TESTIMONY OF
ANTHONY K. ODIERNO
WOUNDED WARRIOR PROJECT

BEFORE THE
COMMITTEES ON VETERANS AFFAIRS
OF THE
U.S. SENATE AND HOUSE OF REPRESENTATIVES

MARCH 30, 2011

Chairmen Murray and Miller; Ranking Members Burr and Filner; and Members of the Committees:

Thank you for inviting Wounded Warrior Project (WWP) to present our 2011 policy agenda at this joint session.  WWP was founded on the principle of warriors helping warriors, and we pride ourselves on outstanding service programs that advance that principle.  We are driven by our mission to honor and empower wounded warriors and our vision is to foster the most successful, well-adjusted generation of veterans in our nation’s history.

 I am Tony Odierno, and I am testifying this morning not only as a Member of the Board of Directors of WWP, but also as a wounded warrior myself.  While I have had a successful readjustment, I am deeply committed to the ideal of warriors carrying and caring for one another, and recognize that there is still much to be done to help my fellow servicemembers and veterans, and their families, who still face barriers on their path to recovery.
 
We appreciate the committees’ recognition of the important perspective that our organization brings to the table and we look forward to working with you on four key objectives this session:
 to ensure that severely wounded warriors have access to optimal, long-term rehabilitative care, and needed supports for their caregivers;
 to eliminate barriers to improved mental health of warriors and their families and caregivers;
 to foster the economic empowerment of wounded warriors by closing critical program gaps; and
 to improve the effectiveness of programs established to help wounded warriors and their families make the transition to successful community reintegration.
More specifically we urge your consideration of our top policy initiatives, which focus particularly on the two signature invisible wounds of this war – traumatic brain injury and post-traumatic stress. 

Implementation of Caregiver-Assistance Program
We are grateful to the Senate and House Veterans Affairs Committees for developing and shepherding to passage last year historic legislation to establish a program of comprehensive supports for family caregivers of severely wounded warriors.  As an organization that is deeply committed to the successful implementation of that law, we greatly appreciate your recent collective efforts to press VA and the Administration to “get it right.”  Your strong challenge to VA’s initial implementation plan – a plan that was not only untimely, but more importantly altogether inadequate -- sent a clear message reaffirming the congressional intent behind this law.  The Secretary’s belated acknowledgement that only 840 families would be covered next year under the VA’s astonishingly strict eligibility proposal means that another 2500 family caregivers will be ineligible, based on your projections last year.  That figure includes many full-time family caregivers who are devastated by these developments.  Working on behalf of these dedicated families, WWP was proud to join your efforts in challenging the VA plan, and pressing the Administration to reverse course.  We will continue to work with you to ensure that the program VA ultimately implements faithfully carries out the letter and spirit of your hard work.

Long-term Rehabilitative Care for Severely Wounded Warriors
Improvements in military logistics and innovations in battlefield medicine have saved the lives of many OEF/OIF warriors who would likely not have survived in previous conflicts. As a result, unprecedented numbers have suffered severe polytraumatic injuries, requiring not only multiple surgeries and long convalescence, but extensive rehabilitation.  But few are more challenging than severe traumatic brain injury.

Each traumatic brain injury is unique.  Depending on the injury site and other factors, individuals may experience a wide range of problems – from profound cognitive deficits to marked behavioral changes.  Those with severe TBI may have such profound cognitive and neurological impairment that they require long years of caretaking.  But as clinicians themselves recognize, it is difficult to predict a person’s ultimate level of recovery.    To be effective in helping an individual recover from a brain injury and return to a life as independent and productive as possible, rehabilitation must be targeted to the specific needs of the individual patient.  In other words, rehabilitation must be “veteran-centered.”

While many VA facilities have dedicated rehabilitation-medicine staff, the scope of services actually provided to veterans with a severe TBI can be limited, both in duration and in the range of services VA will provide or authorize.  It is all too common for staff to advise families that VA can no longer provide a particular service because the veteran is no longer making significant progress.   Whatever the explanation for limiting the duration of a veteran’s therapy, the result can be loss of cognitive and other gains made during earlier rehabilitation.   To illustrate, consider the experience of one warrior, Iowa City’s first polytrauma patient with a severe and penetrating TBI. Despite the Iowa City VA medical center’s classification as a polytrauma treatment center, the facility was ill-equipped to handle the warrior’s cognitive and physical therapy needs.  Even after the warrior’s wife advocated for her husband to receive services at a better-equipped private facility, the VA soon terminated this care, reasoning that he was not improving quickly enough. As a result, the veteran began to fall frequently, making it necessary for VA to arrange for physical therapy through a community provider.  But VA terminated these services as well, based apparently on a policy that limited coverage to an arbitrary number of sessions.  With discontinuation of therapy, the veteran’s wife had no choice but to become his physical therapist, mimicking therapy techniques she had earlier videotaped. 

We have heard time and again from this young generation of warriors that independent living and community reintegration are of the utmost importance. Yet the VA’s rehabilitation focus relies almost exclusively on a medical model that does not necessarily provide the range of supports a young person needs to achieve the fullest possible life in the community.  In contrast, other models of rehabilitative care meet those needs through such services as life-skills coaching, supported employment, and community reintegration therapy.   But these services are seldom made available to veterans.   Yet research has shown that with these types of innovative non-medical supports, individuals with severe TBI can flourish in a community setting.  Denying wounded warriors such supports compromises their experiencing the fullest possible recovery.
 
Congress can play a critical role in closing the gaps in the rehabilitative care provided veterans with severe traumatic brain injuries.  In that regard, we applaud Chairman Miller and Congressmen Walz and Bilirakis, the original cosponsors for the introduction last year of the Veterans Traumatic Brain Injury Rehabilitative Services Improvement Act.   The legislation would clarify statutory language to ensure veterans can receive therapy to maintain rehabilitative gains, and can receive needed services to support independent living in the community.  WWP looks forward to the reintroduction of that legislation, and hopes to work with the committees to win its enactment.

Mental Health
The frequency of individual deployments to Iraq and Afghanistan, and exposure to the risk of improvised explosive devices in those war zones have contributed to a higher than expected prevalence of mental health conditions among those who have deployed.  According to a recent study among OEF/OIF veterans utilizing VA health care, 18 percent met the criteria for a diagnosis of PTSD, while an additional 14 percent met the criteria for a diagnosis of depression. 
 
Without question the VA has made earnest efforts to identify and treat mental health issues by instituting system-wide mental health screening, increasing levels of mental health staffing, conducting training on clinical techniques and an increasing focus on integrating primary care and mental health treatment. VA has reported that as of 2009 approximately 537,000, or 47% of OEF/OIF combat veterans sought care at VA facilities.  But a comprehensive study of 50,000 OEF/OIF veterans diagnosed with PTSD found that fewer than 10 percent completed the recommended course of treatment, while one in five did not have a single follow-up visit.   These data calls into question VA’s strategy for engaging and sustaining veterans in treatment for combat-stress and related mental health conditions. We know very little about the veterans who have not sought care at VA facilities, but given the documented stigma surrounding seeking help for mental health issues, particularly embodied in the military and veteran culture, we cannot assume these individuals are not experiencing distress.

Last year, Congress provided VA new direction that could help overcome young veterans’ reluctance to participate in VA treatment for PTSD.  Specifically, section 304 of the Caregiver and Veterans Omnibus Health Services Act, Public Law 111-163, directs VA with respect to OEF/OIF veterans to provide not only needed mental health services and readjustment counseling, but also peer-outreach and peer support services.  The law also directs VA to establish a national veterans training program to provide those peer services, and further directs the department to provide needed mental health services to immediate family members of returning veterans to assist in their readjustment or recovery. To date, however, these critical provisions – which were to have been implemented last November under the law – have not been carried out. Given the importance of improving OEF/OIF veterans’ retention in mental health treatment, peers can not only help normalize and de-stigmatize mental health treatment, but -- serving as clinical supports and facilitators -- can help veterans become more engaged and stay in treatment. 

Last September, WWP sponsored a warrior empowerment summit to gain a better understanding of our warriors’ experiences with PTSD and with VA’s counseling and treatment programs. Overwhelmingly our participants described frustrations with VA medical center encounters, notably with staff who lacked both an understanding of military culture and the ability to connect with combat veterans; lack of outreach; and lack of peer-support and family mental health services.  Meaningful implementation of section 304 of last year’s Caregiver Law would help close these troubling gaps.   WWP urges the Committees to press VA through your oversight to implement this important provision of law.
 
Community-Reintegration
VA mental health programs play an important role in early identification and treatment of mental health conditions.  Yet success in addressing combat-related PTSD is not simply a matter of a veteran’s getting professional help, but of learning to navigate the transition from combat to home.   In addition to coping with the often disabling symptoms, many OEF/OIF veterans with PTSD, and wounded warriors generally, are likely also struggling to readjust to a “new normal,” and to uncertainties about finances, employment, education, career and their place in the community.  While some find their way to VA programs, no single VA program necessarily addresses the range of issues these young veterans face, and few, if any, of those programs are embedded in the veteran’s community.  VA and community each has a distinct role to play.  A veteran’s transition to civilian life and successful community-reintegration must ultimately occur in that community.  For some veterans that success may take the collective efforts of many local community partners -- businesses, a community college, the faith community, veterans’ service organizations, and agencies of local government -- all playing a role.  Yet there are relatively few communities effectively organized to help returning veterans and their families reintegrate successfully. and there  are other instances where VA and veterans’ communities are not even closely aligned.  Some examples do exist, however, that suggest the linking of critical VA programs with committed community engagement can make a marked difference to warriors’ realizing successful reintegration.

With relatively few communities organized to support and assist wounded warriors, WWP urges the establishment of a grant program to provide seed money to encourage local entities to mobilize key community sectors to work as partners in support of veterans’ reintegration.  In short, a grant to a community leadership entity (which, in any given community, might be a non-profit agency, the mayor's office, a community college, etc.) could be the focal point for mounting a community group to work with a VA medical center or Vet Center to support veterans and their families on their path to community reintegration.  There is ample precedent for use of modest grants to stimulate the development of community-based coalitions working in concert with government to provide successful wraparound services.

We look forward to working with you to develop legislation that would authorize VA to provide modest grants to stimulate community initiatives to support and assist returning veterans on the path to community reintegration.

Vocational Rehabilitation and Employment
Whether a warrior is one of the more than 40,000 visibly wounded in action in Iraq and Afghanistan or one of the hundreds of thousands battling unseen, invisible injuries such as post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI),  every wounded warriors’ path to recovery must include access to the tools and skills necessary to obtain and maintain suitable employment.  That is fundamental to a successful post-service transition and a productive life.
 
VA’s Vocational Rehabilitation and Employment (VR&E) program should be a critical transitional pathway for these wounded warriors.   But while the program was designed to give service-connected disabled veterans the help they need to make a successful transition to the civilian workforce, VR&E too often fails our wounded warriors.   A weak economy and sluggish job market certainly compound the challenges they face.   But we look forward to working with the Committees in pursuing a revitalized 21st century vocational rehabilitation and employment program – one that will help achieve our vision that this become the most successful generation of veterans in our history. 

Today, however, VR&E is not up to that task.  For too long, VA has failed to make this program a real priority or to request the level of funding needed to assure that this generation of warriors is getting effective help.   Too many warriors have come to question whether VR&E is really a veteran-centered program.   It is especially troubling to learn of VR&E counselors’ blocking warriors’ aspirations by denying them access to the program of their choice – either based on misperceptions about their disabilities or by pressing them instead to pursue “any job.”   Counselors who lack experience or even training to work with individuals with severe TBI or PTSD have stymied many warriors.    

Overall, the VR&E program is notoriously short-staffed. Counselors’ caseloads have grown so large that sheer volume can compromise their capacity to provide effective service.  VA has yet to determine the appropriate staff numbers and skill levels needed to adequately serve current and future veterans program participants.   In short, far too many warriors are not receiving the skilled counseling and support they need to thrive economically.

Until recently, the law governing the VR&E program had not kept pace with veterans’ financial needs. We applaud both Committees’ work last year to eliminate a financial disincentive for veterans to pursue vocational rehabilitation.    The change in law will increase for most the subsistence allowance VA provides participants to the level provided to those pursuing education under the Post 9/11 GI Bill.   Given a marked disparity in levels of support under the two programs, financial need led many wounded warriors to elect Post 9/11 GI Bill benefits and forgo the testing, counseling, and other services VR&E affords, probably to their detriment.   We urge the Committees to press VA to implement this important change expeditiously and to work to ensure that no additional financial barriers keep disabled veterans from using this important program.

We also urge the Committees to focus on limitations associated with the VR&E’s Independent Living (IL) track. The IL Track aims to help those whose disabilities are so severe as to preclude gainful employment develop the skills necessary to live independently and increase their potential to one day return to work.   This program operates under a statutory cap, limiting access to 2700 participants annually.   Given the unprecedented numbers of returning warriors who have sustained polytraumatic and severe traumatic brain injuries in combat, and the many who remain at risk of grievous injury, it is difficult to understand the rationale for maintaining ANY cap on this program.   Enrollment in a rehabilitation program with a record of proven success in assisting service-connected disabled veterans exclusively, should surely be open to any wounded warrior who could benefit.   

Those who do participate in the program may be hampered by apparent confusion among VR&E staff as to the program’s goals.   Many in the IL program may require life-long assistance and a vocational goal or any type of employment may never be feasible. Yet, for other IL participants, having a vocational goal or participating in some type of employment, whether volunteer or part-time, can provide a sense of purpose and help the veteran achieve the fullest possible rehabilitation and a stronger sense of independence and dignity. In some instances, however, veterans participating in IL who could benefit from a vocational or work-focused goal are denied help in reaching that goal, based apparently on staff misunderstanding regarding the scope of the program. Veterans for whom future employment or some level of “work” is a feasible goal should be encouraged to pursue that goal through IL. WWP urges the Committees to press VA both to clarify that the core goals of IL include fostering future employability (whether voluntary work, part-time, or full-time employment), when feasible, and to provide appropriate training to VR&E staff to ensure that that policy is realized in practice. 

In sum, we urge the Committees to make VR&E modernization a top priority this year so that the program actually realizes it’s vital goals.   Of course, VR&E is ultimately dependent on the availability of jobs. With the unprecedented high level of unemployment among young, recently separated veterans, we also urge you to foster employment-specific measures for disabled young veterans.

Individual Unemployability Disability Ratings: Disincentive to Employment
Another problem that impedes numbers of wounded warriors from overcoming disability and regaining productive life is rooted in VA’s compensation program.  As you know, the VA disability compensation system provides for compensating veterans for service-connected conditions based on the severity of disability; the system relies on a rating schedule that is based on “average impairment of earning capacity.”  While the rating schedule provides criteria for evaluating gradations of disability – from 0% disabling to 100% -- VA regulations have long provided a mechanism to address the situation where the rating schedule would assign a less than a 100% rating but the veteran is nevertheless unable to work because of that service-connected condition.   Accordingly, in instances where a veteran has a disability rating of 60 percent of higher, or multiple disabilities with a combined total rating, VA may grant a 100% disability rating when it determines the veteran is “unable to follow a substantially gainful occupation as a result of service connected disabilities.”  This Individual Unemployability (IU) rating results in a very substantial increase in the veteran’s compensation.  But while veterans receiving IU are compensated at the same monetary level as those who receive a 100% rating, the implications for employment drastically differ. A veteran who receives a schedular rating of 100% is not precluded from gainful employment.   But for veterans receiving IU, a return to the workforce for longer than 12 months or at an income level that exceeds the federal poverty line can result in a loss of the IU benefit, and a subsequent reduction in financial compensation. For some veterans, this can spell a sudden loss of as much as $1700 in monthly income. Both the Institute of Medicine (IOM) and Veterans’ Disability Benefits Commission have recognized this decrease as a “cash-cliff” that may deter some veterans from attempting to re-enter the workforce which surely cannot be the desired effect. 

We concur with the recommendations of the IOM and VA Disability Commission that the IU benefit should be restructured to encourage veterans to reenter the workforce.  The experience of the Social Security Administration (SSA) – which has had success piloting a gradual, step down approach to reducing benefits for beneficiaries who return to employment – offers a helpful model.  SSA’s experience has shown that, for those reentering the workplace, a gradual rather than sudden reduction in disability benefits not only allowed participants to minimize the financial risk of returning to work,  but over time participants actually increased their earning levels above what they would have received in disability payments.   Inherent in this approach is the underlying assumption that individuals with disabilities can and will re-enter the workforce if benefits are structured to encourage that opportunity. Recognizing that employment often acts as a powerful tool in recovery and is an important aspect of community reintegration for this young generation of warriors, WWP believes that VA should revise the IU benefit accordingly. 

For warriors with severe injuries facing a long road to recovery, IU can provide an important short term financial benefit, but – as currently administered – it also discourages some from seeking employment.  This disincentive can certainly compromise the course of rehabilitation and full community reintegration. WWP urges the restructure of this benefit by adopting a gradual step-down in compensation.  A less precipitous and intimidating drop in income would help to encourage re-entry into the workforce.   Such a change would remove a critical barrier to full reintegration and recovery for many severely wounded warriors.
 
VA-DoD Federal Recovery Coordination Program
 Severely wounded warriors often rely on a great many VA and other federal programs to overcome their disabilities.  As Congress realized several years ago, navigating that landscape can be overwhelming. 

Carrying out requirements of the National Defense Authorization Act of 2008 , the Departments of Defense and Veterans Affairs established a joint VA-DoD Federal Recovery Coordination Program to assist those with a severe or catastrophic injury or illness who are highly unlikely to return to active duty and will most likely be medically separated.  (A separate DoD Recovery Coordinator Program was designed for those with category 2 injuries who might or might not return to duty.)

The Federal Recovery Coordination (FRC) Program is a too rare instance of a holistic, coordinated initiative to help severely injured veterans thrive again.  While this truly veteran-centered program has proven exceptional in assisting those severely injured in Iraq and Afghanistan, and their families, gain access to care, services, and benefits, the program has not systematically reached warriors injured before its inception in 2007, some of whom still need help in coordinating rehabilitation and facilitating re-integration.  In fact, we do not believe the FRC Program has had sufficient funding and staffing since its inception.  Moreover, we understand that Service department practices – at odds with DoD policy  – have also foreclosed severely wounded servicemembers from the assistance a federal recovery coordinator could provide, and many are not provided a federal recovery coordinator prior to separation from service.

Given the complexity of care and transitional needs of those with severe or catastrophic wounds, it is critical that a care-coordinator have the depth of experience, training, and authority to navigate multiple care/benefits systems.  In contrast to those demanding requirements for a federal recovery coordinator, recovery care coordinators (RCCs) – who are to assist servicemembers whose injuries, while serious, are not deemed likely to result in a need for medical separation -- necessarily have a more limited role.   Service departments’ apparent reluctance to assign FRC’s to those who have been severely or catastrophically wounded, including those with severe TBI, denies these servicemembers the kind of coordinated help they need when it might be most effective, delaying and potentially compromising their recovery, rehabilitation and re-integration. 

WWP urges the committees to work to ensure that all servicemembers who have sustained severe or catastrophic injuries that make a return to duty highly unlikely are enrolled in the Federal Recovery Coordination Program.  It is also important that the program finally gain sufficient funding and staffing to provide this invaluable support to those who still need it, including veterans injured before the program’s inception.
 
Systematic Oversight of Wounded Warrior Programs
Finally, WWP recommends that the committees, ideally in concert with the Armed Services committees, undertake a systematic “veteran-centric” review and oversight of the operation and effectiveness of DoD and VA wounded-warrior programs, and gaps that have yet to be addressed.

The Wounded Warrior Act provisions of the National Defense Authorization Act for Fiscal Year 2008 addressed wide-ranging concerns regarding the quality and availability of health care services for returning servicemembers, and difficulties they had encountered in making the transition from military service to veteran status.  The Act required the establishment of new programs, systems, centers, studies and reports.  Key institutional structures DoD and VA established to implement the law remain in place.
While questions regarding the implementation-status of some the Act’s provisions remain outstanding, the challenges still facing wounded warriors underscore the urgency of reviewing and assessing the effectiveness of the wounded-warrior programs, operations, and mechanisms that have been established.  Some have won plaudits, while others appear to have had only mixed success.  For example, as WWP testified last year, VA has certainly established a polytrauma network of care for veterans with traumatic brain injury, but “while many VA facilities have dedicated rehabilitation physicians, therapists and other specialists, the scope of services actually provided these veterans is often limited, both in duration and in the range of services VA will provide or authorize.”    Other initiatives have not lived up to their promise; the establishment of Warrior Transition Units (WTU’s), for example, was well-intentioned, but experience suggests a wide gap between a promising concept and operational realities, and argues for thoughtful oversight.   WWP understands that the committees do not have primary jurisdiction with respect to the design and operation of WTU’s.  But for too many servicemembers, the WTU experience has exacerbated their problems, particularly regarding mental health, making both their transition and efforts to reintegrate much more challenging than they should be – certainly matters of concern for the committees.

Finally, while the Wounded Warrior Act is sweeping and seemingly comprehensive in scope, the enactment last year of legislation to provide for caregiver-assistance underscores that Congress in 2008 was not able to foresee the full range of needs wounded warriors would encounter.   In short, WWP sees a need for oversight into whether the systems and programs instituted  to assist wounded warriors and their families are truly “veteran (or servicemember)-centered,” whether the initiatives are really “working” as intended, and whether all the gaps have been closed.  

In closing, we look forward to the coming session, and to working with the Committees to realize the changes needed to help our wounded warriors achieve the goals to which we all aspire.