Veterans Affairs Committee on May 29th, 2008

[The Chair, Conservative, Rob Anders]

I now call to order the Standing Committee on Veterans Affairs.

We have some guests by video conference. I will introduce them. From the United States Department of Veterans Affairs, we have as witnesses Susan McCrea, liaison officer for intergovernmental affairs; Keith Pedigo, associate deputy undersecretary of benefits for policy and program management; Steve Muro, director of field programs; Gail Graham, director of health data and informatics, veterans health administration; and Linda Fischetti, acting chief of the health information office. Thank you very much.

Usually the way we work is that our witnesses....

Sorry, Mr. Sweet.

[David Sweet, Conservative, Ancaster—Dundas—Flamborough—Westdale, ON]

Just before you address the witnesses and they give their testimony, I wanted to commend the staff for their great job in making this meeting look very appropriate and official, with our witnesses having the flag of the United States of America directly behind them and our chairman the flag of Canada directly behind him. I just wanted to commend them for the great set-up of this.

Thank you very much.

[The Chair, Conservative, Rob Anders]

There we go. Mr. Sweet has noticed the wonderful official protocol being noted. And yes, it is well done.

Generally the way it works is that witnesses have about 20 minutes, but I understand that the arrangement today is for 10 minutes each. Fair enough.

The floor is yours. I turn it over now to our American witness friends.

[Susan McCrea, Liaison Officer, Intergovernmental Affairs, United States Department of Veterans Affairs]

Good afternoon.

As you said, my name is Susan McCrea. I am going to do introductions, but before I do that, I want to give you a few statistics about the VA.

First, we have 24 million veterans in the United States. Our budget for fiscal year 2008 is about $90 billion; and for the next year, the President has asked for $94 billion. We're the second-largest government agency, with 264,000 employees. We partner with our veteran service organizations, such as the American Legion, the VFW, and Disabled American Veterans, who help prepare claims for veterans. They also partner with state veterans affairs agencies in claims preparation, provide long-term care to veterans, and provide burial benefits also.

We have three administrations: health, benefits, and cemetery.

As you've already said, Keith Pedigo will talk to you about veterans benefits; Steve Muro will talk about the cemetery benefits; and Gail Graham and Linda Fischetti will talk about veterans health care benefits.

Keith.

[Keith Pedigo, Associate Deputy Under Secretary, Benefits for Policy and Program Management, United States Department of Veterans Affairs]

Good afternoon, committee members. It's a pleasure to be with you this afternoon. I'm going to give you a quick run-through of the five benefit programs administered by the veterans benefits administration.

Let me start by telling you that we have 57 regional offices around the country involved in providing these benefits to our 24 million veterans.

I'm going to start with the largest of our benefit programs, which is our compensation and pension program. That program has five major elements, the largest of which is the disability compensation program. Veterans who incur injury in military service, or have an injury or illness that was aggravated by military service, can apply for disability compensation. The veteran makes his or her contentions. The VA then gets involved in a very protracted process of developing medical information and other evidence to try to support the veteran's contentions.

If we are able to do so, then we award disability compensation. That compensation amount is based on the severity of the injury, and it ranges from 10% up to 100%. So a veteran who is approved for 10% disability compensation would receive $117 a month. A veteran at the 100% level would receive $2,527 per month. There is a possibility for veterans with more traumatic injuries to go to as high as $7,500.

We also have a disability pension program. This program is designed to assist veterans who have a total and permanent disability, but a disability that is not in any way related to their military service. The veterans who qualify for this must have served during a wartime period. This is a means-tested program, and we check all of a veteran's countable income in an effort to determine whether or not he or she deserves a payment under this benefit.

We then have another program that we call the dependency and indemnity compensation program, which is designed to provide monetary assistance to the survivors of a veteran who has died as a result of his or her service-connected disability. This is both for the spouse any minor children the service member may have had, and we can pay up to $1,091 a month under this program.

The fourth program is yet another pension program. This we call our death pension, which is designed to provide pension payments to the survivors of a veteran who served during a wartime period. This, like the other pension programs, is means-tested, so we look very closely at the level of income the veteran had before we make a determination.

Last year we paid disability compensation to 2.84 million veterans. We paid out $27 billion. We had 323,000 veterans in receipt of pensions and we paid almost $3 billion to those veterans.

The second benefit program that I want to talk about is our education program. Back in 1944, Congress provided us with the GI Bill, which began the education program for veterans.

Presently we have four major programs that Congress has provided for us. Each of these programs has been designed to serve a particular segment of the veterans population, based on the type of military service they had.

The largest of these programs is what we call the Montgomery GI Bill for active duty. This means that active duty service members who have served at least three years in the military and have contributed $1,200 of their own money can become vested in this program, and they can then receive 36 months of educational benefits, most of which are generally used to seek a four-year college degree.

We have a second program, the Montgomery GI Bill for the selected reserve. This is designed for those service members or veterans whose only military service was either in a reserve component of our military or the National Guard. This program does not pay as much as the active duty program, but it does pay $317 a month while that veteran is in school.

The third program is our reserve education assistance program. This is the newest of our programs, and it was designed to address the increasing incidence of our service members being called up, either from the reserves or the National Guard, to serve on active duty, either in Iraq or Afghanistan. This program allows these veterans to qualify for some amount of money very similar to what those on active duty would normally receive.

The final education program is designed to provide educational assistance to the survivors of a veteran who died as a result of a service-connected disability, or for the minor children and spouse of a veteran who was 100% service-connected disabled.

Since 1944 we have served 21 million veterans under the education program. This past year we had over half a million veterans receiving benefits and we paid out $3 billion for education.

The third benefit program is our vocational rehabilitation and employment program. This program is designed to allow disabled veterans who have an employment handicap to undergo training that the VA pays for to receive rehabilitation counselling provided by VA, with the ultimate goal of helping that disabled veteran find suitable employment. In essence, this is an employment program.

We recognize that there are a number of veterans whose disabilities are so serious they cannot reasonably be expected to qualify for employment, so we're able to provide services to them under this rehab program to help them learn to live independently.

Last year we served 89,000 veterans under this program, and we paid out $802 million.

The next program is our home loan guarantee program. This program has been with us since 1944. It is designed to allow veterans to purchase a home without the need to make a down payment. The program is structured so that the loans are actually made by private lending institutions, and VA provides a guarantee that can be as high as $104,250. That level of guarantee would allow a veteran to obtain a no-down-payment VA loan of up to $417,000. We've made a little over 18 million loans, and at present we have guarantees outstanding amounting to $209 billion.

The final program that I will talk about is the VA insurance program. The VA has a large insurance program. If it were in the private sector in the United States, it would be the fifth-largest life insurance program in our country. There are five insurance programs that we administer in VA.

The most popular and probably the best known is the service members' group life insurance. This is the insurance that those on active duty military service can take advantage of. In the event of their death, it would pay their beneficiaries up to $400,000.

When service members get out of military service they can take advantage of the second program that we administer, which is the veterans' group life insurance. This enables them to make an easy transition from one insurance program for members in active duty to an insurance program for veterans.

The newest of our insurance programs, the third one that I will talk about, is our traumatic service members' group life insurance. Our Congress gave us the authority to administer this program in 2005. The purpose of this program is to provide financial assistance to service members who have been seriously injured in combat, as well as their families, in a effort to help them meet their financial needs during the long period of recovery. So this is not technically a life insurance program, simply an insurance program that provides assistance to the veteran who is still living.

The fourth program that we administer is for veterans who have a service-connected disability. It's difficult to get insurance in the private sector if you're disabled, so the VA steps in and provides this insurance for those individuals.

Finally, we have a fifth program that is designed to provide insurance for seriously injured members of the military and the veteran community who have received a grant from the VA to build an accessible home that would be suitable for wheelchair use. In the event of that veteran's death, this insurance program would pay down the mortgage that they obtained in order to buy or build a home.

Members of the committee, that's a very quick run-through on some of the benefits in the veterans benefits administration.

At the appropriate time, I will be happy to take any questions that you might have.

[The Chair, Conservative, Rob Anders]

You have 10 minutes each, so I think we're moving to the next witness, are we?

[Steve Muro, Director of Field Programs, United States Department of Veterans Affairs]

Yes, thank you, Chairman, and thank you committee members for the opportunity to present the goals of the national cemetery administration.

We are the smallest of the three within the Department of Veterans Affairs, yet our mission is an extremely important one. We maintain and provide dignified burial space for veterans and their dependants, and we maintain our cemeteries as national shrines.

We also administer the federal grants program, which helps states develop state-run veterans cemeteries. We actually pay 100% of the cost to develop the cemetery. They just need to own the land.

We're also responsible for headstones and markers that we ship all over the world to private cemeteries and also to all the national cemeteries that are federally administered as well as state cemeteries.

We also administer the Presidential Memorial Certificate. Any veteran with an honourable discharge can and will receive a Presidential Memorial Certificate. We normally send it out if they've been buried at a national cemetery or if they requested a headstone or a marker in a private cemetery. The program also allows that if the family members would like to have more, they can request it. It's a certificate that has the President's signature embossed on it.

We have 125 national cemeteries throughout the United States and including Puerto Rico. We have five memorial service network offices that administer these cemeteries and provide them financial support and guidance as they operate the cemeteries.

In 2007 we conducted over 100,000 burials of veterans and their dependants in our national cemeteries. We have 1,600 employees who manage these cemeteries, and we maintain 2.8 million gravesites. One thing that's unique about national cemetery administration is that 70% of our employees are veterans. We actually have a higher percentage of veterans than any other federal agency, including DOD. They're at 34% veterans, and the VA as a whole is at 33% veterans. We're proud that most of our employees--at least 70% of them--are veterans who have served this nation.

Regarding burial in a national cemetery, there is a long list of eligibility. I'll just go over some short ones really quickly. Anyone who served in the armed forces of the United States and died on active duty or was discharged from the military, for any reason other than dishonourable, may be eligible for burial in a national cemetery--to include their dependants.

Any National Guard member or reservist who has served 20 years and is eligible for retirement from the National Guard or reserves and has reached the age of 60 would be eligible. Spouses and minor children are eligible. The term “children” refers to anyone under the age of 21 unless they are going to an accredited college, in which case it goes up to the age of 23 or if they become physically or mentally disabled prior to reaching the age of 21, in which case they would become adult dependant children and would be eligible for burial in our national cemeteries.

The responsibilities we have are to provide gravesites, open and close the grave, provide an outside container--what we call a grave liner, which is normally concrete--headstones and markers, perpetual care, a U.S. flag that drapes the casket at the time of the veteran being brought to the cemetery for the service, and the Presidential Memorial Certificate.

Unfortunately, you don't have the pictures, but hopefully you'll get some pictures of the headstones that we provide and the Presidential Memorial Certificate that we also provide. We have marble, granite, or bronze headstones that we provide at the national cemeteries and in private cemeteries. Last year we provided over 360,000 headstones throughout the world and over 420,000 Presidential Memorial Certificates.

The median age of the World War II veteran is 84. We have over 16 million who participated. In Korea there were five million-plus, and their median age is 77. In Vietnam it was eight million, with a median age of 61. Currently there are five million who have served in the Gulf War, with a median age of 38.

The death rate for our population from World War II is dropping off, but from Korea and Vietnam it's picking up, and our workload actually peaked this year in terms of our burial rate. It has not and will not drop off fast. It's dropping off slowly, and then it will increase because of what we call second interments. Once there's an individual buried there, either the veteran or the spouse can come at their time of need.

As to our strategy for the future, we're developing new cemeteries. We've recently opened six new cemeteries, and we are in the planning and construction stage of opening six more throughout the United States. We're expanding our existing cemeteries. Our goal is to continue to have services at national cemeteries, so we'll try to find land, whether we buy it or it gets donated or transferred from DOD, to keep our existing cemeteries open.

Right now, the six new cemeteries that are in the construction phase and planning phase are at Bakersfield, California; Washington Crossing, Pennsylvania; the District of Columbia area; Alabama; Jacksonville, Florida; and this Sunday we're going to dedicate a cemetery in Sarasota, Florida, which will be our 126th cemetery to come online.

With the straight grant program, as I said before, we pay 100% of the cost to develop the cemetery, from designing it to building it to providing the equipment. The states then hire the employees and run the cemetery. As it needs expansion, we help them expand it by spending the dollars in funding so that they can pay for the construction. Since 1980 we've spent over $300 million in 162 grants to states to develop state cemeteries. Our goal is to maintain the cemeteries as shrines to commemorate veterans' service to our country.

Thank you.

[The Chair, Conservative, Rob Anders]

Thank you.

[Gail Graham, Director, Health Data and Informatics, Veterans Health Administration, United States Department of Veterans Affairs]

Thank you.

Good afternoon. I'm Gail Graham from the veterans health administration, the last of the three administrations we'll discuss. We were specifically asked to talk about digitization of medical records. We have an electronic health record that we've been using for about 20 years. I'm going to tell you just a little bit about the eligibility for health care.

Currently, as was discussed under benefits administration, health care is provided to those who are service-connected veterans, those who have a financial need determined by a means test, or those who, by virtue of serving in combat, are provided a five-year eligibility for health care services. We deliver health care directly through over 1,800 sites of care, including hospitals, nursing homes, domiciliaries, and clinics. We also administer a large purchase program for health care that runs in excess of $2 billion. We have a foreign medical program through which we pay for health care services provided to veterans living in foreign countries. We have a lot of rural areas, common with your country, and we are using telemedicine quite broadly in those areas.

Ms. Fischetti and I both represent the office of information within the veterans health administration.

So who are the veterans? We've talked about the different populations that each of us treat. Last year veterans health administration treated about 5.6 million veterans, and 209,000 of those came from current conflicts, what we refer to as Operation Enduring Freedom and Operation Iraqi Freedom. We do see the number of women veterans increasing, and it's projected to double in the next five years. The median age today of the veterans to whom we provide health care is 60 years. We have a large population of veterans of 85 years and older; we have about one million of those, compared to only 164,000 of that same age group in 1990. It's projected that the number of veterans over age 85 will grow to 1.3 million by 2011.

We spend a lot of time preparing for a different veteran of the future. We see the veterans who are coming out of current conflicts as Internet-savvy. They use that as their primary source of information, and we've had to move along to support that need. They're also convenience oriented--not quite as patient as our World War II veteran to wait for appointments or tolerate appointments and diagnostic services that aren't performed together, for example, or that aren't conveniently located. So we've opened a lot of clinics in the last few years that are located in small rural communities, and then we use referrals to larger medical centres.

We also find a more highly educated population, for example.

In certain segments, such as the Vietnam veterans, we see a population that is aging with disabilities, both a high rate of mental illness as well as physical ailments, which complicates treatment and broadens it to many areas and increases the need for geriatric intervention. We see projected needs higher in the area of mental health, for example, for post-traumatic stress disorder, substance abuse, and other mental illnesses, and a higher need for long-term care, which we are trying to satisfy in ways other than institutional long-term care.

As I said at the opening, VA has had an electronic health record, with components of it over about 20 years and full implementation over about the past 10 years. This enables us to have records that are available to practitioners wherever the patient may seek care. For example, with the population we have who are over 65, it's common that they would receive care in the northern part of the United States in the summer, and in the southern part of the United States in the winter. Our providers can look at these records regardless of where the patient presents for care. This also spans over different clinic settings and health care settings. For example, the records are available in acute settings, long-term care, and clinics, in the home health arena, and in telemedicine.

As I said, the most recent capabilities are really the ability to share these records, both the clinical information and the images from information such as diagnostic images. This is also an area where we're expanding our use due to shortages, for example, in radiologists. We're developing centralized reading centres, so the digital films are taken at the site where the veteran is located but are read elsewhere.

We try to make this data more easily accessible to the providers, but it's also accessible to our partners and the veterans benefits administration. As Mr. Pedigo mentioned, when they're processing claims, they also have access to this information as needed to adjudicate a claim for a veteran, and it may be at times used to do presumptive adjudication--for example, if there's been a presumption of connection between Vietnam service exposures and diabetes.

We've seen this adoption of the electronic health record help us in controlling health care costs in many aspects, from not repeating diagnostic tests because the results are available regardless of the location of the veteran to just being able to control our resources in a more equitable manner--using tertiary facilities as needed, but treating patients in a local setting whenever possible.

Thank you.

[The Chair, Conservative, Rob Anders]

Thank you.

[Linda Fischetti, Acting Chief, Health Information Office, United States Department of Veterans Affairs]

Mr. Chairman, members of the committee, good afternoon.

My name is Linda Fischetti. I'm going to be talking about two programs and one workforce issue. “My HealtheVet” is a personal health record that we offer to our veterans. We also have an interoperability program with the Department of Defense, which I'll mention. I'll also speak to the informatics workforce.

My HealtheVet is a personal health record. It is accessible to the veterans from home. There is a three-tiered level of access to this. The first tier is that anyone can go and look at a limited amount of information online.

The second tier of access is that a veteran will go in and register himself or herself, and at that point in time the veteran is able to see information that is educational and targeted directly to our veterans. This information has been vetted by a content-matter expert team of both clinicians and other veterans, so we're making sure that the veterans are receiving information from trusted sources to educate them about their health care issues.

The third level of access is that a veteran can choose to go to a local VA medical centre and, through the health information management professional, be in-person authenticated. At the point in time that a veteran is in-person authenticated, they are then able to actually import information from our electronic health record, which Ms. Graham just spoke about, into the personal health record.

We're rolling out at a number of sites. We have not completed our national rollout. That will be finished by the end of this year.

The feedback we've received from the veterans on this ability to import their own electronic health record information is very empowering. They feel that they're able to be more of a partner in their care. They're also able to journal their own information. For example, they can import information from the electronic health record related to lab results, and then, on the other hand, journal some of the personal choices, lifestyle choices, that might influence those lab results. Therefore, they'd be able to see a trend in their personal journal of salt intake and weight changes related to blood pressures that were recorded when they were at the medical centre at their different visits. So we partner with our veterans for this ability to give them their own personal health record.

Our typical veteran who chooses to participate is a Vietnam War veteran who is between 51 and 70 years old, actually changing the paradigm of the assumption that it's the younger generation that has a greater affinity for IT.

The frequency at which this veteran comes and visits us is about once a month. The reason for this is that the veterans who choose to use the personal health record are able to reorder their prescriptions online. No longer do they have to go into the medical centre or pick up the phone and call someone during the times they're open and reorder their medicine, in person or by phone. They're able to go online and reorder their medicines. We believe this is what drives the majority of our veterans coming in once a month.

We currently have 590,000 users, who have racked up 18 million visits, and we have refilled six million prescriptions. We have found also that as we bring new functionality online, the number of people who participate in the use of it increases.

One of the things we also do is use a web survey tool, called the American consumer satisfaction index, to make sure that we are capturing veterans' level of confidence in the information on the website and their opinion on the look and feel of the website. As well, we ask them what future functionality they would like us to put into the personal health record. Based on this, we're able to prioritize our future development efforts.

We know, for example, that the very next thing the veterans would like to see are all of their upcoming appointments. We know this because we asked them in this web-based survey that takes place when they're in the personal health record online, at which point in time we can float that to the top of our development priority.

The next program that I want to speak about is the interoperability that we have with the Department of Defense. There are different levels of interoperability. For example, you can just move text from one electronic health record system to another in such a way that the text is then displayed to the clinician. It's human-readable text. You're not able to sort it or parse it or to compute any logic against it, such as with clinical reminders. We have that as our first effort of interoperability.

The second level of interoperability is the ability to recognize that different parts of the electronic health information coming from a foreign electronic health record is in fact a lab value, or a pharmacy order, or a progress note that has been entered by a clinician, at which point in time you're able to put those appropriately where they belong within your electronic health record.

The highest level of interoperability that we're speaking about today has to do with information that's semantically interoperable, against which in fact you would be able to do pharmacy checks.

Within our DOD-VA interoperability, we started with the first type, the ability to just view the information from DOD in 2002. At this point in time, we have moved information on four million patients from DOD over to VA. This is a one-way interface called a federal health information exchange. It is only the big chunk of human-readable text information that comes across at the lower level of interoperability.

As our systems have become more sophisticated, we have been able to move information in both directions--from VA over to DOD and from DOD over to VA--and we're able to do this in real time, at the time the clinician asks for it. We've been able to move approximately three million patients' records this way. This information is also sorted. We call this our bidirectional health information exchange.

In response to the severely wounded warriors, since the beginning of the current engagement we have realized the value of moving all of the veterans information that has been collected at every point at which they've been seen within DOD. So not only the lab results but also the X-rays and the pathology results, and everything related to the patients who are severely wounded, needs to be moved into the VA polytrauma centres. With that, we were able to quickly set up an exchange that involved collecting and moving all of that information to a single point.

We continue to explore the highest level of interoperability in a project that we call the clinical health data repository. With that, we have mapped common terms for pharmacies, allergies, and a few other domains so that we are able to actually do an order check to see, for example, if two orders have been written for the same medication.

Lastly, I want to talk about a workforce issue. You've heard a great deal from Ms. Graham in terms of the use of IT within the health environment. What VA has done is impressive. The level of saturation at which clinical and business processes within the health care environment are supported by IT is pretty unprecedented, when you look at our size and the number of processes we support.

Yes, this is an IT issue in terms of how we protect the information, keep it secure, and move it to wherever the patient is and where the clinicians need that information, but there is also a culture change. So we work with a workforce called “informaticists”. Informaticists are a group of people who focus specifically on the area between the IT domain knowledge and the clinical domain knowledge.

These are people who work on things such as what I just spoke about--semantic interoperability. How do you make systems sophisticated enough and normalize the information to the point that you can do this? It takes a great deal of effort. How do you take IT and insert it into a physician's process of writing an order and do it in a way that's effective so that the physician will continue to use the IT and actually feel a level of trust and safety that in fact there's a value added in having the IT there?

Within our environment operationally, informaticists are at the elbow of the clinicians who are using the system. They're also involved in system development. In fact, with the system development, they continue to work with the development teams to give iterative direction. For example, if you display a serum sodium that way, the clinician is not going to know what it means. A software developer would not know that. The clinician and the informaticist at the elbow of the software developer can help improve product that comes out.

In terms of research, we have a large research community here within the veterans health administration. We partner with them to do things such as human factors engineering software before it's put into the clinical space, or look at whether we have in fact improved clinical outcome with the insertion of a new technology into the health care environment.

Very important is the health information management professional. One of the most important things when you are moving from the paper record and you're changing the media of that health record to now become an electronic record is to preserve all of the policies and guidelines that have been in place to assure the integrity and legal accountability of that paper record. The health information management professional is the one who has to rewrite all of the policies or continue to enforce the policy and is a very important check-off for any IT that's going out into the clinical space to make sure that in fact you're capturing information that will have the integrity of the previous paper medical record.

That ends my comments. I'm going to hand it back to Susan.

[Susan McCrea]

We're open for questions now.

[The Chair, Conservative, Rob Anders]

Thank you very much.

I've made a number of notes myself. However, I'm going to turn it over to other committee members, because that's the nature of things when you're the chair.

It now goes to the Liberal Party of Canada, to Mr. Roger Valley for seven minutes.

[Roger Valley, Liberal, Kenora, ON]

Thank you very much.

Thank you for trying to help us as we deliver some of the changes that we make to our Veterans Affairs.

You may not know, but this is a fairly new committee brought in by this government. Before it was attached to the Department of National Defence, but now it's a stand-alone committee in our Parliament, which gives it a lot more say.

We're looking for areas in which we can improve. We know our cousins to the south have a lot of experience in this.

Somebody mentioned that many of your departments are quite proud of the number of veterans who are serving in them. Are any of you veterans...?

Well, it's nice to see some of the brass at the top.

[Voices]

Oh, oh!

[Roger Valley, Liberal, Kenora, ON]

I have a question that we've struggled with in committee. We don't have a definition, or one that I'm comfortable with myself, of what a veteran is. I'd like to ask anyone at the table if they have a definition in the United States of what a veteran is.

While you're thinking of an answer, I'll give an example. Right now in Canada we say that a veteran is someone who has served in the forces and has left the uniform. But at the same time, we have many people in uniform receiving pensions from Veterans Affairs.

So I'm wondering if you could elaborate on your definition of a veteran in the United States.

[Keith Pedigo]

Sir, I will take a shot at that, and I'm sure my colleagues might want to weigh in.

The simple definition is that anyone who has served in the military for any period of time is a veteran, but that doesn't necessarily mean they qualify for the various benefits that we administer in the Department of Veterans Affairs. Because our benefit programs, our health care programs, and our national cemetery administration programs were developed over time in a piecemeal fashion based on statutory changes provided by our Congress, there is not even uniformity within our own Department of Veterans Affairs.

For example, if you serve during a period of war, you can qualify for many benefits after 90 days of service. But if you are disabled on your first day of military service, you can also become qualified for most VA benefits based on one day of service. If you served in peacetime, sometimes you require two years of military service or the full term for which you are called to active duty to qualify for the benefit.

I think you can see that there is no simple definition of what a veteran is for the purposes of qualifying for the benefits that we administer.

[Roger Valley, Liberal, Kenora, ON]

Thank you for that.

If anybody else wants to join in, please feel free.

I'm trying to make the definition of a veteran up here that when you put on the uniform you're our responsibility, not when you drop the uniform. We're having ongoing discussions on that. I think it's something we have to continue to work on so they're clear on where they stand.

I have many questions, but I'm going to go right to the bottom of the page—and this goes to what you mentioned, Keith, at the very start—that you have so many offices and branches reaching out into small areas. The area I serve in Canada is northern Ontario, where there's lots of land—a huge piece of real estate—and no people, and almost no levels of service.

One of the things that we benefit from in Canada is a very strong system of legions. In many, many small communities, a legion is the heart of the community. It's also the only point of contact for the veterans.

I'm just wondering, do legions play any role in the United States? Is there any involvement from any government departments making sure that legions exist? We know that legions want to be stand-alone entities, so they can feel free to critique the government or some of our programs. They feel they're the speakers for the veterans in our country.

So I'm just wondering if any of you have any comments on how organizations like the legions, or other organizations in the United States, strengthen some of the veterans' positions as they deal with the bureaucracy and the politicians.

[Gail Graham]

I'll start and say that we have in excess of 20 different veterans service organizations. They are independent of the VA, but have strong ties to the VA. So, for example, our secretary and our undersecretaries meet with them on a monthly basis. They do frequently speak on behalf of the veterans, whether it be on benefits issues or health issues. For example, they might see genetic issues coming up, and they'd bring it to the forefront relative to the veteran.

We do not fund them, but we work closely with them. I do think that in many cases they see the need for that separation so they can fully serve the veteran and be a separate entity.

[Keith Pedigo]

Yes, and with respect to the benefit side of our house, we really couldn't get the job done without the support of these service organizations.

A large percentage of veterans who file claims for disability are using the services of one of our many veterans service organizations, and in many cases the veteran has given these organizations the power of attorney to submit their claim and to pursue that claim to the final step. Literally, there are thousands of veterans service organization employees around the country, who really enhance the level of staffing that we have.

As I said, we really could not provide even a modicum of service if we didn't have the support of these organizations.

[Steve Muro]

And one thing with us at the national cemetery administration is that the veterans organizations are our eyes and ears out there in the field and in the cities, where we don't have a cemetery to get the word out.

Also, where we do have cemeteries, many of our cemeteries have grouped together with our rifle squads to provide honours at the end of the funeral services for our veterans. DOD normally sends two individuals on its behalf for honours, but with the veterans organizations, we can have a rifle salute, and they fold and present the flag. It really helps us to give the veteran a nice service when they're there.

[Roger Valley, Liberal, Kenora, ON]

Thank you.

I'll ask my last question, and I'd like to ask each responder to comment on it as briefly or at length as they'd like.

We have a lot to learn from you. You've had a lot of experience in this and you're covering a lot of areas, especially in the health care records, with the transfers going both ways. All of this is good news for us and we can learn from this.

But I want to ask each one of you—and you know this, because you're in the business and know the answer in some ways—what are the gaps in each of your areas? What have you not been able to deliver that could be a forewarning to us? What is missing from the puzzle that you're all dealing with on how we can better serve veterans? As you build these systems, you're always going to have people who are going to be left behind, whether it's because they are at remote cites, or are in different categories and don't fit into the box.

Please feel free to elaborate on this for each of your responsibilities.

[Steve Muro]

I'll go ahead and start. I think that for us, the biggest gap is getting to all the veterans. Of all the veterans there are, we serve about 15% of the veteran population, which means that a lot of veterans who die are being buried in a private cemetery, and it is costly to them. We provide nice cemeteries. We provide perpetual care.

The question for us, and what we constantly work on, is how do we get the word out there to all veterans who have served? Again, a lot of people don't want to hear about their burial benefit, because they think they're never going to need it. Well, we're all going to need it some day, and how do we get to it?

[Gail Graham]

I think that one of our gaps on the health side—and this may not translate to you, because of your health care system—is the private sector treatment that the patient receives. For example, our elderly veterans may be using both VA and their Medicare, and there is a gap for us in not knowing that Medicare information or clinical information paid for by Medicare, or for the younger veterans receiving some help outside the VA.

[The Chair, Conservative, Rob Anders]

Go ahead, sir.