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THE INDEPENDENT BUDGET VSO's "CRITICAL ISSUES REPORT"

ON FISCAL YEAR 2008 -- An in-depth look at the many

critical issues facing the VA.

 

 

This will mark the 21st year that the Independent Budget Veterans' Service Organizations take their message to Capitol Hill.

The Independent Budget VSOs are the American Veterans (AMVETS), the Disabled American Veterans (DAV), the Paralyzed Veterans of America (PVA) and the Veterans of Foreign Wars (VFW).

More on the Independent Budget and documents from past years here...
http://es1.pva.org/independentbudget/ 

Prior to the release of the Independent Budget, the VSOs publish their Critical Issues Report. 

This Report should be read by every veteran.  It details problems the VA is facing and offers viable solutions.  Now, the question is:  Will Congress and the VA listen?

Full Report here... http://es1.pva.org/independentbudget/pdf/CI_FY08.pdf

Full report below:

---------------

The Independent Budget

Critical Issues Report

On Fiscal Year 2008

As this report is being written, more than 2,700 American men and women have died and nearly 20,000 more have been wounded since fighting began in Iraq in March 2003 and in Afghanistan in October 2001. These brave soldiers, sailors, airmen, and Marines are only the latest in a long line of men and women who have unhesitatingly come forward in time of war to confront those who seek to unalterably change the world we know and the liberty we cherish.

It is for these men and women and the millions who came before them that we set out each year to assess the health of the one federal department whose sole task it is to care for them and their families.

The Independent Budget is based on a systematic methodology that takes into account changes in the size and age of the veteran population, cost-of-living adjustments, federal employee staffing, wages, medical care inflation, construction needs, the aging health-care infrastructure, trends in health-care utilization, benefit needs, efficient and effective means of benefits delivery, and estimates of the number of veterans and their spouses who will be laid to rest in our nation’s cemeteries.

While The Independent Budget will be released in February 2007 concurrent with the release of the president’s proposed budget for the Department of Veterans Affairs, this Critical Issues Report is designed to alert the president and his staff, members of Congress, VA, and the public to those issues concerning VA health care, benefits, and benefit delivery that we believe deserve special scrutiny and attention. We are releasing this report now as a guide to policy makers so they can produce a budget for FY 2008 that is more likely to correct existing problems and to better position VA to successfully meet the challenges of the future.

The president has stated that the war on terrorism is likely to be long, with dangers from unexpected directions and enemies who are creative and flexible in planning and executing attacks on our citizens and on our friends.

With this new reality ever present in our minds, we must do everything we can to ensure that VA has all the tools it needs to meet the challenges of today and the problems of tomorrow. Our sons, daughters, brothers, sisters, husbands, and wives who serve in the darkest corners of the world, keeping the forces of anarchy, hatred, and intolerance at bay, need to know that they will come home to a people who not only cherish their service, but also honor them with the best medical care to make them whole, the best vocational rehabilitation to help them overcome the employment challenges created by injury, and the best claims processing system to deliver education, compensation, and survivors’ benefits in a minimum amount of time to those most harmed by their service to our nation.

It is fitting that our twenty-first Independent Budget comes early in the twenty-first century. AMVETS, Disabled American Veterans, Paralyzed Veterans of America, and the Veterans of Foreign Wars of the United States—The Independent Budget veterans service organizations, or IBVSOs—work hard each year to ensure that The Independent Budget is the voice of responsible advocacy and that our recommendations are based on facts, rigorous analysis, and sound reasoning.

We hope that each reader approaches this Critical Issues Report with an open mind and a clear understanding that America’s veterans should not be treated as the refuse of war, but rather as the proud warriors they are.

James B. King                                                                   David W. Gorman
National Executive Director                                               Executive Director
AMVETS (American Veterans)                                        Disabled American Veterans

Louis Irvin                                                                        Robert E. Wallace
Executive Director                                                            Executive Director
Paralyzed Veterans of America                                        Veterans of Foreign Wars
                                                                                          of the United States

 

CRITICAL ISSUE 1: Adequate Funding Needed for VA Health Care

VA must receive adequate funds to meet the ever-increasing demands of veterans seeking health care.

This year proved to be unique for reasons very different from last year. Last summer the Department of Veterans Affairs (VA) faced a tremendous budgetary shortfall, which was subsequently addressed through supplemental appropriations. This year the Administration submitted a budget request that nearly matched the recommendations of The Independent Budget, which validated our analysis and budget projections.

For FY 2007 the Administration requested $31.5 billion for veterans health care, a $2.8 billion increase over the FY 2006 appropriation. Although we recognize this as a significant step forward, we believe that more can be done. The Independent Budget recommended approximately $32.4 billion for FY 2007, an increase of $3.7 billion over the FY 2006 appropriation and $900 million over the Administration’s request. Moreover, the Administration’s request is approximately $1.3 billion less than The Independent Budget recommendation for medical services.

The Administration indicated that it would require $25.5 billion to fund medical services, an amount very close to what we recommended. However, we disagree with the Administration’s desire to impose a new enrollment fee and to increase prescription drug copayments to achieve that funding level. Once again the president recommended a $250 enrollment fee for Priority 7 and 8 veterans and an increase in prescription drug copayments from $8 to $15 for a 30-day supply. VA estimated that these proposals would force nearly 200,000 veterans to leave the system. Another 1 million veterans would probably choose not to enroll. As in previous years, Congress soundly rejected the Administration’s proposals, and we urge them to do so again if these fees are proposed next year.

Although The Independent Budget health-care recommendation did 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 decision. VA estimates that more than 1 million Category 8 veterans will have been denied enrollment into the VA health-care system by FY 2007. For FY 2007, we estimated that VA would need approximately $684 million to provide services to Category 8 veterans, and we intend to recommend additional funding to reopen the system in FY 2008.

Unfortunately, despite a good starting point in the budget process this year, VA again did not receive its appropriation prior to the start of the new fiscal year on October 1. When VA does not receive its funding in a timely manner, it is forced to ration health care. Much-needed medical staff cannot be hired, patients have to suffer through longer waiting times, and the quality of care decreases, particularly if staff must be cut. These conditions place enormous stress on the system and leave VA struggling to provide the care that veterans have earned and deserve.

Any future budget delays will have a significant impact on the nursing shortage that VA is already experiencing. When managers do not have a budget for the coming year, they are unable to plan for new hires of critical staff. Then VA is forced to place hiring freezes on its medical centers nationwide. The hiring freezes force medical facilities to assign non-nursing duties to current nurses, which detracts from immediate bedside care and ultimately jeopardizes the health of our nation’s veterans.

Previous budgets have been inadequate and have exacerbated the problem. In the last several years, the VA health-care budget has not kept pace with the rising cost of inflation. VA has testified in the past that the Veterans Health Administration requires a minimum increase of 13–14 percent to meet this cost. VA cannot be competitive in the marketplace for health-care professionals if it does not have the necessary funding. The IBVSOs firmly believe that VA’s basic salary for nurses who provide direct bedside care is already too low to be competitive with community hospitals. These low salaries lead to high attrition rates, as VA nurses leave government service to seek better pay in other facilities.

We are disappointed that Congress continues to push spending caps, which could significantly harm important veterans programs. In June the Senate Committee on the Budget approved S. 3521, the Stop Overspending Act of 2006. This legislation contains an overall cap on nondefense domestic discretionary funding levels for the next three years and a fixed deficit reduction mechanism that would be enforced through automatic across-the-board cuts in all entitlement programs except Social Security.

S. 3521 would have an adverse effect on disabled veterans and military retirees. Starting in 2007, with the exemption of tax cuts and nondefense discretionary spending from the pay-as-you-go rules, dozens of federal programs vital to the quality of life of millions of men and women who have honorably served this nation would be eviscerated. For example, over a 10-year period, veterans benefits would be reduced by $51 billion and military retirement benefits by $60 billion. It makes no sense for Congress to consider any legislation that would reduce veterans benefits for the service men and women who are being placed in harm’s way each and every day.

To address the problem of adequate resources being 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 instead. This would not create a new entitlement; rather, it would change the manner of health-care funding, removing 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.

The Independent Budget request for VA health care for FY 2007 will address these concerns, and if accepted, will provide VA with the resources it needs to meet its responsibilities. The Independent Budget recommendation will enable VA to meet the demands of current veterans as well as those who are now being denied care by VA. It will also ensure that VA is not faced with the possibility of a shortfall due to faulty modeling or any other reason. As the number of new veterans seeking health care through VA continues to grow at the same time that VA continues to care for veterans of prior conflicts, we must ensure that VA can provide the quality health care that veterans have earned with their service and their sacrifices.

Recommendation:

•   Congress and the Administration must provide adequate funding for veterans’ health care in a timely manner to ensure that VA can meet the needs of veterans seeking care.

CRITICAL ISSUE 2: Mental Health Services for Veterans with Post-Traumatic Stress Disorder and Traumatic Brain Injury

The Department of Defense (DOD) and the Department of Veterans Affairs (VA) share a unique obligation to meet the health-care (including the mental health care) and rehabilitation needs of veterans experiencing readjustment difficulties as a result of combat service or traumatic brain injury (TBI).

The DOD, VA, and Congress must remain vigilant to ensure that federal mental health programs are sufficiently funded and adapted to meet the unique needs of the newest generation of combat service personnel and veterans, while continuing to address the needs of older veterans with post-traumatic stress disorder (PTSD) and other combat-related mental health challenges.

Issues Affecting Our Newest Generation of Combat Veterans

VA and the DOD are well aware that combat veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) are at high risk for PTSD and other mental health problems. In a 2006 study published in the Journal of the American Medical Association, Col. Charles Hoge, MD, of the Walter Reed Military Research Institute, evaluated the relationship between combat deployment and use of mental health services in the first year following return from the war. The study also reviewed lessons learned from postdeployment mental health screening efforts, the correlation between screening results and subsequent use of military mental health services, and attrition from military service.

The Hoge study found that 19 percent of soldiers and Marines who had returned from Iraq screened positive for mental health problems, including PTSD, generalized anxiety, and depression. Hoge reported that mental health problems recorded on the postdeployment self-assessments by military service members were significantly associated with combat experiences and mental health care referral and utilization. Thirty-five percent of Iraq war veterans had received mental health services in the year after returning home, and 12 percent each year were diagnosed with a mental health problem. According to the study findings, mental health problems remained elevated at twelve months postdeployment among soldiers preparing to return to Iraq for a second deployment. Hoge postulated that although OIF veterans were using mental health services at a high rate, many military personnel with mental health concerns did not seek help due to stigma and other barriers. The study revealed that service members resisted care because of personal concerns over being perceived as weak or because seeking treatment could have a negative impact on their military career. Finally, Hoge noted that the large number of veterans who served in Iraq and who later sought mental health services following deployment illustrates the challenges in ensuring that there are adequate resources to meet the mental health needs of this group, both within the military services and in followup VA programs.

The VA system is also seeing an increase in health-care utilization among OEF/OIF veterans. As of August 2006, according to VA, among the nearly 589,000 veterans who have separated from service since OEF/OIF began, more than 184,000, or 31 percent, have enrolled for and sought VA health care. VA reports that veterans of the current wars seek care for a wide range of possible medical and psychological conditions, including mental health conditions such as adjustment disorder, anxiety, depression, PTSD, and the effects of substance abuse. To date, nearly 64,000 VA patients have received a diagnosis of a mental disorder.¹

VA has intensified its outreach efforts to 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 free of charge for two years following separation from service for problems related to wartime service. However, VA estimates that only 109,191 veterans of the Iraq and Afghanistan wars will be seen in VA facilities in 2007 (1,375 fewer than it expects to see in 2006). But with increased outreach, ongoing internal mental health screening efforts, and expanded access to health care for OEF/OIF veterans, we are concerned that these estimates are artificially low and could result in a shortfall in the amount of funding necessary to meet the demand. Experts agree that if newly returning veterans do not have timely access to PTSD counseling and other readjustment services, an opportunity will be lost to reduce the severity of symptoms and the development of more serious, long-term, chronic mental health problems in this population.

VA’s Specialized PTSD Programs

According to VA, the department operates a network of more than 190 specialized PTSD outpatient treatment programs throughout the country, including specialized PTSD clinical teams or a PTSD specialist at each VA medical center. As of August 2006, more than 29,000 of the enrolled OEF/OIF veterans had a probable diagnosis of PTSD. Additionally, Vet Centers, which provide readjustment counseling in 207 community-based centers, have reported rapidly increasing enrollment in their programs, with nearly 77,000 readjustment counseling visits by OEF/OIF veterans in FY 2005 and projected visits of 242,000 in FY 2006.

In 1989, VA established the National Center for Post-Traumatic Stress Disorder to promote research into the causes and diagnosis of this disorder, train health-care and related personnel in diagnosis and treatment, and serve as an information clearinghouse for professionals. The center offers a monthly five-day clinical training program to VA clinical staff and maintains a Web site ( www.ncptsd.va.gov ) with information about trauma and PTSD. The center also offers guidance on the effects of PTSD on family and work and indicates treatment modalities and common therapies used to treat the disorder. Last year the center published a guide for military personnel titled “Returning from the War Zone.” This guide discusses common experiences in combat; postdeployment

ICD diagnoses used in these analyses are obtained from VA computerized data. VA reports these are considered “possible” mental health disorders among OEF/OIF veterans because “…up to one-third of coded diagnoses may not be confirmed when initially coded because the diagnosis is ‘rule-out’ or provisional, pending further evaluation.”

readjustment issues, including the primary symptoms of PTSD; and other common stress reactions such as depression, anger, aggressive behavior, alcohol and drug abuse, feelings of guilt and shame, and suicidal ideation. The guide also includes a checklist of trauma symptoms for self-assessment, a summary of eligibility requirements for VA services, and guidance for seeking further help. Because of the expanded role of women in the military and their exposure to combat in OEF/OIF theaters, we encourage VA to continue to address, through its treatment programs and research initiatives, the unique needs of female veterans in terms of treatment for PTSD and military sexual trauma.

Although VA has improved access to mental health services at its more than 800 community-based outpatient clinics, such services are not readily available at all sites. Likewise, VA has not yet achieved its goal of integrating mental health staff in all of its primary care clinics. We remain concerned about the capacity of specialized PTSD programs and the decline in availability of VA substance-use disorder programs of all kinds, over time, 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 the possible rationing of—these specialized services.

The President’s New Freedom Commission on Mental Health

Following the release of the report of the President’s New Freedom Commission on Mental Health in July 2003, VA undertook an unprecedented, critical examination of its mental health programs. Like other institutions that provide mental health care, VA found that it tended to focus on managing symptoms, rather than aiding patients’ recovery and restoration. The New Freedom Commission found that many people with mental illness can regain productive lives, and the report provided the government with a bold new blueprint for system change based on the goal of recovery. VA leaders embraced the changes envisioned by the commission and developed an agenda for realizing that goal. VA established a National Mental Health Strategic Plan (MHSP) as an outgrowth of the New Freedom Commission report and promised to commit $100 million in FY 2005 and $200 million in FY 2006 to fund new mental health initiatives. Unfortunately, we understand that VA’s internal policy on funding certain new initiatives to address gaps in services related to psychosocial rehabilitation and recovery-oriented services limits funding to two years. The expectation is that this “seed money,” which is provided to specific initiatives, will generate sufficient creditable patient care workload counts through VA’s internal resource allocation system to make further centrally funded earmarks unnecessary after the first two years. This is an untested concept that could dampen local interest in proposing or embracing such new initiatives. If a VA medical center director believes that a centrally controlled earmark is temporary, the temptation may be to limit investment in the program. The after-effects of this two-year funding policy bear close scrutiny by mental health advocates and Congress.

In September 2006, the U.S. Government Accountability Office (GAO) issued a preliminary report on the resources allocated for VA’s MHSP initiatives. The GAO found that VA did not allocate all of the funding it had planned in FY 2005 for new mental health initiatives to address identified gaps in mental health services. Funding was to be used to expand PTSD services, to provide postdeployment mental health services for veterans returning from combat in Iraq and Afghanistan, and to expand treatment programs for substance-use disorders. Additionally, the GAO reported that the VA Central Office did not inform network and medical center officials that certain funds were to be used for these specific mental health initiatives and therefore that it is likely some funds were given to other health-care services. Likewise, according to the GAO, some officials felt uncertain that they would be able to spend by the end of the year all the funds earmarked for plan initiatives in FY 2006. These findings illustrate the need for continued congressional oversight to ensure that dedicated mental health funds for MHSP initiatives are used properly.

Traumatic Brain Injury and Mental Health

It has been said that TBI—caused by improvised explosive devices (IEDs), vehicular accidents, gunshot and shell fragment wounds, falls, and other traumatic injuries to the brain and upper spinal cord—is the signature injury of OEF/OIF. Severe TBI resulting from blast injuries or powerful bomb detonations, which severely shake or compress the brain within the skull, often causes devastating and permanent damage to brain tissue. Likewise, veterans who are in the vicinity of an IED blast or who are involved in a minor motor vehicle accident can suffer from a milder form of TBI that is not always immediately detected and can produce symptoms that mimic PTSD and other mental disorders. It is believed that many OEF/OIF veterans have suffered mild brain injuries and concussions that have gone undiagnosed and that symptoms will only be detected later, after these veterans return home. We are concerned about the emerging literature, which strongly suggests that even mild TBI patients may have long-term mental and medical health consequences. The DOD admits that it lacks a systemwide approach for proper identification, management, and surveillance of individuals who sustain mild to moderate TBI/concussion, in particular mild TBI/concussion.² Therefore, VA should coordinate with the DOD to better address mild TBI/concussion injuries and develop a standardized followup protocol using appropriate clinical assessment techniques to recognize the neurological and behavioral consequences of TBI as recommended by the Armed Forces Epidemiological Board. The influx of returning OEF/OIF service members with brain trauma has increased the opportunity for research on the evaluation and treatment of these injuries in newer veterans; however, we suggest that any such study include older veterans of previous conflicts who may have suffered similar injuries that went undetected, undiagnosed, and untreated.

The most severely injured service members will require extensive rehabilitation and lifelong personal and clinical support, including neurological and psychiatric services and physical, psychosocial, occupational, and vocational therapies. Currently VA has four designated TBI facilities in Minneapolis, Minnesota; Palo Alto, California; Richmond, Virginia; and Tampa, Florida. These TBI Lead Centers provide a full spectrum of TBI

Memorandum issued by the Armed Forces Epidemiological Board regarding Traumatic Brain Injury in Military Service Members, August 11, 2006.

care for patients suffering moderate to severe brain injuries. VA is also establishing a polytrauma center in each of its Veterans Integrated Service Network for followup care of polytrauma and TBI patients referred from the four lead centers or from military treatment facilities. To raise awareness of TBI issues, VA requires training of primary care, mental health, spinal cord, and rehabilitation providers via a Web-based independent study course. However, VA is still working to develop a systemwide screening tool for clinicians to use for assessing TBI patients.

In July 2006, VA’s Office of the Inspector General (OIG) issued a revealing report titled

Health Status of and Services for Operation Enduring Freedom/Operation Iraqi Freedom Veterans after Traumatic Brain Injury Rehabilitation. The report assesses health-care and other services provided for VA patients with TBI, then examines their status approximately one year following discharge from inpatient rehabilitation. The OIG found that better coordination of care was needed so that veterans could make a smooth transition between the DOD and VA health-care services. The report also called for additional assistance—including more caregivers and improved case management—for the immediate family members of brain-injured veterans.

VA has designated TBI care as one of its special emphasis programs and is committed to working with the DOD to provide comprehensive acute and long-term rehabilitative care for veterans with brain injuries. We are encouraged that VA has responded to the growing demand for specialized TBI care and, fulfilling the requirements of P.L. 108422, has established four Polytrauma Rehabilitation Centers that are co-located with the existing TBI Lead Centers. However, we are particularly concerned about capacity and question whether VA has fully addressed the staffing and other resources that will be needed to provide intensive rehabilitation services, treat the long-term emotional and behavioral problems often associated with TBI, and support the families and caregivers of these seriously brain-injured veterans. During a September 2006 House Veterans’ Affairs Subcommittee on Health hearing, a statement for the record indicated that the 20year health-care costs estimate for TBI could exceed $14 billion.

We face several challenges in ensuring that these veterans and their families get the specialized care and support services they need.  Clinicians indicate that in the case of mild TBI, the veteran’s denial of problems that can accompany damage to certain areas of the brain often leads to difficulties receiving services. Likewise, with more severe injuries, the extreme burden of care can lead to family disintegration and loss of this major resource for patients. As noted in the OIG report, “these problems exact a huge toll on patients, family members, and health-care providers.”

To facilitate access to services, VA assigns a case manager to each OEF/OIF veteran seeking treatment at one of its medical facilities. The case manager is responsible for coordinating all VA services and benefits. Additionally, VA has hired liaison/social workers at DOD facilities to assist injured service members. However, in subsequent interviews with case managers, the OIG found several problems that warrant attention:

                        Inability to transfer medical records from referring military facilities

                        Difficulty securing long-term placements of TBI patients with extreme behavioral problems

                        Difficulty obtaining appropriate services for veterans living in geographically remote areas

                        Inconsistency in long-term case management

                        Limited ability to follow patients after discharge to remote areas

                        Discharged veterans’ poor access to transportation and other resources

 

The report found that although many patients had achieved a substantial degree of recovery, “…approximately half remained considerably impaired.” The report concluded that improved coordination of care among agencies is necessary and that families need additional support in the care of TBI patients.

Finally, we are concerned by accounts in the news media and reports by veterans with TBI and their families who claim that VA TBI care is not up to par, requiring them to seek rehabilitation services in the private sector. We encourage VA and Congress to address these complaints to ensure that severely wounded TBI veterans receive the best rehabilitative care available.

Summary

Overall, we are pleased with the direction VA has taken and the progress it has made with respect to its mental health programs. We are also pleased that the DOD has acknowledged the need to conduct more rigorous pre- and postdeployment health assessments and reassessments of military service personnel who serve in combat theaters and that the DOD has been working to improve its collaboration with VA to ensure this information is accessible to VA clinicians. Likewise, VA and the DOD are to be commended for dealing with the issue of stigma and other barriers that prevent service members and veterans from seeking mental health services. Nevertheless, the DOD and VA are far from achieving the universal goal of seamless transition.

Emerging evidence suggests that the burden of combat-related mental illness from OEF/OIF will be high. Utilization rates for health-care and mental health services predict an increasing demand for such services in the future, which suggests that the current wars are presenting new challenges to the DOD and VA health-care systems. Fortunately, American citizens agree that care for those who have been wounded as a result of military service is part of the continuing cost of national defense. The effects of PTSD, TBI, and other injuries with mental health consequences that are not so easily recognizable can be devastating and can lead to serious health catastrophes, including occupational and social disruption, personal distress, and even suicide if these conditions are not treated. We can meet these challenges by ensuring a stable, robust VA health-care system that is dedicated to the unique needs of the nation’s veterans—one that is there now for the aging veterans of World War II, Korea, and Vietnam and that remains viable for the newest generation of war fighters who will need specialized medical and mental health services for decades to come.

All of the challenges we face will require an unprecedented level of interagency cooperation. Nevertheless, we believe that with proper resources, clearly defined goals, and determination to overcome institutional and social barriers, our government can fulfill its commitment to provide the best care available to service members and veterans with mental health problems.

Recommendations:

                        The IBVSOs recommend that VA work more effectively with the DOD to ensure that a seamless transition of early intervention services is established to help returning service members from Iraq and Afghanistan obtain effective treatment and followup services for war-related mental health problems.

                        VA must do its part to sustain VA mental health care as a high priority grounded in the principles of the President’s New Freedom Commission on Mental Health. The system must continue to provide access to specialized services for veterans with mental illness, PTSD, and substance-use disorders commensurate with their prevalence and must ensure that recovery from mental illness, with all its positive benefits, becomes the guiding beacon for VA mental health planning, programming, budgeting, and clinical care.

                        Congress should carefully monitor VA’s two-year limit on providing startup funding for new initiatives under VA’s National Mental Health Strategic Plan and provide oversight to ensure that the resources allocated to expand and improve mental health services are used for this express purpose.

                        The IBVSOs believe that more research on the consequences of brain injury and on best practices for its treatment is needed and is warranted by VA to deal with both the medical and mental health aspects of TBI, including research on the long-term consequences of mild TBI in OEF/OIF veterans, as well as similar injuries in previous generations of combat veterans.

                        To ensure a smooth transition for veterans with TBI and their caregivers, VA should evaluate ways to provide further assistance to immediate family members of brain-injured veterans, including additional resources, improved case management, and continuous followup.

                        The goal of achieving optimal function of each individual TBI patient requires improved interagency coordination between the DOD and VA. Veterans should be afforded the best rehabilitation services available and the opportunity to achieve maximum functioning so they can reenter society or, at minimum, achieve stability of function in an appropriate setting.

                        The president and Congress should sufficiently fund the DOD and VA to ensure these systems adapt to meet the unique needs of the newest generation of combat

 

service personnel and veterans and continue to address the needs of older veterans with PTSD and other combat-related mental health challenges.

CRITICAL ISSUE 3: VA Needs a Sufficient Construction Budget

The Independent Budget veterans service organizations (IBVSOs) believe that the Department of Veterans Affairs (VA) needs more resources for major medical facilities construction to support the implementation phase of the Capital Asset Realignment for Enhanced Services (CARES) plan, and to make up for a manifest lack of resources dedicated to recapitalization and maintenance of its aging physical plant.

For the past five years, many of VA’s major medical facility construction repair and maintenance needs have been delayed while waiting for completion of the Capital Asset Realignment for Enhanced Services (CARES) process. This data-driven assessment of VA’s capital infrastructure considered the future needs of veterans and the VA infrastructure needed to meet them. It was intended to produce a facilities “road map” to the future. Those interested in veterans health care—sick and disabled veterans, VA health-care providers, veterans service organizations, affiliated health profession schools, and other supporters—were advised that the primary intent of CARES was to enhance health-care services for veterans. We were assured that CARES would continue to meet current health-care demands of enrolled veterans, but it would also determine what kinds of VA health-care facilities would be needed in the future to assure that VA maintained an infrastructure consistent with 21st century veterans’ health-care needs.

While the IBVSOs have been supportive of the intent of CARES, we do have several concerns about the final implementation phase of the process, specifically related to established CARES priorities and further facility construction planning. While the CARES process was under way, the Administration delayed a large number of significant, and often urgent, construction proposals identified and submitted by managers of aging VA health care facilities. During that same period, the Veterans’ Committees in both houses of Congress approved legislation to authorize dozens of well-justified and overdue major construction projects, including House passage of a “Veterans Hospital Emergency Repair Act” to address the most urgent of those needs. The Congressional Appropriations Committees, however, delayed nearly all funding due to the ongoing CARES review. While supporting the intent of CARES, the IBVSOs argued that a de facto moratorium was unnecessary because of our conviction that a number of projects needed to go forward that would be fully justified in any future plans produced through CARES. The passage of that authorization language by the Veterans’ Affairs Committees indicates that there was some Congressional agreement with this reasonable position. But Administration officials and Congressional appropriators demurred. As a result, VA lost billions of dollars that otherwise would have been invested to meet critical infrastructure needs.

We continue to believe that it was poor policy to defer all major VA construction projects until CARES was completed. In the five-plus years, while the process was ongoing, construction and major maintenance improvements lagged far behind what VA facilities actually needed. With CARES nearly completed, funding has not yet been proposed by the Administration nor approved by Congress to begin to address the very large, yet predictable project backlog. We note this year that both Veterans’ Committees have considered legislation that would authorize resumption of VA major medical facility construction projects in a significant amount, with each Committee’s bill totaling more than $1 billion in new project authorizations for fiscal years 2007 and 2008. However, as of the pre election Congressional recess, those bills have not been enacted. Absent Congressional authorizations, even if the Secretary receives significant new appropriated funding this year for major medical facility construction, the funds cannot be obligated.

In July 2004, then-VA Secretary Anthony Principi testified before the House Veterans’ Affairs Health Subcommittee that CARES “reflects a need for additional investments of approximately $1 billion per year for the next five years to modernize VA’s medical infrastructure and enhance veterans’ access to care.” Yet, over the past two fiscal years since that testimony was offered, the amounts requested by the Administration and appropriated by Congress for VA major medical facility construction have been roughly half that level. For FY 2007, the Administration recommended a paltry $307 million for major medical facility construction. After a five-year delay caused by CARES, and without additional funding coming from the Administration, many VA facilities are in an even more deteriorated state than they were when the House passed its “VA Hospital Emergency Repair Act” four years ago. We strongly urge the Administration to keep its commitment to veterans by making a steady investment of $1 billion or more each year until the VA’s capital infrastructure is brought up to date for the 21st century needs of veterans.

Likewise, Congress should fund only budget requests and authorize the projects requested by the Administration that are consistent with the CARES Decision Document. We note that Secretary Nicholson has made a series of press announcements this year for new VA facilities in various sites, including a large number of new VA community-based outpatient clinics. Similarly, several members of Congress have announced that facilities in their Districts have been “saved” from CARES and will remain open. All CARES decisions should be consistent with the CARES Decision Document and its established priorities, or with findings of the CARES Review Commission, which largely confirmed those priorities. Proposed changes to the plan should undergo the same rigorous data validation of other projects. While we are pleased that Secretary Nicholson and Members of Congress are interested in the future of VA capital facilities, we urge the Secretary, the Administration and Congress to maintain consistency with the apolitical process that, as agreed to by all parties, would provide the best way to determine future VA infrastructure needs to care for all veterans. That was a hallmark of the CARES plan.

The lack of proper funding not only affected the construction of future facilities and major renovations to existing structures. It also obstructed VA from making necessary and routine investments in its existing physical infrastructure—even though its structures average more than fifty years in age.

We continue to cite a 1998 Price Waterhouse study of VA’s facilities management that recommended that VA needed to spend 2-4 percent of the value of its buildings on nonrecurring maintenance (NRM). The NRM account has not been funded properly over the past several years, and the Administration proposed only $514 million for these purposes in FY 2007. Additionally, NRM is funded out of the Medical Services appropriations account and is allocated through the Veterans Equitable Resource Allocation (VERA) formula to each Veterans Integrated Service Network. While this allocation technique does move the funding toward geographic areas with the highest demand for health care, it also tends to move funds away from facilities with the oldest capital structures—facilities that generally need the most maintenance. Embedding the NRM funds in VERA could also create incentives at some facilities to use funds intended for NRM to address shortfalls in funding for direct health care to veterans. In fact, in the spring of 2005, the Veterans Health Administration discovered its available health care funding for FY 2005 would be insufficient. Plans were formulated to defer a number of scheduled FY 2005 construction and maintenance projects to FY 2006 and to use those freed-up funds for general operating expenses. This decision was later overturned by Congress.

The IBVSOs have continued concerns with respect to CARES planning for veterans long-term care and mental health needs. 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 strategic 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 infrastructure and support networks will be there for all veterans in the future. We also agree with the CARES Commission’s recommendation that VA take action to ensure consistent availability of mental health services across the system. This would include mental health care at community-based clinics along with the appropriate infrastructure to match the growing demand for these specialized services.

In 2004, Congress directed VA to further study optional uses for 18 VA medical facilities identified by the CARES Commission as facilities whose future missions were unclear. VA issued a contract to a major national accounting firm to complete most of these studies. The IBVSOs are highly interested in the Secretary’s intentions with respect to decisions on further uses of these VA facilities.

In last year’s “Critical Issues Report,” we described the impact of 2005’s Gulf Coast hurricanes and the devastation they reaped. We continue to have the deepest sympathy for everyone who was affected by those disasters, especially sick and disabled veterans and the dedicated VA staffs at the Biloxi, Gulfport, and New Orleans VA facilities. Also, we thank the Administration and Congress for addressing the reconstruction funding needs in that region in accordance with our recommendation from last year’s Critical Issues Report.

Recommendations:

                        Congress and the Administration should provide sufficient funding for the major construction of new VA health-care facilities and for renovation and restoration of existing facilities, as determined by the CARES process.

                        VA must be provided with sufficient funding to properly reinvest in and maintain its aging physical plant, and accordingly, VA’s budget for NRM must be increased to 24 percent of the value of VA’s existing structures. We recommend VA examine its use of VERA for allocation of NRM funds, in particular whether these funds are being expended for their intended purpose.

                        Mental health services and long-term care are part of the full continuum of health care for veterans and therefore should be included in the CARES plan. VA should develop a long-term care strategic plan and proceed with the implementation of its mental health strategic plan, keeping in mind that both of these plans will require adequate capital facilities.

                        We urge planning to be accelerated in designing and constructing new VA health care facilities in the Gulf Coast, in particular in New Orleans, Louisiana, and Biloxi, Mississippi.

                        We urge the Congressional Veterans’ Committees to resolve their differences and enact an authorization bill at the earliest possible date to address VA’s major medical facility construction needs—in accordance with the established priorities of the CARES process.

 

CRITICAL ISSUE 4: Claims Backlogs Remain High

To overcome the persistent and longstanding problem of disability claims backlogs and the resulting delays in delivery of crucial disability benefits to veterans and their families, the Administration must invest adequate resources and commit to a new strategy to improve quality, proficiency, and efficiency within the Veterans Benefits Administration.

A core mission of the Department of Veterans Affairs (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 the economic effects of disability (and death) upon veterans and to compensate their families for loss. For those payments to effectively fulfill their intended purpose, VA must deliver them promptly, based on accurate adjudications. The ability of disabled veterans to feed, clothe, and provide shelter for themselves and their families often depends on these benefits.

The need for financial support among disabled veterans is generally urgent. While awaiting action by VA on their pending claims, they and their families must suffer hardships; protracted delays can lead to deprivation and even bankruptcy. Some veterans have died after waiting for years for their claims for disability to be resolved. In sum, VA disability benefits are critical, and meeting the needs of disabled veterans should be a top priority of the federal government.

Recently VA has adopted a tactic of diverting public attention away from the structural claims backlog it holds by demonstrating great speed and efficiency in adjudicating the claims of soldiers and Marines wounded in the current conflicts in Iraq and Afghanistan. While at the same time boasting that it is breaking all records in awarding these new veterans their rightful benefits, VA sits on hundreds of thousands of older claims filed by veterans of prior conflicts and military service. These claims lie dormant, awaiting some future resolution. We applaud VA’s efforts to help our nation’s new veterans, but we feel dismayed when VA continues to fail our older veterans by allowing the backlog to grow daily.

VA can deliver benefits promptly to veterans only if it can adjudicate and process their claims in a timely and accurate way. Given the critical importance of disability payments to veterans’ financial stability, VA has an undeniable responsibility to maintain an effective delivery system and to take decisive action to correct deficiencies as soon as they become evident. However, VA has neither maintained the capacity necessary to meet its growing claims workload nor corrected the systemic deficiencies that compound the problem of inadequate capacity.

Rather than making headway in overcoming the chronic claims backlog and consequent protracted delays in disposition of claims, VA has lost ground, and the backlog of pending claims has grown substantially larger in recent years. In fact, the backlog of compensation claims grew from 363,412 in December 2000 to 589,583 in September 2006—an increase of almost 50 percent. During this same period, three VA secretaries representing both political parties stated publicly on multiple occasions that reducing the chronic backlog was their highest management priority. We also note that during this same period the staffing of the Veterans Benefits Administration (VBA) remained essentially flat at about 9,000 full time employee equivalents.

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. These dynamics have been thoroughly detailed in several studies, but they persist without remedy—that is, without the development and execution of real strategic remedial measures. While the problem has been exacerbated by lack of action, the IBVSOs believe most of the causes can be directly or indirectly traced to the availability of resources. The problem was primarily triggered and is now perpetuated by insufficient resources.

Instead of requesting the additional personnel and funding needed to accomplish better results, the Administration has sought and Congress has provided fewer resources for VBA. Recent budget requests have proposed reducing the number of full-time employees who process claims for VBA. Such reductions in staffing are clearly at odds with the realities of VBA’s growing workload and its own well-established adjudication policies and procedures. Adjudication of veterans’ claims is a labor-intensive, hands-on system of decision making with lifelong consequences. Our government’s political and management decisions have conspired to diminish the quality of claims processing and to cause the agency to lose ground against the claims backlog. During congressional hearings, VA is routinely forced to defend VBA budgets that it knows will be inadequate to the task at hand. The goals of the immediate political stagnation are at odds with the need for a long-term strategy in which VA fulfills its mission and confirms the nation’s moral obligation to its disabled veterans.

VA must establish a long-term strategy focused principally on attaining quality and not merely on achieving arbitrary production quotas in claims processing. The current emphasis on how well the system is dealing with the needs of new veterans of current wars is beside the point. VA must obtain supplementary resources for VBA, and it must invest these resources in a long-term strategy rather than reactively targeting them to short-term, temporary, and superficial gains. Only then can VBA proceed in a way that addresses veterans’ needs and alleviates the effects of disability through prompt delivery of appropriate benefits. Previously disabled veterans should not have to suffer needless additional economic deprivation because of the inefficiency and ultimately, the benign neglect, of their government. We believe this situation defines the very concept of “unconscionable.”

This year, in both houses of Congress, bills have been introduced that seek to remedy the claims backlog in VA by introducing private attorneys into the adjudication system. The IBVSOs oppose this development for a number of reasons, but principally because the VA adjudication system is not by nature an adversarial system. The introduction of attorneys to the process would simply be the latest gimmick that ultimately becomes the latest problem.

As directed by law, VA has a duty to assist veterans in developing and presenting their claims. Congress established a special federal court to hear any disputes that arise as VA adjudicates those claims, and veterans possess the right by law to appeal their disagreements with adjudication decisions to a special appeals board as well. That self-checking system exists because national veterans organizations—including the IBVSOs—have insisted that veterans’ war injuries and other service-related health problems be dealt with in a humane manner and without rancor to the greatest extent practicable. Bringing private attorneys into the system will not relieve the almost 600,000 claims backlog VA now holds, but will in fact burden it with new disputes and further delays.

The IBVSOs have observed court cases in which attorneys have been retained by veterans. Very few of these cases resulted in any improvement of the veteran’s disability rating, and in many cases the veteran’s award was reduced to the degree that the attorney’s fee had to be paid from award amounts that otherwise would have gone to the veteran. The IBVSOs believe that each veteran who is awarded compensation is entitled to full payment and that no disabled veteran should be encouraged or forced to obtain a private attorney to secure a proper and accurate disability rating from VA.

Recommendations:

                        To seek the beginning of the end of this long series of repeated failures from inadequate resources and misplaced priorities, The Independent Budget will recommend funding levels for FY 2008 adequate to meet the real staffing and other needs of the Veterans Benefits Administration. We urge Congress and the Administration to enact this higher level in VA’s FY 2008 appropriation.

                        Private attorneys should not become part of the VA disability claims adjudication system. Congress should reject proposals that would admit attorneys into the VA claims adjudication process.

                        VA should establish a new strategy, based on the premise of obtaining sufficient staff and other resources, to reduce the claims backlog with accurate adjudications to an irreducible minimum backlog. As part of this strategy, VA should implement a new communications plan that will better inform veterans and the organizations that represent them of the status and progress of their claims.

 

CRITICAL ISSUE 5: Seamless Transition from the DOD to VA

The DOD and VA must ensure that all service men and women separating from active duty have a seamless transition from military to civilian life.

As service men and women return from the wars in Iraq and Afghanistan, the Department of Defense (DOD) and Department of Veterans Affairs (VA) must provide them with a seamless transition of benefits and services as they leave military service and become veterans. Currently, the transition from the DOD to VA is anything but seamless, and undue hardship is placed on new veterans trying to gain access to VA. The IBVSOs believe that veterans should not have to wait to receive the health-care and other benefits they have earned and deserve.

The Independent Budget supported the recommendations of the President’s Task Force to Improve Health Care Delivery for Our Nation’s Veterans (PTF) report, released in May 2003, on the transition of soldiers to veteran status. The PTF report stated that “providing these individuals [veterans] timely access to the full range of benefits earned by their service to the country is an obligation that deserves the attention of both VA and the DOD. To this end, increased collaboration between the departments for the transfer of personnel and health information is needed.” This need has not yet been met.

The IBVSOs believe that the DOD and VA must develop electronic medical records that are interoperable and bidirectional, allowing for a two-way electronic exchange of health information and occupational and environmental exposure data. We applaud the DOD for beginning to collect medical and environmental exposure data electronically while personnel are still in theater. This must continue. But it is equally important that this information be provided to VA. These electronic medical records should include an easily transferable electronic DD214 forwarded from the DOD to VA. This would allow VA to expedite the claims process and give the service member faster access to health-care and other benefits.

The Joint Electronic Health Records Interoperability (JEHRI) plan, which was agreed to by both VA and the DOD through the Joint Executive Council and is overseen by the Health Executive Council, is a progressive series of exchanges of related health data between the two departments, culminating in the bidirectional exchange of interoperable health information. The first two phases of implementation have met with some success. However, achieving real-time sharing of computable health information is heavily dependent on health data standards and technology not wholly under the control of either department. Moreover, the IBVSOs are not encouraged by reports that, in some instances, medical data gathered in theater and stored on electronic smart cards provided to the soldier are not readable by other military medical facilities upon the service member’s return. This does not bode well for an electronic system meant to exchange information among federal agencies.

The Independent Budget is not the only party concerned about this exchange. In June 2004, the chairman and ranking member of the House Veterans’ Affairs Committee and the Armed Services Committee sent letters to Secretary Principi and Secretary Rumsfeld expressing concern about the current transition of service men and women and indicating that “despite earnest desire by both the DOD and VA to provide each service member with a seamless transition, their efforts remain largely uncoordinated in important respects and suffer from the failure to make planning for transition a high priority for the Executive Branch.”

The Independent Budget concurred with the PTF recommendation that “DOD and VA must implement a mandatory single separation physical as a prerequisite of promptly completing the military separation process.” But currently, a separation physical is not mandatory for demobilizing reservists. Although the number of physical examinations of demobilizing reservists has increased in recent years, there are still a number of soldiers who opt out of the physicals, even when encouraged by medical personnel to have one performed. Though the expense and manpower needed to perform these physicals might be significant, the separation physical needs to be done, because the information collected will be critical to the demobilizing soldier’s future care. We cannot allow a recurrence of the lack of information that led to so many unknowns in the diagnosis and treatment of Gulf War Syndrome. This could be of particular concern with the large numbers of our National Guard and Reserve forces currently serving. Finally, mandatory separation physicals would enhance collaboration by the DOD and VA on the identification, collection, and maintenance of the type of data needed by both departments to recognize, treat, and prevent illnesses and injuries resulting from military service

The Independent Budget also support the Army Wounded Warrior program, formerly known as the Disabled Soldier Support System (DS3), which was implemented in spring 2005. Its responsibility is to assist the most severely injured service members and their families in the transition from military to civilian life. However, the program maintains only minimal staff with a limited budget. Because of the large number of severely injured soldiers returning from Iraq and Afghanistan, it is essential that Congress and the Administration support and enhance this successful program. Similarly, we support the Marine for Life program.

In the last several years, the DOD and VA have made positive strides in helping our nation’s service members transition out of the military into civilian jobs and lives. The Department of Labor’s Transition Assistance Program (TAP) and Disabled Transition Assistance Program (DTAP), handled by the Veterans Employment and Training Service (VETS), is generally the first type of assistance that a separating service member will receive. In particular, local military commanders, through the insistence of the DOD, have been allowing their soldiers, sailors, airmen, and Marines to attend these programs well enough in advance to take greatest advantage of the information. These programs can really help when they are provided early enough to educate these future veterans on the importance of proper discharge physicals and on the need for complete and proper documentation. The programs advise service members how to seek services from VA and give them sufficient time to think about their situations and then seek answers prior to discharge.

The TAP and DTAP programs continue to improve. But challenges remain at some domestic military installations and overseas locations with the level of information and services provided to those with injuries. Disabled service members who wish to file a claim for VA compensation benefits, and thus other ancillary benefits, are dissuaded by the specter of being assigned to a medical holding unit for an indefinite period. Furthermore, the process for disseminating the information appears to be disorganized, haphazard, and inconsistent, and the amount of time devoted to processing is too short. Some individuals easily fall through the cracks. This is of particular risk in the DTAP program, because those with severe disabilities may already be getting health care and rehabilitation from a VA spinal cord injury center despite being on active duty. Because these individuals are no longer located on or near a military installation, they are often forgotten in the transition assistance process. Consequently, DTAP has not had the same level of success as TAP; and the DOD, VA, and VETS need closer coordination to improve this situation.

We applaud the DOD and VA for their achievements in better preparing our departing active-duty soldiers for civilian life, but we share great concern over the large numbers of Reserve and National Guard soldiers moving through the discharge system. Due to the number of troops that are on Stop-Loss—a DOD action that prevents troops from leaving the military at the end of their enlistments during deployments—large numbers of troops must transition rapidly to civilian life upon their return. Both the DOD and VA seem ill-prepared to handle the large numbers and prolonged activation of reserve forces for the global war on terrorism. The greatest challenge these service members face is their rapid transition from active duty to civilian life. Unless these soldiers are injured, they may clear the demobilization station within a few days. Little of this time is dedicated to informing them about veterans services and benefits. Additionally, the focus of DOD personnel at these sites is on processing soldiers through the site. Lack of space and facilities often limits the amount of contact VA representatives have with the demobilizing soldiers.

The IBVSOs believe that the DOD and VA have made progress in the transition process. Unfortunately, limited funding and a focus on current military operations interfere with providing for service members who have chosen to leave military service. If we are to ensure that the mistakes of the first Gulf War are not repeated during this extended global war on terrorism, it is imperative that proper funding levels be provided to VA and other agencies that provide services for the large number of new veterans from the National Guard and Reserves. Service men and women exiting military service should be afforded easy access to the health-care and other benefits they have earned. This can only be accomplished by ensuring that the DOD and VA improve their ability to share vital information, coordinate services and benefits, and thus create a truly seamless transition.

Recommendations:

                        The DOD and VA must ensure that service men and women have a seamless transition from military to civilian life.

                        The DOD and VA must continue to develop electronic medical records that are interoperable and bidirectional, allowing for two-way electronic exchange of health information and occupational and environmental exposure data. The DOD and VA must continue to move forward with the JEHRI plan to ensure that this bidirectional exchange takes place.

                        The DOD and VA must implement a mandatory single separation physical as a prerequisite of promptly completing the military separation process.

                        Congress and the Administration must provide additional funding for expansion of the Army Wounded Warrior program so that it can address the needs of more seriously disabled service members. Likewise, it is imperative that proper funding levels be provided to VA and other agencies that provide services for the large numbers of new veterans from the National Guard and Reserves.

 

CRITICAL ISSUE 6: Homeland Security: Funding for the Fourth Mission

The Veterans Health Administration (VHA) is playing a major role in Homeland
Security and bioterrorism prevention without additional funding to support this vital
statutory fourth mission.

 

The Department of Veterans Affairs (VA) has four critical health-care missions. The first mission is to provide health care to veterans. The second is to educate and train health-care professionals. The third mission is to conduct medical research. The fourth mission, as stated in a General Accountability Office Report of October 2001, is to “serve as a backup to the Department of Defense (DOD) health system in war or other emergencies and as support to communities following domestic terrorist incidents and other major disasters[.]”

The devastation created by Hurricanes Katrina and Rita in the Gulf Coast region last year more than met the criteria for the fourth mission. VA proved to be fully prepared to care for veterans affected by the hurricanes. It did an outstanding job removing veterans from the threatened areas, yet the skills and abilities offered by VA were not leveraged to support the other federal, state, and local agencies as they struggled to react to these events. Had this occurred, it might have reduced suffering in the region.

VA has statutory authority, under 38 U.S.C. § 8111A, to serve as the principal medical care backup for military health care “[d]uring and immediately following a period of war, or a period of national emergency declared by the President or the Congress that involves the use of the Armed Forces in armed conflict[.]” On September 18, 2001, in response to the terrorist attacks of September 11, 2001, the president signed into law the Authorization for Use of Military Force, which constitutes specific statutory authorization within the meaning of section 5(b) of the War Powers Resolution. This resolution, P.L. 107-40, satisfies the statutory requirement that triggers VA’s responsibilities to serve as a backup to the DOD.

As part of its fourth mission, VA has a critical role to play in protecting the homeland and responding to domestic emergencies. The National Disaster Medical System (NDMS), created by P.L. 107-188 (Public Health Security and Bioterrorism Preparedness Response Act of 2002), is responsible for managing and coordinating the federal medical response to major emergencies and federally declared disasters. These disasters include natural disasters, technological disasters, major transportation accidents, and acts of terrorism, including events involving weapons of mass destruction, in accordance with the National Response Plan. NDMS is a partnership of the Department of Homeland Security, VA, the DOD, and the Department of Health and Human Services (HHS). According to the VA Web site ( www.va.gov ), some VA medical centers have been designated as NDMS Federal Coordinating Centers. These centers are responsible for developing, implementing, maintaining, and evaluating the local NDMS program. VA has also assigned Area Emergency Managers to each Veterans Integrated Service Network to support this effort and assist local VA management in fulfilling this responsibility.

In addition, P.L. 107-188 requires VA to coordinate with HHS to maintain a stockpile of drugs, vaccines and other biological products, medical devices, and other emergency supplies. The secretary is also directed to enhance the readiness of medical centers and provide mental health counseling to those individuals affected by terrorist activities.

In 2002, Congress enacted P.L. 107-287, the Department of Veterans Affairs Emergency Preparedness Act of 2002. This law directs VA to establish four emergency preparedness centers. These centers are to be responsible for research and development of methods of detection, diagnosis, prevention, and treatment of injuries, diseases, and illnesses arising from the use of chemical, biological, radiological, or incendiary or other explosive weapons or devices that threaten public health and safety. In addition, the centers would provide education, training, and advice to health-care professionals. They would provide laboratory, epidemiological, medical, and other assistance to federal, state, and local health-care agencies that are responding to a disaster or emergency. Although authorized by law, these centers have not received any funding.

The IBVSOs are concerned that VA lacks the resources to meet its fourth mission responsibilities. VA’s contributions in Alabama, Louisiana, and Mississippi prove that the department has done everything it can to prepare itself under the requirements of the fourth mission. It has also invested considerable resources to ensure that it can support other government agencies when a disaster occurs. However, VA has not specifically received any funding to support the fourth mission. Although VA administrators have requested funds in the past for this mission, no specific line item was created in the budget to address medical emergency preparedness or other homeland security initiatives. Instead, funding has had to be drawn from the Medical Care Account, leaving the department with even fewer resources to meet the health-care needs of veterans. VA will make every effort to perform the duties assigned it as part of the fourth mission, but if sufficient funding is not provided, scarce resources will continue to be diverted from direct health-care services.

VA’s fourth mission is vital to our defense, homeland security, and emergency preparedness needs. In light of the natural disasters that have wreaked havoc on our country, this fact has never been more apparent. The integrity of the VA system, especially its ability to provide a full range of health-care services to its constituents, must be maintained. The IBVSOs do not believe that VA has the resources it needs to provide adequate care for all of our nation’s veterans—now or in the future. If VA is to fulfill all of the responsibilities it has been given, it must be provided sufficient resources to do so.

Recommendations: