Vital Issues: VA Secretary Nicholson addresses.

DAV: Hurricanes Katrina and Rita were tragic disasters, and there has been a lot of criticism about the level of preparedness and the ability of state, local and federal governments to respond to the needs of those affected by the storms. However, the VA seems to have done a very good job of taking care of its patients in the medical centers and in making sure veterans receive their disability compensation and other benefits.

What is the current situation and the outlook in the Gulf Coast region regarding VA medical facilities and patient services and benefits delivery to those affected by the hurricanes?

Secretary of Veterans Affairs R. James Nicholson:

I've made three visits to the region [by Oct. 5, 2005], and what our VA employees have been through defies description. Heroic is one word that comes to mind quickly. Our VA health professionals were on the job, taking care of patients, when their own homes were destroyed and their own families scattered. Words can't describe how proud of them I am, and how honored I am to serve with them.

Our health care system in the region got through the second storm, Hurricane Rita, all right. But the first one, Hurricane Katrina, gave us quite a pounding. Our health care facility in Gulfport, Miss., is damaged beyond repair. We're still assessing whether we'll be able to move back into our New Orleans medical center and what will happen to our New Orleans regional office.

A number of newspaper stories after Hurricane Katrina pointed out that our computerized patient records allowed our health care providers to have the complete records of VA patients who were evacuated from New Orleans and Gulfport immediately after the storm. If there was ever any doubt about the usefulness of computerized patient records, Hurricane Katrina swept away those doubts.

I'd also like to salute DAV for its assistance during those disasters. Your disaster relief grants allowed many veterans throughout the Gulf Coast to begin putting their lives back together, while your Mobile Service Offices are providing indispensable assistance. And, as always, there was the cadre of DAV volunteers. Whenever and wherever veterans need help, DAV is right there. It's difficult to imagine VA doing its job without the help of our DAV volunteers.

Mental Health Services for Returning Troops

DAV: Given the elevated projections for mental health issues, including post-traumatic stress disorder (PTSD), in returning troops we anticipate a need for increased mental health clinicians and obviously the need for additional resources. We are already hearing from mental health professionals in the field that they are doing their very best to meet the needs of veterans returning from Iraq and Afghanistan who need VA mental health services. However, they report their staffs are stretched thin already, which is affecting their ability to meet the continuing mental health needs of other veterans seeking care.

What is VA doing to monitor the demand in the field for mental health services and what commitment have you made to ensure the resources are available to meet the needs of veterans seeking mental health services?

Secretary Nicholson: Bullets and bombs and shrapnel are not the only hazards of the battlefield. Combat troops go through traumatic events that can have life-long effects, especially if they're not treated properly in the early stages. This isn't new-it's probably been happening for as long as men under arms have taken to the field. What's new is our ability to understand it and treat it. And I'm proud to say that VA has been leading the nation probably the world-in the field of PTSD treatment.

We operate an internationally recognized network of more than 140 specialized programs for treating PTSD, including inpatient units and outpatient clinics. Our National Center for PTSD, located in White River Junction, Vt., promotes research into the causes and diagnoses of the disorder and trains VA employees. The National Center for PTSD is also an information resource for mental health professionals across the nation and throughout the world.

As for mental health care overall, our goal is to ensure that every veteran needing mental health care has access to the level of care he or she requires. In the last 10 years, VA has shifted its mental health services away from inpatient care to more accessible outpatient and residential care. This has vastly improved the quality of care we provide. We're spending less time, attention and money on structures and more on medical outcomes that show we're providing veterans with the care they need.

The bottom line for our OIF (Operation Iraqi Freedom) and OEF (Operation Enduring Freedom) veterans is that VA has the programs, facilities and expertise to meet their mental health needs when they return home.

DAV: Does VA anticipate an increase in PTSD claims?

Secretary Nicholson: OIF and OEF veterans represent a small percentage of our overall PTSD work. In fiscal year 2004, we saw approximately 279,000 patients at VA health care facilities for PTSD and 63,000 in Vet Centers. Our latest data on OEF and OIF veterans indicate about 12,300 were seen in VA medial facilities for PTSD. This represents approximately four to five percent of our overall PTSD population. This doesn't include more than 3,500 OIF and OEF veterans who received services for PTSD at our 207 Vet Centers.

Allowing for those who have received services at both VA medical centers and Vet Centers, about 14,600 individual OEF and OIF veterans have been seen with actual or potential PTSD at VA facilities following their return from Iraq or Afghanistan. This figure represents about three percent of the PTSD patients we saw in fiscal year 2004.

DAV: Is VA prepared to handle them?

Secretary Nicholson: Can we handle this? We most certainly can.

We've been ramping up the training of our ratings specialists for several years. We've asked for additional staffing in fiscal year 2006. And, frankly, we've gotten better at reaching people early, which our health experts tell me will minimize their symptoms and improve their outlook for high-quality lives.

I'm especially proud of the initiatives underway with the Department of Defense to reach men and women as they're separating from active duty. Now we're seeing people file claims as they're leaving the military, which eliminates some of the time-consuming problems faced by other veterans getting their personnel files and medical records. "Seamless transition" isn't just a slogan--it's a well-developed program that provides solid benefits to our newest generation of veterans.

VA has used the goals of the New Freedom commission to develop a five-year Mental Health Strategic Plan, with 265 individual initiatives. The strategic plan gives us a direction to close current gaps in health care. It envisions a future in which the stigma of mental illness will be eliminated; where veterans with these illnesses will be diagnosed early and treated effectively; and where their social, occupational and community functioning is maximized.

This plan is a guide to ensure that every veteran has equal access to care, and that all their individual needs are addressed. It puts greater reliance upon community-based outpatient clinics, which is good news for veterans, because it means care will be more conveniently located. We'll also incorporate the families more in the treatment and planning for these patients.

As long as there is war, there will be PTSD. We have troops in combat right now and, as I said earlier, PTSD is an unfortunate, inevitable consequence of the sacrifices being made today in Iraq and Afghanistan.

VA Budget Issues

DAV: The recent embarrassing shortfall in health care funding, some $3 billion in fiscal years 2005 and 2006, which Congress and the administration have acted to correct, raises some serious concerns. How did the miscalculation happen?

Secretary Nicholson: Our fiscal year 2005 budget turned out to be about $1 billion short. This came to light clearly in the late spring of 2005. As the demand for VA health care services surged, it was clear that our resources would be strained. We had planned for a 2.9 percent increase in medical care, but what we got was a 5.2 percent increase--nearly twice the growth rate.

Once this trend was clear, we notified the administration and Congress and immediately submitted a supplemental budget request, which Congress quickly passed. Based upon this new data, we also increased the fiscal year 2006 budget request.

DAV: What is being done to prevent a repeat of this situation?

Secretary Nicholson: VA is making strong efforts to improve our forecasting methods for the budget and our monitoring processes so that we can adjust for the time-lag between the formulation of a budget and its passage by Congress. We're also working with the Department of Defense to better link the numbers of military members leaving the service with VA's budgeting process. And we will continue to improve its overall financial and accounting practices to inform stakeholders should any future trends impact estimates. Also, I plan to report to the oversight committees of Congress every quarter on the status of our dynamic budget situation due to the war to avoid any surprises.

DAV: What is VA's assessment of the funding needs for fiscal year 2007?

Secretary Nicholson: When the President's fiscal year 2007 budget is submitted to Congress next February, I will be happy to discuss it with you.

Long-Term Care 

DAV: Based on VA's own projection of the aging veteran population, it is likely to see a significant increase in long-term care need over the next decade. Last year's projections show the number of veterans most in need of long-term care services--those 85 years old and older--is expected to increase from about 870,000 to 1.3 million over this period. We are concerned about recent trends in VA long-term care service delivery and how VA plans to meet the nursing home care and related long-term care needs of veterans as the elderly population most in need of long-term care increases.

What is VA's strategic plan on long-term care to position itself to meet the needs of the frail elderly veteran population?

Secretary Nicholson: From talking to veterans and their families, it's clear that long-term care should be provided in the least restrictive setting that's compatible with a veteran's medical condition and personal circumstances. Whenever possible, veterans should be cared for at home or in community-based non-institutional settings, which help to maintain ties with families, friends and communities. Nursing home care should be reserved for situations in which the veteran can no longer be safely cared for at home.

Inevitably, some veterans will require nursing home care. However, it is clear that VA alone cannot possibly provide nursing home care for all of the veterans projected to need this care over the next decade. Although we are meeting the current demand and will meet all of the projected demand for nursing home care for veterans whose care is mandated by statute, we must, nonetheless, prioritize care for those veterans most in need.

We expect to meet much of the growing need for long-term care through non-institutional services, such as care coordination, home health care, adult day health care, respite, home hospice and palliative care, and homemaker and home health aide services.

DAV: Many of these veterans will rely on VA to provide or pay for nursing home care or non-institutional services that may help them remain at home and, for some, delay or prevent the need for nursing home care. VA operates its own nursing home care units in 132 locations, and VA also pays for nursing home care under contract in non-VA nursing homes--referred to as community nursing homes. In addition, VA pays part of the cost of care for veterans at state veterans nursing homes and also pays a portion of the construction costs for some state veterans nursing homes. We are concerned about previous legislative proposals included in VA's budget request to control long-term care expenditures coupled with the $446 million error in estimating long-term care costs for fiscal years 2005 and 2006.

How will VA ensure it requests and receives adequate funding for its long-term care services?

Secretary Nicholson: VA will focus its resources for long-term care on its core mission. Our first priority will remain veterans with compensable service-connected disabilities; veterans with special needs--such as spinal cord injury, serious mental illness, or ventilator dependence--and veterans who require short-term restorative care, respite care and hospice care.

As I mentioned before, VA expects to meet much of the growing need for long-term care through non-institutional services, such as home health care and adult day health care. This patient-centered approach has allowed us to expand the number of veterans served by these programs. These programs received a substantial budget increase last year and are expected to receive an additional 18 percent increase in 2006.

Under the policy proposed in the President's fiscal year 2006 budget, which still provides care to veterans well beyond the requirements of the law, VA will reach out to the broader veteran population, as resources permit. We will continue, within the normal budget process, to request funding we believe will adequately support the plans I've outlined.

Gulf War Illness Research Gets Boost

* The Department of Veterans Affairs has approved funding for 12 new research projects to better understand and treat illnesses affecting some Gulf War veterans.

The total cost of the research projects is estimated to be $5.2 million over three years, with $1.7 million approved for 2006. The new programs bring projected Gulf War veterans' illnesses research spending for the year to $11.3 million. Some veterans who took part in Operation Desert Shield and Operation Desert Storm have reported a variety of ailments including fatigue, weakness, sleep disturbances, persistent headaches, skin rashes, respiratory problems and other illnesses at significantly higher rates than those reported by other veteran groups.

The newest Gulf War veterans' illnesses research programs will be administered through VA medical centers in Bedford, Mass.; Baltimore, Md.; Washington, D.C.; Durham, N.C.; Miami, Fla.; Tampa, Fla.; Minneapolis, Minn.; Omaha, Neb.; Salt Lake City, Utah; and San Francisco, Calif.

Editor's Note: DAV requested an in-depth interview with Secretary of Veterans Affairs R. James Nicholson soon after his nomination was confirmed by the U.S. Senate and on subsequent occasions, but honoring our request was delayed by scheduling conflicts and time constraints. The Secretary was able to grant DAV an interview on Sept. 29, 2005, and requested to respond to questions more fully in writing. Following are questions submitted by DAV and the Secretary's written responses, which have been minimally edited for presentation in DAV Magazine.