Nov 21, 2017
Statement of
Keith Harman
Commander-in-Chief
Veterans of Foreign Wars of the United States
Before the
Committee on Veterans' Affairs
United States Senate
With Respect to
“State of VA Service in Ohio”
WASHINGTON, D.C.
Chairman Isakson, Ranking Member Tester and members of the Committee, on behalf of the men and women of the Veterans of Foreign Wars of the United States (VFW) and its Auxiliary, thank you for the opportunity to discuss the issues important to Ohio’s veterans, which also impact veterans throughout the country.
Community Care: In the past three years, the VFW has assisted hundreds of veterans who have faced delays receiving care through the Choice Program, and has surveyed more than 8,000 veterans specifically on their experiences using Department of Veterans Affairs (VA) community care. Through this work, the VFW has identified a number of issues and has proposed more than 15 common sense recommendations on how to improve this important program. Some of these common sense recommendations include making VA the primary payer for Choice Program care, removing restrictions on when VA is able to share medical records with Choice providers and making clinical necessity the trigger for community care.
The VFW must also commend VA and the third party administers for their willingness to work with us to address issues veterans encounter when obtaining care through the Choice Program. VA has made more than 70 modifications to the Choice Program’s contract to address many of the pitfalls that have plagued the program, such as allowing the contractors to conduct outbound calls when they have the proper authorization to begin the scheduling process.
However, the Choice Program continues to face several challenges that must be addressed. Some of these challenges include assuring the decision of whether a veteran will receive care within VA or the community is determined by a patient and their provider, consolidating all community care programs to one and making the program discretionary instead of mandatory.
The VA health care system delivers high quality care and has consistently outperformed private sector health care systems in independent assessments. The VFW’s numerous health care surveys have also validated that veterans who use VA health care are satisfied with the care they receive. In fact, our latest survey found that 77 percent of veterans report being at least somewhat satisfied with their VA health care experience. When asked why they turn to VA for their health care needs, veterans report that VA delivers high quality care which is tailored to their unique needs and because VA health care is an earned benefit.
VA has made significant strides since the access crisis erupted in 2014 when whistleblowers across the county exposed how long veterans were waiting for the care they have earned and deserve. However, VA still has a lot of work to do to ensure all veterans have timely access to high quality and veteran-centric care. Veterans deserve reduced wait times and shorter commutes to their medical appointments. This means turning to community care when needed, but also means improving VA’s ability to provide direct care.
The VFW urges this committee to quickly pass a community care bill that would continue to invest in VA’s ability to improve its internal system and develop a consolidated care program that supplements, not supplants, the VA health care system. The VFW looks forward to working with this committee to pass veteran-centric reforms to VA’s community care programs.
Mental Health: In September 2016, the VFW launched our mental wellness campaign. We partnered with five organizations in our efforts to help service members, veterans and their families cope with their mental health conditions. During this process we consistently heard from our members that the biggest barrier they face when trying to address the health of their brains is stigma, but this is not new. Thirty years ago people were ashamed to talk about cancer. It was a shameful word. Nobody used to talk about diabetes either. It was embarrassing to admit you had a health condition people wrongly associated with an improper diet. Today, people are ashamed to admit they have a mental health condition. Why? The brain is an organ. It is part of our body. It needs treatment to address injuries and illnesses, but can recover just as any other part of the body can.
The VFW has worked tirelessly in the past two years to get people talking about mental health; to notice when someone may be in a mental health crisis; and to finally eliminate the stigma our society has placed on mental health. The more we talk about it, educate people about it and address the actualities of mental health and suicide, the more comfortable society and individuals suffering from mental health conditions are going to become with accessing the care they need. Most citizens can identify somebody experiencing a heart attack. People who have a heart attack know they must seek medical treatment. Now it is time for people to recognize the five signs of mental distress and to know when to seek help.
This is why VFW Posts throughout the world have hosted nearly 300 events in the past two years in partnership with the Campaign to Change Direction. Many of these Posts partnered with VA, Given an Hour providers and Walgreen pharmacies to ensure their communities know about the resources available to veterans and family members suffering from mental health conditions. Now they know to identify the five signs of mental distress: personality change, agitation, withdrawn behavior, poor self-care and feelings of hopelessness.
This past year VA released the most extensive study ever conducted on veteran suicide. This study was possible thanks to interagency cooperation and the necessity for VA, the Department of Defense (DOD) and more than 30 states to fully understand the details such as who is more at risk, how many veterans are dying by suicide and where these veterans reside.
The study found that on average, twenty veterans die by suicide each day, yet only six out of these twenty use VA health care. To the surprise of many, 65 percent of veterans who die from suicide are 50 years old or older. Additionally, the risk for suicide in the female veteran population is 2.4 times higher when compared to their civilian counterparts. While these numbers are all alarming, they are also incredibly insightful for purposes of helping Congress and VA work toward eliminating this current plague of suicide in the veteran population.
This summer, VA released a more thorough analysis of last year’s study. This analysis focused on the data broken down at a state level. With the national veteran suicide rate being 38.4, the state of Ohio is doing better than the national average at 32.1, but is not a statistically significant difference. In 2014, 244 veterans died by suicide in the state of Ohio.
In order to eliminate veteran suicides, VA must increase access to competent mental health care that is individualized to the patient. While the data shows VA mental health care is making a positive impact on those who use it, there is still room for improvement. More studies must be conducted to find more innovative ways to treat mental health conditions. VA has conducted research pertaining to areas such as service animals and emerging technologies, but other therapeutic alternatives, such as medicinal marijuana, need to be studied.
The VFW continues to hear from veterans that VA needs to hire more mental health care providers. This shortage of providers has been continually highlighted by Government Accountability Office and VA Office of Inspector General (OIG) reports in past years. Specifically, the VAOIG’s yearly determination of occupational staffing shortages across the VA health care system has placed psychologists among the top five VA health care professions’ staffing shortages. This is due in large part to a general lack of mental health care professionals in the United States.
But we must not forget about the importance of public-private partnerships. Providing veterans with resources such as Ohio’s Star Providers is absolutely crucial in addressing needs for veterans who may not trust VA or be able to access the care they need and want in a timely manner.
Whether PTSD or any other mental health conditions stem from combat in Afghanistan or rape, veterans deserve the treatments that work best for them. Yet, VA struggles to arrange group therapy sessions for sexual trauma survivors, simply due to the lack of patients willing to partake in group therapy. Though there may only be one, two or three veterans wanting group therapy, it does not mean they should be denied access or placed in uncomfortable group therapy sessions. That is why the VFW supports expanding VA’s telemedicine authorities to ensure sexual assault patients within VA have the opportunity to talk comfortably in a virtual group setting of people who endured the same traumas.
Women Veterans: Women veterans are the fastest growing population within the military and veteran community. There are currently two million female veterans, with nearly 68,000 of them in Ohio. Of the women who have served in Iraq and Afghanistan, more than 160 of them have paid the ultimate sacrifice and, as of 2016, women service members are able to serve in any career field they desire. Now more than ever, as their population and roles in the military continue to increase, it is important VA and Congress address their gender-specific needs.
There are certain gender-specific needs for both men and women. Our nation’s women veterans are younger than the average male veteran. They are more likely to have served in Gulf War or Post-9/11 eras than in previous conflicts. Women veterans are also more likely to come from diverse racial backgrounds. They are more likely to have a service-connected disability and are more likely to use VA health care when compared to their male counterparts.
VA reports that more than 447,000 women veterans used the VA health care system in fiscal year 2015, which is a 123 percent increase since fiscal year 2003. VA has worked to improve their gender-specific care for this population of veterans, but more work needs to be done. In 2016, the VFW conducted a survey of nearly 2,000 women veterans as a way to identify the most important issues they were facing in VA. Of those respondents, three percent were from Ohio. The most common feedback the VFW received from Ohio respondents was clear ––increase the number and accessibility to gender-specific providers. With 58 percent of Ohio’s women veterans using VA’s gender-specific care, this concern must be addressed.
To make sure these issues are addressed, and the voices of women veterans are heard, the Ohio Department of Veterans Affairs hosts a quarterly women veteran’s advisory committee meeting. The committee also hosts a statewide conference every two years, which is open to all veterans and has seen turnouts of as many as 750 attendees.
This committee has found that funding and outreach are the largest barriers for VA’s gender-specific care in Ohio. When outreach is conducted to women, the outreach does not appear to the population as being targeted specifically toward them. The committee commonly hears back that outreach to get women veterans into VA seems to be heavily reliant on electronic outreach and social media, when women veterans in Ohio report to the committee that they would rather have face-to-face outreach conducted. This makes sense as 46 percent of VFW’s survey respondents from Ohio were 55 or older. VA must ensure its outreach efforts are effective with all generations of women veterans.
Lastly, the Ohio committee has found recognition of women veterans within VA to be a continuing struggle. As one member put it, “Women are not as likely to have on a ball hat or t-shirt that states she is a veteran.” Women veterans who use women’s clinics in Ohio VA medical facilities have reported an increase in recognition of their service, but for women not using women’s clinics there are still continuous battles. When a woman walks into a clinic there is no reason for VA staff to ask what her spouse’s information is –– it should be assumed that she is a veteran.
Oversight: Earlier this year, a damning report was released by the VA Office of Inspector General concerning the Louis Stokes Cleveland VA Medical Center (VAMC). The report identified discrepancies regarding patient safety, environmental cleanliness, and VAMC staff training related to disruptive and violent behavior, just to name a few. Even more reprehensible was that the report concludes by stating that the VAOIG was not confident that the facility employees were properly trained; that clinicians were effectively monitoring patients receiving high-risk medications, such as anticoagulants; nor that patient equipment was clean.
To be frank, this is beyond unsatisfactory. A facility with a yearly budget of approximately $1B which serves more than 110,000 veterans per year should not have untrained staff and dirty equipment.
Since 2014, VA has told us the situation is improving, but to the veterans’ community, this is not good enough. VA’s obligation is to provide our veterans with the best health care our nation has to offer. This investigation only adds to the hundreds of concerns we heard from veterans at VA facilities from coast to coast over the past three years.
In light of these findings, we must reject any urge to paint Veterans Health Administration (VHA) as an overall failure that should be abandoned in exchange for privatized care. If the system is failing, it is the duty of the leadership to fix it. While this task at one time was daunting and yielded little in the way of results, thanks to the recent passage of the Department of Veterans Affairs Accountability and Whistleblower Protection Act, leaders now are empowered to hold underperforming employees accountable, regardless of seniority.
Appeals Modernization: Currently, Ohio is home to 769,267 veterans of which 470,192 are receiving VA benefits in some form or another. An all-out push by the Veterans Benefits Administration (VBA) in the past few years has reduced the disability compensation and pension workload by more than 164,000 claims. In doing so, VBA continued to define its “workload” and “backlog” as only initial disability and pension claims, diverting nearly all its people to working on those cases.
As a result, the significant backlog reduction came at the expense of more difficult work. Appeals soared by more than 28,000 during this period, bringing the total number of appeals pending to more than 300,000. Appeals continue to average more than three years before the Board of Veterans Appeals makes its first decision. Initial pension claims continue to rise, and disability claims with eight or more conditions remain unreasonably high at nearly 43,000. Pending dependency claims remain unreasonably high at over 231,000 –– up from 40,000 just a few years ago.
In 2015 alone, the Cleveland VA Regional Office processed 32,187 claims. Since the first discussions on appeals reform with VA, the VFW has been very clear that any changes to the system must be coupled with aggressive initiatives to adjudicate legacy appeals in a timely manner through both legislative authority and proper resourcing.
While VFW applauds Congress for passing S.1024, the Veterans Appeals Improvement and Modernization Act of 2017, we have significant concerns with regard to how VA intends to implement these prescribed changes by way of the Rapid Appeals Modernization Program. Furthermore, the VFW urges Congress and VA to properly resource VBA and the Board of Veterans Appeals to ensure they are able to timely adjudicate appeals from veterans who do not opt into the new appeals process, and the potential influx of supplemental claims and higher level review requests at VA Regional Offices. VA must be empowered to manage its workload if the new framework to expected to succeed.
Forever G.I. Bill: The VFW would like to thank this committee for its hard work and dedication on the swift passage of the Forever G.I Bill, which will make a difference for countless veterans in Ohio and throughout the country. Specifically, we would like to thank Senator Brown for his continued push to ensure survivors who use the Marine Gunnery Sergeant John D. Fry Scholarship can achieve their educational goals without accruing large student loan debts. The VFW is particularly proud that the G.I. Bill is now a lifetime benefit. Veterans who were discharged after 2013 no longer have to worry about an expiration date for their G.I. Bill benefits. This rightfully recognizes that many transitioning service members do not need to use their G.I Bill benefits immediately after separating from military service. The VFW will closely monitor the implementation of the Forever G.I. Bill to ensure veterans are aware of their expanded educational benefits and ensure VA meets its obligations to America’s student veterans.
Overpayments: With more than 187,000 overpayment notices being sent to veterans nationwide in the past year alone, one would hope that VA would not only be prepared to share the most precise information that triggered the notice in the first place, but also be prepared to assist the veteran in a timely fashion. Sadly, this is not the case.
In the past year, the VFW’s National Veterans Service (NVS) has directly assisted more than 200 veterans who have experienced issues stemming from overpayments. According to our estimates, about 60 percent of the cases where NVS has intervened have resulted in the veteran being granted either partial or full relief from the debt from VA’s Debt Management Center.
In our experience, we have found that legitimate overpayments most often occur with G.I. Bill benefits when a veteran’s enrollment status changes at his or her college. If a student decides that they are having a difficult time meeting their educational obligations and chooses to switch to part-time, it is the responsibility of the school, not the student, to notify VA. In the event that the school fails to notify VA of the change in status, the veteran will continue to receive the full living stipend and the school will continue to be paid the full-time rate for tuition.
Once the error is noticed, VA will send an ambiguously worded notification of overpayment, which also provides options for repayment. If the veteran is unable to contact VA to establish that the debt is erroneous, make a repayment in a timely manner, or enter into a payment agreement with VA, their debt is sent to collections and VA will garnish payments from their disability compensation benefits until the debt is satisfied.
The VFW understands that overpayments must be recouped in order for benefit programs to work efficiently. However, it is important to state that not only must debt notices be clear and provide the proper information regarding what steps veterans need to take in order to resolve any outstanding debts as soon as possible; but it is also imperative that these notices actually reach the veterans in the first place.
That is why the VFW fully supports H.R. 3705, the Veterans Fair Debt Notice Act of 2017, which directs VA to require that certified mail be used to send a veteran any debt demand or debt information notification concerning collection of debts resulting from the veteran's participation in a VA benefit or home loan program. This piece of legislation passed the House earlier this month and we urge a swift passage by the Senate.
Sequestration: Ending sequestration has been a top priority for the VFW since it was created by the Budget Control Act of 2011, which set spending caps for the federal budget through fiscal year 2022 and included a provision to activate automatic cuts if such spending caps are exceeded. As a result, VA and DOD are forced to work within the confines of spending caps that were set more than six years ago which fail to account for increased demand for VA benefits and services, or for the costs required to man and equip a force capable of deterring and defeating emerging global threats. While Congress has negotiated temporary deals in the past to avoid the dangerous cuts, the issue of sequestration has not been addressed and continues to impact the resources afforded to DOD and VA.
Compounding the problem is Congress’ increasing reliance on continuing resolutions (CRs) to fund the government. CRs bring instability and uncertainty into the funding process by limiting long-term decision making, preventing new acquisitions and constraining spending to predetermined category levels. For DOD, this means canceled training, penalties on contracts, delayed maintenance on weapons systems, lack of equipment, cuts to quality of life programs, longer deployments, wear on materials, and an overall decreased readiness status.
In my travels across the country and the world, I have seen firsthand the impact sequestration is having on our troops stationed overseas. Pilots barely fly enough hours to maintain their certifications and troops lack the training needed to combat the ever-increasing threats to our national security. The effect mandatory sequestration will have on recruiting and retention, when combined with better job opportunities in a healthy civilian market, could jeopardize the continued viability of the all-volunteer force. For example, the Army Reserve has nearly 5,800 soldiers and more than 2,600 civilians employed (DOD and non-DOD combined) in Ohio. It is projected that sequestration has an impact of $16.7 million for fiscal year 2018 just in Ohio as it relates to the Army Reserve.
What this means for veterans is that the resources VA is given to care for our nation’s veterans has increased in past years, but outdated and arbitrary budget caps on federal discretionary spending have prevented budget increases from keeping pace with the growing demand on the VA health care system. Budget caps have forced VA to request less resources than needed to accomplish its mission and required Congress to provide VA less resources than it has requested, which hinders VA’s ability to meet its obligation to our nation’s veterans.
Until now, VA has been exempt from sequestration, but no one said that will be the case in the future since nearly half of VA’s budget comes through the discretionary process. Despite recent legislative victories, sequestration could dramatically affect VA’s ability to reduce the claims backlog or improve hospital infrastructure that is already in rapid decline, potentially diminishing access and timeliness of care. Additionally, programs that have not been exempt from sequestration would have a direct impact on our nation’s veterans, such as services the Department of Labor-VETS provides for veterans seeking employment, as well as the number and size of housing grants that the Department of Housing and Urban Development would have available for homeless veterans.
Blue Water Navy: When asking my fellow Ohio veterans what issues are important to them, one that continued to come up is the¬ frustration with continued inaction to provide Blue Water Navy veterans the benefits they deserve. The VFW strongly supports S. 422, the Blue Water Navy Vietnam Veterans Act of 2017, which would expand disability compensation benefits to veterans who were exposed to Agent Orange while serving in the territorial seas of the Republic of Vietnam in support of ground operations during the Vietnam War.
Currently, VA relies on what the Court of Appeals for Veterans Claims has called an “arbitrary and capricious” interpretation of inland waterways, which unjustly denies veterans who served aboard ships in the coastal waters of Vietnam the benefits they deserve. The VFW calls on Congress to swiftly pass the Blue Water Navy Vietnam Veterans Act of 2017. However, we recognize the position that Congress is in concerning the cost of this legislation. To help move this issue forward, the VFW has written a letter to President Trump asking him to change the regulations associated with Title 38 of the United States Code. Doing so would alleviate the need for congressional action or reduce the cost associated with the passage of S. 422. The VFW call on this committee to move this important bill as soon as possible.
Burn Pits: The use of open air burn pits in combat zones has caused invisible but grave health complications for many service members, past and present. Particulate matter, polycyclic aromatic hydrocarbons, volatile organic compounds and dioxins –– the destructive compound found in Agent Orange –– and other harmful materials are all present in burn pits, creating clouds of hazardous chemical compounds that are unavoidable to those in close proximity.
The VFW is glad to see that nearly 100,000 veterans have enrolled in VA’s burn pit registry. The VFW is also anxiously awaiting the results of the National Academies of Science’s study on the burn pit registry which will serve to determine whether veterans exposed to airborne hazards from burn pits experience certain pulmonary conditions. The VFW urges VA and Congress to act swiftly on recommendations from this important study.
VA must also take measures to improve the Airborne Hazards and Open Burn Pits Registry. For example, a similar registry operated by Burn Pit 360 allows the spouse or next of kin of registered veterans to report the cause of death for veterans. VA must add a similar feature to its registry to ensure VA is able to track trends. Other improvements include streamlining the registration process, updating duty locations, and eliminating technical glitches to ensure veterans are able to register.
While the VFW is glad to see VA has commissioned independent research on the burn pit registry, more independent research is necessary. That is why the VFW supports funding for research through the Congressional Directed Medical Research Program (CDMRP) specifically for burn pit related conditions. The CDMRP for Gulf War Illness has shown some progress in identifying causes, effective treatments and biomarkers for Gulf War Illness, and the VFW is confident that similar research for burn pits will help veterans finally determine whether their exposure to burn pits during combat is associated with their negative health care outcomes.