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Budget Legislation Update

House Budget Committee Chairman Paul Ryan (WI) presented his proposed budget for fiscal year (FY) 2014 on Wednesday. It is expected that the House will vote on it next week before it recesses for Easter.

According to the committee, the budget calls for $4.6 trillion in mostly unspecified spending cuts, holding both spending and revenues to 19.1 percent of the Gross Domestic Product (GDP). Reforms in Medicare, Medicaid, and food stamps are again called for as in last year’s budget, Obamacare is repealed, and the sequester remains in effect. [Note: there appears to be some flexibility in new spending for Defense.] Ryan’s budget aims for balance in ten years, with no provision for increasing tax revenue other than through economic growth. Please remember the Budget Control Act, enacted in 2011, set annual spending limits from 2013 through 2021 and calls for across-the-board cuts to enforce those limits.

The budget directs the House Ways and Means Committee to prepare a tax reform bill that will lower tax rates by closing loopholes and limiting credits and deductions, such as the Work Opportunity Tax Credit (WOTC). The American Legion supports WOTC for companies to hire veterans. The Senate Budget Committee, under Chairman Patty Murray (WA), released its version of the FY 2014 budget this week, the first one in four years. One of the preliminary reports from the staff indicated that the budget will save $1 trillion over ten years, split equally between spending cuts and higher taxes. This $1 trillion will replace the sequester, which is repealed in the budget.

The President announced he will submit his budget April 8, nine weeks after the statutorily-mandated February 4 due date.

There will be much media coverage of all these budgets, but it is the opinion of your Legislative staff that the House and Senate budgets appear to be too far apart to be reconciled; therefore we expect the House to write bills adhering to its budget resolution and the Senate will do the same, assuming a budget resolution passes the Senate.

The Legion will monitor any tax bills because we want the WOTC tax credits to be extended through December 31, 2018. The Legion supports this tax credit for companies that hire unemployed veterans. [The VOW to Hire Heroes Act explicitly makes veterans hiring credits part of WOTC, but we mention both here to insure Legionnaires know about these complex credit provisions.] If the House Ways and Means and Senate Finance committees take up tax reform, we will seek permanent extension of WOTC (including VOW Act credits).

House VA Committee Hearing on Meeting Patient Care Needs

On March 13, 2013, the House Veterans’ Affairs Committee held a hearing aimed at examining VA physician staffing standards. These standards and practices can greatly affect the quality and timeliness of care received by veterans at VA health centers. The witness list included: Ms. Linda Halliday, Assistant Inspector General for Audits and Evaluations, Office of the Inspector General, Department of Veterans Affairs (VA), accompanied by Mr. Larry Reinkemeyer, Director, Kansas City Audit Operations Division Office of the Inspector General, VA; Larry Conway B.S., R.R.T., Director of Communications, National Association of Veterans Affairs Physicians and Dentists; and Madhulika Agarwal M.D., M.P.H., Deputy Under Secretary for Health for Policy and Services, Veterans Health Administration (VHA) , VA accompanied by: Jeffrey Murawsky M.D., Director, Great Lakes Health Care System (VISN 12), VHA; and Carter Mecher M.D., Senior Medical Advisor, Office of Public Health, VHA.

Ms. Halliday testified that a large part of the problem is a lack of understanding as to how to create and implement a staffing plan. She noted that "current VHA policy does not provide sufficient detail for medical facilities to develop their staffing plans." She noted that five medical facilities investigated stated that they were unsure what was required to implement a staffing plan. Though VHA asserts that "staffing policy [is] intentionally general in nature because medical facility officials determine staffing levels [based on] various factors". The recommendations from the inspector general included ensuring that the Under Secretary of Health establishes "productivity standards from at least five specialty care services by the end of FY 2013 and approve a plan that ensures all specialty care services have productivity standards within 3 years." Further, it was recommended that the under secretary provide more specific guidance for the development and renewal of staffing plans. She emphasized that "While [the office of the inspector general does] not endorse any one specific method to measure physician productivity, we do believe that VA needs to have measurable and comparable productivity standards in place to assist in determining the number of specialty physicians needed to meet patient care needs."

Mr. Conway stated that the greatest barrier to the development and implementation of an accurate assessment of productivity and staffing needs is defining a measurement unit and applying it in all procedures. The second greatest barrier, he noted, was encouraging staff participation. "Health care providers are especially suspicious of [productivity monitoring systems because] they realize they are working with people…and that ‘cookbook’ approaches do not account for the variability of people and their medical responses." In a medical system such as VA, which is not-for-profit, Mr. Conway suggested that "production" in terms of billable hours may not be an appropriate measurement of outcomes and needs. "In the VA system, profitability is not a factor and so assessing the productivity of a physician should be based on the time spent producing care results [rather than billable hours]."

Dr. Agarwal stated that "It is my privilege to inform this subcommittee…of the actions we are taking to ensure our physician workforce is optimally deployed to provide American’s Veterans with the quality care they have earned…" She went on to state that "VHA is committed to establishing appropriate productivity models for five additional specialties by the close of this fiscal year. Over the next three years, we will refine and develop additional models that are individualized for specialty care." These goals are notably directly consistent with the recommendations made by the Office of the Inspector General.

Later questioning focused largely on examining the reasons behind the delay of more than a decade in recognizing the issues and implementing fixes.

HVAC Subcommittee Examines Gulf War Illness Research

On Wednesday, March 13th the House Veterans’ Affairs Subcommittee on Oversight and Investigations held a hearing looking into the state of research on Gulf War illness, most specifically regarding VA research. Representative Mike Coffman (CO), a Gulf War era veteran himself with his Marine Corps service, chaired the hearing. The opening panel consisted of:

• Dr. Lea Steele – Research Professor of Biomedical Studies and Director of the Veterans Health Research Program at Baylor University;

• Dr. Steven S. Coughlin, Adjunct Professor of Epidemiology at Emory University;

• Dr. Bernard M. Rosof, Chairman of the Board of Directors of Huntington Hospital and Chair, Committee on Gulf War Health: Treatment for Chronic Multi-Symptom Illness at the Institute of Medicine of the National Academies; and,

• Anthony Hardie, a Gulf War veteran

The primary focus of the opening panel revolved around the perceived marginalization of Gulf War illness (GWI) by the Department of Veterans Affairs (VA). Dr. Steele opened by noting the Congressionally Directed Medical Research Program (CDMRP) administered by DOD was making progress with combating GWI, and was focused on treatments and recognized GWI as a physical ailment, while VA seemed to "minimize the problem."

The second speaker was the key figure of the panel. Dr. Coughlin is a former VA employee who left VA recently over what he cited were "ethics concerns" regarding research into GWI and burn pit exposure. Dr. Coughlin stated he believed VA had deliberately not released results of studies showing correlation between environmental exposures and illnesses. He further stated when examining burn pits and conditions such as asthma and bronchitis, he was directed not to look at data regarding hospitalizations and doctor visits. When he stated to his chain of command he did not feel he could continue as an investigator under those research conditions, he states he was threatened by superiors.

Dr. Rosof stressed his concerns with how VA put forth information in advisory groups, and noted they continued to "write off [GWI] as ‘stress’ and ‘a psychological problem’ and minimized the physical nature of the symptoms. Mr. Hardie, the final member of the panel, part of a research advisory committee stated the "white washing" of the results to shunt the condition towards "just being in veterans’ heads" made him question the nature of his participation in the committee.

The second panel, the VA’s witnesses, consisted of: Dr. Victoria Davey, VAs Chief Officer, of the Office of Public health and Environmental Hazards, although she was accompanied by Tom Murphy, the Director of Compensation and Pension Services; and several VA doctors.

The Committee repeatedly pressed VA on the issue of whether GWI was "a physical or mental illness" and VA’s panel was generally evasive on this topic. Dr. Stephen Hunt refused to be pinned down to one topic and stated the condition was "complicated." Dr. Davey finally equivocally stated, when pressed, "We do not believe it is psychological."

Mr. Murphy from Compensation and Pension Service was questioned as to why VA could still not track GWI effectively in terms of claims. He allowed that "undiagnosed, multi-symptom illness" is such a broad category it is difficult to give it one tracking code.

Chairman Coffman closed by taking note that none of the people sent before the committee by VA were Gulf War veterans themselves, and opined if VA had more people who were Gulf War veterans involved in the decisions on this research, there would be no foot dragging or minimizing the problem.

The Committee stated no particular follow up, but clearly was unhappy with the answers provided by VA.

In a coda to the hearing, Secretary Eric Shinseki of VA announced afterwards that he had directed the Office of Research Oversight to review Dr. Coughlin’s allegations about harassment and being threatened.

Senate Armed Services Subcommittee Holds Hearing on Military Sexual Trauma

On Wednesday, March 13 the Senate Armed Service Subcommittee on Personnel held a hearing on the military’s policies on sexual assault. Senator Kirsten Gillibrand (NY), Chair of the committee, opened the hearing by insisting the promises of zero tolerance by military officials meant little if jury verdicts could be held aside and a single convening authority had sole discretion to set aside guilty verdicts and sentences, or to reverse a jury verdict. Senator Gillibrand’s concern – echoed by first panelist Senator Barbara Boxer (CA) – was directed at the recent action by Air Force Lt. General Craig Franklin to overturn the guilty verdict in the case of Lt. Col. James Wilkerson, a former inspector general at Aviano Air Force Base in Italy. The incident is currently being reviewed under order by incoming Secretary of Defense Chuck Hagel. Sen. Boxer insisted the single take away from the hearing should be to remove the ability to void decisions of the military justice systems from single individuals.

The panel immediately following Sen. Boxer consisted of four veterans who were survivors of sexual assaults in the military who were present to relate their experiences with the military’s system for handling such incidents. These veterans: were Anu Bhagwati, Executive Director and Co-Founder of the Service Women’s Action Network (SWAN) and a Marine Corps veteran; BriGette McCoy, a former US Army SPC; Rebekah Havrilla, a former Army EOD SGT; and Brian K. Lewis, a former Petty Officer 3rd Class. The presence of Mr. Lewis was of particular note, because as various members of the panel noted, although a large percentage of those assaulted in the military are men (approximately 10,700 of 19,000 assaulted in 2011 according to DoD estimates) very few men have come forward to speak about the issue, sometimes leading people to think of sexual assault in the military as a "woman’s problem."

The stories of the veterans were tragic. SPC McCoy, after the convening authority determined her assailant should make an apology to her reported the person "pulled up next to me on Post, rolled down the window and muttered ‘sorry’ and drove off. Command considered that fine." Petty Officer Lewis stated he was directed by his command not to report the incident, and that they refused to accept his report, despite the sailor in question later assaulting other men. Perhaps most horrific was the story of SGT Havrilla, who had to endure not only pictures of the event surfacing on the internet, but also being told by a chaplain she was sent to for counseling "Maybe the rape was God’s way of telling you that you need to come back to the Church?" Sen. Lindsey Graham (SC), the Ranking Member of the committee and a thirty-year veteran of the US Army JAG Corps, expressed sympathy and outrage at the action and told SGT Havrilla "You don’t have to say it out loud in front of the room, but if you can tell us the name of that chaplain, this Committee is going to want to have words with him."

Graham noted that no service member should ever have to deal with this kind of threat from their own allies, and that freedom from these fears is essential to the good order and discipline necessary to preserve an effective fighting force. For his part, he advocated for victim’s advocates to be provided to anyone who suffered an assault, to help them navigate the system. The victims noted this may help somewhat, but were skeptical of any advocate’s ability to override the determinations within the command structure. What became clear from a number of people was the problems inherent with the investigatory and decision-making powers residing within the chain of command. SWAN advocated for removal of the authority for these investigations and trials to outside the chain of command, to independent structures within the military not unlike special victims’ units in police forces.

The American Legion’s concerns with Military Sexual Trauma (MST) in an active duty sense largely revolve around the problems these veterans later face with claims for disability and treatment. By resolution The American Legion advocates for the same standard of evidence to apply in PTSD cases for MST as for combat, as both situations reflect a lack of concrete records in the service files. The American Legion also advocates for the military to retain records of the incidents indefinitely, as many of the records related to this are destroyed in three to five years.

House VA Committee Hearing Examines VA Patient Wait Times

On Thursday, March 13, 2013, the House Veterans’ Affairs Committee held a hearing to examine the state of the Veterans Health Administration (VHA) with regard to the time that veterans are waiting to be seen for appointments. On hand to offer their testimony were

- Mr. William Schoenhard, FACHE, Deputy Under Secretary for Health for Operations and Management, VHA, Department of Veterans Affairs (VA);

- Mr. Thomas Lynch, M.D., Assistant Deputy Under Secretary for Health Clinical Operations and Management, VHA

- Mr. Philip Matkovsky, Assistant Deputy Under Secretary for Health for Administrative Operations, VHA;

- Mr. Michael Davies, M.D., National Director of Systems Redesign, VHA;

- Ms. Debra A. Draper, Director, Health Care, Government Accountability Office; and,

- Mr. Roscoe Butler, National Field Service Representative Veterans Affairs and Rehabilitation Commission, The American Legion.

Ms. Draper’s testimony focused on problems and shortcomings in VHA’s scheduling system, which creates the inordinate wait times experienced by many veterans based on studies done by the GAO. Her statement was drawn from and highlighted key findings of a GAO report which was published in December, 2012 entitled Appointment Scheduling Wait Oversight and Wait Time Measures Need Improvement (GAO-13-372T). She noted that "inconsistent implementation of certain elements of VHA’s scheduling policy…impedes VAMSs from scheduling timely medical appointments." Further, incorrect recording of the desired date of the appointment has resulted in a reported wait time shorter than that actually experienced by the veteran. In some cases, she said "staff [reported that] they change medical appointment desired dates to show clinic wait times within VHA’s performance goals." That is, it is being reported that data is intentionally being manipulated to show shorter wait times than are actually being experienced by the veteran. She noted that VHA is working to implement "a number of initiatives to improve veterans’ access to care; using medical technology to provide care; using technology to provide care…and using care outside of VHA." She stated that GAO recommended four specific actions: 1. Improve the reliability of its medical appointment wait time measures; 2. Ensure VAMCs consistently implement VHA’s scheduling policy; 3. Require VAMCs to routinely assess scheduling needs for purposes of allocation of staffing resources; and, 4. Ensure that VAMCs provide oversight of telephone access and implement best practices to improve telephone access for clinical care.

Mr. Butler’s testimony echoed many of the concerns highlighted by Ms. Draper and the GAO, including unreliable reporting and delays in finding and applying workable solutions. Mr. Butler’s written testimony included an attachment containing several statements reported by American Legion Department Service Officers from across the country, providing the committee with real-life, first-hand testimony regarding the conditions being experienced on the ground. Also attached were Legion resolutions pertaining to the issue: Resolution No. 40 Extended Hours and Weekends for Veterans Health Care; Resolution No. 42 Virtual Lifetime Electronic Record; and Resolution No. 44 Decentralization of Department of Veterans Affairs Programs. The American Legion’s testimony offered three recommendations: 1. Devote full effort towards filling empty staff positions; 2. Develop a better plan to address appointments outside traditional business hours; and, 3. Improve the IT solution.

Mr. Schoenhard’s testimony acknowledged the shortcomings of the VHA with regard to veteran wait times. "Determining a reliable and valid way to measure timeliness has been difficult" he said. "We now know that some of our reporting on wait times was not as reliable as our Veteran patient and stakeholders deserve." He noted a relatively new policy, established by VHA in 2011, which "established a wait time goal of 14 days, rather than 30 days, for both primary and specialty care appointments…currently, approximately 40% of new patients and 90% of established patients meet this 14 day goal" he said. In discussing the way forward, he stated that VHA intends to comply with all four of the recommendations made in the December 2012 GAO report, including improvements in documentation of dates, methodologies used to calculate wait times, scheduling policy and training, staffing, and assessment. He also noted that VHA "continues to develop technology for improving the scheduling system," and went on to say that programming for a new mobile phone application and computer program, which will allow veterans to schedule appointments from their mobile device or personal computer, has been completed and is being piloted.

Representative Mike Coffman (CO), chairman of the subcommittee and a Gulf War veteran, was not impressed, however. He chastised Under Secretary Schoenhard saying "You’ve been here, in this position since 2009. You came in (and) the system was in chaos and not serving the veterans community. You’ve been there. You haven’t made a difference. And I have no reason to think that under your leadership, unfortunately, this job is going to get done."


American Legion Legislative Council

The Legislative Division continues the task of re-building the membership of the National Legislative Council for the 113th Congress. Council recommendation forms were emailed to Department leadership in December, asking for nominations for new congressional members. Completed forms were due in the Legislative Division offices in Washington, DC by January 18. To date, 43 Departments have returned their Council nomination forms. As of March 15, the following Departments have not returned their nomination sheets: California, Connecticut, Iowa, New York, Ohio, Rhode Island, and Vermont.

The importance of the Legislative Council cannot be overstated. It is an especially important voice for The American Legion family, and the way in which members of Congress can be quickly contacted when legislative action is needed. Departments are urged to complete their nomination forms and return them to the Legislative Division offices as soon as possible.

Update on Flag Amendment Bill

On January 18, House Joint Resolution (H.J. Res.) 19 was introduced by Representative Jo Ann Emerson (MO). This legislation is a proposed constitutional amendment to protect the American flag from physical desecration. Its text states simply: "The Congress shall have power to prohibit the physical desecration of the flag of the United States."

The next task is finding cosponsors for this legislation. Please contact the offices of your representative and senators, and ask them to become cosponsors of the flag amendment in their respective chambers. [Res. 272-2012]