Veterans’ Health Care Issues

Congressional research reportNov 30, 2007

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Prepared for Members and Committees of Congress

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The Department of Veterans Affairs (VA) provides services and benefits to veterans who meet

certain eligibility criteria. VA carries out its programs nationwide through three administrations

and the Board of Veterans Appeals (BVA). The Veterans Health Administration (VHA) is

responsible for veterans’ health care programs. The Veterans Benefits Administration (VBA) is

responsible for providing compensation, pensions, and education assistance, among other things.

The National Cemetery Administration’s (NCA) responsibilities include maintaining national

veterans cemeteries.

VHA operates the nation’s largest integrated health care system. Unlike most other federal health

programs, VHA is a direct service provider rather than a health insurer or payer for health care.

VA health care services are generally available to all honorably discharged veterans of the U.S.

Armed Forces who are enrolled in VA’s health care system. VA has a priority enrollment system

that places veterans in priority groups based on various criteria. Under the priority system, VA

decides each year whether its appropriations are adequate to serve all enrolled veterans. If not, VA

could stop enrolling those in the lowest-priority groups.

Since the terrorist attacks of September 11, 2001, U.S. Armed Forces have been deployed in two

major theaters of operation. Operation Enduring Freedom (OEF) in Afghanistan and Operation

Iraqi Freedom (OIF) constitute the largest sustained ground combat mission undertaken by the

United States since the Vietnam War. Veterans from these conflicts and from previous wars are

exerting tremendous stress on the VA health care system. With increased patient workload and

rising health care costs, the 110th Congress is focused on such issues as how to contain costs and

at the same time maintain high-quality health care services to veterans who need them. Among

other things, Congress may address the best method of funding for veterans’ health care, while

continuing to focus on ensuring a “seamless transition” process for servicemembers moving from

the military health system into the VA health care system, improving mental health care services

for veterans with Post Traumatic Stress Disorder (PTSD), and improving rehabilitation and

mental health services for those with Traumatic Brain Injuries (TBI).

In recent years, VA has made an effort to realign its capital assets, primarily its buildings, to better

serve veterans’ needs. VA established the Capital Asset Realignment for Enhanced Services

(CARES) initiative to identify how well the geographic distribution of VA health care resources

matches the projected needs of veterans. Given the tremendous interest in the implementation of

the CARES initiative in the previous Congress, the 110th Congress will likely continue to monitor

the CARES implementation. H.R. 327 was enacted into law (P.L. 110-110) on November 5. The

House has passed several measures to improve and expand health care services to veterans: H.R.

327, H.R. 612, H.R. 1315, H.R. 1470, H.R. 2199, H.R. 2623, and H.R. 2874. The Senate VA

Committee has reported the following measures: S. 1233, S. 2004, S. 2142, S. 2160, and S. 2162.

This report will be updated as legislative activities warrant.

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Introduction ..................................................................................................................................... 1

Overview ................................................................................................................................... 1

Historical Background .............................................................................................................. 1

Department of Veterans Affairs (VA) ........................................................................................ 2

Veterans’ Health Care System ................................................................................................... 3

Veterans Health Information Systems and Technology Architecture (VistA)..................... 4

Veteran Population .......................................................................................................................... 7

Eligibility for Veterans’ Health Care ............................................................................................. 10

“Promise of Free Health Care”................................................................................................ 10

VHA Health Care Enrollment ..................................................................................................11

Veteran’s Status................................................................................................................. 12

Priority Groups ................................................................................................................. 12

Health Services........................................................................................................................ 13

Medical Care for Returning Injured Servicemembers................................................................... 14

Overview ................................................................................................................................. 14

OEF and OIF Veterans ............................................................................................................ 15

Transition Issues...................................................................................................................... 19

Initial Medical Care in DOD Facilities ................................................................................... 20

Transfer and Care in VA Facilities .......................................................................................... 21

VA Activities to Assist OEF and OIF Servicemembers .......................................................... 25

VA-DOD Joint Executive Committee............................................................................... 25

Office of Seamless Transition ........................................................................................... 26

Vet Centers........................................................................................................................ 27

Exchange of Health Information....................................................................................... 28

Veterans Tracking Application (VTA) .............................................................................. 30

Two-Year Eligibility for Veterans Returning from Iraq and Afghanistan ......................... 31

Task Force on Returning Global War on Terror Heroes.................................................... 31

Other Health Care Issues ............................................................................................................... 32

Post-Traumatic Stress Disorder (PTSD) ................................................................................. 32

OEF/OIF PTSD Data and Trends ..................................................................................... 32

VA treatment programs for PTSD..................................................................................... 33

Traumatic Brain Injury (TBI).................................................................................................. 33

OEF/OIF TBI Data ........................................................................................................... 33

VA Treatment of TBI......................................................................................................... 34

Mandatory Funding for Veterans’ Health Care ....................................................................... 35

Continued Suspension of Priority Group 8 Veterans............................................................... 36

Filling of Privately Written Prescriptions at VA...................................................................... 37

Capital Asset Realignment for Enhanced Services (CARES)................................................. 38

Beneficiary Travel Program .................................................................................................... 43

Veterans Health Care Legislation .................................................................................................. 45

Health Care Legislation Enacted into Law ............................................................................. 45

Joshua Omvig Veterans Suicide Prevention Act (H.R. 327, H.Rept. 110-055, P.L.

110-110) ......................................................................................................................... 45

Health Care Legislation Passed by the House......................................................................... 46

Returning Servicemember VA Healthcare Insurance Act of 2007 (H.R. 612).................. 46

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Chiropractic Care Available to All Veterans Act (H.R. 1470)........................................... 46

Traumatic Brain Injury Health Enhancement and Long-Term Support Act of 2007

(H.R. 2199, H.Rept. 110-166)........................................................................................ 46

Veterans Benefit Improvement Act of 2007 (H.R. 1315, H.Rept. 110-266) ..................... 46

Veterans Health Care Improvement Act of 2007 (H.R. 2874, H.Rept. 110-268).............. 47

Prohibit the collection of copayments for all hospice care provided by the VA

(H.R. 2623, H.Rept. 110-267)........................................................................................ 47

Health Care Legislation Reported in the Senate ..................................................................... 48

Veterans Traumatic Brain Injury and Health Programs Improvement Act of 2007

(S. 1233, S.Rept. 110-147)............................................................................................. 48

Figure 1. Veterans Integrated Services Networks (VISNs) ............................................................. 6

Figure 2. Veteran Population by State as of September 30, 2006 (in thousands) ............................ 8

Figure 3. Percent of Veterans Enrolled in the VA Health Care System by VISN, FY2005............. 9

Figure 4. Number of Patients by VISN, FY2005 ............................................................................ 9

Figure 5. Frequency of Major Diagnoses among OEF and OIF Veterans..................................... 16

Figure 6. Cumulative Number of OIF and OIF Veterans Discharged from FY2002FY2006....................................................................................................................................... 17

Figure 7. Cumulative Unique OIF and OEF Veteran Patients and OIF and OEF

Discharges from FY2002 thru FY2006 Compared with Annual Number of Unique

Patients ....................................................................................................................................... 18

Figure 8. Current Level of Care from Injury to Definitive Care ................................................... 21

Figure 9. DOD and VA Electronic Information Sharing Focus Areas........................................... 29

Figure 10. Milestones and Plans for Exchange of Medical Information....................................... 30

Table 1. Health Enrollment Process ...............................................................................................11

Table 2. VA Spending and Number of OIF and OEF Veteran Patients.......................................... 19

Table 3. VHA’s Polytrauma System of Care ................................................................................. 23

Table 4. Impact of Priority Group 8 Suspension, FY2003-FY2008.............................................. 37

Table 5. Timeline of Major CARES Activities.............................................................................. 40

Table 6. CARES Decisions on the 18 Sites ................................................................................... 42

Table 7. Veterans Eligible for Travel Benefits............................................................................... 45

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Appendix. Priority Groups and Their Eligibility Criteria.............................................................. 50

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Author Contact Information .......................................................................................................... 51

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This report provides an overview of major issues facing veterans’ health care during the 110th

Congress. The report’s primary focus is on veterans and not military retirees. While any person

who has served in the armed forces of the United States is regarded as a veteran, a military retiree

is someone who has generally completed a full active duty military career (almost always at least

20 years of service), or who is disabled in the line of military duty and meets certain length of

service and extent of disability criteria, and who is eligible for retired pay and a broad range of

nonmonetary benefits from the Department of Defense (DOD) after retirement. A veteran is

someone who has served in the armed forces (in most, but not all, cases for a few years in early

adulthood), but may not have either sufficient service or disability to be entitled to post-service

retired pay and nonmonetary benefits from DOD.1 Generally, all military retirees are veterans,

but not all veterans are military retirees. For the purposes of veterans’ benefits, a veteran is

defined as a person who served in the active military, naval, or air service, and who was

discharged or released under conditions other than dishonorable.2

Currently, there are two health care systems that care for servicemembers and veterans. The

Defense Health Program (DHP) in the DOD provides for worldwide medical and dental services

to active duty military personnel, and other eligible beneficiaries.3 Once they are discharged from

their respective service branches, servicemembers become eligible for care and treatment

provided by the Department of Veterans Affairs (VA). Prior to discussing major health care issues,

this report provides a brief overview of the VA, the Veterans Health Administration (VHA) within

the VA which oversees the largest integrated health care system in the country, and the veteran

population it serves.4 To provide context to the issues discussed in the second part of this report, a

basic overview of eligibility for health care under the veterans health care system is presented.

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Beginning with the early colonial settlements of America, the nation has provided benefits in

varying degrees to those who have worn the uniform and suffered physical disabilities in service

to the nation. For instance, in 1718, the colony of Rhode Island enacted legislation that provided

benefits not only to every officer, soldier or sailor who served in the colony’s armed services, but

also to the wives, children, parents, and other relations who had been dependent upon a slain

servicemember. “The physically disabled were to have their wound carefully tended and healed at

the colony’s expense, while at the same time an annual pension was provided to him out of the

For detailed reports on benefits available for military retirees, see CRS Current Legislative Issue “U.S. Military

Personnel and Compensation” under “Defense,” at http://www.crs.gov/.

38 U.S.C. §101; 38 CFR §3.1. Also see CRS Report RL33113, Veterans Affairs: Basic Eligibility for Disability

Benefit Programs, by (name redacted).

For details on the Defense Health Program, see CRS Report RL33537, Military Medical Care: Questions and

Answers, by (name redacted)

For detailed information on veterans’ benefits issues see, CRS Report RL33985, Veteran’s Benefits: Issues in the

110th Congress, coordinated by (name redacted).

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general treasury sufficient for the maintenance of himself and family, or other dependent

relatives.”5

While pension and disability benefits provided to veterans were gradually increased and in some

cases decreased since the early colonial period, hospital and medical care for veterans on a level

similar to the care provided today was not available until World War I. The VA health care system

has evolved and expanded since World War I. Congress has enlarged the scope of the VA’s health

care mission, and has enacted legislation requiring the establishment of new programs and

services. Through numerous laws, some narrowly focused, and others more comprehensive,

Congress has also extended to additional categories of veterans eligibility for the many levels of

care the VA now provides. No longer a health care system focused only on service-connected

veterans, the VA has become a “safety net” for the many lower-income veterans who have come

to depend upon it.6 Furthermore, with the fragmented private-sector health care system, the lack

of universal access to health care services, and the growing number of people joining the ranks of

the uninsured, many veterans—even some with private health insurance—have chosen to receive

care through the VA.7

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The history of the present-day VA can be traced back to July 21, 1930, when President Hoover

issued Executive Order 5398, creating an independent federal agency known as the Veterans

Administration by consolidating many separate veterans’ programs.8 On October 25, 1988,

President Reagan signed legislation (P.L. 100-527) creating a new federal cabinet-level

Department of Veterans Affairs to replace the Veterans Administration, effective March 15, 1989.

VA carries out its veterans’ programs nationwide through three administrations and the Board of

Veterans Appeals (BVA). The Veterans Health Administration (VHA) is responsible for veterans’

health care programs. The Veterans Benefits Administration (VBA) is responsible for

compensation, pension, vocational rehabilitation, education assistance, home loan guaranty and

insurance among other things. The National Cemetery Administration’s (NCA) responsibilities

include maintaining 120 national cemeteries in 39 states and Puerto Rico. The Board of Veterans

Appeals (BVA) renders final decisions on appeals on veteran benefits claims.9

U.S. Congress. House. Committee on Veterans’ Affairs, The Provision of Federal Benefits for Veterans, Committee

print, 84th Congress, 1st session, December 28, 1955, House Committee Print No. 171. p.2.

For a detailed description of the evolution of eligibility for VA health care, see CRS Report RL32961, Veterans’

Health Care Issues in the 109th Congress, by (name redacted).

Lisa Dubay, John Holahan, and Allison Cook. “The Uninsured And The Affordability Of Health Insurance

Coverage,” Health Affairs - Web Exclusive, November 30, 2006. Catherine Arnst, “The Best Medical Care in the U.S.”

Business Week, July 17, 2006 p.50.

In the 1920s three federal agencies, the Veterans Bureau, the Bureau of Pension in the Department of the Interior, and

the National Home for Disabled Volunteer Soldiers, administered various benefits for the nation’s veterans.

For details on the appeals process, see CRS Report RL33704, Veterans Affairs: The Appeal Process for Veterans’

Claims, by (name redacted).

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VHA operates the nation’s largest integrated direct health care delivery system.10 VA’s health care

system is organized into 21 geographically defined Veterans Integrated Service Networks

(VISNs) (see Figure 1). While policies and guidelines are developed at VA headquarters and

applied throughout the VA health care system, management authority for basic decision making

and budgetary responsibilities are delegated to the VISNs.11 Congressionally appropriated

medical care funds are allocated to the VISNs based on the Veterans Equitable Resource

Allocation (VERA) system, which generally bases funding on patient workload.12 Prior to the

implementation of the VERA system, resources were allocated to facilities primarily on the basis

of their historical expenditures. Unlike Medicare, which administers medical care through the

private sector, the VA provides care directly to veterans.

In FY2007, VHA operated 155 medical centers, 135 nursing homes, 717 ambulatory care and

community-based outpatient clinics (CBOCs),13 45 residential rehabilitation treatment programs,

and 209 Vet Centers (generally these are community-based, non-medical facilities that offer

counseling services).14 VHA also pays for care provided to veterans by independent providers and

practitioners on a fee basis under certain circumstances. Inpatient and outpatient care is provided

in the private sector to eligible dependents of veterans under the Civilian Health and Medical

Program of the Department of Veterans Affairs (CHAMPVA).15 In addition, VHA provides grants

for construction of state-owned nursing homes and domiciliary facilities, and collaborates with

the Department of Defense (DOD) in sharing health care resources and services. Today, VHA has

been commended by peer reviewed journals and independent studies as an outstanding health

care system whose “performance now surpasses that of other health systems on standardized

quality measures.”16 The journal Neurology in its November 2006 issue noted that “The VA has

achieved remarkable improvements in patient care and health outcomes, and is a cost-effective

and efficient organization. Its enrollees are provided comprehensive coverage ... and the system is

Established on January 3, 1946, as the Department of Medicine and Surgery by P.L. 79-293, succeeded in 1989 by

the Veterans Health Services and Research Administration, renamed the Veterans Health Administration in 1991.

Jian Gao, Ying Wang and Joseph Engelhardt, “Logistic Analysis of Veterans’ Eligibility-Status Change,” Health

Services Management Research, vol. 18, (August 2005), p. 175.

About 90% of the VHA appropriation is allocated through VERA. Networks also receive appropriated funds not

allocated through VERA for such things as prosthetics, homeless programs, readjustment counseling, and clinical

training programs. VA facilities could also retain collections from insurance reimbursements and copayments, and use

these funds for the care of veterans.

On June 23, 2006, VA announced plans to open 25 new CBOCs in 17 states and American Somoa. The following

facilities were scheduled to become operational in CY2006: Bessemer, Alabama; Tafuna, American Samoa; MiamiGlobe, Northwest Tucson and Southeast Tucson, Arizona; South Orange County, California; Dover, Delaware; Athens,

Georgia; Canyon County, Idaho; Spirit Lake, Iowa; Hazard and Florence, Kentucky; Bemidji, Minnesota; Holdrege,

Nebraska; Fallon, Nevada; Franklin, Hamlet, and Hickory, North Carolina; Cambridge and Newark, Ohio; Hamblen,

Tennessee; Conroe, Texas; Lynchburg and Norfolk, Virginia; Rice Lake, Wisconsin.

Data from the FY2008 Congressional Budget Submissions, vol. 4 of 4. Number of facilities include facilities

damaged by Hurricane Katrina. Data on the number of CBOCs differ from source to source. Some studies count clinics

located at VA hospitals while others count only freestanding CBOCs. The number represented in this report excludes

clinics located in VA hospitals. The data are current as of September 29, 2006.

For further information on CHAMPVA, see CRS Report RS22483, Health Care for Dependents and Survivors of

Veterans, by (name redacted) and Susan Janeczko.

Kupersmith, Joel, et al. “Advancing Evidence-Based Care For Diabetes: Lessons From The Veterans Health

Administration,” Health Affairs 26, no. 2 (2007): w156-w168 (published online January 26, 2007).

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especially suited to manage chronic disease.”17 In 2005, Health Care Papers dedicated a

complete issue to examining the transformation of VHA, and the lessons that could be learned by

other countries struggling to use their healthcare resources appropriately.18 Furthermore, VA has

led private-sector health care in the American Customer Satisfaction Index for both inpatient and

outpatient services.19

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The previously discussed achievements are related in part to the VHA’s development and use of

electronic health records. Since 1985, VHA has had an automated information system with

extensive clinical and administrative capabilities which supports ambulatory, inpatient, and longterm care. VistA is the single, integrated health information system used throughout VA in all

health care settings. VistA applications are comprised of three types of packages: the clinical

package, the administration and financial package, and the infrastructure package. The clinical

package includes applications such as the Computerized Patient Record System (CPRS). In

addition to CPRS, VistA includes VistA Imaging and Bar-Code Medication Administration.

The CPRS is a single integrated system for VA health care providers. All aspects of a patient’s

medical record are integrated, including active problems, allergies, current medications,

laboratory results, vital signs, hospitalizations and outpatient clinic history, alerts of abnormal

results, among other things. It is used in about 1,300 VHA facilities around the country. CPRS

also incorporates data from scheduling, laboratory, radiology, consults and clinic notes into a

single integrated patient record.20 Remote data view allows clinicians to see health data from any

other VA facility where the veteran has received care. Also as a complement to CPRS, VistA

includes VistA Imaging. This application provides a multimedia, online patient record that

integrates traditional medical chart information with medical images including X-rays, pathology

slides, video views, scanned documents, and cardiology exam results, among other images.

The Bar Code Medication Administration (BCMA) is an application that validates the

administration of medications, including intravenous medications, in real time for inpatients in all

VA medical centers. This ensures that the patient receives the correct medication, at the correct

dosage and at the right time. BCMA also provides visual alerts. For instance, if the software

detects a potential medical error, it alerts the nurse administering the medication. These alerts

require the nurse to review and correct the reason for the alert before actually administering the

drug to the patient. The overall cost of maintaining the VistA system is $87 per patient annually.21

In 2006, Harvard University’s Kennedy School of Government awarded the VA the Innovations

in American Government Award for its electronic health records system. In presenting this award

the Kennedy School stated that

Feasby, Thomas E., “Is the Canadian health care system better for neurologic care?” Neurology, 2006; 67: 17441747.

Veterans Health Administration, HealthcarePapers vol. 5 no. 4, 2005.

See http://www.theacsi.org/, accessed January 23, 2007.

Nedal Arar, Lonnie Wen, John McGrath, et al., “Communicating About Medications During Primary Care

Outpatient Visits: The Role of Electronic Medical Records,” Informatics in Primary Care, vol. 13, p. 14.

Caron Golden, “VA’s Model of Success,” Government Leader, November/December, 2006, p. 27.

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VistA saves lives and ensures continuity of care even under the most extreme circumstances.

Many of the thousands of residents who fled the Gulf Coast because of Hurricane Katrina

left behind vital health records. Records for the 40,000 veterans in the area were almost

immediately available to clinicians across the country, even though the VA Medical Center

in Gulfport, Mississippi, was destroyed and New Orleans VA Medical Center was closed and

evacuated. Veterans were able to resume their treatments, refill their prescriptions, and get

the care they needed because their medical records were immediately accessible to providers

at other VA facilities.22

See http://www.excelgov.org/UserFiles/VA%20VistA%20release%20finale.pdf.

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Figure 1. Veterans Integrated Services Networks (VISNs)

Information provided by the Department of Veterans Affairs. Map Resources. Adapted by CRS.

Note: VISN 21, the Sierra Pacific Network, includes northern and central California, northern Nevada, Hawaii,

the Philippines, and several Pacific islands including Guam and American Samoa.

Source:

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At the end of FY2006 the veterans population in the United States was approximately 24 million,

and of these 17.8 million were war veterans. According to the VA, the total veteran population is

expected to decline to 21.7 million by 2011, and 18.1 million by 2020. VA attributes this decline

to the number of veteran deaths exceeding the number of new separations from the military.23 The

largest population of veterans are living in California, followed by Florida and Texas (Figure 2).

In FY2005 there were approximately 7.7 million veterans enrolled in the VA health care system

(Figure 3). Most VISNs showed enrollments between 26%-30% of the total eligible veteran

population in those VISNs; two VISNs (VISN 5 and VISN 11) showed enrollments below 25%.

The total number of veterans enrolled in VA’s health care system is estimated to increase to

almost 8.0 million veterans in FY2008. It should be noted that in any given year not all veterans

seek care from VA, either because they are not ill or because they have other sources of care such

as private health insurance.

In FY2005, VHA provided care to approximately 4.9 million unique patients. The greatest

number of patients were in VISNs 4, 8 and 16. Each of these VISNs had more than 265,000

patients (Figure 4). The overall patient population reflects where the total veteran population is

the largest. During FY2007, VHA provided health care to about 5.2 million unique veteran

patients. These patients generated 64.4 million outpatients visits and almost 800,000 inpatient

episodes of care.24 According to VHA estimates, the number of unique veteran patients is

estimated to increase by approximately 109,000 between FY2007 and FY2008.25 And VA is

expected to treat about 5.3 million veteran patients in FY2008. Patients in Priority Groups 1-6

(described below)—those veterans with service-connected conditions, lower incomes, special

health care needs, and service in Iraq or Afghanistan—will comprise 75% of the total veteran

patient population in FY2008.

U.S. Department of Veterans Affairs, Office of the Secretary, Strategic Plan FY2006-2011, October 2006, p.11.

VHA schedules about 39 million appointments a year. According to VHA, 37 million of these are scheduled within

30 days of the request of the patient’s desired date.

U.S. Department of Veterans Affairs, FY2008 Congressional Budget Submissions, Medical Programs, vol. 1 of 4,

p.2-2.

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.Veteran Population by State as of September 30, 2006 (in thousands)

Figure 2

Source:

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Department of Veterans Affairs.

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. Percent of Veterans Enrolled in the VA Health Care System by VISN,

FY2005

Figure 3

Source:

Department of Veterans Affairs.

Figure 4. Number of Patients by VISN, FY2005

Source:

Department of Veterans Affairs.

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To understand some of the issues discussed later in this report, it is important to understand

eligibility for VA health care, VA’s enrollment process, and its enrollment priority groups. Unlike

Medicare or Medicaid, VA health care is not an entitlement program. Contrary to numerous

claims made concerning “promises” to military personnel and veterans with regard to “free health

care for life,” not every veteran is automatically entitled to medical care from VA.26 Prior to

eligibility reform in 1996, all veterans were technically eligible for some care, however, the actual

provision of care was based on available resources.27

The Veterans’ Health Care Eligibility Reform Act of 1996, P.L. 104-262, established two

eligibility categories and required VHA to manage the provision of hospital care and medical

services through an enrollment system based on a system of priorities.28 P.L. 104-262 authorized

VA to provide all needed hospital care and medical services to veterans with service-connected

disabilities, former prisoners of war, veterans exposed to toxic substances and environmental

hazards such as Agent Orange, veterans whose attributable income and net worth are not greater

than an established “means test,” and veterans of World War I. These veterans are generally

known as “higher priority” or “core” veterans.29 The other category of veterans are those with no

service-connected disabilities and with attributable incomes above an established “means test.”

P.L. 104-262 also authorized VA to establish a patient enrollment system to manage access to VA

health care. As stated in the report language accompanying P.L. 104-262,

[t]he Act would direct the Secretary, in providing for the care of ‘core’ veterans, to establish

and operate a system of annual patient enrollment and require that veterans be enrolled in a

manner giving relative degrees of preference in accordance with specified priorities. At the

same time, it would vest discretion in the Secretary to determine the manner in which such

enrollment system would operate.30

Furthermore, P.L. 104-262 was clear in its intent that the provision of health care to veterans was

dependent upon the available resources. The Committee report accompanying P.L. 104-262 states

that the provision of hospital care and medical services would be provided to “the extent and in

the amount provided in advance in appropriations Acts for these purposes. Such language is

intended to clarify that these services would continue to depend upon discretionary

appropriations.”31

For a detailed discussion of “promised benefits,” see CRS Report 98-1006, Military Health Care: The Issue of

“Promised” Benefits, by (name redacted).

Barbara Sydell, Restructuring the VA Health Care System: Safety Net, Training and Other Considerations, National

Health Policy Forum, Issue Brief no. 716, March 1998. Available at http://www.nhpf.org/pdfs_ib/IB716_VA_3-2598.pdf.

U.S. Congress, House Committee on Veterans Affairs, Veterans’ Health Care Eligibility Reform Act of 1996, report

to accompany H.R. 3118, 104th Cong. 2nd sess., H.Rept. 104-690, p. 2.

Ibid. p.5.

Ibid. p.6.

Ibid. p.5.

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As stated previously, P.L. 104-262 required the establishment of a national enrollment system to

manage the delivery of inpatient and outpatient medical care. The new eligibility standard was

created by Congress to “ensure that medical judgment rather than legal criteria will determine

when care will be provided and the level at which care will be furnished.”32

For most veterans, entry into the veterans’ health care system begins by completing the

application for enrollment. Some veterans are exempt from the enrollment requirement if they

meet special eligibility requirements.33 A veteran may apply for enrollment by completing the

Application for Health Benefits (VA Form 10-10EZ) at any time during the year and submitting

the form online or in person at any VA medical center or clinic, or mailing or faxing the

completed form to the medical center or clinic of the veteran’s choosing.34 See Table 1 for steps

in the enrollment process.

Table 1. Health Enrollment Process

Step

The veteran may apply for enrollment in person at a VA health care facility, by mail, or by completing an online application. VHA uses the military service, demographic and, as applicable, financial information collected

on the application form as the basis for determining whether the veteran qualifies for VA health care

benefits.

The local VA health care facility receives the application for enrollment and intake staff enter the data into

the Veterans Health Information Systems and Technology Architecture (VistA). VistA automatically queries

the Master Patient Index (MPI) to determine if a record has already been established, if not it uniquely

identifies the veteran record. At this time, the intake staff may also query VBA for compensation and pension

and/or known military status information. Typically, the veteran is provided a preliminary eligibility

determination at the conclusion of an in-person application for enrollment.

VistA transmits the veteran data to the Eligibility and Enrollment System (national system).

Step

The Eligibility and Enrollment System establishes the veteran’s record and queries the Social Security

Administration (SSA) to verify the veteran’s Social Security Number (SSN). Note: SSN verification does not

occur in real time and is not on the critical path.

The Enrollment System queries VBA to reconfirm the compensation and pension and/or military status.

Currently, this is done in a batch mode; however, when VHA deploys Enrollment System Redesign (ESR), the

Enrollment System will immediately trigger a query to VBA; as a result the cycle time, for the enrollment

process noted above will be reduced by another day.

The Enrollment System verifies the veteran’s enrollment eligibility and shares this data with VistA (at the

local level). Note: If the Enrollment System is unable to verify eligibility, then the system sends the local VA

Medical Center a bulletin to alert them to take further action (i.e., confirm whether the veteran has

qualifying military service). The Enrollment System establishes an enrollment record upon transmission of

verifying data by the local station.

Ibid. p.4.

Veterans do not need to apply for enrollment in VA’s health care system if they fall into one of the following

categories: veterans with a service-connected disability rated 50% or more (percentage ratings represent the average

impairment in earning capacity resulting from diseases and injuries encountered as a result of or incident to military

service; those with a rating of 50% or more are placed in Priority Group 1); less than one year has passed since the

veteran was discharged from military service for a disability that the military determined was incurred or aggravated in

the line of duty, but the VA has not yet rated; or the veteran is seeking care from VA for only a service-connected

disability (even if the rating is only 10%).

VA Form 10-10EZ is available at https://www.1010ez.med.va.gov/sec/vha/1010ez/#Process.

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Step

The Enrollment System produces the letter to the veteran with the official enrollment determination.

Step

The veteran receives the letter from VA telling him or her about their eligibility and enrollment

determination.

Source:

Affairs.

Appendix C. Task Force on Returning Global War on Terror Heroes report, Department of Veterans

Once a veteran is enrolled in the VA health care system the veteran remains in the system and

does not have to re-apply for enrollment annually. However, those veterans who have been

enrolled in Priority Group 5 based on income must submit a new VA Form 10-10EZ annually

with updated financial information demonstrating inability to defray the expenses of necessary

care.35

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Eligibility for VA health care is primarily based on “veteran’s status” resulting from military

service. Veteran’s status is established by active-duty status in the military, naval, or air service

and an honorable discharge or release from active military service. Generally, persons enlisting in

one of the armed forces after September 7, 1980, and officers commissioned after October 16,

1981, must have completed two years of active duty or the full period of their initial service

obligation to be eligible for VA health care benefits. Servicemembers discharged at any time

because of service-connected disabilities are not held to this requirement. Also, reservists that

were called to active duty and who completed the term for which they were called, and who were

granted an other than dishonorable discharge are exempt from the 24 continuous months of active

duty requirement. National Guard members who were called to active duty by federal executive

order are also exempt from this two year requirement if: 1) they completed the term for which

they were called, and 2) were granted an other than dishonorable discharge.

When not activated to full-time federal service, members of the reserve components and National

Guard have limited eligibility for VA health care services. Members of the reserve components

may be granted service-connection for any injury they incurred or aggravated in the line of duty

while attending inactive duty training assemblies, annual training, active duty for training, or

while going directly to or returning directly from such duty. Additionally, reserve component

servicemembers may be granted service-connection for a heart attack or stoke if such an event

occurs during these same periods. The granting of service-connection makes them eligible to

receive care from VA for those conditions. National Guard members are not granted serviceconnection for any injury, heart attack, or stroke that occurs while performing duty ordered by a

governor for state emergencies or activities.36

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After veteran’s status has been established, VA next places applicants into one of two categories.

The first group is composed of veterans with service-connected disabilities or with incomes

below an established means test. These veterans are regarded by VA as “high priority” veterans,

38 C.F.R. §17.36 (d)(3)(iv) (2005).

38.U.S.C. §101(24); 38 C.F.R. §3.6(c).

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and they are enrolled in Priority Groups 1-6 (see the Appendix). Veterans enrolled in Priority

Groups 1-6 include:

•

veterans in need of care for a service-connected disability;37

•

veterans who have a compensable service-connected condition;

•

veterans whose discharge or release from active military, naval or air service was

for a compensable disability that was incurred or aggravated in the line of duty;

•

veterans who are former prisoners of war (POWs);

•

veterans awarded the purple heart;

•

veterans who have been determined by VA to be catastrophically disabled (these

are veterans who have a permanent severely disabling injury, disorder, or disease

that compromises the ability to carry out the activities of daily living);

•

veterans of World War I;

•

veterans who were exposed to hazardous agents (such as Agent Orange in

Vietnam) while on active duty; and

•

veterans who have an annual income and net worth below a VA- established

means test threshold.

VA also looks at applicants’ income and net worth to determine their specific priority category

and whether they have to pay copayments for nonservice-connected care. In addition, veterans are

asked to provide VA with information on any health insurance coverage they have, including

coverage through employment or through a spouse. VA may bill these payers for treatment of

conditions that are not a result of injuries or illnesses incurred or aggravated during military

service.

The second group is composed of veterans who do not fall into one of the first six priority groups.

These veterans are primarily those with nonservice-connected medical conditions and with

incomes and net worth above the VA established means test threshold. These veterans are enrolled

in Priority Group 7 or 8 (see the Appendix).38

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VHA provides a standard benefits package to all enrolled veterans. Broadly, this includes

preventive care services (e.g., immunizations, physical examinations, health care assessments,

screening tests); inpatient and outpatient medical care, surgery, and mental health care, including

care for substance abuse; prescription drugs, including over-the-counter drugs and medical and

The term “service-connected” means, with respect to disability, that such disability was incurred or aggravated in

line of duty in the active military, naval, or air service. VA determines whether veterans have service-connected

disabilities, and for those with such disabilities, assigns ratings from 0 to 100% based on the severity of the disability.

Percentages are assigned in increments of 10%.

VA considers a veteran’s previous year’s total household income (both earned and unearned income as well as

his/her spouse’s and dependent children’s income). Earned income is usually wages received from working. Unearned

income can be interest earned, dividends received, money from retirement funds, Social Security payments, annuities,

or earnings from other assets. The number of persons in the veteran’s family will be factored into the calculation to

determine the applicable income threshold. 38 C.F.R. § 17.36(b)(7) (2005).

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surgical supplies; and durable medical equipment and prosthetic and orthotic devices, including

eyeglasses and hearing aids.

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The National Strategy for Combating Terrorism issued in September 2006, stated that the “War

on Terror will be a long war.”39 Along with all other facets of the U.S. government, it is likely that

the U.S. military will continue to play a leading role in this “long war.” Since the terrorist attacks

of September 11, 2001, U.S. Armed Forces have been deployed in two major theaters of

operation. Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom

(OIF) constitute the largest sustained ground combat mission undertaken by the United States

since the Vietnam War. Veterans from these conflicts and from previous wars are exerting

tremendous stress on the VA health care system. With increased patient workload and rising

health care costs, the 110th Congress is focused on ensuring a “seamless transition” process for

veterans moving from active duty into the VA health care system.

Compared with previous wars that the nation has fought, because of the advancement in battle

field medicine, a larger proportion of soldiers are surviving their injuries. In World War II, 30% of

the U.S. servicemembers injured in combat died. In Vietnam, the proportion dropped to 24%. In

OEF and OEF operations about 10% of those injured have died.40 In November 2007, DOD

reported that over 30,000 servicemembers have been wounded in action since the beginning of

OEF and OEF.41 With increasing numbers of soldiers returning from Iraq and Afghanistan—both

injured and non-injured—Congress and veterans’ advocates are very concerned that returning

servicemembers may not have a smooth transition from DOD health care to VA health care. The

final report of the President’s Commission on Care for America’s Returning Wounded Warriors

acknowledged that handoffs between inpatient and outpatient care and between the two separate

DOD and VA health care and disability systems are problematic.42 It should be noted that injured

servicemembers receiving care in VA health care facilities are not considered veterans until they

are formally discharged from active duty service.43

National Security Council, National Strategy for Combating Terrorism, September 2006, p.19, available at

http://www.whitehouse.gov/nsc/nsct/2006/nsct2006.pdf.

Atul Gawande, “Casualties of War - Military Care for the Wounded from Iraq and Afghanistan,” The New England

Journal of Medicine, vol.351, iss. 24, (December 2004), p. 2471.

Data current as of November 24, 2007 http://www.defenselink.mil/news/casualty.pdf.

The President’s Commission on Care for America’s Returning Wounded Warriors, July 2007, p.2, available at

http://www.pccww.gov.

Title 38 U.S.C. §§ 8111, Sharing of Department and Department of Defense Health Care Resources, provides the

authority for VA and the DOD to enter into agreements and contracts for the mutual use or exchange of use of services,

supplies or other resources. Title 38 U.S.C. §§ 8111A, Furnishing of Health-care Services to Members of the Armed

Forces During a War or National Emergency, authorizes VA to provide care during and immediately following a period

of war, or a period of national emergency as declared by the President or Congress that involves the use of the Armed

Forces in armed conflict. P.L. 97-174, Section 2(b), notes that DOD might not have adequate health care resources to

care for military personnel wounded in combat and other active duty personnel. The law further notes that VA has an

(continued...)

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Since the onset of OEF and OIF, more than 1.6 million servicemembers have served in these two

theaters of operation, making them potentially eligible for veterans benefits.44 Since FY2002,

751,273 OEF and OIF veterans have separated (discharged) from active duty.45 Of this amount,

362,237, or 48%, were active duty troops, while 389,036, or 52%, were separated National Guard

and Reserve component members. Approximately 35%, or 263,909, of all separated OEF and OIF

veterans since FY2002 have sought care from VA. About 96% of the veterans who sought care

have received outpatient care, while 4%, or a little more than 10,000, have been hospitalized at

least once in a VHA facility. Figure 5 provides a breakdown of the five major diagnoses among

returning OIF and OEF veterans. While diseases of the musculoskeletal system have the highest

frequency of diagnosis, mental disorders ranks second among major diagnoses. Mental disorders

may include, among other conditions, nondependent abuse of drugs, alcohol dependent

syndrome, and PTSD.

Figure 6 below provides data on the number of OEF and OIF discharges per fiscal year. The

number of new discharges was highest in FY2004, followed by FY2003, whereas FY2006 had

the lowest number of discharges. However, note that the numbers in the graph are from FY2002FY2006 and do not reflect the most recent data presented above, which includes FY2007 3rd

quarter data.

(...continued)

extensive, comprehensive health care system that could be used to assist DOD in caring for such personnel.

OEF, which commenced in October 2001, conducts combat operations in Afghanistan and other locations. OIF,

which began in March 2003,conducts combat operations in Iraq and other locations.

Since October 2003, DOD’s Defense Manpower Data Center (DMDC) has periodically (every 60 days) sent VA an

updated personnel roster of troops who participated in OEF and OIF, and who have separated from active duty and

become eligible for VA benefits. The roster was originally prepared based on pay records of individuals. However, in

more recent months it has been based on a combination of pay records and operational records provided by each

service branch. The current separation data are from FY2002 through May 31, 2007.

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Figure 5. Frequency of Major Diagnoses among OEF and OIF Veterans

CRS Analysis of VA Data.

Notes: These diagnoses are based on broad International Classification of Diseases 9th Revision (ICD-9)

categories. These data are cumulative data since FY2002, with data on hospitalizations and outpatient visits as of

June 30, 2007. A veteran is counted only once in any single diagnostic category but can be counted in multiple

categories. Therefore, above numbers add up to greater than 263,909.

Source:

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. Cumulative Number of OIF and OIF Veterans Discharged from FY2002FY2006

Figure 6

FY06 New Discharges

650,000

600,000

550,000

500,000

450,000

400,000

350,000

300,000

250,000

200,000

150,000

100,000

50,000

631,174

FY05 New Discharges

FY04 New Discharges

548,931

82,243

460,322

88,609

179,110

171,870

FY 2003

FY 2004

FY 2005

FY 2006

FY03 New Discharges

FY02 New Discharges

281,212

109,342

FY 2002

Source: Department of Veterans Affairs.

Although National Guard and Reserve component members make up 52% of OIF and OEF

servicemembers who have separated from active duty, they compose 34% of those who have

sought VA health care since FY2002. While active duty OIF and OEF servicemembers make up

48% of those who have separated from service, they make up 36% of those who have received

VA care.

VA expects to treat 263,345 OEF and OIF veterans in FY2008 (Table 2). This is an increase of

54,037, or 26%, over the number of veterans from these two theaters of operation that VA

anticipates will enter the VA health care system in FY2007, and 108,073, or 70%, more than the

number VA treated in FY2006. As seen in Table 2, there is a 223% increase in funding between

FY2005 and the projected amount for FY2008. Figure 7 shows the cumulative number of unique

OIF and OEF patients that the VA treated between FY2002 and FY2006, with projections for

FY2007 and FY2008. In FY2005 and FY2006, VA treated more OIF and OEF veterans than it

had budgeted for at the beginning of the fiscal year.

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FY 2005

FY 2006

FY 2007

263,345

548,931

FY 2004

209,308

FY 2003

205,097

155,272

FY 2002

103,544

-50,000

126,819

50,000

2,563

150,000

109,342

350,000

59,417

56,703

450,000

250,000

460,322

550,000

13,822

650,000

13,085

750,000

281,212

Cum ulative Unique

Discharges

Cum ulative Unique

Patients

Annual Unique

Patients (Budget)

631,174

Figure 7. Cumulative Unique OIF and OEF Veteran Patients and OIF and OEF

Discharges from FY2002 thru FY2006 Compared with Annual Number of Unique

Patients

FY 2008

Source: Department of Veterans Affairs.

In March, VA testified that the number of severely injured or ill active duty servicemembers and

veterans that have transitioned from DOD to VHA facilities is over 6,800;46 of these 342 have

been polytrauma patients.47 VHA defines polytrauma as “injury to the brain in addition to other

body parts or systems resulting in physical, cognitive, psychological, or psychosocial

impairments and functional disability.”48

As of April 1, there were 571 amputees reported by DOD. Since FY2002,VA’s Prosthetic and

Sensory Aids Service (PSAS) has provided services and products to over 22,000 OEF and OIF

unique veterans. PSAS has served a total of 187 major amputees (those with upper or lower limb

amputations) from OEF and OIF, including veterans and active duty servicemembers.49

Testimony of Acting Under Secretary for Health Department of Veterans Affairs Dr. Michael J. Kussman, in U.S.

Congress, House Committee on Veterans’ Affairs Subcommittee on Oversight and Investigations, hearing on

Servicemembers’ Seamless Transition into Civilian Life—The Heroes Return, 110th Cong., 1st sess., March 8, 2007.

Testimony of Acting Undersecretary for Health, Department of Veterans Affairs, Michael Kussman, in U.S.

Congress, House Committee on Appropriations, Subcommittee on Military Construction, Veterans Affairs and Related

Agencies, hearing on FY 2008 funding for the Veterans Health Administration, 110th Cong., 1st sess., March 6, 2007.

Department of Veterans Affairs, Veterans Health Administration Directive. Polytrauma Rehabilitation Centers.

Washington (DC): Veterans Health Administration; Jun 8, 2005, p. 2.

Data provided by the Department of Veterans Affairs.

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Table 2.VA Spending and Number of OIF and OEF Veteran Patients

FY2005

actual

FY2006

actual

FY2007

estimate

FY2008

estimate

Obligations

$232,500,000

$404,840,000

$572,562,000

$752,438,000

Number of

OEF/OIF

100,808

155,272

209,308

263,345

patients

Average

Annual Cost

per

$2,306

$2,607

$2,736

$2,857

OIF/OEF

Patient

Source: U.S. Department of Veterans Affairs, FY2008 Congressional Budget Submissions, Medical Programs, vol. 1

of 4, pp. 9-14.

a. Total VA spending on OEF and OIF veteran patients.

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In 2003, several injured servicemembers or their parents testified on the obstacles faced during

the transition from DOD’s health care system to VHA.50 However, since that time there have been

significant improvements in that area as described later in this report. Aside from this day-to-day

handoff, coordination and sharing of health information between VA and DOD has been

problematic.51 In 2003, the President’s Task Force to Improve Health Care Delivery for Our

Nation’s Veterans identified several issues with regard to sharing of information between DOD

and VA. It stated that “the VA/DOD processes for sharing information about eligible service

members do not facilitate quick and accurate enrollment into VA programs.”52

In March 2005, the Government Accountability Office (GAO) testified that VA still does not have

systematic access to DOD data about returning servicemembers who may need its services.53

Again in September 2005, GAO testified that while VA has developed policies and procedures to

provide OEF and OIF servicemembers and veterans with timely access to care, the sharing of

health information between DOD and VA is limited.54 In March 2007, GAO testified that despite

coordination efforts by DOD and VA, these two Departments were still having problems sharing

medical records.55 Among other things, the recently appointed Task Force on Returning Global

U.S. Congress, House Committee on Veterans’ Affairs, Subcommittee on Health, “Handoffs or Fumbles?” Are DOD

and VA Providing Seamless Health Care Coverage to Transitioning Veterans?, 108th Cong., 2nd sess., October 16,

2003.

For detailed information on issues related to disability evaluation of returning servicemembers see, CRS Report

RL33991, Disability Evaluation of Military Servicemembers, by (name redacted), (name redacted), and

(name redacted).

The President’s Task Force to Improve Health Care Delivery for Our Nation’s Veterans, Final Report, May 2003, p.

24.

U.S. Government Accountability Office, VA Disability Benefits and Health Care, Providing Certain Services to the

Seriously Injured Poses Challenges, GAO-05-444T, p. 5.

U.S. Government Accountability Office, VA and DOD Health Care: VA Has Policies and Outreach Efforts to

Smooth Transition from DOD Health Care, but Sharing of Health Information Remains Limited, GAO-05-1052T.

U.S. Government Accountability Office, DOD and VA Health Care: Challenges Encountered by Injured

Servicemembers during Their Recovery Process, GAO-07-606T, p 4.

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War on Terror Heroes identified that “currently, there are no formal interagency agreements

between DOD and VA to transfer case management responsibilities across the military services

and VA”56 In its July 2007 report, the President’s Commission on Care for America’s Returning

Wounded Warriors acknowledged that handoffs between the two separate DOD and VA health

care and disability systems have been problematic, and recommended the integration of medical

and rehabilitation programming across the two Departments.57

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In general, as shown in Figure 8, when a solider is injured on the battlefield he or she is

stabilized in theater by a combat medic/lifesaver and then moved to a battalion aid station. If the

servicemember has serious injuries he or she is transferred to a forward surgical team to be

stabilized and then moved to a combat support hospital and further stabilized for a period of about

two days. If the servicemember needs more specialized care he or she is evacuated from OEF and

OIF conflict theaters and brought to Landstuhl Regional Medical Center (LRMC) in Germany for

treatment. Most patients arrive at LRMC 24 to 72 hours after injury. In general, servicemembers

remain in Germany for a period of about 4 to five days.58 Length of stay at in-theater medical

facilities is determined by the stability of the patient and the availability of medical evacuation

aircraft. After further stabilization at LRMC they are evacuated to the United States and arrive at

an echelon V Military Treatment Facility (MTF) such as Walter Reed Army Medical Center

(WRAMC) in Washington, DC, or the National Naval Medical Center in Bethesda, Maryland. All

catastrophic burn patients are flown to the Brooke Army Medical Center (BAMC) at Fort Sam

Houston, Texas. BAMC has also established a specialized amputee rehabilitation center.59

Task Force on Returning Global War on Terror Heroes, Executive Summary, p.2.

Report of the President’s Commission on Care for America’s Returning Wounded Warriors, July 2007, p.2 and 13,

available at http://www.pccww.gov/.

Joachim J. Tenuta, “From the Battlefields to the States: The Road to Recovery. The Role of Landstuhl Regional

Medical Center in US Military Casualty Care,” Journal of the American Academy of Orthopedic Surgeons, vol 14,

(2006), S45-S47.

The Center for the Intrepid, a $50 million, 60,000 sq. ft., physical rehabilitation center, and two new Fisher Houses,

21-room residences for hospitalized soldiers’ families were declared open on January 29, 2007.

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Figure 8. Current Level of Care from Injury to Definitive Care

Source: DOD, Major Alfred A. Hamilton, PH.D, Government Health IT 2007 Conference, Adapted by CRS

Graphics.

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Once a seriously injured servicemember enters a major MTF, DOD can elect to send those with

traumatic brain injuries (TBI) and other complex polytrauma cases to one of the four VA

Polytrauma Rehabilitation Centers (PRCs) at the following locations: James A. Haley Veterans

Affairs Medical Center (VAMC), Tampa, Florida; Minneapolis VAMC, Minneapolis, Minnesota;

Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and Hunter Holmes

McGuire VAMC, Richmond, Virginia.60 VA recently announced the decision to locate a fifth

Polytrauma Center in San Antonio, Texas. As previously noted, injured servicemembers receiving

care in VA health care facilities are not considered veterans until they are formally discharged

from active duty service.

The PRCs have resources and clinical expertise to provide care for complex patterns of injuries,

including TBI, traumatic or partial limb amputation, nerve damage, burns, wounds, fractures,

vision and hearing loss, pain, mental health, and readjustment problems. In total there are

The Veterans Health Programs Improvement Act of 2004 (P.L. 108-422) required VA to establish centers for

research, education, and clinical activities related to complex trauma due to combat injuries, and the Department of

Veterans Affairs, and Housing and Urban Development, and Independent Agencies Appropriations Act, 2005 (P.L.

108-447) required VA to establish a new prosthetics and integrative health care initiative. The PRCs were designated as

a response to these mandates.

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currently 76 polytrauma clinic teams in the VA. These local teams of providers deliver follow up

services in consultation with regional and network specialists. They also assist in management of

stable patients through direct care, consultation and the use of tele-rehabilitation technologies,

when needed. These PRCs have social work case managers at a ratio of one for every six patients.

These case managers help assess the psychosocial needs of each patient and family, match

treatment and support services to meet identified needs, coordinate services, and oversee the

discharge planning process.61 Table 3 provides an brief summary of VHA’s polytrauma system of

care.

Statement of William F. Feeley, Deputy Undersecretary for Health for Operations and Management, Department of

Veterans Affairs, hearing on Servicemembers’ Seamless Transition into Civilian Life—The Heroes Return, in U.S.

Congress, House Committee on Veterans Affairs, Subcommittee on Oversight and Investigations, 110th Cong., 1st sess.,

March 8, 2007.

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Table 3.VHA’s Polytrauma System of Care

Level I. Comprehensive Polytrauma Rehabilitation Centers (PRCs)

•

provide acute comprehensive medical, surgical, and rehabilitation care for complex and severe

polytraumatic injuries

serve as a resource to other facilities in the system via the development of tele-rehabilitation for

consultation, best practices in polytrauma care, educational programs, and evaluation of new technology

provide all clinical services and serve concurrently as Level II sites within their respective Veterans

Integrated Service Networks (VISNs)

Level II. Polytrauma Network Sites (PNSs)

•

there are 21 PNSs, one in each of VHA’s 21 VISNs

these sites manage veterans with complex injuries requiring specialized expertise as they return to their

VISNs

these sites provide a high level of expert care, with a full range of clinical and ancillary resources

these sites provide specialized outpatient care to polytrauma patients not requiring inpatient services

these sites develop a referral network within their VISN, and identify VISN resources for TBI/polytrauma

services

Level III. Polytrauma Facility Teams (PFTs)

•

these facilities have more limited resources than Level I and Level II centers

Level III PFTs include a core polytrauma clinic team that could deliver a continuum of follow-up services in

consultation with Level I and II centers

these facilities are more likely to be closer to a veterans home and to provide day-to-day care, contact and

support

Level IV. Polytrauma Care Coordination Points of Contact (POCs)

these sites are smaller facilities with limited resources

•

these sites serve as coordinators of referrals and consultations of polytrauma patients to Level I, II, or III

facilities

•

Level IV coordinators are knowledgeable about the services available within the system of care and about

the avenues for access to care

Source: Department of Veterans Affairs, Office of Inspector General, Health Status of and Services for Operation

Enduring Freedom/Operation Iraqi Freedom Veterans after Traumatic Brain Injury Rehabilitation, (Report No. 05-01818-165),

July 12, 2006.

•

VA has stationed employees at Army and Navy hospitals to act as VHA/DOD liaisons.62 These

VA/DOD liaisons assist with the transfer of patients as they move from MTFs to VHA hospitals

and clinics. In general, once the MTF decides to transfer a patient to a PRC, it refers the patient to

a VA/DOD liaison. The VA/DOD liaison then contacts the liaison at the PRC. The PRC completes

a medical screening and initiates the transfer process. Medical records are obtained through direct

There are a total of ten VA/DOD liaisons located at Walter Reed Army Medical Center, Washington, DC (two

VA/DOD liaisons); National Naval Medical Center, Bethesda, Maryland; Brooke Army Medical Center, Fort Sam

Houston, Texas; Eisenhower Army Medical Center, Fort Gordon, Georgia; Fort Hood Army Medical Center, Fort

Hood, Texas; Madigan Army Medical Center, Tacoma, Washington (two VA/DOD liaisons); Evans Army Medical

Center Fort Carson, Colorado; Camp Pendleton, San Diego, California; Womack Army Medical Center, Ft. Bragg,

North Carolina.

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access to WRAMC and Bethesda National Naval Medical Center. However, not all medical

records are available electronically. In such cases Nursing Admissions Coordinators in PRCs

obtain specific paper records through the VA/DOD liaison personnel stationed at both WRAMC

and Bethesda. Video teleconferencing between the MTFs and PRCs provides an opportunity for

families to meet the VA interdisciplinary team and facilitate the transition-of-care process.

Upon admission to a PRC, members of the rehabilitation team individually evaluate the

servicemember within 24 hours.63 According to the VA, the rehabilitation team generally meets

three times weekly to discuss each patient and to continually adjust the therapeutic plan of care.

“Each patient undergoes three to six hours of therapy each day based on their individual

functional and cognitive needs.”64

By July 2007, VA plans to develop 4 Residential Transitional Rehabilitation Programs co-located

with the Level I PRCs. The stated goal of these programs is to improve the veterans’ physical,

cognitive, communicative, behavioral, psychological and social functioning under necessary

supervision, and to return these patients to active duty, work, school or independent living in the

community.

In July 2007, the Dole-Shalala Commission proposed the appointment of recovery coordinators to

manage individualized recovery plans that would be used to guide the servicemembers’ care. The

Dole-Shalala Commission further recommended that these recovery coordinators possibly come

from the U.S. Public Health Service, and be highly skilled and have considerable authority to be

able to access resources necessary to implement the recovery plans.65 As reported recently by

GAO, the Army and the Senior Oversight Committee’s66 workgroup on case management “have

initiated efforts to develop case management approaches that are intended to improve the

management of servicemembers’ recovery process.”67 As of October 2007, VA, DOD, and the

Department of Health and Human Services (HHS) have signed a memorandum of understanding

to define the role of the Public Health Service in the Recovery Coordinator program. In addition,

two members of the Public Health Service Commissioned Corps have been detailed from HHS to

VA and are presently working with VA and DOD to establish the Recovery Coordinator (RC)

program.68

The rehabilitation team consists of a Rehabilitation Physician, Rehabilitation Nurses, Physical Therapists,

Occupational Therapists, Speech and Language Pathologists, Recreation Therapists, Kinesiotherapists,

Neuropsychologists, Psychologists, Dieticians, Social Worker/Case Manager, Military Liaisons, and Blind

Rehabilitation Therapists.

Testimony of Shane McNamee, Medical Director, Richmond Polytrauma Rehabiliation Center, Department Of

Veterans Affairs, hearing on Servicemembers’ Seamless Transition into Civilian Life—The Heroes Return, in U.S.

Congress, House Committee on Veterans Affairs, Subcommittee on Oversight and Investigations, 110th Cong., 1st sess.,

March 8, 2007.

The President’s Commission on Care for America’s Returning Wounded Warriors, July 2007, pp5-6.

Senior Oversight Committee is an interagency committee specifically established to address concerns about the care

and services provided to returning servicemembers. The committee is co-chaired by the Deputy Secretary of VA and

the Deputy Secretary of Defense.

U.S., Government Accountability Office (GAO), DOD AND VA: Preliminary Observations on Efforts to Improve

Health Care and Disability Evaluations for Returning Servicemembers, GAO-07-1256T,p.8.

Testimony of Patrick W. Dunne, Assistant Secretary for Policy and Planning, Department of Veterans Affairs,

hearing on VA and DOD Collaboration: Report of the President’s Commission on Care For America’s Returning

Wounded Warriors; Report of the Veterans Disability Benefit Commission; and other related reports in U.S. Congress,

Senate Committee on Veterans’ Affairs, October 17, 2007.

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The RC would be designated by DOD and VA as the individual with delegated authority for

oversight/coordination of the clinical and non-clinical care identified in the Individualized

Recovery Plan (IRP) for every eligible severely injured/ill servicemember/veteran from initial

admission to the MTF. The RC would (1) ensure the development, implementation, and oversight

of the IRP and (2) ensure that the servicemembers/veterans and their families have access to all

clinical and non-clinical case management services, including medical care, rehabilitation,

education- and employment-related programs, and disability benefits.

According to the VA, the RC positions would be located at the following locations: Walter Reed

Army Medical Center in Washington, DC; Bethesda Naval Medical Center in Bethesda, MD;

Brooke Army Medical Center in San Antonio, TX; and Balboa Naval Medical Center in San

Diego, CA.

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VA has stated that it has taken numerous steps to ease the transition of seriously injured

servicemembers between DOD and VA medical facilities. VA has conducted several thousand

briefings to servicemembers and their families about VA benefits and services, and about where to

obtain VA health care services. VA also sends “thank-you” letters together with information

brochures to each OEF and OIF veteran identified by DOD as having separated from active duty.

These letters provide information on health care and other VA benefits, toll-free numbers for

obtaining information, and appropriate VA websites for accessing additional information. Letters

and educational “tool kits”explaining VA services and benefits are also sent to each of the

National Guard Adjutants General and the Reserve Chiefs. VA has stated that it has developed an

outreach, education, and awareness program for the National Guard and Reserve. To ensure

coordinated transition services and benefits, a Memorandum of Agreement (MOA) was signed

with the National Guard in May 2005. VA is also in the process of developing MOAs with both

the United States Army Reserve and the United States Marine Corps. According to VA these new

partnerships will increase awareness of, and access to, VA services and benefits during the

demobilization process and as service personnel return to their local communities.69

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The VA- DOD Joint Executive Committee (JEC) was established by the National Defense

Authorization Act for 2004 (P.L. 108-136). The JEC is required to report annually to Congress

with recommendations for improving coordination and sharing between the two departments. As

part of preparing the recommendations, P.L. 108-136 requires the JEC to: (1) review all polices,

procedures, and practices related to the coordination and sharing of resources between the

departments; (2) identify changes to the policies, procedures, and practices that would benefit the

coordination and sharing of resources between the agencies with the goal of improving the

delivery of benefits and services; (3) identify further opportunities for coordination and

collaboration between the departments that would not affect the quality of care, range of services,

or priorities for benefits; (4) review each department’s plans for acquiring additional resources

such as facilities, equipment, and technology to determine the effect on future opportunities for

Testimony of Gordon H. Mansfield, Deputy Secretary, Department of Veterans Affairs hearing on VA/DOD

Cooperation and Collaboration in U.S. Congress, Senate Committee on Veterans’ Affairs, 110th Cong., 1st sess.,

January 23, 2007.

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coordination and sharing of resources; and (5) review the implementation of activities designed to

promote coordination and resource sharing between the departments. By statute, the JEC has at

least two subordinate committees (for health and benefits), but may have other subordinate

committees, or working groups, as deemed necessary by the Deputy Secretary of Veterans Affairs

and the Under Secretary of Defense.70 In April 2004, VA signed a Memorandum of Understanding

(MOU) with DOD to provide health care and rehabilitation services to servicemembers who

sustain spinal cord injury, TBI, or visual impairment. The MOU established referral procedures

for transferring active duty inpatient servicemembers from DOD medical facilities to VA medical

facilities.

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On January 3, 2005, VA established the National Veterans Affairs Office of Seamless Transition

to ensure that there is no interruption of care as a servicemember moves from being a DOD

patient to a VA patient, that whatever kinds of treatment are being delivered in the MTF are

continued, and that treatment plans are shared. The office is composed of representatives from

VHA, VBA, as well as an active duty Marine Corps officer from Marine4Life, a representative

from the Army Wounded Warrior (AW2) program, and representatives from the National Guard

and Reserve Components. The office also facilitates priority access to care by enrolling patients

in the VA system before they leave an MTF. Major activities of this office undertaken in 2006, are

summarized below:

•

Placed additional VA/DOD Liaisons at the Naval Medical Center in San Diego,

California, and Womack Army Medical Center at Ft. Bragg, North Carolina.

•

Placed a VA certified Rehabilitation Registered Nurse at the WRAMC to assess

and provide regular updates to the Polytrauma Rehabilitation Centers on the

medical condition of the patients, educate families and prepare the active duty

servicemember for transition to the rehabilitation phase of recovery.

•

Established an OIF/OEF Polytrauma Call Center to assist seriously injured

veterans. The Call Center is operational 24 hours a day, 7 days a week to answer

and/or refer clinical, administrative, and benefit inquiries from OIF/OEF

polytrauma patients and their families.

•

Trained 54 National Guard Transition Assistance Advisors (TAAs). TAAs would

serve as the statewide point of contact and coordinator, to provide advice to

Guard members, their families and all other reserves as to VA benefits and

services, and to assist in resolving problems with VA healthcare, benefits, and

TRICARE.71

•

Implemented a seamless transition performance measure for FY2007. Under this

performance measure severely injured OEF and OIF servicemembers who are

transferred by VA/DOD Liaisons at the military treatment facilities must be

assigned a VA medical center case manager prior to the transfer. This VA case

For more information on the JEC, see VA/DOD Joint Executive Council, Fiscal Year 2006 Annual Report, at

http://www.tricare.mil/DVPCO/downloads/VADoD2006.pdf .

TRICARE is the health plan of the military health system. For detailed information about this program see, CRS

Report RL33537, Military Medical Care: Questions and Answers, by (name redacted)

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manager must contact the service member/veteran within 7 calendar days of

notification of the transfer.

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The Department has emphasized that it has enhanced its outreach efforts through the Vet Center

program. This program was originally established by Congress in 1979 to meet the readjustment

needs of veterans returning from the Vietnam War.72 From their inception, Vet Centers were

designed to be community-based, non-medical facilities that offered easy access to care for

Vietnam veterans who were experiencing difficulty in resuming a normal civilian life.

Today, VHA’s Vet Center program consists of 209 community-based centers located across the

country, and in Puerto Rico, the Virgin Islands, and Guam. On February 7, 2007, the Department

announced that it will be establishing 23 new centers in communities across the nation during

2007 and 2008.73 The Vet Center program is primarily funded through the Medical Services

appropriation (personnel costs), with additional funds provided from the Medical Facilities

(leasing costs), Information Technology, and Medical Administration accounts. Vet Center

funding is designated as specific purpose funding within the overall medical care appropriation.

Funds are allocated at the direction of the Readjustment Counseling program office.

Each Vet Center is managed by a Team Leader who reports to one of the seven Readjustment

Counseling Service (RCS) Regional Managers. The Chief Readjustment Counseling Officer at

the VA Central Office is responsible for direct line supervision, through the seven RCS Regional

Managers, of all Vet Center clinical and administrative operations. The Chief Readjustment

Counseling Officer reports directly to the Under Secretary for Health.

Site selection for the new Vet Centers is based on demographic data from the U.S. Census Bureau

and the DOD Defense Manpower Data Center. Initial input is provided by the seven RCS

Regional Offices. Finally, recommendations and supporting data are evaluated by the Chief

Readjustment Counseling Officer and the Office of the Under Secretary for Health. The final

decision is made by the Under Secretary for Health. Vet Centers utilize permanently leased space

and are usually staffed by one or two counselors who provide full-time services to area veterans

on a regular basis. Vet Centers also remain open after normal business hours or on weekends to

accommodate veterans traveling in from greater distances.

Vet Centers have hired and trained 100 new outreach workers from among the ranks of recently

separated OIF and OEF veterans. In May 2007, VHA announced that it plans to recruit an

additional 100 staff positions to the Vet Center program in FY2008 and another 100 staff

positions for FY2009. Vet Center outreach is primarily for the purpose of providing information

that will facilitate a seamless transition and the early provision of VA services to newly returning

veterans and their family members upon separation from the military. These positions are being

located on or near active military out-processing stations, as well as National Guard and Reserve

Established by the Veterans’ Health Care Amendments of 1979 (P.L. 96-22).

New Vet Centers will be located in Montgomery, Alabama; Fayetteville, Arkansas; Modesto, California; Grand

Junction, Colorado; Orlando, Fort Myers, and Gainesville, Florida; Macon, Georgia; Manhattan, Kansas; Baton Rouge,

Louisiana; Cape Cod, Massachusetts; Saginaw and Iron Mountain, Michigan; Berlin, New Hampshire; Las Cruces,

New Mexico; Binghamton, Middletown, Nassau County and Watertown, New York; Toledo, Ohio; Du Bois,

Pennsylvania; Killeen, Texas; and Everett, Washington. During 2007, VA plans to open facilities in Grand Junction,

Orlando, Cape Cod, Iron Mountain, Berlin and Watertown. The other new Vet centers are scheduled to open in 2008.

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facilities. New veteran hires are providing briefing services to transitioning servicemen and

women regarding military-related readjustment needs, as well as the complete spectrum of VA

services and benefits available to them and their family members. VA also has stated that it

expects to add staff to 61 existing facilities to augment the services these centers provide.74

All combat veterans are eligible for Vet Center readjustment counseling services.75 From FY2003

through the end of the third quarter of FY2007, the Vet Center program has provided services to

183,530 veterans and clinical services to 58,504 veterans.76 The Vet Center program also provides

bereavement counseling services to family members of those servicemembers killed while on

active. From FY2003 through the end of the third quarter of FY2007, such services have been

provided to more than 1,570 family members. In addition, the Vet Centers provide counseling to

veterans who have experienced sexual trauma while on active duty.

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As discussed previously, a key component of the seamless transition of patients from DOD to the

VA is the exchange of medical information between the two Departments. Since the late 1990s,

VA and DOD have been working toward an interoperable medical record.77 Before OEF and OIF,

VA and DOD had been focusing on unidirectional exchange of information from DOD to VA,

which would have helped VA understand the care provided to veterans while they were in the

military. In June 2005, a memorandum of understanding (MOU) was signed between DOD and

VA for the purposes of defining data sharing between the two departments. This MOU provides

the necessary governance for the sharing of protected health information and other individually

identifiable information. Later, the two Departments decided to implement a bi-directional

exchange of medical information (Bidirectional Health Information Exchange—BHIE) to include

information on patients’ allergies, lab and radiology results, and pharmacy data. Both

Departments have deployed the BHIE interface. This new interface allows VA providers to access

information from all DOD health care facilities, and allows providers at all military treatment

facilities to access BHIE directly from DOD’s electronic medical record system. To facilitate the

transfer of servicemembers from DOD treatment facilities to VA Polytrauma Rehabilitation

Centers, scans of patients’ radiology and medical records are now being transferred to the VA’s

integrated imaging system.

At present, the Clinical Health Data Repository interface is being tested in several DOD and VA

locations. This interface would support the exchange of data elements in real time rather than

transmitting batches of data at regular intervals. Figure 9 shows the current and planned health

information exchanges between the two Departments.

Testimony of Acting Under Secretary for Health Department of Veterans Affairs Dr. Michael J. Kussman, in U.S.

Congress, House Committee on Veterans’ Affairs Subcommittee on Oversight and Investigations, hearing on

Servicemembers’ Seamless Transition into Civilian Life—The Heroes Return, 110th Cong., 1st sess., March 8, 2007.

For a list of who is eligible for Vet Center services, see http://www.va.gov/RCS/Eligibility.asp.

Testimony of Under Secretary for Health, Department of Veterans Affairs, Dr. Michael J. Kussman, in U.S.

Congress, House Committee on Veterans’ Affairs, hearing on the Long-Term Costs of the Current Conflicts, 110th

Cong., 1st sess., October 17, 2007.

In 1996, the President’s Advisory Committee on Gulf War Veterans’ Illnesses reported on many deficiencies in VA’s

and DOD’s data capabilities for handling servicemembers’ medical records. In November 1997, the President called for

the two departments to start developing a comprehensive, lifelong medical record for each service member. In 1998 the

President issued a executive order requiring VA and DOD to develop a “computer-based patient record system that will

accurately and efficiently exchange information.”

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Figure 9. DOD and VA Electronic Information Sharing Focus Areas

Source: DOD presentation to CRS, July 10, 2007, adapted by CRS Graphics.

The full timeline and critical milestones supporting the exchange of medical information between

the VA and the DOD are depicted in Figure 10.

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Figure 10. Milestones and Plans for Exchange of Medical Information

Source: DOD presentation to CRS, July 10, 2007, adapted by CRS Graphics

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The VTA was activated on Monday, April 23, 2007.78 VTA would provide access to medical

records in real time on wounded soldiers evacuated from Afghanistan and Iraq. Prior to this only

VA’s four polytrauma centers were able to access this information. The VA liaisons at the DOD

MTFs and the point of contacts at the VA medical centers would now be able to use VTA to track

the referral of patients from the DOD MTFs such as Walter Reed Army Medical Center to VA

medical centers. According to VA, clinicians would continue to access clinical data on OEF and

OIF servicemembers being treated in their facilities through DOD’s Joint Patient Tracking

Application (JPTA)79 or through VTA.

The VA has stated that by the end of 2007, it expects that data in VTA will be available to

providers through VistA. This VistA interface would assure that VA providers get VTA data in a

format with which they are familiar and would reduce the training burden on the providers in the

field.

Bob Brewin, “VA to debut new patient tracking system,” Government Executive, April 20, 2007. Available at

http://www.govexec.com/dailyfed/0407/042007br1.htm.

The Joint Patient Tracking Application (JPTA) was created primarily as an electronic record for tracking where a

patient was in the military healthcare system when moving from the battlefield to a field hospital to Landstuhl,

Germany, and then on to Military Treatment facilities in the US. Although there has been some medical information

inserted into the JPTA, including X-rays and scans done in theater, JPTA is not a complete medical record.

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Veterans who have served or are now serving in Iraq and Afghanistan may, following separation

from active duty, enroll in the VA health care system and, for a two-year period following the date

of their separation, receive VA health care without copayment requirements for conditions that are

or may be related to their combat service. Following this initial two-year period, they may

continue their enrollment in the VA health care system but may become subject to any applicable

copayment requirements.80 For information on legislation to expand eligibility, see section on

“Veterans Health Care Legislation” below.

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On February 18, 2007, the Washington Post reported the first in a series of articles describing

problems with outpatient medical care and other services provided at the Walter Reed Army

Medical Center (a DOD facility in Washington, DC) to injured servicemembers returning from

combat theaters in support of OEF and OIF.81 In response to these the President appointed several

task forces and study panels to report on ways to improve services to returning servicemembers

and reduce bureaucratic delays. On April 19, 2007, the interagency task force chaired by VA

Secretary Nicholson issued a report providing 25 recommendations to improve delivery of federal

services to returning military men and women. A summary of the health care recommendations is

given below:82

•

Develop a system of co-management and case management for returning

servicemembers to facilitate ease of transfer from DOD care to VA care.

•

Screen all OEF and OIF veterans seen in VA health care facilities for mild to

moderate TBI.

•

Assist the VA enrollment process by modifying the VA 10-10EZ form for

returning servicemembers, enhance the on-line benefits package to self-identify

OEF and OIF servicemembers, and expand the use of DOD military service

information to establish eligibility for health care benefits.

•

Require VA to provide full support at Post-Deployment Health Reassessments for

Guard and Reserve members to enroll eligible members and schedule

appointments.

•

Standardize VA Liaison agreements across all military treatment facilities.

The Veterans Programs Enhancement Act of 1998 (P.L. 105-368) [38 U.S.C. § 1710(e)(1)(D) and § 1710(e)(3)(C)]

authorized VA to provide health care for an initial two-year period after discharge from service for veterans (including

National Guard and Reserve components) in combat during any period of war after the first Gulf War or during any

other future period of hostilities after November 11, 1998, even if there is insufficient medical evidence to conclude

that such illnesses are attributable to such service. For combat veterans who do not enroll with VA during the two-year

post-discharge period, eligibility for enrollment and subsequent health care is subject to such factors as a serviceconnected disability rating, VA pension status, catastrophic disability determination, or financial circumstances (as

described in this report). If their financial circumstances place them in Priority Group 8, they will be “grandfathered”

into a Priority Group 8a or Priority Group 8c, and their enrollment in VA will be continued, regardless of the date of

their original VA application.

Dana Priest and Anne Hull, “Soldiers Face Neglect, Frustration At Army’s Top Medical Facility,” Washington Post,

February 18, 2007.

The Task Force on Returning Global War on Terror Heroes, Report to the President, p. 3.

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Expand VA access to DOD records to coordinate improved transfer of a

servicemember’s medical care through patient “hand-off.”

•

Enhance the Computerized Patient Record System (CPRS) to more specifically

track OEF and OIF servicemembers.

•

Develop a Veterans Tracking Application (VTA) and identifiers to improve

monitoring of returning servicemembers (the VTA was activated in April 2007).

•

Create an “Embedded Fragment” surveillance center to monitor returning

servicemembers who have possibly retained fragments of materials (shrapnel

etc.) in order to provide early medical intervention.

•

Enhance capacity for OEF and OIF servicemembers to receive dental care in the

private sector as VA continues to improve their capacity for dental services at

their facilities.

•

Expand collaboration between VA and the Department of Health and Human

Services to improve access to returning servicemembers in remote or rural areas.

•

Expand coordination on IT interoperability with the goal to adopt standardized

data sharing between the VA and Indian Health Service (IHS) health care

partners.

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PTSD is the most prevalent mental disorder among returning OEF and OIF servicemembers and

has drawn the most attention. Congress has held hearings about mental health care services

provided by VA to these returning servicemembers. Demand for mental health services, including

treatment for PTSD, is likely to grow not only from new soldiers returning from active combat,

but also among veterans experiencing increased levels of anxiety and mental stress during

wartime.83

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As of June, 30 2007, VHA facilities have examined a total of 56,246 OEF and OIF veterans for

potential PTSD. This includes inpatient, outpatient, and Vet Center visits. Of these veterans,

48,559 have received a possible diagnosis of PTSD.

The hallmark characteristics of PTSD include flashbacks, nightmares, intrusive recollections or

re-experiencing of the traumatic event, avoidance, numbing, and hyperarousal. When such

symptoms last under a month, they are typically associated with acute stress disorder, not PTSD.

In order for a diagnosis of PTSD, symptoms have to persist for at least a month and cause

significant impairment in important areas of daily life.

Alan West and William Weeks, “Veterans Before, During, and After the Invasion of Iraq,” Psychiatric Services, vol.

57. no. 2 (Febrary 2006).

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PTSD is known to have high rates of comorbidity with other anxiety disorders, major depressive

disorder and substance abuse. Some studies indicate that more than 80% of people with PTSD

also experience a major depressive or other psychiatric disorder.84 Studies investigating rates of

comorbidity for PTSD and lifetime prevalence of alcohol abuse have indicated rates from 68% of

individuals with PTSD to as high as 82%.85

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Within the VA, programming for mental health is driven by the Mental Health Strategic Plan

(MHSP). The goal of MHSP is to anticipate need and fill in the gaps of current mental health

programs based on the CARES model (Capital Asset Realignment for Enhanced Services,

discussed later in the report) and recommendations from the President’s New Freedom

Commission on Mental Health.

The VA delivers mental health services in a variety of clinical settings and specialized programs.

Specifically, VA provides PTSD services in medical facilities, community settings, and Vet

Centers. The VA medical centers include a network of more than 100 specialized programs for

veterans suffering from PTSD. Outpatient PTSD programs offer three types of clinics where

veterans meet with mental health professionals and PTSD specialists. PTSD Day Hospital

Programs provide a “therapeutic community” offering social, recreational and vocational

activities in addition to counseling throughout the week. Inpatient programs provide PTSD

treatment in hospital units with 24-hour psychiatric and nursing care.

Beginning in 2005, VHA created Returning Veterans Education and Clinical Teams in medical

centers to help, educate, evaluate, and treat returning veterans with mental health and

psychosocial issues. These programs collaborate with other VAMC PTSD, substance abuse and

mental health programs, and with polytrauma, TBI and primary care services, as well as with Vet

Centers. By the close of FY2007 VA anticipates that it would have 90 of these programs

operational throughout the country.

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Among the more than 22,600 U.S. soldiers wounded in the conflicts in Iraq, Afghanistan, and

other locations as of November 4, 2006, blasts from Improvised Explosive Devices (IEDs) have

been by far the most common cause of injury, and 59% of blast-exposed patients at Walter Reed

have been found to have a TBI.86 On April 14, 2007, the VA began screening veterans who had

seen service in Iraq or Afghanistan since the beginning of October 2001 for symptoms that may

be associated with TBI.87 Of the 61,285 veterans that VA has screened for TBI to date, 11,804

National Academies, Institute of Medicine, Posttraumatic Stress Disorder: Diagnosis and Assessment, 2006.

National Academies, Institute of Medicine, Posttraumatic Stress Disorder: Diagnosis and Assessment, 2006, p.13.

Susan Okie, “Traumatic Brain Injury in the War Zone,” New England Journal of Medicine, Vol. 352, pp. 2043-2047

May 19, 2005; and “Reconstructing Lives—A Tale of Two Soldiers,” New England Journal of Medicine, volume 355

pp. 2609-2615 December 21, 2006.

The instrument used to screen veterans is a highly sensitive, not specific, questionnaire. The questionnaire is

designed to identify everyone who may possibly have suffered a TBI. It should be noted that some of those who are

(continued...)

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(19.26%) screened positive for TBI symptoms. At present, VA clinicians are further evaluating

these 11,804 to determine whether they have actually suffered a TBI or whether the symptoms

they exhibit are due to other causes, such as PTSD or other combat-related stress. A

representative sample of 127 recently completed evaluations indicated that 41 veterans received a

definitive diagnosis of TBI, suggesting that about one-third (32.28%) of the veterans who screen

positive have actually suffered a traumatic brain injury.

TBI is the result of a severe or moderate force to the head, where physical portions of the brain

are damaged and functioning is impaired. Common problems after TBI include headache,

decreased memory, slow mental processing, poor attention, inability to tolerate sound, sleep

disturbance, and irritability. Closely related to cognitive impairment are emotional issues such as

PTSD, depression, and anxiety disorders. These psychological issues often interact with the

physical injury to decrease patients’ overall health status and adherence to medical regimens.

Those who experience TBI may behave impulsively because of damage that removes many of the

brain’s checks on the regulation of behavior. Without the limits provided by these higher brain

functions, these individuals may overreact to seemingly innocent or neutral stimuli.88

The outcome of TBI is particularly relevant for understanding PTSD because the amnesia that

often occurs with TBI challenges the role of traumatic recollections in the etiology of PTSD.

Studies have shown that in the absence of factual recall, individuals have delusions or reconstruct

memories of trauma. These individuals may retain the delusional memories better than the factual

events. Hence, traumatic recall does not have to be accurate or factual to be part of PTSD.89

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The four VA polytrauma centers in Minneapolis, Palo Alto, Richmond, and Tampa provide care to

those with TBI. These facilities were designated as polytrauma centers because of their

experience in medical and rehabilitative care for patients with TBI and other traumatic conditions,

as well as their collaborative status with the national Defense and Veterans Brain Injury Centers

(these are facilities that coordinate treatment and research for traumatic brain injuries affecting

active-duty military, and veterans).90

(...continued)

identified by this questionnaire as possibly having a TBI will not, in fact, receive that diagnosis upon a subsequent indepth evaluation.

Drawn from Henry L. Lew, Guest Editorial, “Rehabilitation needs of an increasing population of patients: Traumatic

brain injury, polytrauma, and blast-related injuries,” Journal of Rehabilitation Research & Development, volume 42,

no. 4 July/August 2005.

Peleg T, Shalev AY, “Longitudinal Studies of PTSD: Overview of Findings and Methods,” CNS Spectrum, vol 11,

no. 8, pp. 589-602, 2006.

Defense and Veterans Brain Injury Centers are located at Walter Reed Army Medical Center, Washington, DC;

Wilford Hall US Air Force Medical Center, Lackland Air Force Base, TX; Brooke Army Medical Center, Fort Sam

Houston, TX; Naval Medical Center-San Diego, San Diego, CA; Hunter McGuire VA Medical Center, Richmond, VA;

James A Haley VA Hospital, Tampa, FL; Veterans Affairs Medical Center, Minneapolis, MN; VA Palo Alto Health

Care System, Palo Alto, CA; and Lakeview Virginia NeuroCare, Charlottesville, VA (Civilian Partner Site). Further

information available at http://www.dvbic.org/index.html.

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Veterans’ advocates say that the unpredictable timing, if not uncertain funding amounts inherent

in the yearly discretionary appropriations process, is a major management problem for the VA.

Furthermore, veterans’ groups have stated that Congress’s failure to enact appropriations bills by

the beginning of the fiscal year adds further strain on the VA health care system, by postponing

the hiring of new medical staff, foregoing medical facility maintenance and repairs, and thereby

compromising on the quality of health care provided to veterans. Therefore, national veterans’

organizations have been calling for “assured funding” for veterans’ health care. This has also been

called “mandatory funding” by other veterans’ advocates. This discussion will use mandatory

funding to refer to these policy proposals.

To understand mandatory funding proposals, it is essential to understand how VA programs are

funded presently. Under current law, VA programs are funded through both mandatory and

discretionary spending authorities. The following programs are among mandatory spending

programs: cash benefit programs, that is, compensation and pensions (and benefits for eligible

survivors); readjustment benefits (education and training, special assistance for disabled

veterans); home loan guarantees; and veterans’ insurance and indemnities. Each of these

programs is an appropriated entitlement that is funded through annual appropriations.91 With any

entitlement program, because of the underlying law, the government is required to provide

eligible recipients with the benefits to which they are entitled, whatever the cost. Congress is

obliged to appropriate the money necessary to fund the obligation. If the amount Congress

provides in the annual appropriations act is not enough, it is obliged to make up the difference in

a supplemental appropriation. Like other entitlement programs, spending automatically increases

or decreases over time as the number of recipients eligible for benefits varies. Certain of these VA

entitlement benefits are indexed for inflation; the benefit amount will increase automatically

based on the measured increase in the cost-of-living adjustment.

The remaining VA programs, primarily health care, medical facility construction, medical

research, and VA administration, are funded through annual discretionary appropriations. Each

year, Congress takes up the matter of providing budget authority for discretionary programs. As

such, the amount of funds VHA can spend on discretionary programs is determined by the

amount of its appropriation.

Generally, the mandatory funding proposals that have been suggested by veterans’ advocates are

based on a formula that takes into account the number of enrolled and nonenrolled veterans

eligible for VA medical care, and the rate of medical care inflation. Proponents believe that

mandatory funding will eliminate the year-to-year uncertainty about funding levels and close the

gap between funding and demand for veterans’ health care. Opponents believe that with these

proposals spending for VHA will increase significantly as enrollment in the VA health care

system soars; in most of the proposed funding formulas, automatic funding increases are

primarily based on enrollment figures. Furthermore, critics believe that a static funding formula

cannot adequately take into consideration the changing needs of veterans, which could affect the

funding level necessary to provide a different mix of services, and that Congress is better able to

evaluate the funding needs through the current annual appropriation process. For instance, not all

enrolled veterans use the VA health care system in a given year. Should the number of users grow

For a detailed explanation on appropriated entitlements, see CRS Report RS20129, Entitlements and Appropriated

Entitlements in the Federal Budget Process, by (name redacted)

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in one year and the number of enrollees remain stagnant, no additional funding would be

available for the additional patients with increased utilization of health care services.

During a hearing in the 109th Congress, Chairman Buyer of the House Veterans’ Affairs

Committee stated that “[a]ccording to the Congressional Budget Office [CBO], mandatory

funding would cost nearly half-a-trillion dollars over ten years. That would be a costly

experiment. In contrast, the strong discretionary budgets of the past decade have proven

responsive to change”92 However, CBO stated that “although the bill would primarily affect

funding for health care services provided by VHA, it also would result in some savings in direct

spending for other government programs, primarily Medicare and Medicaid.”93

As highlighted by some budget analysts, changing veterans’ medical care into a mandatory

budget authority may not solve the issue of closing the gap between funding and demand for

veterans’ health care. Congress can place caps on spending for mandatory programs through

budget reconciliation language, which would limit spending on veterans’ health programs.94 Since

Congress can act to change the formula or cap the spending amounts, the issue of uncertainty in

funding amounts may not be resolved either. In recent testimony before the House Veterans

Affairs Committee, Henry J. Aaron of the Brookings Institution stated that “converting the VHA

to mandatory funding would not entirely insulate it from budgetary pressures. Congress could cut

the per person funding amount or exclude certain groups of veterans from the formula used for

computing annual funding.”95

The Veterans Health Care Full Funding Act (H.R. 1041), Mandatory Funding for Veterans Act of

2007 (H.R. 1382), Assured Funding for Veterans Health Care Act (H.R. 2514) have been

introduced in the 110th Congress. H.R. 1041 would require appropriations for VA health care to be

funded based on recommendations proposed by an independent Veterans Health Care Funding

Review Board. H.R. 1382 and H.R. 2514 would require the Secretary of the Treasury to make

mandatory appropriations for VA health care based on a formula.

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Veterans’ advocates want the suspension of Priority Group 8 veterans from enrolling in VA’s

health care system lifted, since they believe that all veterans must be able to receive care from

VA. As discussed earlier, the Veterans Health Care Eligibility Reform Act of 1996 (P.L. 104-262)

included language that stipulated that medical care to veterans will be furnished to the extent

appropriations were made available by Congress on an annual basis. Based on this statutory

authority, the Secretary of Veterans Affairs announced on January 17, 2003, that VA would

temporarily suspend enrolling Priority Group 8 veterans.96 Those who were in VA’s health care

House Committee on Veterans’ Affairs, “Committee Hears Legislative Views of Millions of Veterans,” press release,

September 20, 2006.

U.S. Congressional Budget Office, Cost Estimate, H.R. 515 (109th Congress), Assured Funding for Veterans Health

Care Act of 2005, July 25, 2005, p.1.

Testimony of Richard Kogan, Center on Budget and Policy Priorities at the Alternative Processes for Funding

Veterans Health Care Forum, June 3, 2004. Transcript available at http://www.dav.org/voters/mandatory_funding.html.

U.S. Congress, House Committee on Veterans Affairs, hearing on Funding the U.S. Department of Veterans Affairs

of the Future, 110th Congress, 1st sess.,October 3, 2007.

Department of Veterans Affairs, “Enrollment—Provision of Hospital and Outpatient Care to Veterans Subpriorities

of Priority Categories 7 and 8 and Annual Enrollment Level Decision; Final Rule,” 68 Federal Register 2670, January

(continued...)

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system prior to January 17, 2003, were not to be affected by this suspension. VA claims that,

despite its funding increases, it cannot provide all enrolled veterans with timely access to medical

services because of the tremendous increase in the number of veterans seeking care from VA.97

Table 4 provides data from FY2003 through August 2006 on the number of Priority Group 8

veterans who applied for enrollment and were unable to enroll, and provides cumulative estimates

from FY2006 thru FY2008. As seen in Table 4, the VA estimates that if the suspension on

enrollment were to be lifted in FY2008, almost 1.6 million Priority Group 8 veterans would be

eligible to enroll in the VA health care system.

Table 4. Impact of Priority Group 8 Suspension, FY2003-FY2008

FY2003

FY2004

FY2005

cumulative cumulative cumulative

2006

cumulative

through

August 2006

FY2006

cumulative

estimate

FY2007

cumulative

estimate

FY2008

cumulative

estimate

93,228

327,457

830,203

1,254,460

1,570,503

192,419

263,257

Source: Department of Veterans Affairs.

The number of Priority Group 8 veterans already enrolled in VA’s health care system is expected

to decline from 1.27 million in FY2005 to 1.22 million in FY2006; this is mostly due to projected

death rates for these veterans and the continued suspension of new enrollments.98 In 2004, VA

estimated that resumption of enrollment for Priority Group 8 veterans would require an additional

$519 million over the FY2005 requested VHA budget, and an estimated $2.3 billion in FY2012.99

The Senate Veterans Affairs Committee estimates that $1.113 billion would be needed to restore

access for Priority Group 8 veterans. According to the Committee this number is based on VA’s

own estimates of what it would cost to reopen the system to Priority Group 8 veterans.100

Congress has shown a keen interest in providing access to VHA care for Priority Group 8

veterans, and legislation has been introduced to lift the suspension (H.R. 463, and a companion

measure S. 1147). Provisions from S. 1147 have been incorporated into S. 1233 (see section on

“Health Care Legislation Reported in the Senate” below).

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As part of VA’s comprehensive medical care benefits package, VA provides all veterans who are

enrolled for VA care with appropriate prescription medications, at the nominal charge of $8 for a

30-day supply per prescription. In general, the copayments are waived if the prescription is for a

(...continued)

17, 2003.

For detailed information on the FY2007 veterans health care budget see, CRS Report RL33409, Veterans’ Medical

Care: FY2007 Appropriations, by (name redacted).

Department of Veterans Affairs, FY2006 Budget Submission, Medical Programs, vol. 2 of 4, pp. 2-4.

U.S. Congress, Senate Committee on Appropriations, Department Veterans Affairs, and Housing and Urban

Development and Independent Agencies Appropriations for FY2005, hearings on H.R. 5041/S. 2825, 108th Cong., 2nd

sess., April 6, 2004, S.Hrg. 108-776, p. 379.

100

Democratic and Independent Members of the Committee on Veterans’ Affairs Views and Estimates on the FY2008

budget for Function 700 (Veterans’ Benefits and Services), March 1, 2007.

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service-connected condition, if the veteran is severely disabled or indigent, or if the veteran was a

former Prisoner of War (POW). VA dispenses medications, however, only to those veterans who

are enrolled for, and who actually receive VA-provided care. Generally, VA does not provide

medications to veterans unless those medications are prescribed by a physician who is employed

by or under contract with VA.

However, there are two exceptions to this general requirement. VHA is required to provide

medications, upon the order of any licensed physician, to: 1) veterans receiving additional

disability compensation under Chapter 11 of Title 38 of the United States Code (U.S.C.), as a

result of being permanently housebound or in need of regular aid and attendance due to a serviceconnected condition, or veterans who were previous recipients of such compensation and in need

of regular aid and attendance; and 2) veterans receiving nonservice-connected pensions under

Chapter 15 of Title 38 U.S.C. as a result of being permanently and totally disabled from a

nonservice-connected disability, and who are permanently housebound or in need of regular aid

and attendance.101

To address the growing waiting lists for primary care and specialty care appointments and to

reduce the waiting times for a first appointment, VA implemented a program in September 2003

to provide access to VA prescription drugs for veterans experiencing long waits for their initial

primary care appointment. This temporary program was known as the Transitional Pharmacy

Benefit (TPB). Under this program, VA pharmacies and VA’s Consolidated Mail Outpatient

Pharmacies (CMOPs) were authorized to fill prescriptions written by non-VA (private) physicians

until a VA physician could examine the veteran and determine an appropriate course of treatment.

The TPB included most, but not all, of the drugs listed on the VA National Formulary (VANF).102

To be eligible for the program, veterans had to be enrolled in the VA health care system prior to

July 25, 2003, and had to have requested their initial primary care appointment prior to July 25,

2003. To qualify for this program, veterans also must have been waiting more than 30 days for the

initial primary care appointment as of September 22, 2003.

Although VA anticipated that around 200,000 veterans would be eligible to participate in the

program, about 41,000 veterans were ultimately deemed eligible to enroll; of those veterans,

about 8,300 veterans participated. VA attributes low participation to the fact that many veterans

had already received VA services by the start of the program. According to the VA, the TPB

program incurred administrative costs associated with contacting private physicians to suggest

formulary alternatives, as many of them had prescribed medications that were not on VA’s

formulary. VA has discontinued this pilot program.

There was considerable interest in the 108th and 109th Congresses in providing a prescription-only

health care benefit for veterans. While several bills were introduced, none of them was enacted

into law.

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VA holds a substantial inventory of real property and facilities throughout the country. A majority

of these buildings and property support VHA’s mission. Much of VA’s medical infrastructure was

101

102

38 U.S.C. § 1712(d); 38 C.F.R. §17.96.

A formulary is a list of drugs approved for coverage under a drug benefit.

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built decades ago when its focus was inpatient care. In the past several years VA has been shifting

from a hospital-based system and, today, more than 80% of the treatment VA provides is on an

outpatient basis through Community Based Outpatient Clinics (CBOCs). In 1999, GAO projected

that one in four medical care dollars was spent on maintaining and operating VA’s buildings and

land. It estimated that VA has over 5 million square feet of vacant space which can cost as much

as $35 million a year to maintain.103

In October 2000, VA established the CARES program with the goal of evaluating the projected

health care needs of veterans over the next 20 years, and of realigning VA’s infrastructure to better

meet those needs. In August 2003, VA’s Under Secretary for Health issued a preliminary Draft

National CARES Plan (DNCP). The DNCP, among other things, recommended that seven VA

health care facilities be closed and duplicative clinical and administrative services delivered at

over 30 other VHA facilities be eliminated. The sites slated to be closed were in: Canandaigua,

New York; Pittsburgh, Pennsylvania (Highland Drive Division); Lexington, Kentucky (Leestown

Division); Cleveland, Ohio (Brecksville Unit); Gulfport, Mississippi; Waco, Texas; and

Livermore, California. Patients currently provided services at these VHA facilities would be

provided care at other nearby sites. The DNCP recommended that new major medical facilities be

built in Las Vegas, Nevada, and in East Central Florida. Furthermore, the DNCP recommended

significant infrastructure upgrades at numerous sites, including at or near locations where VA

proposed to close facilities. In addition, the draft plan called for the establishment of 48 new highpriority CBOCs.

Following the release of the DNCP, the VA Secretary appointed a 16-member independent

commission to study the draft plan. The commission was composed of individuals from a wide

variety of backgrounds outside of the federal government. The CARES Commission developed

and applied six factors in the review of each proposal in the DNCP: (1) impact on veterans’

access to health care; (2) impact on health care quality; (3) veteran and stakeholder views; (4)

economic impact on the community; (5) impact on VA missions and goals; and (6) cost to the

government. The commission conducted 38 public hearings and 81 site visits throughout 2003,

and submitted its recommendations to the Secretary in February 2004. After reviewing the

recommendations, the Secretary announced the final details of the CARES plan in May 2004

(Secretary’s CARES Decision). Table 5 provides a time-line of major activities under the CARES

process.

The final plan included consolidating the following facilities: (1) Highland Drive campus in

Pennsylvania with University Drive and Heinz campuses in Pennsylvania; (2) Brecksville campus

in Ohio with Wade Park campus in Cleveland, Ohio; and (3) Gulfport campus with Biloxi campus

in Mississippi. The following facilities were to be partially realigned: (1) Knoxville campus in

Iowa; (2) Canandaigua campus in New York; (3) Dublin campus in Georgia; (4) Livermore

campus in California; (5) Montrose campus in New York; (6) Butler campus in Pennsylvania; (7)

Saginaw campus in Michigan; (8) Ft. Wayne campus in Indiana; and (9) Kerrville campus in

Texas.104

103

U.S. General Accounting Office, VA Health Care: Capital Asset Planning and Budgeting Need Improvement,

GAO/T-HEHS-99-83, March 10, 1999, pp. 1-6.

104

The Draft National CARES Plan (DNCP) defines realignment as: moving services from one facility to another,

contracting for care to ensure inpatient access to care is available when needed, and in all cases maintaining outpatient

services in the community.

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The final plan also called for building new hospitals in Orlando and Las Vegas; adding 156 new

CBOCs, four new spinal cord injury centers, and two blind rehabilitation centers; and expanding

mental health outpatient services nationwide. By opening health care access to more veterans, VA

expects to increase the percentage of enrolled veterans from 28% of the veterans’ population

today, to 30% in 2012 and 33% in 2022. This percentage increase can be attributed in part to a

projected decline in the overall veteran population. Nationally, the number of veteran enrollees is

projected to increase 6% by 2012 and decrease 5% by 2022 from the number of veteran enrollees

reported in 2001. VA asserts that the CARES plan will reduce the cost of maintaining vacant

space over the period 2006 to 2022 from an estimated $3.4 billion to $750 million and allow VA

to redirect those funds to patient care.105

Table 5.Timeline of Major CARES Activities

Date

Activity

Description

February

2002

VA announced the results

of a pilot CARES study.

August

2003

VA’s Under Secretary for

Health presented the Draft

National CARES Plan.

February

2004

An independent CARES

Commission issued

recommendations.

May 2004

VA’s Secretary announced

the CARES decisions.

CARES follow-up studies.

The pilot study assessed current and future use of health care assets in

the three markets of Network 12, which includes parts of five states:

Illinois, Indiana, Michigan, Minnesota, and Wisconsin. It resulted in

decisions to realign health care services and renovate or dispose of

several buildings consistent with VA mission and community zoning issues.

The Under Secretary’s Draft National CARES Plan included

recommendations about health care services and capital assets in VA’s

remaining 74 markets. These recommendations reflected input from

managers of VA’s health care networks.

An independent 16-member commission appointed by the Secretary of

Veterans Affairs issued recommendations to the Secretary based on its

review of the Draft National CARES Plan and related documents and

information obtained through public hearings, site visits, public meetings,

written comments from veterans and other stakeholders, and

consultations with experts.

The Secretary based his decisions on a review of the CARES

Commission’s recommendations.

VA awarded a contract for additional studies at 18 VA facilities. These

studies will include evaluating outstanding health care issues, developing

capital plans, as well as determining the best use for unneeded VA

property consistent with VA mission and community zoning issues.

January

2005

Source: Government Accountability Office, VA Health Care: VA Should Better Monitor Implementation and Impact

of Capital Asset Alignment Decisions, GAO-07-408, March 2007.

Critics of the CARES plan contend that closures are being considered without assessing what

kind of facilities will be needed for long-term care and mental health care in the future. For

instance, at the time of the release of the DNCP, projections for outpatient and acute psychiatric

inpatient care contained data inconsistencies on future needs. VA asserted that it would improve

its forecasting models to ensure that projections adequately reflect future need. Also, some

believe that the CARES plan does not focus enough on future nursing home needs, and would

leave VA short of beds in a few decades. In this view, VA would not have any choice but to

privatize some parts of the health care system. Moreover, some veterans’ groups believe that

CARES is only about closing “surplus” hospitals and do not believe that CARES will result in the

105

Department of Veterans Affairs, Office of the Secretary, Secretary of Veterans Affairs, CARES Decision, May 2004,

pp. 1-8.

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building of new and modern facilities. Finally, the closure of some VA medical facilities raised

serious concern among some Members of Congress who felt that they had little input into the

CARES process.106

The Veterans Health Programs Improvement Act of 2004 (P.L. 108-422), signed into law on

November 30, 2004, required VA to notify Congress of the impact of actions that may result in a

facility closure, consolidation, or administrative reorganization. The law also prohibits such

actions from occurring until 60 days following the notification.

The Secretary’s CARES Decision identified implementation issues that required further study,

including additional stakeholder input at selected sites. On September 29, 2004, the Secretary of

VA established an Advisory Committee for CARES Business Plan Studies. The committee and its

subcommittees generally consist of representatives from veterans’ service organizations,

governmental agencies, health care providers, planning agencies, and community organizations

with a direct interest in the CARES process. This committee is to consult with stakeholders

during implementation of the Secretary’s CARES Decision. The committee is to ensure that the

full range of stakeholder interests and concerns are assembled, publicly articulated, accurately

documented, and considered in the development of site-level business plans.

In January 2005, VA awarded a contract to PricewaterhouseCoopers to complete studies at 18

sites throughout the country during a 13-month period, as required by the Secretary’s CARES

Decision.107 Local Advisory Panels (LAPs) gathered views of stakeholders regarding the range of

potential options provided by the contractor and made recommendations to the Secretary. In 2006

VA announced the Secretary’s decision for some of the 18 sites. For some sites decisions have not

yet been announced.

VA has begun implementing some of the projects under the CARES decisions. Specifically, as of

February 2007, VA was in the process of implementing 32 of more than 100 major capital

projects that were identified in the CARES process.108 Given below in Table 6 is a summary of

the final decisions announced thus far.

106

Honorable Bob Graham, “Statements on Introduced Bill and Joint Resolutions,” remarks in the Senate,

Congressional Record, 108th Congress, vol. 149 (June 18, 2003), p. S8135.

107

The 18 sites are Boston, MA (VISN 1); Canandaigua, NY (VISN 2); Montrose, NY (VISN 3); New York City, NY

(VISN 3); St. Albans, NY (VISN 3); Perry Point, MD (VISN 5); Montgomery, AL (VISN 7); Louisville, KY (VISN 9);

Lexington, KY (VISN 9); Poplar Bluff, MO (VISN 15); Biloxi, MS (VSIN 16); Muskogee, OK (VISN 16); Waco, TX

(VISN 17); Big Spring, TX (VISN 18); Walla Walla, WA (VISN 20); White City, OR (VISN 20) Livermore, CA

(VISN 21); West LA, CA (VISN 22).

108

Government Accountability Office, VA Health Care: VA Should Better Monitor Implementation and Impact of

Capital Asset Alignment Decisions, GAO-07-408, March 2007.

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Study Site

Boston, MA

(VISN 1)

Canandaigua, NY

(VISN 2)

Montrose/Castle

Point, NY

(VISN 3)

New York City,

NY (VISN 3)

St. Albans, NY

(VISN 3)

Perry Point, MD

(VISN 5)

Montgomery, AL

(VISN 7)

Louisville, KY

(VISN 9)

Lexington, KY

(VISN 9)

Poplar Bluff, MO

(VISN 15)

Biloxi, MS

(VSIN 16)

Muskogee, OK

(VISN 16)

Table 6. CARES Decisions on the 18 Sites

CARES Decision

The contractor’s final report proposed closing four Boston VAMCs and creating a single

medical center for the metropolitan area. The Secretary rejected this proposal and has

instructed the contractor to proceed to Stage 2 and provide more detailed analysis of several

other options. The additional options include shifting inpatient psychiatry and long-term care

from the Bedford VAMC facility to the Brockton VAMC, while retaining outpatient care at

Bedford and consolidating services currently located at West Roxbury VAMC into the Jamaica

Plain VAMC, or vice versa.

After reviewing the contractor’s final report, the Secretary rejected all proposals to move

services to an off-site facility. The Secretary decided to construct a new single-floor, 120-bed

nursing home and a new 50-bed residential rehabilitation facility and to renovate the outpatient

building. VA will also explore partnerships with the private sector to generate revenue and

complementary services for veterans by leasing under-used buildings and land. As required by

the Military Quality of Life, Military Construction, Veterans Affairs, and Related Agencies

Appropriations Act FY2006 (P.L. 109-114, H.Rept. 109-305), VA has designated the

Canandaigua VAMC as a mental health and post traumatic stress disorder (PTSD) “Center of

Excellence,” and has housed its National Suicide Prevention Hot Line at Canandaigua.

Based on the contractor’s final report, the VA decided to maintain the current residential

treatment program and build a multi-specialty ambulatory care facility at the Montrose campus.

Furthermore, VA would completely modernize the Castle Point campus.

Based on the contractor’s final report, the Secretary has decided to retain the existing VAMCs

in both Brooklyn and Manhattan.

Based on the contractor’s final report, the Secretary has decided that VA would replace

existing facilities at St. Albans with a new nursing home, outpatient clinics and a domiciliary

consolidated on the north end of the campus.

After reviewing the contractors report and the recommendations of the Local Advisory Panel

(LAP) the Secretary decided to build a new nursing home and modernize existing mental health

and outpatient facilities. VA will continue the study internally to complete a capital plan for the

campus. There will be no Stage 2 study.

Based on the contractor’s final report, the Secretary has decided to continue inpatient services

at the Montgomery facility.

Based on the contractor’s final report, a new medical center will replace the current facility.

VA’s Office of Facility Management has created a site selection board, and is in the process of

selecting an architectural and engineering firm to support the analysis of site locations.

After reviewing the contractor’s final report, the Secretary requested the contractor to

proceed to Stage 2 and provide a more detailed study of two options selected by the Secretary.

The first option is to replace all facilities on the southeastern part of the Leestown facility; and

the second option is to construct appropriately sized new clinical care buildings on the central

portion of the Leestown facility.

After reviewing the contractor’s report and the recommendations of the Local Advisory Panel

(LAP) the Secretary decided to maintain inpatient services and added cardiology services to the

existing list of services. The Secretary’s decision rejected the option for the closure of Poplar

Bluff inpatient services, and referral of inpatient VA care to a community hospital.

Hurricane Katrina obviated the need for this study because the facility was destroyed. Future

construction requirements are being addressed through emergency appropriations in response

to Hurricane Katrina.

After reviewing the contractor’s recommendations the Secretary decided to maintain inpatient

services at the Muskogee VAMC and to expand psychiatric services.

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Study Site

Waco, TX

(VISN 17)

Big Spring, TX

(VISN 18)

Walla Walla, WA

(VISN 20)

White City, OR

(VISN 20)

Livermore, CA

(VISN 21)

West LA, CA

(VISN 22)

CARES Decision

The Military Quality of Life, Military Construction, Veterans Affairs, and Related Agencies

Appropriations Act FY2006 (P.L. 109-114, H.Rept. 109-305) required VA to designate Waco

VAMC as a mental health and PTSD “Center of Excellence.” The Secretary decided to keep the

facility open.

The contractor’s final report did not recommend the closure and transfer of inpatient care,

stating that the Big Spring VAMC is in good condition, quality of care is excellent and change

would result in no improvements to access. Therefore, the Secretary decided that inpatient

services will remain at the Big Spring VAMC.

After reviewing the contractor’s final report, the Secretary rejected options to close the Walla

Walla VAMC and move the services to the Tri-Cities market. VA would replace the current

Walla Walla VAMC with a new multi-specialty outpatient facility and ensure that inpatient and

nursing home services are available.

After reviewing the contractor’s final report, the Secretary has decided that VA will not

transfer services from the White City Southern Oregon Rehabilitation Center and Clinic

(SORCC). However, VA will continue to evaluate if it will renovate or replace the current

facility.

After reviewing the contractor’s final report, the Secretary requested the contractor to

proceed to Stage 2 and provide a more detailed study of three options selected by the

Secretary. The first option is to construct a new nursing home on the current site, the second

option is to relocate the current nursing home care unit to a new off-site stand-alone facility

co-located with ambulatory care services. The third option is to renovate the current nursing

home unit and consolidate all necessary logistics and support functions.

After reviewing the contractor’s final report, the VA has decided to completely modernize the

inpatient facility for outpatient services. In addition, a new VA building to place the urns

containing the remains of cremated veterans, and a new facility for the Veterans Benefits

Administration Regional Office, will be housed on campus. Buildings 205, 208, and 209 have

been designated for homeless veterans programs.

Source: CRS analysis of VA decision announcements.

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In general, the beneficiary travel program reimburses certain veterans for the cost of travel to VA

medical facilities when seeking health care. P.L. 76-432, passed by Congress on March 14, 1940,

mandated VA to pay either the actual travel expenses, or an allowance based upon the mileage

traveled by any veteran traveling to and from a VA facility or other place for the purpose of

examination, treatment, or care. P.L. 85-857, signed into law on September 2, 1958, authorized

VA to pay necessary travel expenses to any veteran traveling to or from a VA facility or other

place in connection with vocational rehabilitation counseling or for the purpose of examination,

treatment, or care. However, this law changed VA’s travel reimbursement into a discretionary

authority by stating that VA “may pay” expenses of travel.

Due to rapidly increasing costs of the beneficiary travel program, on March 12, 1987, VA

published final regulations that sharply curtailed eligibility for the beneficiary travel program.109

Under these regulations beneficiary travel payments to eligible veterans were paid when

specialized modes of transportation, such as ambulance or wheelchair van, were medically

required. In addition, payment was authorized for travel in conjunction with compensation and

109

Veterans Administration, “Transportation of Claimants and Beneficiaries,” final regulations, 52 FR 7575-01, March

12, 1987. These regulations became effective on April 13, 1987.

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pension examinations, as well as travel beyond a 100-mile radius from the nearest VA medical

care facility. It also authorized the VA to provide transportation costs, when necessary, to transfer

any veteran from one health care facility (either a VA or contract care facility) to another in order

to continue care paid for by the VA. The following transportation costs were not authorized under

these regulations:

•

Cost of travel by privately owned vehicle in any amount in excess of the cost of

such travel by public transportation unless public transportation was not

reasonably accessible or was medically inadvisable.

•

Cost of travel in excess of the actual expense incurred by any person as certified

by that person in writing.

•

Cost of routine travel in conjunction with admission for domiciliary care, or

travel for family members of veterans receiving mental health services from the

VA except for such travel performed beyond a 100-mile radius from the nearest

VA medical care facility.

Travel expenses of all other veterans were not authorized unless the veterans were able to present

clear and convincing evidence to show the inability to pay the cost of transportation; or except

when medically-indicated ambulance transportation was claimed and an administrative

determination was made regarding the veteran’s ability to bear the cost of such transportation.110

The Veterans’ Benefits and Services Act of 1988 (P.L. 100-322, section 108), in large part

restored VA travel reimbursement benefits. It required that if VA provides any beneficiary travel

reimbursement under Section 111 of Title 38 U.S.C. in any given fiscal year, then payments must

be provided in that year in the case of travel for health care services for all the categories of

beneficiaries specified in the statute. In order to limit the overall cost of this program, the law

imposed a $3 one-way deductible applicable to all travel, except for veterans otherwise eligible

for beneficiary travel reimbursement who are traveling by special modes of transportation such as

ambulance, air ambulance, wheelchair van, or to receive a compensation and pension

examination. In order to limit the overall impact on veterans whose clinical needs dictate frequent

travel for VA medical care, an $18-per-calendar-month cap on the deductible was imposed for

those veterans who are pre-approved as needing to travel on a frequent basis. At present, eligible

veterans are reimbursed at the rate of 11 cents a mile for routine visits and 17 cents a mile for

compensation and pension exams. Although the deductible rates are set in statute, the mileage

rates are left to the discretion of the Secretary. Table 7 provides details on veterans who are

currently eligible to receive travel benefits.

110

Ibid.

ȱȱȱ

ŚŚȱ

Ȃȱ ȱȱ ȱ

Table 7.Veterans Eligible for Travel Benefits

•

Veterans with service-connected disabilities rated 30% or more.

Veterans with service-connected disabilities rated less than 30% traveling for treatment of a serviceconnected condition.

Veterans in receipt of a VA pension.

Veterans traveling for a compensation or pension (C&P) exam.

Veterans whose income does not exceed the maximum annual VA pension rate with an additional aid and

attendance allowance.

With the rise in gasoline prices Congress has shown interest in changing the method of

determining the mileage reimbursement rate and/or eliminating the current deductible amount. S.

1233, as reported in the Senate, includes a provision that would require the VA to reimburse

qualifying veterans at the particular rate authorized by the Administrator of General Services, for

federal government employees traveling on official business.

ȱ ȱȱȱ

ȱȱȱȱȱ ȱ

ȱȱȱȱȱȱǻ ǯǯȱřŘŝǰȱ ǯǯȱŗŗŖȬŖśśǰȱǯǯȱ

ŗŗŖȬŗŗŖǼȱ

The House passed this measure on March 21, 2007, and the Senate passed the House measure

with an amendment on September 27. The bill was signed into law on November 5, 2007. P.L.

110-110, would, among other things, require the VA to establish a comprehensive program for

suicide prevention among veterans. In carrying out this comprehensive program, the VA must

designate a suicide prevention counselor at each VA medical facility. Each counselor is required

to work with local emergency rooms, police departments, mental health organizations, and

veterans service organizations to engage in outreach to veterans. The Act also requires the VA to

provide for research on best practices for suicide prevention among veterans. P.L. 110-110

requires the Secretary to provide for outreach and education for veterans and the families of

veterans, with special emphasis on providing information to veterans of OIF and OEF and the

families of such veterans. The Act requires VA to provide for the availability of 24-hour mental

health care for veterans and to establish a 24-hour hotline for veterans to call if needed. (In July

2007, the VA established a national suicide prevention hotline for veterans. The toll-free number,

1-800-273-TALK [8255], is staffed by mental health professionals 24 hours a day, 7 days a

week).

ȱȱȱ

Śśȱ

Ȃȱ ȱȱ ȱ

ȱȱȱȱ¢ȱȱ ŗŗŗȱ

ȱȱȱ ȱ ȱȱȱŘŖŖŝȱǻ ǯǯȱŜŗŘǼȱ

The House passed this bill on May 23, 2007. H.R. 612 as amended, would extend the eligibility

period from two years to five years following discharge or release for veterans who served in

combat during or after the Persian Gulf War, to receive hospital care, medical services, or nursing

home care provided by the VA, without having to prove that their condition is attributable to such

service. H.R. 612 also provides for an additional three years of eligibility for veterans discharged

more than five years before the enactment of this Act who have not enrolled.

ȱȱȱȱȱȱȱǻ ǯǯȱŗŚŝŖǼȱ

The House passed H.R. 1470 on May 23, 2007. The measure would require that chiropractic

services be made available in not fewer than 75 VAMCs by the end of December 2009, and at all

health care centers by the end of 2011.

ȱȱ ¢ȱ ȱȱȱȬȱȱȱȱ

ŘŖŖŝȱǻ ǯǯȱŘŗşşǰȱ ǯǯȱŗŗŖȬŗŜŜǼȱ

The House passed this measure on May 23, 2007. H.R. 2199, as amended, would require

mandatory screening of veterans for traumatic brain injury (TBI). It would also require the VA to

establish a comprehensive program of care for post-acute traumatic brain injury rehabilitation.

H.R. 2199, as amended, would require the VA to establish TBI transition offices at each

Department polytrauma network site to coordinate health care and services to veterans who suffer

from moderate to severe traumatic brain injuries. Furthermore, the measure, as passed by the

House, would require the VA to establish a registry of those who served in Operation Enduring

Freedom or Operation Iraqi Freedom (OEF or OIF) who exhibit symptoms associated with TBI.

H.R. 2199 also includes two provisions to improve the quality of care provided to rural veterans.

It would create an advisory committee on rural veterans and establish a pilot program to provide

readjustment counseling, related mental health services, and benefits outreach, through mobile

Vet Centers.

ȱȱ ȱȱȱŘŖŖŝȱǻ ǯǯȱŗřŗśǰȱ ǯǯȱŗŗŖȬŘŜŜǼȱ

This measure was passed by the House on July 30, 2007. Among other things, this bill contains a

provision that would require the VA to establish a Vision Education Scholarship Program under

the Health Professional Education Assistance Program. Those who receive a scholarship award

would be required to work for three years in a VA health care facility. H.R. 1315 also mandates

the Secretary to provide financial assistance to students enrolled in a program of study leading to

a degree or certificate in blind rehabilitation in a U.S. state or territory, provided they agree with

applicable requirements. The purpose of this scholarship is to increase the supply of qualified

blind rehabilitation specialists for the VA.

111

For benefit legislation, see CRS Report RL33985, Veteran’s Benefits: Issues in the 110th Congress, coordinated by

(name redacted).

ȱȱȱ

ŚŜȱ

Ȃȱ ȱȱ ȱ

ȱ ȱȱ ȱȱȱŘŖŖŝȱǻ ǯǯȱŘŞŝŚǰȱ ǯǯȱŗŗŖȬŘŜŞǼȱ

This bill was passed on July 30, 2007. Among other things, H.R. 2874 would allow VA to

establish a grant program for nonprofit entities to conduct workshops to assist in the therapeutic

readjustment and rehabilitation of OEF and OIF veterans. The amount of the grants would be

limited to $100,000 for each calendar year, and there would be $2 million authorized each fiscal

year to carry out the program. The grant program would terminate on September 30, 2011. It

would also require the VA to establish a grant program for rural veterans service organizations,

state veterans’ service agencies, and nonprofits to provide innovative transportation options to

veterans in remote rural areas to travel to VA medical facilities. Grant amounts would be limited

to $50,000, and the bill authorizes $3 million for each fiscal year from 2008 to 2012 to carry out

the program.

H.R. 2874 would permanently authorize VA’s authority to provide higher priority health care to

veterans who participated in Project Shipboard Hazard and Defense (SHAD), Project 112, or

related land-based tests. Under current law, VA is authorized to provide higher priority health care

to these veterans with any illness, without those veterans needing an adjudicated serviceconnected disability to establish their priority for care. This special treatment authority will expire

on December 31, 2007. This measure would also extend through September 30, 2009, VA’s

authority to require certain nonservice-connected veterans to pay a $10 per diem copayment when

they receive VA hospital care, and extend through October 1, 2009, VA’s authority to bill a

service-connected patient’s third-party insurance carrier for the cost of care VA provides the

veteran for any nonservice-connected condition.

H.R. 2874 would also require VA to provide readjustment counseling and mental health services

for OEF and OIF veterans. Such services would include contracting with community mental

health centers in areas not adequately served by VA and contracting with nonprofit mental health

organizations to train OEF and OIF veterans in outreach and peer support. It also directs VA to

conduct training programs for clinicians that have contracts with VA to provide such services. It

would also require the VA to ensure that VA domiciliary programs are adequate in capacity and

safety to meet the needs of women veterans.

Furthermore, H.R. 2874 would reduce the time that a homeless veteran would have to wait to

receive dental treatment from 60 days to 30 days. Under current law, VA can provide dental

services to eligible homeless veterans as long as they have been receiving care for a period of 60

consecutive days in a domiciliary, therapeutic residence, community residential care coordinated

by VA, or a setting for which the VA provides funds for a grant and per diem provider.

ȱȱȱȱ¢ȱȱȱȱȱȱ¢ȱȱȱ

ǻ ǯǯȱŘŜŘřǰȱ ǯǯȱŗŗŖȬŘŜŝǼȱ

H.R. 2623 was passed by the House on July 30. This bill would exempt all hospice care provided

through VA from copayment requirements. Under current law, a veteran receiving hospice care in

a nursing home is exempt from any applicable copayments. However, if the hospice care is

provided in any other setting, such as in an acute-care hospital or at home, the veteran may be

subject to an inpatient or outpatient primary care copayment. By exempting all hospice care

provided by the VA regardless of the setting, H.R. 2623 would align the VA health care system

with the Medicare program, which does not impose copayments for hospice care regardless of the

setting.

ȱȱȱ

Śŝȱ

Ȃȱ ȱȱ ȱ

ȱȱȱȱȱȱȱ

ȱȱȱ ¢ȱȱ ȱȱ ȱȱȱ

ŘŖŖŝȱǻǯȱŗŘřřǰȱǯǯȱŗŗŖȬŗŚŝǼȱ

S. 1233, as amended, was ordered to be reported by the Senate Veterans’ Affairs Committee on

June 27, 2007.112 This bill includes several provisions related to enhancing veterans health care.

As reported, S. 1233 would require VA to develop individual rehabilitation and community

reintegration plans for veterans and servicemembers with TBI who are being treated in the VA

health care system. The plan would identify a case manager to oversee its long-term

implementation and would specify dates for review of the plan. The bill would also authorize the

VA to use non-VA facilities for the implementation of rehabilitation and community reintegration

plans for traumatic brain injury under certain specified circumstances. S. 1233, as reported, would

require VA to develop and implement a research, education, and clinical care program on severe

TBI. It also would authorize a five-year pilot program on assisted living services for veterans with

traumatic brain injury and would require the VA to provide age-appropriate nursing home care for

veterans who suffer from severe TBI

The Veterans Programs Enhancement Act (P.L. 105-368) authorized priority eligibility for health

care for a period of two years following discharge or release from active duty to any veteran who

served in a combat theater of operations. S. 1233 would extend the period from two to five years.

According to the committee report (S.Rept. 110-147), this extension is necessary to ensure that

veterans returning from combat receive health care during their transition from military service to

civilian life and to address health care issues such as PTSD, which may take years to manifest. S.

1233 would require VA to establish a Hospital Quality Report Card Initiative to inform veterans

and their families of the quality and performance of VA hospitals. According to S.Rept. 110-147,

“the initiative is intended to help veterans and their families to make informed health care

choices.”113

S. 1233, as reported in the Senate, would require the VA to annually—by August 1—to publish a

notice in the Federal Register of which categories of veterans are eligible to be enrolled in VA

health care in the upcoming fiscal year. Furthermore, in any year in which the VA proposes to

stop enrollment, the VA Secretary would be required to provide to the House and Senate VA

Committees an estimate of the cost of enrolling all eligible veterans. After the notice is published,

the VA would be required to wait 45 days before implementing any change in enrollment.

According to the committee report, “this notice-and-wait requirement would provide Congress

with an opportunity to oversee the enrollment of veterans in the Veterans Health Administration,

and to respond to any proposed limitation on enrollment.”114 Furthermore, it is the view of the

committee that when resources are provided by Congress to enable the VA to keep pace with

demand for services, the VA health care system should be open to all veterans who seek care.115

112

S. 1233 contained provisions from the following bills: S. 117, S. 383, S. 472, S. 692, S. 874, S. 994, S. 1026, S.

1146, S. 1147, S. 1326, S. 1384, S. 1392, and S. 1396.

113

U.S. Congress, Senate Committee on Veterans’ Affairs, Veterans’ Traumatic Brain Injury and Other Health

Programs Improvement Act of 2007, report to accompany S. 1233, 110th Congress, 1st sess., S.Rept. 110-147, p. 12.

114

Ibid, p. 13.

115

Ibid.

ȱȱȱ

ŚŞȱ

Ȃȱ ȱȱ ȱ

S. 1233 would require the VA to establish a grant program to provide transportation options to

veterans in rural areas. Under this grant program, VA would provide grants for rural veterans’

service organizations and community-based organizations to provide transportation to veterans in

remote rural areas. For each of FY2008 through FY2012, $6 million would be authorized to be

appropriated for this grant program. The grants would be awarded to state veterans’ service

agencies, veterans service organizations, and qualified community transportation organizations.

Among other things, S. 1233 would require VA to establish demonstration projects on alternatives

for expanding care for veterans in rural areas. Under the committee-reported measure, two

demonstration projects would be required to be carried out in geographically dispersed areas. It

would require VA to partner with the Department of Health and Human Services (HHS) and the

Indian Health Service (IHS) to expand care for Native American veterans.

Furthermore, S. 1233 would exempt veterans in Priority Group 4 (veterans who have been

determined by the VA to be catastrophically disabled) from paying copayments for nonserviceconnected hospital care or nursing home care. Under current law, these veterans are required to

pay copayments for all nonservice-connected care they receive from the VA.

S. 1233, as reported in the Senate, would increase reimbursement rates for travel to VA medical

facilities. At present, eligible veterans are reimbursed at the rate of 11 cents a mile for routine

visits and 17 cents a mile for compensation and pension exams. Under S 1233, the VA would

reimburse qualifying veterans at the particular rate authorized for government employees under

section 5707(b) of Title 5 U.S.C.

On November 14, 2007, the Senate Veterans’ Affairs Committee ordered the following bills

reported without amendment: S. 2004 (to amend Title 38 U.S.C. to establish epilepsy centers of

excellence in the Veterans Health Administration of the Department of Veterans Affairs), S. 2142

(the Veterans Emergency Care Fairness Act of 2007), S. 2160 (The Veterans Pain Care Act of

2007), and S. 2162 (Mental Health Improvements Act of 2007). The committee has not released

the Committee Print versions of these bills.

ȱȱȱ

Śşȱ

Ȃȱ ȱȱ ȱ

¡ǯ ¢ȱ ȱȱȱ¢ȱ

Priority Group 1

Veterans with service-connected disabilities rated 50% or more disabling

Priority Group 2

Veterans with service-connected disabilities rated 30% or 40% disabling

Priority Group 3

Veterans who are former POWs

Veterans awarded the Purple Heart

Veterans whose discharge was for a disability that was incurred or aggravated in the line of duty

Veterans with service-connected disabilities rated 10% or 20% disabling

Veterans awarded special eligibility classification under Title 38, U.S.C., Section 1151, “benefits for individuals disabled

by treatment or vocational rehabilitation”

Priority Group 4

Veterans who are receiving aid and attendance or housebound benefits

Veterans who have been determined by VA to be catastrophically disabled

Priority Group 5

Nonservice-connected veterans and noncompensable service-connected veterans rated 0% disabled whose annual

income and net worth are below the established VA means test thresholds

Veterans receiving VA pension benefits

Veterans eligible for Medicaid benefits

Priority Group 6

Compensable 0% service-connected veterans

World War I veterans

Mexican Border War veterans

Veterans solely seeking care for disorders associated with

—exposure to herbicides while serving in Vietnam; or

—ionizing radiation during atmospheric testing or during the occupation of Hiroshima and Nagasaki; or

—for disorders associated with service in the Gulf War; or

—for any illness associated with service in combat in a war after the Gulf War or during a period of hostility after

November 11, 1998.

Priority Group 7

Veterans who agree to pay specified copayments with income and/or net worth above the VA means test threshold

and income below the HUD geographic index

Subpriority a: Noncompensable 0% service-connected veterans who were enrolled in the VA Health Care system on

a specified date and who have remained enrolled since that date

Subpriority c: Nonservice-connected veterans who were enrolled in the VA health care system on a specified date

and who have remained enrolled since that date.

Subpriority e: Noncompensable 0% service-connected veterans not included in Subpriority a above

ȱȱȱ

śŖȱ

Ȃȱ ȱȱ ȱ

Subpriority g: Nonservice-connected veterans not included in Subpriority c above

Priority Group 8

Veterans who agree to pay specified copayments with income and/or net worth above the VA means test threshold

and the HUD geographic index

Subpriority a: Noncompensable 0% service-connected veterans enrolled as of January 16, 2003, and who have

remained enrolled since that date

Subpriority c: Nonservice-connected veterans enrolled as of January 16, 2003, and who have remained enrolled since

that date

Subpriority e: Noncompensable 0% service-connected veterans applying for enrollment after January 16, 2003

Source: Department of Veterans Affairs.

ȱȱ ȱ

(name redacted)

Analyst in Veterans Policy

[redacted]@crs.loc.gov, 7-....

ȱȱȱ

śŗȱ

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