Appropriations for the Department of Veterans Affairs for Fiscal Year 2005 (Written Tesimony)
Appropriations Subcommittee on Veterans Affairs, Housing and Urban Development, & Independent Agencies, U.S. House of Representatives
Anand Kumar, MD, AAGP President
3/25/2004
Mr. Chairman and members of the Subcommittee, I am Anand Kumar, M.D., a geriatric psychiatrist and President of the American Association for Geriatric Psychiatry (AAGP). I thank you for this opportunity to present AAGP’s recommendations related to Fiscal Year (FY) 2005 appropriations for mental health research and services for veterans. AAGP is a professional organization dedicated to promoting the mental health and well being of older Americans and improving the care of those with late-life mental disorders. Our membership consists of approximately 2,000 geriatric psychiatrists as well as other health professionals who focus on the mental health problems faced by senior citizens.
Mr. Chairman, AAGP greatly appreciates your willingness to hear our recommendations for appropriations for the Department of Veterans Affairs (VA) health services and research. Although we agree with others in the mental health community about the importance of Federal support for mental health research and treatment, AAGP brings a unique perspective to these issues because our members serve the older adult patient population.
We appreciate the Subcommittee’s continued support for the highest quality health care for our nation’s veterans and for the research necessary to advance the quality of their care, and are pleased that the final FY 2004 appropriations bill increased funding for veterans’ health care. Our veterans put forth their lives for our nation, and they deserve access to quality health care.
The Challenge of Meeting the Mental Health Needs of the Aging Veteran Population
AAGP is extremely concerned that the mental health needs of our aging veteran population are not being adequately met by current resources; and that the gap between needs and resources will widen unless Congress acts to increase support for veterans’ mental health care, with an emphasis on older veterans.
Of the nation’s 25.5 million veterans, nine million—approximately 35 percent—are seniors who served in World War II or the Korean War. More than half a million veterans are 85 years of age or older, and the VA predicts that this oldest group will grow to 1.2 million by 2010. Historically, as many as one-third of all veterans seeking care at the VA have received mental health treatment, and research indicates that serious mental illnesses affect at least one-fifth of the veterans who use the VA health care system. In addition, those who are older often suffer from co-existing medical conditions such as heart disease, hypertension, diabetes, lung disease, debilitating arthritis, or other conditions. For these patients, treatment of their medical illnesses is often complicated by psychiatric disorders. Conversely, their psychiatric care is more complex because of the co-occurrence of medical illness, which commonly requires treatment with multiple medications. Thus, for older veterans with mental health problems, psychiatric treatment must be integrated and coordinated with their general medical care needs.
Between the years 1990 and 2000, the number of veterans in the 45-54 year-old age group who received mental health services from the VA more than tripled. As the nation pursues the war in Iraq, thousands of younger veterans may soon turn to the VA for the special care and services only it can provide. All of these individuals will swell the ranks of those who will ultimately require geriatric care. However, the most rapid growth in demand during the last decade was among the oldest veterans. During that time, there was a four-fold increase in the number of veterans aged 75-84 who received VA mental health services. This substantial increase in utilization is even more striking when one considers that research has revealed an ongoing problem with under diagnosis of mental disorders in older age groups.
Despite the increasing need for coordinated mental health and general health care services for rapidly growing numbers of older veterans, funding for VA mental health services, training, and research remains disproportionately low. Overall, the proportion of VA spending for mental health care has decreased by approximately eight percent over the last six years. This level of support for psychiatric services, training and research is inadequate to meet the needs of the aging veteran population.
President’s Fiscal Year 2005 Budget Proposal
According to President Bush’s budget recommendation for the Department of Veterans Affairs for FY 2005, approximately $29.2 billion of the $65.3 billion proposed for the Department would go to medical care programs, an increase of approximately $1.3 billion over the FY 2004 funding level of $23.9 billion. However, the proposed increase of $665 million in fees collected from veterans substantially lowers the actual government expenditures. The budget recommendation makes no allowance for rising costs in providing care, and it certainly does not adequately address the existing shortfalls in the provision of mental health care.
The President’s budget includes a provision to charge a $250 annual user fee to veterans with non-service connected disabilities and illnesses along with increased copayments for outpatient primary care and pharmaceutical drugs. Institutional long-term care will only be available to veterans with disability ratings of 70 percent or greater and to veterans who require transitional post-acute care. Therefore, for all but the highest priority veterans, there will be no more access to nursing home care.
Along with looking to veterans to cover an even greater amount of the cost of operating the VA system, the Administration’s FY 2005 budget proposal appears to be a very deliberate move to suppress demand for veterans’ medical care that is extremely disturbing. At a time when our nation is at war, what kind of message does this send to our young men and women who are fighting for this country, as well as to past defenders of this nation? They have all earned and deserve the best health care system that we can provide. Rather than charging fees to some veterans and cutting off services to others, AAGP believes that the VA health care budget needs to rely on appropriated dollars—not enrollment fees, copayments, and service charges—to fulfill obligations to veterans. All veterans should be eligible to receive care, regardless of income or the nature of their illness or injury.
Given that the VA health care system, and particularly its psychiatric and substance abuse programs, has sustained deep cuts in recent years, the Administration’s budget proposal is inadequate. While the proposed budget is a purported increase in funding, it relies heavily on suppressing demand, limiting services, increasing veterans’ copayments and so-called “management efficiencies.” It provides no plan for restoring lost capacity in VA mental health care and substance abuse programs. Rather than offering improved access to care, this budget would increase barriers to veterans’ access to mental health services. And to which system do we direct elderly veterans diverted from the VA when Medicare, Medicaid and state programs are no less constrained by budgetary shortfalls? There is no safety net. Elderly veterans with mental illness are especially vulnerable because employer-sponsored health plans and Medicare HMOs have limited mental health coverage and continue to reduce and eliminate drug benefits.
Comprehensive, Integrated Mental Health and General Health Care for Aging Veterans
Mental health treatment must address the special needs of those older veterans with concurrent psychiatric disorders, medical illness, and substance use disorders, as well as those with severely debilitating psychotic disorders and post-traumatic stress disorder (PTSD). According to the Veterans Administration, of the 455,000 veterans suffering from a service-connected mental disorder, more than 130,000 have chronic, severe psychotic disorders such as schizophrenia, and approximately 130,000 have PTSD, conditions that often have emerged or were aggravated during time in the service. PTSD is often directly related to combat duty. Surely those veterans should be afforded services of the highest quality, with access to a comprehensive continuum of care that defines state-of-the-art mental health treatment.
AAGP believes that the range of integrated services within the hospital and upon discharge to the community that is provided to veterans with mental disorders should serve as a benchmark for health care services in all public and private health care systems in our country. Older veterans with co-occurring medical and psychiatric disorders, often complicated by alcohol or drug abuse, require access to a well-integrated system of services. For those veterans with serious mental illness, state-of-the-art care for severe mental illness is recovery-oriented, rather than dependency-oriented, as documented in the U.S. Surgeon General’s Report on Mental Health (1999). Such recovery requires an array of services that includes care coordination for a majority of patients, and intensive case management for the most seriously ill; pharmacological treatment for mental disorders and access to substance abuse treatment; and psychosocial rehabilitation that includes housing and employment services, independent living and social skills training, and psychological support. Within this continuum of services, Readjustment Counseling Service Vet Centers are a community-based component that provides veterans with counseling for psychological war trauma, using an interdisciplinary team approach. With the growth of the aging veteran population, which includes Vietnam-era veterans, AAGP regards these Vet Centers as an important site for the provision of integrated geriatric psychiatric care over the next ten to fifteen years.
AAGP strongly recommends greater investment in Community Based Outpatient Clinics and the development of an outpatient continuum of care that includes this array of services. In particular, AAGP applauds the VA leadership for pursuing more efficient models of care coordination, designed to promote effective case management for outpatients. AAGP believes that these models, including peer monitoring and other non-traditional support systems, can help to maintain elderly veterans in the community, including many of those with cognitive impairment. While a majority of patients can benefit from these approaches to care coordination, AAGP also urges continued support of Mental Health Intensive Case Management programs in community and home settings for those veterans with the most serious mental illnesses and the most complex, demanding treatment needs. Intensive Case Management is a vital element of care that is needed if the VA is to maintain the sickest patients outside the hospital setting. By providing comprehensive, integrated medical and mental health care through Community Based Outpatient Clinics, and ensuring continuity of care across service sites through care coordination and Intensive Case Management programs, veterans will receive the highest quality care, and further reductions in inpatient services and spending will be possible. VA mental health professionals have identified these as needs “that should be the target of developmental efforts in the coming years” (Report of the Committee on Care of the Severely Chronically Mentally Ill Veterans, February 2000, page 64).
Despite the outstanding advocacy of VA mental health professionals, the Department is still struggling to furnish this comprehensive spectrum of services to veterans with severe mental illness today. Unless the VA budget for psychiatric care is increased, barriers to providing the full spectrum of mental health services will continue to mount, and effective care coordination will remain an elusive goal.
AAGP remains concerned about the viability of some of the programs developed to care for veterans with mental health needs. Congress previously enacted a provision to designate $15 million in VA funding specifically to assist medical facilities in their efforts to improve care for veterans with substance use disorders and PTSD. This additional funding has enabled the VA to develop better outpatient substance abuse and PTSD treatment programs, outpatient dual-diagnosis programs, more PTSD community clinical teams, and more residential substance use disorder rehabilitation programs. The funds for these mental health programs, mandated by the “Millennium Benefits and Health Care Act of 1999” will soon revert to a general fund. As a significant step toward strengthening mental health services where they are most needed, AAGP strongly supports legislation (S. 548) introduced by Senator John “Jay” Rockefeller (D-West Virginia) on March 6, 2003 to ensure that this funding will remain “protected” for three more years, and to increase the total amount of funding for treatment of substance abuse disorders and PTSD from $15 million to $25 million. In addition, that legislation would allow the VA to establish up to ten more Mental Illness Research, Education, and Clinical Centers (MIRECCs) to study and treat mental illnesses. AAGP urges the Congress to enact this bill, and also recommends that Congress incrementally augment funding for the care of seriously mentally ill veterans by appropriating an additional $100 million both in FY 2005 and FY 2006.
Veterans and long-term care
The projected aging of the veteran population will require the VA to increase its capacity to provide long-term health care and to continue its efforts to expand non-institutional options while preserving and enlarging its network of nursing homes. Although the Veterans Millennium Health Care and Benefits Act requires the VA to provide extended care services at 1998 levels, this will not be sufficient to meet the demands of the wave of baby boomer veterans who are about to enter old age. Congress should not only support the VA’s commitment to non-institutional options, but must also ensure the continued availability of nursing homes for the oldest, most frail patients who cannot be maintained in home or community settings. Moreover, the current models of extended care are sorely deficient in the provision of age-appropriate mental health care. Quality of care for elderly veterans with long-term care needs will require substantial attention to the epidemiology of mental illness in this population, and the provision of geriatric mental health services that are vertically integrated into both institutional and non-institutional programs and horizontally integrated with general medical care and mental health services. This is the only way to prevent aging veterans with medical-psychiatric co-morbidity from falling through the “service system” cracks.
An estimated 30 percent of the patients in veterans’ nursing home facilities currently suffer from Alzheimer disease or other types of dementia. As the elderly veteran population increases, the capability of the traditional veterans’ nursing home facilities to care for veterans with Alzheimer’s disease will be overwhelmed. The VA should encourage innovation in the methods utilized by VA health personnel in treating veterans with Alzheimer’s disease; and should also develop family and caregiver support programs to enable veterans to remain at home for an extended period, and receive necessary community based support services, before nursing home care becomes necessary. AAGP recommends the creation of a new line of mental health research funding earmarked for the development, testing, and dissemination of interventions to manage the psychiatric manifestations and complications of Alzheimer’s disease and related dementias
Veterans’ Access to Medication
AAGP is concerned about restrictions on the availability of those medications that are safer or better tolerated by elderly patients. Restricted access to such medications specifically discriminates against older veterans with mental illness who, as a result of the effects of aging, medical illness, and concurrent use of medications for the treatment of medical and psychiatric illnesses, are more susceptible to the potential adverse effects of medications. When safer, better-tolerated medications exist, they should be made available as first-line treatments.
AAGP appreciates this Subcommittee’s support for veterans with schizophrenia, as reflected in your report accompanying the FY 2002 VA-HUD appropriations bill in which you directed the VA to immediately suspend the “fail-first” policy as applied to anti-psychotic medications. AAGP believes this will avert unnecessary suffering, especially in older veterans who are the most vulnerable to drug side effects.
Research and MIRECCs
Although the VA has made genuine progress in psychiatric research in recent years, the level of research funding remains disproportionate to the utilization of mental health services by veterans. Despite the fact that veterans with mental illness account for approximately one-third of all veterans receiving treatment within the VA system, VA resources devoted to psychiatric and behavioral health research have lagged far behind those dedicated to research on other medical conditions. In fact, support for psychiatric research dedicated to chronic mental illness, substance abuse, and PTSD has remained relatively flat for the last 15 years, despite the growing numbers of patients in the VA system receiving treatment for mental illness. As the elderly veteran population expands, and the number with mental illness grows, strengthening the research base in geriatric psychiatry becomes increasingly urgent. VA sponsored research into mental disorders of aging benefits all Americans, not just our veterans.
A vitally important VA program for coordinating mental health research with education and clinical care are the Mental Illness Research, Education, and Clinical Centers (MIRECCs). Since 1996, Congress has authorized the VA to establish eight of these centers dedicated to mental illness research, education and clinical activities. AAGP believes the MIRECCs have successfully demonstrated that coordinated research and education projects can achieve rapid translation of new scientific knowledge into improved models for clinical services for veterans with mental illness. These programs should be continued. MIRECCs focus on problems highly relevant to veterans with schizophrenia, PTSD, and other serious mental illnesses, including those whose treatment is complicated by homelessness, substance abuse, or alcoholism. AAGP wishes to emphasize the value of those MIRECCs that focus on issues related to aging, including dementia, and psychiatric disorders in older veterans with concurrent medical illness and/or substance use disorders.
MIRECCs have encouraged research, increased our fundamental understanding of mental illnesses, and given VA healthcare professionals more and better tools to treat patients with mental disorders. Much more can be done in this area if the program is expanded. The MIRECCs are a tremendous resource for improving the quality of mental health services and improving the outcomes of veterans living with mental illnesses. Given the importance of these programs, AAGP urges that full funding for existing MIRECCs be continued and strongly recommends the full funding of a minimum of two new MIRECCs in FY 2005.
Conclusion
In conclusion, AAGP commends this Subcommittee for its recognition, in the FY 2004 appropriations bill, that VA psychiatric services should be maintained at no less than the previous year’s level. Representing physicians who are specialists in geriatric psychiatry, AAGP is concerned that reductions in mental health services will undermine the provision of proper treatment not only to elderly veterans, but also to those who are currently young and middle-aged; a course that will lead to more severe problems later in life as their mental disorders become complicated by medical problems that commonly occur with aging. While the VA is facing budget constraints, delivering quality health care for all veterans—for both physical and mental health—must be a top priority. We therefore urge the Subcommittee to increase support for mental health services, training, and research; and to commit the resources necessary to provide our nation’s veterans with access to quality, affordable, coordinated physical and mental health care.
I would like to thank the Subcommittee for the opportunity to testify here today. On behalf of the American Association for Geriatric Psychiatry, we look forward to working with you to ensure that all veterans have access to quality affordable mental health care.
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