Mr. Chairman, Ranking Member Brown, and distinguished members of the House Veterans' Affairs Subcommittee on Health, Vietnam Veterans of America appreciates the opportunity to present our views on nine bills up for your consideration this morning.
H.R. 3843, the "Transparency for America's Heroes Act," would direct the Secretary of Veterans Affairs to publish on the VA website redacted medical quality-assurance records and documents (but not personal identifying information) created by the VA.
In general, despite lapses in care at individual medical centers, the VA – actually, the Veterans Health Administration – provides good to excellent care at medical centers and community-based outpatient clinics for more than five million veterans annually. If the VA is to achieve and retain the confidence of the veterans it serves, opening for ease of public inspection quality-assurance records makes good managerial sense. If passage of H.R. 3843 can help bring a measure of transparency to what has, for the most part, been a cloistered process, it has VVA's full endorsement.
H.R. 4041 would direct the Secretary of Veterans Affairs to provide collaborative recovery coordinator training at a "qualified" nursing or medical school, and would authorize said nursing or medical school to train 45 recovery coordinators.
While this bill, on the surface, sounds important, and while it addresses a very real need, VVA believes it is in the purview of the VA Secretary to determine how best to set up recovery coordinator training and train whatever number of recovery coordinators he deems fit.
At the same time, Congress needs to exercise its powers of oversight to ensure that the VA does all that is necessary to coordinate the treatment and recovery of badly wounded or injured veterans. We do not believe that a prescriptive bill such as H.R. 4041 will necessarily be an effective way to get VHA to comply with its national mandate, although we certainly understand your frustration with the VHA on this and other issues that should be "no-brainers" for the VHA to accomplish.
We would respectfully point out that provisions in H.R. 4041, specifically for the development of "care coordination software," open the possibility of a boondoggle, and seem at odds with the centralization of IT within the VA.
H.R. 5428 would direct the Secretary of Veterans Affairs to ensure that an Injured and Amputee Veterans Bill of Rights is printed on signage in accessible formats and displayed prominently and conspicuously in each VA prosthetics and orthotics clinic. It would require that VA employees who work at such clinics, as well as patient advocates for veterans who receive care there, receive training on the elements in said Bill of Rights. It also would direct the Secretary to conduct outreach to inform veterans of this Bill of Rights.
The difficulty we have with this piece of legislation is elemental: If Congress sees fit to enact a Bill of Rights for injured and amputee veterans, why not enact a similar Bill of Rights for blinded veterans, and one for homeless veterans, and one for women veterans? Or perhaps one Bill of Rights for all veterans? (This latter VVA would heartily endorse.)
We also quibble with the provision that would direct the Secretary to conduct outreach to inform veterans of the provisions in an Injured and Amputee Veterans Bill of Rights. The VA needs to do a far better job in informing all veterans, and their families, about the health care and other benefits earned by veterans by virtue of their service in uniform, and about health conditions that may derive from a veteran's time in service. Under the leadership of Secretary Shinseki, the VA is finally moving in this direction, although it admittedly has little expertise with marketing and advertising.
We would quibble, too, with the provision of submitting a quarterly report to the VA's Chief Consultant of Prosthetics and Sensory Aids on information collected relating to alleged mistreatment of injured and amputee veterans. If this is to be done for one subgroup of veterans, why not for all subgroups of veterans? Or, better yet, simply for all veterans?
H.R. 5516, the "Access to Appropriate Immunizations for Veterans Act of 2010," would include within authorized preventive health services available to veterans through the Department of Veterans Affairs immunizations against infectious diseases on the recommended adult immunization schedule established by the Advisory Committee on Immunization Practices established by the Secretary of Health and Human Services and delegated to the Centers for Disease Control and Prevention.
This bill makes good sense insofar as it focuses on vaccinations for infectious diseases with vaccines approved by the FDA. We would hope, however, that it doesn't do for veterans what was done for active-duty troops in the all too recent past, who were forced to be inoculated against smallpox and then anthrax in a panic over the possibility that rogue enemies could somehow unleash these viruses on an unsuspecting American military and public.
VVA also urges this distinguished committee to take similar action for all pharmaceutical treatments approved by the FDA, and automatically list them on the VA formulary unless it is demonstrated through open hearings that a product is not effective or potentially harmful. The VA formulary process needs to be brought out into the light of day, exposed tot eh sunshine, and codified in statute to end the backroom deals in the "dead of night" non-transparent process that the VA currently uses. This President has often emphasized his Administration's commitment to "Open Government." VVA lauds that principle, and urges the Congress to bring that open government process to listing of pharmaceuticals. Enacting a process that mirrors the DOD formulary process into Title 38 for VA is appropriate, and should be a high priority for the Congress to get done within the next year.
VVA supports the enactment of H.R. 5516.
H.R. 5543 would repeal the prohibition on collective bargaining with respect to matters and questions concerning compensation of employees of the Department of Veterans Affairs other than rates of basic pay.
VVA sees no legitimate reason why VA clinicians and other healthcare professionals are barred from bargaining over additional compensation issues such as overtime pay and physician performance bonuses. VVA sees no credible rationale why these professionals are not accorded the same rights as are other federal employees when it comes to seeking redress in disputes with management.
Frankly, the VA nursing service has for far too long been plagued by a destructive mind-set that favors "nurse executives" and is disdainful of bedside nurses and other actual care givers who actually touch patients and are the heart of the provision of good medical care. This inappropriate and ugly attitude manifests in the treating of the staff members who provide actual "hands-on" care virtually as chattel who should have no say in working conditions. This must end.
Because enactment of H.R. 5543 would bring a long-needed measure of justice for health care professionals at VA medical facilities, VVA strongly supports its passage.
H.R. 5641, dubbed the "Heroes at Home Act," would authorize the Secretary of Veterans Affairs to enter into contracts for the transfer to non-Department adult foster homes for veterans who are unable to live independently.
If such a veteran who is eligible to be transferred to a non-VA nursing home prefers to be transferred instead to a home designed to provide non-institutional, long-term, supportive care in a family setting, VVA sees no reason why policy – and the legal foundation for such policy – would not facilitate this. Nursing homes, even well run facilities, can be oppressive places. Adult foster homes, with proper oversight by the VA, can be attractive alternatives. As such, VVA supports enactment of this legislation.
VVA also notes that much more attention overall needs to be paid to our most vulnerable veterans, especially in regard to those with guardians and whose funds are controlled by someone else who is supposed to be looking out for those who cannot care for themselves. A GAO report that examines all aspects of fiduciaries would be useful in this regard.
H.R. 5996 would direct the Secretary of Veterans Affairs to improve the prevention, diagnosis, and treatment of veterans with chronic obstructive pulmonary disease "subject to the availability of appropriations provided for such purpose."
While we have no problem with the intent of this legislation, the only way it will realistically happen is if Congress does in fact appropriate funds for its implementation. That said, Congress ought to mandate the VA to develop techniques and strategies to encourage veterans who smoke to cease smoking, whether they have developed COPD or not, and to prioritize an anti-smoking campaign at the top of its preventive health programs. If passed without specifically targeted funding, H.R. 5996 will be little more than another item on a laundry list of "Things to Do" at VA medical facilities.
VVA specifically notes that there are pharmacological treatments and other treatment modalities available in the private sectors that are difficult if not virtually impossible to get on the VA formulary. We suspect that much of the problem here is the "blame game" that goes "It is his own fault he is sick, so we should not do much to help him." That attitude has no place in veterans' health care.
H.R. 6123, the "Veterans' Traumatic Brain Injury Rehabilitative Services' Improvements Act of 2010," would in essence tweak Section 1710C of title 38 to more broadly define provisions for assisting veterans afflicted with Traumatic Brain Injury (TBI), the "signature injury" of the wars in Afghanistan and Iraq. VVA supports the intent of this legislation.
H.R. 6127 would provide for the continued provision of health care services to veterans who were exposed to sodium dichromate while serving in the U.S. Armed Forces at or near the water injection plant at Qarmat Ali, Iraq, during Operation Iraqi Freedom.
Toxic substances can be insidious; often their effects do not manifest till health conditions develop years after a veteran's exposure in the military. As Vietnam veterans, we know this to be the case vis a vis exposure to dioxin, to Agent Orange, when we served in Southeast Asia. Because we are still learning about the effects of exposure to sodium dichromate to troops who were stationed at or near Qarmat Ali, extending their eligibility for VA health care would be a prudent investment in maintaining their health and treating maladies that may have derived from their service in Operation Iraqi Freedom.
We would submit, however, that the VA has an obligation to track the health status of all veterans thus exposed so as to better determine what health conditions may, in fact, be attributed to exposure to sodium dichromate. There may also be other toxins that emanate from these same or similar sources, so VVA urges more complete epidemiological tracking of health problems in returning warriors, depending on when and where they served. Ensuring such tracking ought to be an added provision of H.R. 6127.
H.R. 6188, the Veterans' Homelessness Prevention and Early Warning Act of 2010, would amend paragraph (4) of subsection (a) of section 3732(a)(4)(A) of title 38, United States Code, to ensure that a case manager develops a plan to provide alternate housing for the veteran in the event that the veteran loses the veteran's home. VVA supports enactment of this bill.
Draft legislation to make certain improvements in programs for homeless veterans administered by the Secretary of Veterans Affairs contains many very well-thought out facets that should assist Secretary Shinseki and his staff in their efforts to end homelessness among veterans by 2015.
Ending homelessness among veterans surely is a worthy goal. If policies, processes, and practices by the VA and other entities of three levels of government – local, state, and federal – can function in concert, to create a continuum of care, we would hope that homelessness among veterans can continue to be reduced significantly, although some veterans for whatever reasons will choose to live their life on the streets, in flophouses, or out in the woods.
This legislation does contain some particularly important clauses. For instance, it would direct grant recipients, as a condition of accepting a grant, to "maintain referral networks . . . for establishing eligibility for assistance and obtaining services, under available entitlement and assistance programs."
We do believe, however, that the schedule of appropriations for grants -- $10 million for FY'2011, $15 million for FY'2012, and $21 million for FY'2013 – perhaps ought to be reversed. Why? Because if the programs and services currently in existence, and additional programs and services as established by this and other legislation succeed in achieving their stated purpose, there will be fewer veterans to avail themselves of these programs and services. Hence, we would suggest that appropriations be at a constant level, e.g., $15 million for each of the next three fiscal years.
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It should be noted that VVA continues to urge that VA Homeless Grant and Per Diem (HGPD) funding must be considered a payment rather than a reimbursement for expenses, a key distinction that will enable the community-based organizations that deliver the majority of these services to operate more effectively.
This legislation attempts to make the funding provided to HGPD providers more accessible by creating a vehicle to enable them to better access reimbursement. If a provider is able to draw from the available funds on a monthly basis with program expenditures for reconciliation on a quarterly basis, then VVA supports this language.
If funds are available on a "short turnaround" drawdown that is directly deposited into provider accounts, monies would be more immediately available. The current method of voucher submissions through local medical centers creates a lag in payment for weeks. With the monthly drawdown, a non-profit agency would not have to utilize its line of credit (if it even has one) to make payroll or pay program expenses. Also, the fees associated with this practice cannot be charged back as an expense to the program.
VVA also supports allowing greater than quarterly expenditures in any given quarter if a need for these additional expenses exists.
Community non-profit providers, most of them small, that serve homeless veterans cannot survive if they are permitted to draw down from the quarterly amount only on a quarterly basis. Creditors, purveyors, utilities, and the like must be paid monthly. Non-profits held to a quarterly payment method would be hard-pressed to meet their financial obligations in a timely fashion. If bill language means that the providers can only draw down from the quarterly amount on a quarterly basis, then VVA must oppose this provision.
VVA also supports the submission of future anticipated expenses rather than past spent program expenses.
One of the most effective front-line outreach operations funded by VA HGPD is the Day Service Center, sometimes referred to as a Drop-In- Center. Few even remain in the HGPD system because of limited per diem funding support. These service centers are an indispensable resource for VA outreach. They can reach deep into the homeless veteran population on the streets and in the shelters of our cities and towns. They are the portal from the streets and shelters to substance abuse treatment, job placement, job training, VA benefits, VA medical and mental health care and treatment, homeless domiciliary placement, and transitional housing. They are the first step to independent living. They can be the first step to ending homelessness. But this can only happen if they are able to operate in an effective environment.
Under the VA HGPD program, non-profits receive per diem at rates based on an hourly calculation per diem (one-eighth of the allowable per diem for residential programs) for the time that the homeless veteran is physically in the center. While this may cover the cost of the coffee and food that the veteran receives, it does not come close to paying for the professional staff that must provide the assistance and comprehensive services long after that veteran leaves the facility, and the demands on staff require a significant amount of time, energy, and manpower in order to be effective and, hence, successful.
It is unfortunate that the current per diem funding model is simply not sufficient to sustain the operations of many community-based service centers. Many have either closed or never opened after being funded by VA HGPD. The VA acknowledges and understands that this situation exists.
At the very least, VVA hopes that Service Centers are also included in the annual set-aside program funding available monthly with quarterly reconciliation. If not, we believe that it is necessary to create "Service Center Staffing/Operational" grants, much like the VA "Special Needs" grants that were previously legislated, although this is hardly an optimal solution, particularly with regards to funding programs that work with some of the hardest to place and most chronic of our homeless veteran population.
Draft legislation to ensure that the Secretary of Veterans Affairs provides veterans with information concerning service-connected disabilities at health care facilities makes sense insofar as it goes. However, it does not go far enough.
VVA would like to see Congress orient a major outreach campaign to all veterans, not only to those veterans who already use VA healthcare facilities. Seven out of ten veterans do not obtain health care at VA facilities, and far too many of them are unaware not only of the benefits to which they are entitled by virtue of their service to this nation, but of health conditions that may derive from their time in service because of exposure to toxic substances.
The VA needs to conceptualize and coordinate an outreach and information campaign that avails itself of public service announcements featuring real veterans as well as recognizable stars like Gary Sinise and Dennis Franz; signage on billboards; point-of-purchase displays in hardware stores, sporting emporiums, doctors' offices, and other places patronized by veterans and their families (because more often than not veterans are reached through their families).
Thanks you for the opportunity to appear here this morning to express the views of VVA. I will be pleased to answer any questions, Mr. Chairman.