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Improving Care for America’s Wounded Warriors
Chairman Filner Calls on Pentagon and VA to Address the Need for Improved Continuum of Care Services and Programs

June 11, 2008

On Wednesday, the House Committee on Veterans’ Affairs, led by Chairman Bob Filner (D-CA), held a hearing to examine the progress that has been made in implementing the wounded warrior provisions in the National Defense Authorization Act of 2008 (NDAA).  The hearing also explored barriers to implementation and analyzed what additional actions need to be taken by the Department of Defense (DOD) and the Department of Veterans Affairs (VA) to enhance the care given to wounded service members and veterans. 

“No matter where we stand on the war in Iraq, we all stand together in our desire to make sure that our returning service members get the seamless health care they need, and the benefits they have earned,” commented Chairman Filner.  “These seriously injured veterans have a right to get on with their lives and focus on their recovery – not deal with endless paperwork and a stubborn bureaucracy.  We have lost the trust of many and we have a long way to go to provide the care worthy of their service and sacrifice.  We must be prepared to welcome back every soldier, sailor, airman and marine with all the compassion this grateful nation can bestow.”   

In February 2007, a series of Washington Post articles detailing the poor living conditions and a general lack of coordinated care for outpatients at Walter Reed Medical Center highlighted the challenges our veterans face and illustrated a break in faith with our troops. 

On March 28, 2007, the House of Representatives passed H.R. 1538, the Dignified Treatment of Wounded Warriors Act, to address the problems facing wounded service members and improve their transition from the militarynhj to the VA.  This language was inserted into the NDAA which was signed by the President on January 28, 2008. Among the key provisions to improve care for veterans and their families, the NDAA:

  • Provides an additional three years of access to free VA health care for returning service members from Iraq and Afghanistan;
  • Improves and expands VA’s ability to care for veterans returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom OEF) with traumatic brain injury (TBI), including research, screening, care coordination, and working with non-VA providers to provide the care needed by our veterans;
  • Requires a comprehensive policy to address mental health conditions, including post-traumatic stress disorder (PTSD);
  • Requires DOD and VA to streamline the records transmission process, including moving forward with fully interoperable medical records;
  • Provides for a more seamless transition between active duty and veterans’ status, including a single physical exam for DOD and VA benefits;
  • Creates Wounded Warrior Resource Center to serve as a single point of contact for service members, their families, and primary caregivers to report issues with facilities, obtain health care, and receive benefits information;
  • Requires VA to provide age-appropriate nursing home care for our veterans;
  • Allows members of the National Guard and Reserves that are eligible for Reserve Educational Assistance Program (REAP) to use their education benefits for ten years after separation;
  • Requires a study on the feasibility of streamlining statutory provisions addressing GI Bill benefits for active duty and guard and reserves.

Certain provisions of the NDAA require VA and DOD to collaborate to improve the care, management, and transition of recovering service members.  The hearing focused on the sections of the law which address wounded warrior matters (Title XVI) and the progress the two Departments have made in implementing these provisions.

The first panel focused on an April 2008 report from the Rand Corporation, “Invisible Wounds of the War.”  Dr. Lisa Jaycox presented the key findings on psychological and cognitive injuries in her testimony:

“Our study revealed a high prevalence (18.5%) of current PTSD and depression among servicemembers who had returned from OEF or OIF, as well as significant gaps in access to and the quality of care provided to this population. Too few of those with PTSD and depression were getting help, and among those that were getting help too few were getting even minimally adequate care. If left untreated or under-treated, these conditions can have negative, cascading consequences and result in a high economic toll. Investing in evidence-based care for all of those in need can reduce the costs to society in just two years.

“With respect to TBI, we found that approximately 19% report having experienced a probable TBI during deployment but that 57% of them had not been evaluated by a physician for a head injury. While the majority of these cases were likely to be mild, similar to a concussion, the extent of impairment in this group remains unknown. At the same time, the science of treating combat-related traumatic brain injury remains in its infancy leaving many unknowns for planning and delivering high quality care to those suffering from long-term impairments associated with TBI.”

Chairman Filner responded: “The Rand study found that some 300,000 troops are suffering from PTSD or depression and 320,000 have experienced brain injuries.  I personally think these already seriously troubling numbers are low estimates of the reality facing our troops and veterans.  And this number is ten times higher than the official casualty statistic from the Pentagon!”   

Study Co-Director Terri Tanielian offered recommendations to the Committee on how best to address the psychological and cognitive injuries among service members returning from OEF and OIF.  Recommendations included increasing the number of providers, closing the quality gap by providing system-wide evidence-based treatments, and investing in research.  Tanelian suggested changing health care policy to urge service members to seek care off-the-record, off-duty, and off-base before symptoms and problems grew to be unmanageable.  Dr. Jaycox recommended that the military actively work to make it acceptable and seen as a sign of strength to seek mental health treatment post-deployment. 

Tanielian suggested that system-level conditions for military, VA, and private sector health care must change nation-wide.  In her research, she found that health care provided by the VA was superior to other options and attributed this to “investment in research as well as in training, and rolling out evidence-based practice guidelines to train providers in the delivery of evidence-based care, and well as the use of tools that they have within the system such as the electronic medical record that would enable them to monitor care.” 

Chairman Filner recommended a more comprehensive evaluation process and remarked that “currently, there are no mandatory evaluations for our troops and veterans – evaluations that would entail spending one hour with a qualified mental health care professional who could interview and observe the soldier or veteran.  I think the best approach is while on active duty, DOD should provide an evaluation, not a screening using a questionnaire, and the VA should provide the veteran consistent follow-up evaluations.  Right now, they are leaving the military with undiagnosed TBI and PTSD, which causes enormous problems for themselves, their communities, and their families.  I think we have a long way to go and the need is so great.”

Panel discussions also focused on predictors for heightened risk for PTSD and depression.    According to the Rand report, the single best predictor that drives the rate of PTSD and depression among service members is the number of combat traumas experienced.  Particularly in the current conflicts, it is common to be exposed to an explosion or face a life-threatening situation, regardless of whether your military occupational specialty involves combat duty. 

Representatives from the DOD and VA comprised the second panel and discussions focused on details of implementation of the NDAA and responses to the Rand report.  Rear Admiral Patrick Dunne (Retired), Acting Under Secretary for Benefits and Assistant Secretary for Policy and Planning, reported that VA is making “demonstrable progress in implementing the provision of the Wounded Warrior Act” of the NDAA.  

Michael L. Dominguez, Principal Deputy Under Secretary of Defense for Personnel and Readiness, offered testimony to update the Committee on improvements implemented and planned for the care, management, and transition of wounded, ill, and injured service members.  He assured the Committee that DOD has dedicated a huge portion of energy and attention to fixing the continuum of care for wounded service members, accomplished much while realizing much more needs to be done, internalized the importance of the mission, and will sustain momentum through the end of 2008 and during the upcoming transition to the next administration. 

Dominguez found that the Rand report finding that 300,000 service members have “experienced some kind of mental health stress is very consistent with our data.  And those people do need to be discovered.  They need to get help.  Many of them will, with very little counseling or assistance, resolve those combat stress issues themselves.  A few, a few, will in fact manifest a clinical diagnosis of PTSD and they’ll need much more sustained intervention by medical health care professionals.”  When asked to clarify “a few,” Dominguez responded that within the DOD system less than one percent will actually have clinical PTSD that would need treatment. 

Filner responded: “I think there has been a contest here between the VA and DOD to see who can suck the humanity out of this issue the best.  Do military leaders really believe that less than one percent of deployed soldiers will have PTSD as a clinical diagnosis?  This is absolutely unacceptable.  We are talking about suicides, homelessness, a lifetime of living with brain injuries.  This is most certainly a matter of life and death!  Our veterans deserve increased attention and a strong investment in improving the services and programs that are available at the DOD and VA.  Congressional leaders anticipate a six-month interim report on this issue by July 2008 and we expect a specific focus on PTSD, TBI, and depression, in order to bring about positive change at the VA and DOD in providing care for our soldiers and veterans.”   

The opening statements of all the witnesses and a link to the webcast are available on the Committee website at   


Panel 1

  • Lisa H. Jaycox, Ph.D., Senior Behavioral Scientist, RAND Corporation
  • Terri L. Tanielian, MA, Senior Social Research Analyst, Co-Director, Center for Military Health Policy Research, RAND Corporation

 Panel 2

  • Michael L. Dominguez, Principal Deputy Under Secretary of Defense for Personnel and Readiness, U.S. Department of Defense
  • Rear Admiral Patrick W. Dunne, USN (Ret.), Acting Under Secretary for Benefits and Assistant Secretary for Policy and Planning, U.S. Department of Veterans Affairs
    Accompanied by
    • Madhulika Agarwal, M.D., Chief Patient Care Services Officer, Veterans Health Administration
    • Paul A. Tibbits, M.D., Deputy Chief Information Officer, Office of Enterprise Development

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