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Mrs. Shannon Middleton

Mrs. Shannon Middleton, American Legion, Deputy Director for Health, Veterans Affairs and Rehabilitation Commission

Mr. Chairman and Members of the Subcommittee:

Thank you for this opportunity to present The American Legion’s view on the several pieces of legislation being considered by the Subcommittee today. The American Legion commends the Subcommittee for holding a hearing to discuss these very important and timely issues. 

H.R. 1448, VA Hospital Quality Report Card Act of 2007, seeks to establish the Hospital Quality Report Card to ensure quality measures data on the Department of Veterans Affairs (VA) hospitals are readily available and accessible. 

The state of VA health care/medical facilities are an important issue for The American Legion.  Each year the organization is mandated by resolution to conduct a series of site visits to various VA medical facilities and submit a report to the President, Congress and VA.

The bill is similar in scope to our report — A System Worth Saving.  Periodic assessments would enable VA to get a clearer picture of its system-wide needs and assist lawmakers in determining adequate funding for the VA health care system.

H.R. 1853, Jose Medina Veterans Affairs Police Training Act of 2007, seeks to ensure that VA police officers receive training on interacting with visitors and patients suffering from mental illness at VA medical facilities.  The American Legion has no official position on this issue, but hopes that VA is training all of its employees to interact with veterans and their families in the dignified, respectable manner in which they deserve.

H.R. 1925, A Bill to Direct the Secretary of Veterans Affairs to Establish a Separate Veterans Integrated Service Network (VISN) for the Gulf Coast Region of the United States, would mandate that the Secretary create a VISN that would encompass several counties in the states of Florida, Alabama and Mississippi.  The American Legion has no position on this issue.

H.R. 2005, Rural Veterans Health Care Improvement Act of 2007, addresses many issues affecting veterans who reside in rural areas.  It seeks to increase the beneficiary travel rate to make it equivalent to the rate provided to federal employees; establish centers for rural health research, education, and clinical activities; offer transportation grants for service organizations that assist rural veterans; and explore alternatives to improve transportation to medical facilities for rural veterans. The American Legion fully supports the provisions in this bill. 

Beneficiary travel pay has not been increased from its current rate since 1978.   The price of gasoline has steadily increased since the $0.11 per mile rate was established, creating a financial hardship for veterans who have to travel long distances for care, or those who have limited financial resources.

Since service-connected veterans and other veterans authorized beneficiary travel only receive $0.11 per mile are subjected to a $6 per trip deductible not to exceed $18 per month—this amount does very little to defray the cost of travel. Eligible veterans are not reimbursed at a reasonable level for costs incurred to visit a VA medical facility for service-connected or other authorized care and treatment. 

There are no provisions in law that VA must increase the per mile travel authorization on a regular basis. The beneficiary travel program is discretionary and the Secretary of Veterans Affairs is required to review the program annually to determine the Department’s ability to maintain the program and its ability to increase the reimbursement rate for eligible veterans.  The Secretary has determined that it is necessary to maintain the current reimbursement rate in order to allow the VA health care system to accommodate the increasing patient workload. 

The lack of a consistent and reliable mechanism to periodically adjust the rate authorized for beneficiary travel creates an injustice and an unfair economic burden for many veterans.  The American Legion believes that mandatory funding for VA health care would allow the Secretary to provide adequate health care without inversely affecting programs designed to mitigate the cost of accessing that care.

Establishing centers for rural health research, education, and clinical activities would afford VA the opportunity to build strategies to improve its system of care for rural veterans, as well as educate and train healthcare professionals on health issues prevalent in specific rural veteran populations. 

Offering transportation grants for veterans’ service organizations that assist rural veterans and exploring alternatives to improve transportation to medical facilities for rural veterans would make accessing care easier for those who are not financially able to travel to facilities, especially those who, due to their physical condition, are not able to makeextremely long trips in one day.  If more transportation options became available, it may also improve coordination of care for those who have to travel distances for special services, especially in the unavailability of a family caregiver. 

H.R. 2172, Amputee Veteran Assistance Act, would require that VA’s orthotic-prosthetic laboratories, clinics, and prosthetists are certified by either the American Board for Certification in Orthotics and Prosthetics or the Board of Orthotics and Prosthetic Certification.  It is The American Legion’s understanding that VA's ortho-prosthetic labs/clinics are accredited and each has at least one orthotist that has certificationwhich is how the labs were able to gain accreditation.  The orthotists and prosthetists are being trained on latest prosthesis at Walter Reed, so they can be knowledgeable about the prosthetics being given to returning soldiers.  They also participate in focus groups with veterans’ service organizations, and OIF veterans.  Furthermore, VA already contracts with non-Department entities when the medical facility is not capable of providing the service or the veteran lives too far away and patients are given information about their prosthetic choices.  

H.R. 2173, Seeks to Amend Title 38, United States Code, to Authorize Additional Funding for the Department of Veterans Affairs to Increase Capacity for Provision of Mental Health Services Through Contracts with Community Mental Health Centers, and for Other Purposes.   The American Legion believes that VA should contract with community providers only when it is unable to provide needed services to the veteran, if travel for the veteran would be a danger to his or her health, or if the veteran resides in a rural area.  As long as VA health care remains discretionary, VA will always struggle to obtain sufficient funding to provide access to quality care for eligible veterans seeking care in VA facilities.  Assured (mandated) funding would provide a method to provide dependable, stable and sustained funding for veterans’ health care.  The American Legion believes that Congress should designate assured funding for VA medical care; continue to provide discretionary funding, as required, to fully operate other programs within the Veterans Health Administration’s budgetary jurisdiction; and provide, if necessary, supplemental appropriations for budgetary shortfalls in VHA’s mandated and discretionary appropriations to meet the health care needs of America’s veterans.

H.R. 2192, A Bill to amend Title 38 USC, to establish an Ombudsman within the Department of Veterans Affairs, would designate an Ombudsman to serve as a liaison for veterans and their families to guarantee the receipt of VA healthcare and benefits.  The American Legion supports the provisions of this bill.  Establishing a point of contact to work with families to ensure that veterans receive all benefits, to which he or she is entitled, based on his or her unique situation, would reduce the stress and frustration associated with navigating the complex VA health care and benefits system. 

H.R. 2219, Veterans Suicide Prevention Hotline Act of 2007.  The American Legion has no position on this issue. 

H.R. 2378, Services to Prevent Veterans Homelessness ActThis bill aims to establish a financial assistance program to facilitate supportive services for very-low income veteran families to assist them in ending their chronic homeless state and to prevent chronic homelessness. 

Enactment of this legislation will enable funding to provide much needed supportive services to veterans and their dependents.  It takes into account that the VA Grant and Per Diem (GPD) program can only provide services to veterans and fills a much-needed gap of caring for their dependents. . 

The American Legion fully supports this bill in its effort to assist homeless veterans.  We applaud that the bill recognizes that families also suffer alongside the veteran struggling with homelessness. 

The American Legion supports the efforts of public and private sector agencies and organizations with the resources necessary to aid homeless veterans and their families. The American Legion supports proposals that will provide medical, rehabilitative and employment assistance to homeless veterans and their families.  

Currently, the VA has no authority to provide grant funding to create affordable permanent housing units for low-income veterans and those who have completed their transition programs.  Veteran service providers must compete with other housing projects for limited HUD funding, and constantly search for additional funding sources to provide this housing option.

This legislation will be in addition to the VA Grant and Per Diem program, but will enable the mechanism of funding supportive services to become more streamlined.

Homeless veteran programs should be granted full appropriations to provide supportive services such as, but not limited to outreach, health care, habilitation and rehabilitation, case management, daily living, personal financial planning, transportation, vocational counseling, employment and training, and education. 

Veterans need a coordinated effort that provides secure housing and nutritious meals; essential physical health care, substance abuse aftercare and mental health counseling; as well as personal development and empowerment.

Veterans also need job assessment, training and placement assistance.  The American Legion believes all programs to assist homeless veterans must focus on helping veterans reach their highest level of self-management.

The most effective programs for homeless and at-risk veterans are community-based, nonprofit, veteran-staffed groups.  It is critical that community groups continue to reach out and help to provide the support, resources and opportunities most Americans take for granted.

Homelessness impacts every community in the nation.  Approximately 200 community-based veterans’ service organizations across the country have successfully reached homeless veterans through specialized programs.  Veterans who participate in these programs have a higher chance of becoming productive citizens again.

A full continuum of care – housing, employment training and placement, health care, substance abuse treatment, legal aid, and follow-up case management – depends on many organizations working together to provide services and adequate funding. The availability of homeless veteran services, and continued community and government support for them, depends on vigilant advocacy and public education efforts on the local, state and federal levels.

The FY 2006 Department of Veterans Affairs Community Homelessness Assessment, Local Education and Networking Groups (CHALENG) report estimates that nearly 200,000 veterans are homeless at any point in time.  Prior reports state that one out of every three homeless men sleeping in a doorway, alley or box in our cities and rural communities has put on a uniform and served this country. According to the February 2007 Homeless Assessment Report to Congress (U.S. Department of Housing and Urban Development 2007) veterans account for 19 percent of all homeless people in America.

For FY 2006, The VA Health Care for Homeless Veterans (HCHV) reports that 101,182 homeless veterans are enrolled in their programs.  Community-based organizations are attempting to assist the overwhelming remainder of veterans who are homeless. 

In addition to the complex set of factors affecting all homelessness (the extreme shortage of affordable housing, livable income, and access to health care),alarge number of displaced and at-risk veterans live with lingering effects of Post Traumatic Stress Disorder (PTSD), substance abuse, and a lack of family and social support networks.  Many times these veterans have mental health disorders related to their honorable service to their country, are unable to compensate for their condition.  They unfortunately deteriorate to unrecognizable individuals compared to their pre-military experience. 

Operation Iraq Freedom and Operation Enduring Freedom (OIF/OEF) veterans are at high risk of becoming homeless.  Combat veterans of OIF/OEF and the Global War on Terror who need help – from mental health programs to housing, employment training and job placement assistance – are beginning to trickle into the nation's community-based homeless veterans’ service organizations. Already stressed by an increasing need for assistance by post-Vietnam Era veterans and strained budgets, homeless services providers are deeply concerned about the inevitable rising tide of combat veterans who will soon be requesting their support.

Since 9/11, nearly 800,000 American men and women have served or are serving in a war zone.  Rotations of troops returning home from Iraq are now a common occurrence. Military analysts and government sources say the deployments and repatriation of combat veterans is unlike anything the nation has experienced since the end of the Vietnam War.

The signs of an impending crisis are clearly seen in VA's own numbers. Under considerable pressure to stretch dollars, VA estimates it can provide assistance to about 100,000 homeless veterans each year, only 20 percent of the more than 500,000 who will need supportive services. Hundreds of community-based organizations nationwide struggle to provide assistance to as many of the other 80 percent as possible, but the need far exceeds available resources.

VA’s HCHV reports 1,049 OIF/OEF era homeless veterans with an average age of 33 years young.  HCHV further reports that nearly 65 percent of these homeless veterans experienced combat. Now receiving combat veterans from Iraq and Afghanistan daily, the VA is reporting that a high percentage of those casualties need treatment for mental health problems. That is consistent with studies conducted by VA and other agencies that conclude anywhere from 15 to more than 35 percent of combat veterans will experience some clinical degree of PTSD, depression or other psychosocial problems. 

Homeless veteran service providers’ clients have historically been almost exclusively male.  That is changing as more women veterans and women veterans with young children have sought help. Additionally, the approximately 200,000 female Iraq veterans are isolated during and after deployment making it difficult to find gender-specific peer-based support.  Access to gender-appropriate care for these veterans is essential.

More women are engaging in combat roles in Iraq where there are no traditional front lines.  In the past 10 years, the number of homeless women veteran has tripled.  In 2002,the VA began a study of women and PTSD.  The study includes subjects whose PTSD resulted from stressors that were both military and non-military in nature.  Preliminary research shows that women currently serving have much higher exposure to traumatic experiences, rape and assault prior to joining the military.  Other reports show extremely high rates of sexual trauma while women are in the service (20-40 percent).  Repeated exposure to traumatic stressors increases the likelihood of PTSD.  Researchers also suspect that many women join the military, at least in part, to get away from abusive environments.  Like the young veterans, these women may have no safe supportive environment to return to, adding yet more risk of homeless outcomes.

“Homeless providers continue to report increases in the number of homeless veterans with families (i.e., dependent children) being served at their programs. Ninety-four sites (68 percent of all sites) reported a total of 989 homeless veteran families seen with Los Angeles seeing the most families (156). This was a 10 percent increase over the previous year of 896 reported families. Homeless veterans with dependents present a challenge to VA homeless programs. Many VA housing programs are veteran-specific. VA homeless workers must often find other community housing resources to place the entire family – or the dependent children separately. Separating family members can create hardship.” (FY 2006 VA CHALENG report)

Homeless veteran service providers recognize that they will have to accommodate the needs of the changing homeless veteran population, including increasing numbers of women and veterans with dependents.  In conclusion, The American Legion supports the provisions in H.R. 2378 which will be helpful in addressing the issues of homeless veterans.

H.R. 2623, Seeks to amend title 38, United States Code, to prohibit the collection of copayments for all hospice care furnished by the Department of Veterans Affairs.  The American Legion is continuing to study the bill and will provide an addendum to this testimony to the committee.  

Again, thank you Mr. Chairman for giving The American Legion this opportunity to present its views on such important issues. We look forward to working with the Subcommittee to address these and other issues affecting veterans.