
Finally, although VA has improved access to mental health services
at its 800-plus community-based outpatient clinics (CBOCs), such
services are still not readily available at all sites. Neither has VA
yet achieved its goal of integrating mental health staff in all its
primary care clinics. Also, we remain concerned about the capacity in
specialized post-traumatic stress disorder (PTSD) programs and the
decline in availability of VA substance-use disorder programs of all
kinds, including the virtual elimination of inpatient detoxification
and residential treatment beds.
Although additional funding has been dedicated to improving
capacity in some programs, VA mental health providers continue to
express concerns about inadequate resources to support, and consequent
rationed access to, the specialized services they provide.
______
February 12, 2007.
Hon. Daniel K. Akaka,
Chairman, U.S. Senate Committee on Veterans' Affairs,
Russell Senate Office Building,
Washington, DC.
Dear Mr. Chairman: You have been advised of an opinion by Mr.
Joseph A. Violante that opposition to the right legal representation in
VA claims process exists. See: page 9 of his statement of February 13,
2007, to the Committee. I write to state the reason that opposition
exists, how it is factually wrong and how Mr. Violante's statement is
rife with an internal inconsistency. Once that is understood, I submit
the wisdom of permitting, not ``forc[ing],'' as he repeatedly argues,
veterans to obtain a private attorney will be quite apparent.
Opposition to the right to obtain legal counsel in the claims
process is, I submit, based on a desire to maintain the status quo
where DAV and a few other VSOs have a virtual monopoly on
representation of veterans until the final BVA decision. To be sure,
there is and has been a large cadre of lay representatives who for
years have done good work on behalf of veterans. That has changed.
Coupled with the inability of lay veteran service officers to cope with
the increase in the volume of claims, the claims process has become
very complex, indeed as complex as personal injury tort litigation. It
may be argued, with some validity, that the advent of judicial review
was, to some extent responsible. The fact remains the benefits system
is complex, over burdened and understaffed including lay veteran
service officers. As I said in my letter of last year to the then
Chairman of this Committee, there is more than enough room for VSO and
attorney representation in the claims process.
Mr. Violante laments, and probably correctly, ``that VA's
production requirements do not allow for thorough development and
careful consideration of disability claims, resulting in compromise
decisions and, higher appeal rates and even more overload on the
system.'' Id. at p. 9. He also notes that the Inspector General's
survey of the VBA adjudicators revealed that ``nearly half of the VBA
adjudicators admitted that many claims are decided without adequate
record development.'' Id. My years on the Court convince me that he is
correct. How then can it be validly argued as he does, that ``adding
attorneys to the claims system will only complicate, lengthen and make
more fractious the resolution of veterans disability claims''? He
simply asserts he has ``been advised by professionals in the VBA'' as
to this conclusion. It is a highly dubious conclusion, and a self
serving and convenient viewpoint. The professional obligations of
lawyers, which is an enforceable duty, is to ensure an adequate record
is compiled and presented, a thorough analysis of statutory and
regulatory rights and duties is formulated and argued to the
adjudicator which will bring the claim to issue for decision. That duty
is the antithesis of fractioness. I add that since the Court's creation
a national bar of competent attorneys has arisen. It is governed by
disciplinary mechanisms which are lacking in the VSO scheme.
I close with this observation: In our society today, everyone but
veterans with claims is free to have lawyer representation, and they
are wise to seek it given our system of rights and duties. Even a
convicted felon is entitled to counsel, as is a Social Security
claimant. Why should veterans be deprived of the right everyone else
has? Veterans are no longer deemed wards of the state requiring
protection from historically perceived predators possessed only of self
interest. They should be entitled to representation of their choice.
I implore this Committee to leave the right to select
representation at the NOD stage as was enacted in the last Congress as
a first step to permitting that choice to extend to the initial claims
level.
Sincerely,
Frank Q. Nebeker,
Chief Judge (Retired).
______
February 13, 2007.
Hon. Daniel K. Akaka,
Chairman, Senate Committee on Veteran's Affairs,
Russell Senate Office Building,
Washington, DC.
Dear Mr. Chairman: Written testimony has been submitted by the
Disabled American Veterans (DAV) for February 13 hearing on the FY 2008
budget. In that written testimony, the DAV representative addresses, at
pp. 9-10 the issue of attorneys in VA claims.
Last year, in Public Law 109-461, Congress specifically provided
that veterans would be permitted the option to retain counsel for
representation in the claims process at the departmental level. In the
testimony submitted for the February 13 hearing, the DAV advocates
repeal of that provision of Public Law 109-461.
As General Counsel of the Veterans' Administration (1985-1990),
Acting General Counsel of the Department of Veterans Affairs (1990),
and as a judge on the U.S. Court of Appeals for Veterans Claims (1990-
2005; Chief Judge 2004-2005), I have been heavily engaged in the
ongoing debate regarding judicial review. During that period, I have
witnessed many changes in the veterans' claims system and I have
developed a full appreciation of the needs of veterans and the
strengths and weaknesses of the veterans' claims system. I am also a
Vietnam veteran with 5 years active duty and retired after almost 25
years of active reserve duty in the U.S. Army.
In advocating repeal, the DAV states its belief that, ``no disabled
veteran should be forced to retain a private attorney.'' That statement
is without basis in the context of Congress' purpose in permitting
veterans, if they so choose, to retain attorney representation at the
departmental level. The DAV goes on to state, without identifiable
support, that, ``your adding attorneys to the claims system will only
complicate, lengthen and make more fractious the resolution of
veterans' disability claims.'' This is an argument that was made in the
late 1980s in opposition to the Veterans Judicial Review Act which
created the Court of Veterans Appeals, now the United States Court of
Appeals for Veterans Claims. That argument, at that time, became a non-
negotiable political position on the part of the VA and a number of
veterans' organizations. It is no longer a valid position, as evidenced
by the actions of the last Congress and by the fact that the provision
in Public Law 109-461 had substantial support from veterans' groups.
The Honorable Frank Q. Nebeker, the first Chief Judge of the U.S.
Court of Appeals for Veterans Claims, in a letter to you regarding this
subject, points out the weak and misleading nature of the DAV testimony
and also points out that, although veterans have had the benefit of
judicial review for more than 16 years, until the last Congress,
``everyone but veterans with claims is free to have lawyer
representation.'' I repeat his question to you: ``Why should veterans
be deprived of the right everyone else has?''
I strongly urge you and the Members of the Committee to resist any
attempt to repeal the provisions of Public Law 109-461 granting
veterans the option to retain an attorney to represent them at the VA
level.
Sincerely,
Donald L. Ivers,
Chief Judge (Retired),
U.S. Court of Appeals for Veterans Claims.
______
Lung Cancer Alliance,
Washington, DC, March 22, 2007.
Hon. Daniel K. Akaka,
Chair, U.S. Senate Committee on Veterans' Affairs,
Senate Russell Building,
Washington, DC.
Dear Mr. Chairman: As Chairman of the Board of Directors of Lung
Cancer Alliance I would like to express our strong support for The
Independent Budget and would appreciate this letter being included in
the Committee's hearing record on the FY08 budget for the Veterans'
Administration.
In particular we would like to bring to your Committee's attention
the recommendation in The Independent Budget for a $3 million Lung
Cancer Early Detection and Disease Management Research Pilot program, a
copy of which is attached to this letter for inclusion in the hearing
record.
As a longtime VSO and lung cancer patient, I am concerned with the
plight of all Veterans at risk for this disease. Lung cancer kills more
Americans than the next five cancers combined. Repeated studies have
shown that Veterans, for a host of reasons, die of lung cancer at a
greater rate than their fellow Americans who did not serve. I believe
that the Department of Veterans Affairs will be facing a wave of
service connected lung cancer victims as Vietnam Veterans enter their
sixties when the disease most commonly presents.
This is a stealth cancer that usually takes decades to develop. By
the time symptoms do become apparent, the disease is already at late
stage. Currently, only 16 percent of cases are diagnosed at an early
stage when the cancer is curable. For the taxpayer and the VA, the
benefits to screening are economic as well as humanitarian: it costs
half as much to treat someone in Stage One as it does to treat a late
stage lung cancer patient. The alternatives are clear: pay now and save
lives, or pay double for dying patients.
The relatively small investment of $3 million in a pilot early
detection research program gives Congress and the Department an
extraordinary opportunity to get ahead of the problem, saving dollars
and lives in the process. No one contests the fact that CT scanning can
detect lung cancer at its earliest stage.
Several long term, large population trials have demonstrated that
the current 85 percent mortality rate can be reversed through early
detection and treatment. While more studies and trials are underway, it
is imperative that at a minimum a pilot research program be
simultaneously carried out among a high risk Veteran population.
I urge the Committee to include this pilot research program in the
FY08 budget authorization and appropriations for the Department of
Veterans Affairs.
Respectfully,
Philip J. Coady,
Rear Admiral, USN (Retired),
Chairman of the Board, Lung Cancer Alliance.
______
Lung Cancer Screening and Early Disease
Management Pilot Program
More than 50 percent of new lung cancer cases are diagnosed in
former smokers, including many who had quit 20 or 30 years ago. Another
15 percent of new lung cancer cases occur in people who have never
smoked, with possible causes including radon, asbestos, Agent Orange
and other herbicides, beryllium, nuclear emissions, diesel fumes, and
other toxins.
Over the next six years, one million Americans will die from lung
cancer, most within months of diagnosis. It is the leading cause of
cancer death, responsible for nearly 30 percent of all cancer
mortality, more than breast, prostate, colon, liver, melanoma, and
kidney cancers combined.
Since Congress passed the National Cancer Act in 1971, the five-
year survival rates for breast, prostate, and colon cancers have risen
to 88 percent, 99 percent, and 65 percent respectively, primarily
because of major funding investments in research and early detection
for those cancers. Lung cancer's five-year survival rate is still at 15
percent, reflective of the persistent underfunding of research and
early detection. Lung cancer now kills three times as many men as
prostate cancer and nearly twice as many women as breast cancer.
<bullet> Impact on Military and Veteran Populations
The Department of Defense (DOD) routinely distributed free
cigarettes and included cigarette packages in K-rations until 1976. The
1997 Harris report to the Department of Veterans Affairs (VA)
documented the higher prevalence of smoking and exposure to
carcinogenic materials among the military and estimated costs to VA and
TRICARE in the billions of dollars per year. For example, the
percentage of Vietnam veterans who ever smoked is more than 70 percent,
double the civilian ``ever smoked'' rate of 35 percent. Asbestos in
submarines, Agent Orange, Gulf War battlefield emissions, and other
toxins are additional factors that have led to a 25 percent higher
incidence and mortality rate for lung cancer among veteran populations.
A 2004 report by the Board on Health Promotion and Disease
Prevention (HPDP) of the Institute of Medicine (IOM), ``Veterans and
Agent Orange: Length of Presumptive Period for Association Between
Exposure and Respiratory Cancer (2004),'' concluded that the
presumptive period for lung cancer is 50 years or more. Another report
issued in 2005 by the HPDP, ``The Gulf War and Health: Volume 3, Fuels,
Combustion Products and Propellants (2005),'' concluded that there is
sufficient evidence for an association between battlefield combustion
products and lung cancer.
Lung cancer is an indolent cancer that takes decades to develop,
and in most cases no symptoms present until the cancer is already at
late stage. Thus, while the disease may initiate under circumstances
encountered during service under the DOD, the disease burden will fall
most heaavily on VA, and to a lesser extent on TRlCARE. Because of the
predominance of late stage diagnoses, more than 60 percent of lung
cancer patients die within the first year, and late stage treatment is
more than twice as costly as early stage.
<bullet> Justification
On October 26, 2006, the New England Journal of Medicine published
the results of a l3-year study on CT screening of 31,500 asymptomatic
people by a consortium of 40 centers in 26 states and 6 foreign
countries. Lung cancer was diagnosed in 484 participants, 85 percent at
stage 1 (versus 16 percent nationally) and the estimated 10-year
survival rate for those treated promptly is 92 percent (versus a 15
percent 5-year survival rate nationally).
The benefits of this early detection and disease management
protocol should be extended to veterans, especially those whose active
duty service has placed them at higher risk for lung cancer.
<bullet> Legislative History
Senate Report 108-087 on the Department of Defense Appropriations
Bill, 2004 contains the following language:
``Lung Cancer Screening--The Committee' urges the Secretary of
Defense, in consultation with the Secretary of Veterans Affairs, to
begin a multi-institutional lung cancer screening program with
centralized imaging review incorporating state-of-the-art image
processing and integration of computer assisted diagnostic tools.''
Senate Report 109-286, Military Construction and Veterans Affairs
and Related Agencies Appropriations Bill, 2007 contains the following
language:
``Lung Cancer Screening--The Committee encourages the Secretary of
Veterans Affairs to institute a pilot program for lung cancer
screening, early diagnosis and treatment among high-risk veteran
populations to be coordinated and partnered with the International
Early Lung Cancer Action Program and its member institutions and with
the designated sites of the National Cancer Institute's Lung Cancer
Specialized Programs of Research Excellence. The Department shall
report back to the Committee on Appropriations within 90 days of
enactment of this act, on a proposal for this program.''
<bullet> Department of Energy (DOE) and Lung Cancer
Over the past eight years the DOE Office of Environment, Safety and
Health has supported a medical screening program for DOE defense
nuclear workers who were exposed to toxic and radioactive substances.
The Worker Health Protection Program was originally authorized under
Section 3162 of the 1993 Defense Authorization Act and has been funded
through DOE appropriations. Currently more than 7,000 workers at seven
different munitions plant sites are being screened free of charge
annually for lung cancer. In FY 06, funding was increased to $14
milllon to cover an expansion of sites and the number of participants.
recommendations
VA should request and Congress should appropriate at least $3
million to conduct a pilot screening program for veterans at high risk
of developing lung cancer.
VA should partner with the International Early Lung Cancer Action
Program to provide early screening of veterans at risk.
[The Independent Budget for Fiscal Year 2008 follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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