Veterans' Health Care Issues
Prepared for Members and Committees of Congress
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
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 th
rising health care costs, the 110 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 th
the CARES initiative in the previous Congress, the 110 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.
Introduc tion ..................................................................................................................................... 1
Overvi ew ....................................................................................................................... ............ 1
Department of Veterans Affairs (VA)........................................................................................2
Veterans’ Health Care System...................................................................................................3
Veterans Health Information Systems and Technology Architecture (VistA).....................4
Eligibility for Veterans’ Health Care.............................................................................................10
“Promise of Free Health Care”................................................................................................10
VHA Health Care Enrollment..................................................................................................11
Medical Care for Returning Injured Servicemembers...................................................................14
Overvi ew ....................................................................................................................... .......... 14
OEF and OIF Veterans............................................................................................................15
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
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
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 FY2002-
FY2006 ....................................................................................................................................... 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
Appendix. Priority Groups and Their Eligibility Criteria..............................................................50
Author Contact Information..........................................................................................................51
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 1
retired pay and nonmonetary benefits from DOD. 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 2
discharged or released under conditions other than dishonorable.
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 3
to active duty military personnel, and other eligible beneficiaries. 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 4
population it serves. 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.
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
1 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/.
2 38 U.S.C. §101; 38 CFR §3.1. Also see CRS Report RL33113, Veterans Affairs: Basic Eligibility for Disability
Benefit Programs, by Douglas Reid Weimer.
3 For details on the Defense Health Program, see CRS Report RL33537, Military Medical Care: Questions and
Answers, by Richard A. Best Jr.
4 For detailed information on veterans’ benefits issues see, CRS Report RL33985, Veteran’s Benefits: Issues in the
110th Congress, coordinated by Carol D. Davis.
general treasury sufficient for the maintenance of himself and family, or other dependent 5
r e la ti ve s . ”
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 6
to depend upon it. 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 7
care through the VA.
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 8
Administration by consolidating many separate veterans’ programs. 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 9
Appeals (BVA) renders final decisions on appeals on veteran benefits claims.
5 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.
6 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 Sidath Viranga Panangala.
7 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.
8 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.
9 For details on the appeals process, see CRS Report RL33704, Veterans Affairs: The Appeal Process for Veterans’
Claims, by Douglas Reid Weimer.
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 11
and budgetary responsibilities are delegated to the VISNs. Congressionally appropriated
medical care funds are allocated to the VISNs based on the Veterans Equitable Resource 12
Allocation (VERA) system, which generally bases funding on patient workload. 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 13
community-based outpatient clinics (CBOCs), 45 residential rehabilitation treatment programs,
and 209 Vet Centers (generally these are community-based, non-medical facilities that offer 14
counseling services). 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 15
Program of the Department of Veterans Affairs (CHAMPVA). 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 16
quality measures.” 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
10 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.
11 Jian Gao, Ying Wang and Joseph Engelhardt, “Logistic Analysis of Veterans’ Eligibility-Status Change,” Health
Services Management Research, vol. 18, (August 2005), p. 175.
12 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.
13 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; Miami-
Globe, 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.
14 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.
15 For further information on CHAMPVA, see CRS Report RS22483, Health Care for Dependents and Survivors of
Veterans, by Sidath Viranga Panangala and Susan Janeczko.
16 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).
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 18
other countries struggling to use their healthcare resources appropriately. Furthermore, VA has
led private-sector health care in the American Customer Satisfaction Index for both inpatient and 19
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 long-
term 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 20
single integrated patient record. 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 21
drug to the patient. The overall cost of maintaining the VistA system is $87 per patient annually.
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
17 Feasby, Thomas E., “Is the Canadian health care system better for neurologic care?” Neurology, 2006; 67: 1744-
18 Veterans Health Administration, HealthcarePapers vol. 5 no. 4, 2005.
19 See http://www.theacsi.org/, accessed January 23, 2007.
20 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.
21 Caron Golden, “VA’s Model of Success,” Government Leader, November/December, 2006, p. 27.
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 22
at other VA facilities.
22 See http://www.excelgov.org/UserFiles/VA%20VistA%20release%20finale.pdf.
Figure 1. Veterans Integrated Services Networks (VISNs)
Source: 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.
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 23
to the number of veteran deaths exceeding the number of new separations from the military. 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 24
episodes of care. According to VHA estimates, the number of unique veteran patients is 25
estimated to increase by approximately 109,000 between FY2007 and FY2008. 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.
23 U.S. Department of Veterans Affairs, Office of the Secretary, Strategic Plan FY2006-2011, October 2006, p.11.
24 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.
25 U.S. Department of Veterans Affairs, FY2008 Congressional Budget Submissions, Medical Programs, vol. 1 of 4,
Figure 2. Veteran Population by State as of September 30, 2006 (in thousands)
Source: Department of Veterans Affairs.
Figure 3. Percent of Veterans Enrolled in the VA Health Care System by VISN,
Source: Department of Veterans Affairs.
Figure 4. Number of Patients by VISN, FY2005
Source: Department of Veterans Affairs.
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 26
care for life,” not every veteran is automatically entitled to medical care from VA. Prior to
eligibility reform in 1996, all veterans were technically eligible for some care, however, the actual 27
provision of care was based on available resources.
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 28
services through an enrollment system based on a system of priorities. 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 29
known as “higher priority” or “core” veterans. 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 30
enrollment system would operate.
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 31
26 For a detailed discussion of “promised benefits,” see CRS Report 98-1006, Military Health Care: The Issue of
“Promised” Benefits, by David F. Burrelli.
27 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_3-25-
28 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.
29 Ibid. p.5.
30 Ibid. p.6.
31 Ibid. p.5.
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 32
when care will be provided and the level at which care will be furnished.”
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 33
meet special eligibility requirements. 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 34
completed form to the medical center or clinic of the veteran’s choosing. 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 on-
1 line 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
Step The local VA health care facility receives the application for enrollment and intake staff enter the data into
2 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.
Step 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
4 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.
Step The Enrollment System queries VBA to reconfirm the compensation and pension and/or military status.
5 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.
Step The Enrollment System verifies the veteran’s enrollment eligibility and shares this data with VistA (at the
6 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.
32 Ibid. p.4.
33 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%).
34 VA Form 10-10EZ is available at https://www.1010ez.med.va.gov/sec/vha/1010ez/#Process.
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
Source: 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 35
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 service-
connection for any injury, heart attack, or stroke that occurs while performing duty ordered by a 36
governor for state emergencies or activities.
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,
35 38 C.F.R. §17.36 (d)(3)(iv) (2005).
36 38.U.S.C. §101(24); 38 C.F.R. §3.6(c).
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
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 38
in Priority Group 7 or 8 (see the Appendix).
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
37 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%.
38 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).
surgical supplies; and durable medical equipment and prosthetic and orthotic devices, including
eyeglasses and hearing aids.
The National Strategy for Combating Terrorism issued in September 2006, stated that the “War 39
on Terror will be a long war.” 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 th
health care costs, the 110 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 40
OEF and OEF operations about 10% of those injured have died. In November 2007, DOD
reported that over 30,000 servicemembers have been wounded in action since the beginning of 41
OEF and OEF. 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 42
DOD and VA health care and disability systems are problematic. It should be noted that injured
servicemembers receiving care in VA health care facilities are not considered veterans until they 43
are formally discharged from active duty service.
39 National Security Council, National Strategy for Combating Terrorism, September 2006, p.19, available at
40 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.
41 Data current as of November 24, 2007 http://www.defenselink.mil/news/casualty.pdf.
42 The President’s Commission on Care for America’s Returning Wounded Warriors, July 2007, p.2, available at
43 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
Since the onset of OEF and OIF, more than 1.6 million servicemembers have served in these two 44
theaters of operation, making them potentially eligible for veterans benefits. Since FY2002, 45
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 FY2002-rd
FY2006 and do not reflect the most recent data presented above, which includes FY2007 3
extensive, comprehensive health care system that could be used to assist DOD in caring for such personnel.
44 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.
45 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.
Figure 5. Frequency of Major Diagnoses among OEF and OIF Veterans
Source: 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.
Figure 6. Cumulative Number of OIF and OIF Veterans Discharged from FY2002-
FY06 New Discharges631,174
650,000FY05 New DischargesFY04 New Discharges
82,243600,000FY03 New Discharges548,931
550,000FY02 New Discharges
88, 609 88,60950 0, 000 460, 322
45 0, 000
179,110 179,110 179,11035 0, 00040 0, 000
30 0, 000 281, 212
25 0, 000
171,870 171,870 171,870 171,87020 0, 000
15 0, 000 109, 342
109,3425 0, 00010 0, 000
FY 2002FY 2003FY 2004FY 2005FY 2006
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 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.
Figure 7. Cumulative Unique OIF and OEF Veteran Patients and OIF and OEF
Discharges from FY2002 thru FY2006 Compared with Annual Number of Unique
Di s c h a r g e s
209,30817 205,097 1553,5
109,342 63 59,4 126,819,822 56,703 1063150,000
2,5 13,085 132,550,000
-50,000FY 2002FY 2003FY 2004FY 2005FY 2006FY 2007FY 2008
Source: Department of Veterans Affairs.
In March, VA testified that the number of severely injured or ill active duty servicemembers and 46
veterans that have transitioned from DOD to VHA facilities is over 6,800; of these 342 have 47
been polytrauma patients. VHA defines polytrauma as “injury to the brain in addition to other
body parts or systems resulting in physical, cognitive, psychological, or psychosocial 48
impairments and functional disability.”
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 49
amputations) from OEF and OIF, including veterans and active duty servicemembers.
46 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 thst
Servicemembers’ Seamless Transition into Civilian Life—The Heroes Return, 110 Cong., 1 sess., March 8, 2007.
47 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 thst
Agencies, hearing on FY 2008 funding for the Veterans Health Administration, 110 Cong., 1 sess., March 6, 2007.
48 Department of Veterans Affairs, Veterans Health Administration Directive. Polytrauma Rehabilitation Centers.
Washington (DC): Veterans Health Administration; Jun 8, 2005, p. 2.
49 Data provided by the Department of Veterans Affairs.
Table 2. VA Spending and Number of OIF and OEF Veteran Patients
FY2005 actual FY2006 actual FY2007 estimate FY2008 estimate
Obligationsa $232,500,000 $404,840,000 $572,562,000 $752,438,000
OEF/OIF 100,808 155,272 209,308 263,345
per $2,306 $2,607 $2,736 $2,857
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.
In 2003, several injured servicemembers or their parents testified on the obstacles faced during 50
the transition from DOD’s health care system to VHA.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 51
problematic. 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 52
members do not facilitate quick and accurate enrollment into VA programs.”
In March 2005, the Government Accountability Office (GAO) testified that VA still does not have 53
systematic access to DOD data about returning servicemembers who may need its services.
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 54
health information between DOD and VA is limited. In March 2007, GAO testified that despite
coordination efforts by DOD and VA, these two Departments were still having problems sharing 55
medical records. Among other things, the recently appointed Task Force on Returning Global
50 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,
51 For detailed information on issues related to disability evaluation of returning servicemembers see, CRS Report
RL33991, Disability Evaluation of Military Servicemembers, by Christine Scott, Sidath Viranga Panangala, and
Charles A. Henning.
52 The President’s Task Force to Improve Health Care Delivery for Our Nation’s Veterans, Final Report, May 2003, p.
53 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.
54 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.
55 U.S. Government Accountability Office, DOD and VA Health Care: Challenges Encountered by Injured
Servicemembers during Their Recovery Process, GAO-07-606T, p 4.
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 56
and VA” 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 57
and rehabilitation programming across the two Departments.
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 58
remain in Germany for a period of about 4 to five days. 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 59
Houston, Texas. BAMC has also established a specialized amputee rehabilitation center.
56 Task Force on Returning Global War on Terror Heroes, Executive Summary, p.2.
57 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/.
58 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,
59 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.
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
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 60
McGuire VAMC, Richmond, Virginia. 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
60 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.
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 61
discharge planning process. Table 3 provides an brief summary of VHA’s polytrauma system of
61 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. thst
Congress, House Committee on Veterans Affairs, Subcommittee on Oversight and Investigations, 110 Cong., 1 sess.,
March 8, 2007.
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
• 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
• 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
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
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
• 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
62 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,
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 63
servicemember within 24 hours. 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 64
functional and cognitive needs.”
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
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 65
able to access resources necessary to implement the recovery plans. As reported recently by 66
GAO, the Army and the Senior Oversight Committee’s workgroup on case management “have
initiated efforts to develop case management approaches that are intended to improve the 67
management of servicemembers’ recovery process.” 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) 68
63 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
64 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. thst
Congress, House Committee on Veterans Affairs, Subcommittee on Oversight and Investigations, 110 Cong., 1 sess.,
March 8, 2007.
65 The President’s Commission on Care for America’s Returning Wounded Warriors, July 2007, pp5-6.
66 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.
67 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.
68 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.
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
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 69
demobilization process and as service personnel return to their local communities.
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
69 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.
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 70
and the Under Secretary of Defense. 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
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
• 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 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
70 For more information on the JEC, see VA/DOD Joint Executive Council, Fiscal Year 2006 Annual Report, at
71 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 Richard A. Best Jr.
manager must contact the service member/veteran within 7 calendar days of
notification of the transfer.
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 72
needs of veterans returning from the Vietnam War. 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 73
2007 and 2008. 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
72 Established by the Veterans’ Health Care Amendments of 1979 (P.L. 96-22).
73 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.
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 74
expects to add staff to 61 existing facilities to augment the services these centers provide.
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 76
183,530 veterans and clinical services to 58,504 veterans. 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.
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, 77
VA and DOD have been working toward an interoperable medical record. 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.
74 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 thst
Servicemembers’ Seamless Transition into Civilian Life—The Heroes Return, 110 Cong., 1 sess., March 8, 2007.
75 For a list of who is eligible for Vet Center services, see http://www.va.gov/RCS/Eligibility.asp.
76 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 st
Cong., 1 sess., October 17, 2007.
77 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.”
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.
Figure 10. Milestones and Plans for Exchange of Medical Information
Source: DOD presentation to CRS, July 10, 2007, adapted by CRS Graphics
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 79
Application (JPTA) 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
78 Bob Brewin, “VA to debut new patient tracking system,” Government Executive, April 20, 2007. Available at
79 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.
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 80
copayment requirements. For information on legislation to expand eligibility, see section on
“Veterans Health Care Legislation” below.
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 81
combat theaters in support of OEF and OIF. 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 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
• 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
• Standardize VA Liaison agreements across all military treatment facilities.
80 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 service-
connected 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.
81 Dana Priest and Anne Hull, “Soldiers Face Neglect, Frustration At Army’s Top Medical Facility,” Washington Post,
February 18, 2007.
82 The Task Force on Returning Global War on Terror Heroes, Report to the President, p. 3.
• 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
• 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
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 83
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,
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.
83 Alan West and William Weeks, “Veterans Before, During, and After the Invasion of Iraq,” Psychiatric Services, vol.
57. no. 2 (Febrary 2006).
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 84
also experience a major depressive or other psychiatric disorder. Studies investigating rates of
comorbidity for PTSD and lifetime prevalence of alcohol abuse have indicated rates from 68% of 85
individuals with PTSD to as high as 82%.
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.
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 86
have been found to have a TBI. 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 87
be associated with TBI. Of the 61,285 veterans that VA has screened for TBI to date, 11,804
84 National Academies, Institute of Medicine, Posttraumatic Stress Disorder: Diagnosis and Assessment, 2006.
85 National Academies, Institute of Medicine, Posttraumatic Stress Disorder: Diagnosis and Assessment, 2006, p.13.
86 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.
87 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
(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 88
functions, these individuals may overreact to seemingly innocent or neutral stimuli.
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 89
events. Hence, traumatic recall does not have to be accurate or factual to be part of PTSD.
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 90
active-duty military, and veterans).
identified by this questionnaire as possibly having a TBI will not, in fact, receive that diagnosis upon a subsequent in-
88 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.
89 Peleg T, Shalev AY, “Longitudinal Studies of PTSD: Overview of Findings and Methods,” CNS Spectrum, vol 11,
no. 8, pp. 589-602, 2006.
90 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.
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 91
programs is an appropriated entitlement that is funded through annual appropriations. 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
91 For a detailed explanation on appropriated entitlements, see CRS Report RS20129, Entitlements and Appropriated
Entitlements in the Federal Budget Process, by Bill Heniff Jr.
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 92
responsive to change” 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 93
spending for other government programs, primarily Medicare and Medicaid.”
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 94
budget reconciliation language, which would limit spending on veterans’ health programs. 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 95
computing annual funding.”
The Veterans Health Care Full Funding Act (H.R. 1041), Mandatory Funding for Veterans Act of
introduced in the 110 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.
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 96
temporarily suspend enrolling Priority Group 8 veterans. Those who were in VA’s health care
92 House Committee on Veterans’ Affairs, “Committee Hears Legislative Views of Millions of Veterans,” press release,
September 20, 2006.
93 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.
94 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.
95 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.
96 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
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 97
services because of the tremendous increase in the number of veterans seeking care from VA.
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
cumulative FY2006 FY2007 FY2008
FY2003 FY2004 FY2005 through cumulative cumulative cumulative
cumulative cumulative cumulative August 2006 estimate estimate estimate
93,228 192,419 263,257 327,457 830,203 1,254,460 1,570,503
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 98
death rates for these veterans and the continued suspension of new enrollments. In 2004, VA
estimated that resumption of enrollment for Priority Group 8 veterans would require an additional 99
$519 million over the FY2005 requested VHA budget, and an estimated $2.3 billion in FY2012.
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 100
own estimates of what it would cost to reopen the system to Priority Group 8 veterans.
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).
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
97 For detailed information on the FY2007 veterans health care budget see, CRS Report RL33409, Veterans’ Medical
Care: FY2007 Appropriations, by Sidath Viranga Panangala.
98 Department of Veterans Affairs, FY2006 Budget Submission, Medical Programs, vol. 2 of 4, pp. 2-4.
99 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.
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 service-
connected 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 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. 102
The TPB included most, but not all, of the drugs listed on the VA National Formulary (VANF).
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
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 38 U.S.C. § 1712(d); 38 C.F.R. §17.96.
102 A formulary is a list of drugs approved for coverage under a drug benefit.
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 103
as $35 million a year to maintain.
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 high-
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
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 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.
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 105
to redirect those funds to patient care.
Table 5. Timeline of Major CARES Activities
Date Activity Description
February VA announced the results The pilot study assessed current and future use of health care assets in
2002 of a pilot CARES study. 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.
August VA’s Under Secretary for The Under Secretary’s Draft National CARES Plan included
2003 Health presented the Draft recommendations about health care services and capital assets in VA’s
National CARES Plan. remaining 74 markets. These recommendations reflected input from
managers of VA’s health care networks.
February An independent CARES An independent 16-member commission appointed by the Secretary of
2004 Commission issued Veterans Affairs issued recommendations to the Secretary based on its
recommendations. 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.
May 2004 VA’s Secretary announced The Secretary based his decisions on a review of the CARES
the CARES decisions. Commission’s recommendations.
January CARES follow-up studies. VA awarded a contract for additional studies at 18 VA facilities. These
2005 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.
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,
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 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 107
Decision. 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 108
projects that were identified in the CARES process. 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.
Table 6. CARES Decisions on the 18 Sites
Study Site CARES Decision
Boston, MA The contractor’s final report proposed closing four Boston VAMCs and creating a single
(VISN 1) 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.
Canandaigua, NY After reviewing the contractor’s final report, the Secretary rejected all proposals to move
(VISN 2) 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.
Montrose/Castle Based on the contractor’s final report, the VA decided to maintain the current residential
Point, NY treatment program and build a multi-specialty ambulatory care facility at the Montrose campus.
(VISN 3) Furthermore, VA would completely modernize the Castle Point campus.
New York City, Based on the contractor’s final report, the Secretary has decided to retain the existing VAMCs
NY (VISN 3) in both Brooklyn and Manhattan.
St. Albans, NY Based on the contractor’s final report, the Secretary has decided that VA would replace
(VISN 3) existing facilities at St. Albans with a new nursing home, outpatient clinics and a domiciliary
consolidated on the north end of the campus.
Perry Point, MD After reviewing the contractors report and the recommendations of the Local Advisory Panel
(VISN 5) (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.
Montgomery, AL Based on the contractor’s final report, the Secretary has decided to continue inpatient services
(VISN 7) at the Montgomery facility.
Louisville, KY Based on the contractor’s final report, a new medical center will replace the current facility.
(VISN 9) 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.
Lexington, KY After reviewing the contractor’s final report, the Secretary requested the contractor to
(VISN 9) 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.
Poplar Bluff, MO After reviewing the contractor’s report and the recommendations of the Local Advisory Panel
(VISN 15) (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.
Biloxi, MS Hurricane Katrina obviated the need for this study because the facility was destroyed. Future
(VSIN 16) construction requirements are being addressed through emergency appropriations in response
to Hurricane Katrina.
Muskogee, OK After reviewing the contractor’s recommendations the Secretary decided to maintain inpatient
(VISN 16) services at the Muskogee VAMC and to expand psychiatric services.
Study Site CARES Decision
Waco, TX The Military Quality of Life, Military Construction, Veterans Affairs, and Related Agencies
(VISN 17) 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
Big Spring, TX The contractor’s final report did not recommend the closure and transfer of inpatient care,
(VISN 18) 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.
Walla Walla, WA After reviewing the contractor’s final report, the Secretary rejected options to close the Walla
(VISN 20) 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.
White City, OR After reviewing the contractor’s final report, the Secretary has decided that VA will not
(VISN 20) 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
Livermore, CA After reviewing the contractor’s final report, the Secretary requested the contractor to
(VISN 21) 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.
West LA, CA After reviewing the contractor’s final report, the VA has decided to completely modernize the
(VISN 22) 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.
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 109
published final regulations that sharply curtailed eligibility for the beneficiary travel program.
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.
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
• 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 110
determination was made regarding the veteran’s ability to bear the cost of such transportation.
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.
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 service-
• 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
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.
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
1-800-273-TALK , is staffed by mental health professionals 24 hours a day, 7 days a
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.
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.
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
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
Carol D. Davis.
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
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 service-
connected 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.
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
S. 1233, as amended, was ordered to be reported by the Senate Veterans’ Affairs Committee on 112
June 27, 2007. 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 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, 114
and to respond to any proposed limitation on enrollment.” Furthermore, it is the view of the
committee that when resources are provided by Congress to enable the VA to keep pace with 115
demand for services, the VA health care system should be open to all veterans who seek care.
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.
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 nonservice-
connected 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.
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
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
Subpriority e: Noncompensable 0% service-connected veterans applying for enrollment after January 16, 2003
Source: Department of Veterans Affairs.
Sidath Viranga Panangala
Analyst in Veterans Policy