i know it's a question we have a piece of legislation, we're talking about the alaska here's car to create access point again for rural areas that are impossible veterans to get the quality of service and he picks up interest in your comments. and again, thank you thank you for holding this important hearing because as we engage in wars, it's a two-part cause. one is the action of the work, and actions after. and sometimes i can tell you as a new member here, my personal opinion is when we engaged in the wars in iraq and afghanistan, not a lot of people thought about the next cause. i am glad this hearing is here. it's commitment we have to make. and it is owed to the veterans and families of veterans soaking thank you for all the new. and thank you again, madam chair. >> so at this time will now turn to our witnesses. we will first year from paul reickhoff, executive director and founder of iraq and afghanistan veterans of america. next we'll hear from doctor

james hosek, senior economist from the rand corporation. we will hear from mrs. crystal nicely the smh am an opening statement is a caregiver and spouse of an operation enduring freedom veteran. following her testimony we will hear from mrs. lorelei st. james, the director physical infrastructure for the government accountability office, and closing out a pen will be mrs. heidi golding who will be testifying on behalf of congressional budget office. she is cdos principal analyst for military and veterans compensation and the national security division. so thank you again to all of you for being here this morning for the support and. mr. reickhoff, we weekend with you. >> thank you, madam chair, members of the committee. on behalf of iraq and afghanistan and over to a thousand of her members and supporters, many of them are here today, thank you for inviting us to testify in the long-term costs of war for our generation of veterans. i served in iraq from 2003-2004 as a platoon leader.

when my unit returned and i came home from work, we return to the country confused by and a bit uncomfortable with its warriors. people wanted to help. they just didn't know how. bringing to light the true cost of these wars is part of reed we formed iaea. right now our nation to use on the edge of the falls and servicemen and veterans who have concerned and have been scared. iava msha across the country contacted us the past few days. they still don't know if they will get it disability, retirement, g.i. bill checks. they so rightfully own. or even their base pay. have enough to deal with already and they deserve the answers to this question, these questions. it's up to congress to get us is as good we're here to examine the lifetime cost of this new generation of vets and i'll start with the bottom line up on, something i learned in early. it's going to be expensive. and it's going to be complex. but history shows us its it will

be less expensive and less complex if we invest as nation in our veterans now. doing so also has the added bonus of cultivating a new generation of leaders, future teachers, doctors, ceos and maybe even a few numbers of congress. they would lead our nation the only way they know how, from the front. the current condition into society is a pretty. officially 13.3% are unemployed as of this past june, more than 4% higher than the national average. we see numbers in our membership closer to 20%. in indiana it's 24%. in michigan and its nearly 30%. nationwide that means approximate 260,000 people in real numbers are out of work. that's about the same size of the entire marine corps. it does get worse. the military and veterans it's facing a suicide epidemic. there were 46 460.

to veterans is returning to local communities nationwide. costs will be a were thrown around a lot. investment bill probably will not be. and it should be. these are not just cause i'm a they are investment. this committee have been many good things for new veterans returning home. the best example of course was the post-9/11 g.i. bill which has provided close to 500,000 returning servicemen was with educational opportunities they

otherwise would not have dreamed of. the exciting and urgently needed higher the heroes act which amounts of this committee are certainly familiar with proves that you don't have, you have a rested on your laurels. this bill can and should be the first jobs bill passed by this congress. legislation and government can only do so much. the private sector must do its part. companies that commit to hiring veterans will find it is not charity, it's a smart investment. it's good for the bottom line. veterans are on the renewal by nature. although they represent less a 1% of americans, neither the american firms are veteran owned. many have specific skills, logistics, operations, key mutation, medicine and engineering. if the folks want to support the troops they should. something companies and organizations have already realized. i've iava has partnered with google and the chamber of commerce and ever to turn the tide on veteran employment. these are not just government promise our business problems or

nonprofit problems. they are american problems. take the experience of a special to glossary in afghanistan with the 82nd airborne as a medic, he proves himself over and over again. he saved the life of a french soldier that was shot in the head and was awarded a bronze star for action over the course of his deployment. he suffered a traumatic brain injury. he was honorably discharged two months after he left the work. unable to find a job anywhere in the medical field, he was looking to work as a first responder which was the equivalent of what he did overseas but employer said he lacked the proper certificate. while waiting for the two processes does billy clint he was forced to collect unemployment checks to make ends meet. he turned and ran. that the eventually get processes disability claim and he got the right paperwork to be a first responder, nephews, this g.i. bill benefits to begin his senior year at the university of wisconsin this fall. but not all new veterans have a happy ending. though sometimes we must

remember that there are so many more as we plan for the future. long-term, it's estimated the cost will be between 600,000,000,001 trying to care for this generation of veterans alone. those numbers will only increase with time if we slashed better programs. the costs are clear. they are tremendous. but so are the sacrifices that our men and women have made for our nation. and so is the pension shall for turned up when i deployed to iraq, i worked on wall street. if i were analyzing the potential return on this investment i would say my generation gets a strong buy rating. investing in innovation generation is like buying shares of apple stock in 1976. i am here today to put your money where your mouth is, please invest in this generation. we are worthy. we will deliver and we will not let america down. we never have and we never will. thank you for your time and i look forward to your questions. >> thank you very much, mr.

reickhoff. dr. hosek. >> thank you. i would like to thank chairwoman marie, ranking member, and the committee for the opportunity to testify that during the nearly 10 years since 9/11, or the 2.2 million active and reserve members have been deployed. the growing public recognition of the stresses for the service members and their families and the invisible one second hot servicemen was hard to put it in my written testimony i've given an overview of ran studies on deployment at this point i hope to highlight selected findings. these touch on the following topics, the importance of total months of deployment and understand the effects of deployment. the prevalence of ptsd and major depression among those who have deployed. the barriers of the care they face. the importance of providing evidence-based care. and unemployment. in our research we found that

extended lengths of deployment cannot family and societal impacts ranging from the financial and emotional stress of increased divorce rates, academic and emotional consequences for children, to burdens every terrorist -- reduced lead reenlistment. exposure to come out, is the single best predictor of ptsd, major depression and traumatic brain injury. and the chance of exposure increases with months of deployed. height months of deployed but negative pressure on army and marine corps reenlistment. which they countered with bonuses. this meant that personnel with high months of deployment who otherwise would have left or kept in service were at risk for the deployment and exposure to combat trauma. we found that military divorces increase with total months of deployment. upon because of additional divorces among veterans this has not been studied. more months of deployment were

associate with more behavioral and emotional problems for children. for instance, 30% of the children had added sentence of anxiety twice the rate found in other studies. we do not know if children's problems. we found almost one in five returning service members have symptoms of ptsd or major depression. problems that may affect veterans for years to come. in our survey, 18.4% of all returning servicemembers in spring 2008 met criteria for your ptsd or major depression. applying this process to the 2.2 million service members who have deployed by last september emphasized that 405,000 met criteria for ptsd or depression. we do not know the lifetime prevalence of these problems that some will develop later and others may diminish. servicemembers and veterans in our studies reported barriers to care. efforts are underway to reduce

these barriers, but more research may be needed on why veterans do not seek care and what might induce them to do so. we found that about half of those with probable ptsd or depression had not sought care in the prior year. they are reasons include concerns about confidentiality, potential negative career repercussions if care were sought, long wait times and the side effects of the medications. other berries were the diverse seemingly disorganized and incomplete sources of information about where to seek care, what services were available, who was eligible, and how to apply. further much of the care provided was not evidence-based care. evidence-based care is care that's fiscal analysis has shown to be effective. of those event ptsd or depression and sought treatment, just over half receive minimally adequate treatment, and to know who received evidence-based care would be even smaller. in our cause -- cross analysis,

high quality evidence-based care to all veterans who have ptsd or major depression would save money on net for society and improve the outcomes for those treated. finally, veterans transition, transitions on the military and nonmilitary life often involve finding a job or going to school. as many realize, assist in job search or benefits to make the transition smoother. rand study unemployment among returning service. many chose not to return to the pre-activation jobs but instead to unemployment conversation for ex-servicemembers. although aimed at helping reservists did not have a job, these benefits were also helping reserve his search for better positions. also we have identified difficulties in the early implementation of the post-9/11 g.i. bill. this research may help the va and institutions of higher education focus their efforts to make these benefits more

accessible and easier to use. it would be helpful to have researched taking an integrated view of the job search, education, and health care of servicemembers who are transitioning from the military, particularly those with behavioral health conditions. studies in this area including ran studies have not taken an integrated view. thank you once again for the opportunity to address the committee. i hope that rand work on these subjects can be helpful to the committee in fulfilling its in porton mission of serving our nation's veterans. >> thank you very much, dr. hosek. now i will turn to ms. crystal nicely. >> good morning, chairman murray and members of the committee. thank you for inviting me to share me and my husbands expenses with you today. my hopes of a tesla today, but those looking well understood my frustration and heart aches ever since my husband was injured i have assumed a high responsibility to care for him. and support him as we transition into a new life.

my husband lost his arms and his legs while serving his country in afghanistan. in a combat patrol through the village. in the southern helmand province. he was hit by an ied. it has been a long journey since that day in the early 2010, and you think it would be easy for someone to lose hope and motivation after such a catastrophic injury, but my husband has been a fighter since day one. in recovery he deployed the same warrior spirit for which the marines are so beloved. first fighting off infection and disease and working aggressively with his physical medicine and rehabilitation. he continues fighting for the progression of prostate training and also fighting for me and our future together. community of wounded warriors at walter reed is diverse and each marine has the own particular needs. many of them are fortunate enough to be accompanied by their loved one. for most of the family members we were thrown into this new rule, unexpectedly, and

unprepared. we have discovered we could have never prepared ourselves for what we face on a day-to-day basis while caring for a loved ones. many of us after, assumed a new role at walter reed. life. isn't a picnic. there's not much my husband can do without me or someone, without his prosthetic. he is unable to perform many of the very basic activities of the living, that people take for granted. the reality of his injuries requires that i was someone be at his side. this is our new norm. for me i'm not on my husband's caregiver, nonmedical attendant, appointment schedule, cook, driver, and rumor, but also his loving wife face with my own stresses and frustrations. to be clear, this is not an issue of -- but i'm also his

loving wife. this is my own stresses and frustrations. this is not an issue of being overwhelmed of caring for my husband. but what is upsetting is the lack of support, compassion for these individuals. it needs to be just a little bit easier. for the family members we must go through a very tedious process to serve as a nonmedical attendant, especially at a time when we must oversee all other parts of of our household. and our lives. that i had to continue reapplied and keep serving as a nonmedical attendant as though i'm being judged on my love and care for trenton. i won't see him through his treatments is what i want to do. but i need the system to work

with me to do that. it's almost disheartening to think that we believe someone else can care for my husband more than i can. as caregivers, we live, we live out job in schools and there are those of children to look after as well. we leave all of this to inherit another full-time job. i rely on compensation that is provided to nonmedical attendant stood since maintaining my household. with todd's injuries the build did not stop coming, and, in fact, it has gotten more expensive. we are grateful for what assistance we do get from the marine corps, but had we not been greeted his people, who wanted to assist, we would've been lost in the recovery process. although my husband is one only for surviving quadruple amputee's who struggles with hardships are very similar to many wounded warriors. the process in transitioning out of the military has been particularly difficult it todd

has been part of an integrated disability evaluation system which i understand is supposed to be faster, more efficiently through complete evaluations and tradition out of the military service. that has not been our experience. at one point a simple summary of my husband injuries that on someone's desk for almost 70 days, waiting for approval. i think, chairman murray, for helping get the issue resolved. but it should not take me talking to of the state senate to my husband. more importantly what all the other wounded marines who have not had the chance to ask for that kind of help? coordination of care has also been a problem. there seems to be so many coordinators that they're actually not all on the same page. doing opposite things. though she was trying to help, i rarely saw a federal recovery coordinator who seemed to to the

people she was responsible for. this lack of communication has also -- i've received very little information on how to participate or enroll in what is offered. for the benefits we know about, we are faced with problems and actually receiving them. for instance, periodically makes things very difficult. i did not know why this occurs and it is especially difficult to get a clear definition, definite answer. but we need help. chairman murray, i appreciate all that is currently being done to assist the wounded warriors and their family. as for me i will never be able to fully express my appreciation for what assistance we do get, and for what is available to us now, because every little bit counts be a help my testimony today has been helpful to you. as you continue working to resolve these issues. thank you very much and i'm happy to answer any questions you have.

>> crystal, thank you so much for your courage in being here today and sharing your story. and i really appreciate all you and your husband have done to educate me about what you're going through. thank you for being here. this is more like st. james. >> chairman murray, senator brown and members of the committee, i am pleased to be here today to talk about gao's recent work on the a's approach is to estimate future capital and health care budgets. for the aging veteran population and for younger veterans returning from afghanistan and iraq, it is vital that va effectively estimate the facilities and health care the veterans they need. let me first talk about va's capital planning process. va has thousands of facility provide health care and other services to millions of veterans, as thing time and location of facilities and services is a complex process. and as we recently reported, da over the course of several years

has changed its approach to this planning. va's current diary processor ge capital process, or skip. however, i can't tell you can skip is an effective planning tool it is too early to tell. but i can say that va incorporated a number of leading practices in to skip. for example, va now considers capital investments across the organization using weighted criteria and expand its five year planning horizon to 10 years. also, prior to skip the a's planning process appears to be moving in the right direction or for example, the a reduce the number of hospitals and open 82 community-based outpatient clinics. but it's not all good news. va faces a daunting backlog of repairs, about $10 billion, and as we reported in january, 20 for ongoing construction

projects needed an additional $4.4 billion to complete. moreover, va continues to face age-old challenges such as getting stakeholders to agree on needed changes, legal and budgetary limitations, and getting rid of excess or underutilized property. let me now turn to the a's approach to developing as health care budget estimate. in january this year we reported that the use the in raleigh health care projection model and other methods to estimate its health care budget for fiscal years 2011 and 2012. we found a model, use the data reflect the types of health care that veterans might need, projected or potential cost in the number of veterans who might enroll for health care. over all a model predicts the resources to meet demand for over 60 health care services that account for about 83% of va's health care cost estimates.

the models projections only provide a starting point for the budget. throughout the budget process, the health or estimate is reviewed and weighed against other va and omb priorities. and ancient we reported that va's budget estimate using the model for 2012-2013 change as it moves throughout the budget formulation process. in general at the end of the process va's estimate for the president's request to congress could be higher or lower than the models estimate as va and omb way to estimate against other parties or initiatives. along the way, va has a voice in the process. for example, if omb estimate for nonrecurring maintenance is lower than the amount that the model projects, va determined the impact on health care services and decide what action, if any, it will take up with

omb. va could also propose a lower estimate for nonrecurring maintenance in the model projected based on other va priorities. for example, compared to the models estimate nonrecurring maintenance was $904 million lower for 2012, and $1.27 billion lower for 2013. but before that, one has to recognize the model is based on imperfect data and assumptions that change. also, projections are made three to four years into the future, and budgets are developed months in advance. in summary, va uses sophisticated and complex methods to estimate its capital planning and health care budget. these methods to help to provide transparency into va's method, but the us what they produce, like the processes and models themselves, are not perfect, and almost compete for funding, and sometimes unforeseen priorities.

thank you. i'm happy to answer any of your questions. >> thank you very much. and we will turn to ms. heidi golding. >> madam chairman, senator brown, and other members of the committee, thank you for the opportunity to appear before you today to discuss the health care of our veterans returning from overseas contingency operations in iraq and afghanistan, which i'll refer to as i'll go. i will address some of the medical conditions they have the youth of health care provider by the veterans health administration, vha and cbo's projections of future potential cost to treat them. all costs will be expressed in $2011. the medical condition resulting from the purchase of patients affected members of veterans who will require medical care in the future, including that provided by vha. in total about 69,000 service

members have been exactly from the combat theaters. because of injuries and other medical conditions and diseases, many more seek care in theater are after returning home. traumatic brain injury, tbi, impose direct stress disorder, ptsd, our conditions history that could result in substantial future costs for vha. however, the prevalence of tbi and ptsd, the proportion of people with those conditions whether diagnosed with him or not, is uncertain. partly because the conditions can be challenging to identify. this makes resource planning for treatment of better and more difficult. nonetheless, data healthful to plan does exist. for example, through march 2011, dod diagnosed a total of 35,000 tbi's among oca service members. about 90% of those were classified as mild tbi's, which typically heal quickly within

weeks or months, with relatively little medical intervention. both dod and dha have implement programs to clinically screened for tb eyes. vha screen indicates that about 7% of its new oca patients have tbi with ongoing symptoms. in addition to vha has diagnosed about 27% of oca patients with ptsd. that rate is relatively high compared to published studies of prevalence which generally range from about five to 25%, but it's not surprising is veterans who have health problems are more likely than other veterans to seek care. the number of veterans who are eligible for vha benefits and extent to which they use the services will affect future costs. about 1.3 million oca veterans have become eligible for health care through the vha, just over half of them have sought the care through march 2011. the number of oca veterans who

have ever used vha has grown by about 100,000 per year since 2005. roughly half of those, those have ever used vha, began using it within 12 months of separating from service. their use is typically highest in the months immediately after they enroll in that system. vha spent almost 1.9 billion, or $4800 per oca beijing in 2010, and making the total of $6 billion to treat oca veterans through 2010. although oca veterans were 7% of our veterans treated in 2010, they represented 4% of vha spending. cbo has projected the resources that dha would need between 2011 and 2020 to treat all of oca veterans seeking care. co examined two scenarios. under scenario one, cbo assumes the number of deployed service members dropped to 30,000 by 2013 and remained there through

2020. in addition be a chase health care expenditures per oca enrollee grow about the same rate of the national average. under this scenario, dha would treat 1.3 million oca veterans at least once before the end of the decade. the annual cost for the care would nearly triple over the decade, rising from 1.9 billion in 2010, to roughly 5.5 billion in 2020, for a 10 year total of 40 billion. the largest growth would occur early in the projection period due to a large influx of new enrollees. because oca patients are less expensive to treat than the average vha patient, oca veterans would consume 8% of total spending in 2020. for scenario number two, cbo assumes the number of service members deployed drops to 60,000 in 2015 and remained there. in addition, cbo assumes expenditures per oca enrollee