[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
LEGISLATIVE HEARING ON H.R. 93; H.R. 501; H.R. 1063; H.R. 1066; H.R.
1943; H.R. 1972; H.R. 2147; H.R. 2225; H.R. 2327; AND, A DRAFT BILL TO
MAKE CERTAIN IMPROVEMENTS IN VA'S HEALTH PROFESSIONALS EDUCATIONAL
ASSISTANCE PROGRAM
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
TUESDAY, SEPTEMBER 26, 2017
__________
Serial No. 115-31
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
_________
U.S. GOVERNMENT PUBLISHING OFFICE
31-339 WASHINGTON : 2018
COMMITTEE ON VETERANS' AFFAIRS
DAVID P. ROE, Tennessee, Chairman
GUS M. BILIRAKIS, Florida, Vice- TIM WALZ, Minnesota, Ranking
Chairman Member
MIKE COFFMAN, Colorado MARK TAKANO, California
BRAD R. WENSTRUP, Ohio JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American ANN M. KUSTER, New Hampshire
Samoa BETO O'ROURKE, Texas
MIKE BOST, Illinois KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine J. LUIS CORREA, California
NEAL DUNN, Florida KILILI SABLAN, Northern Mariana
JODEY ARRINGTON, Texas Islands
JOHN RUTHERFORD, Florida ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto
Rico
Jon Towers, Staff Director
Ray Kelley, Democratic Staff Director
SUBCOMMITTEE ON HEALTH
BRAD WENSTRUP, Ohio, Chairman
GUS BILIRAKIS, Florida JULIA BROWNLEY, California,
AMATA RADEWAGEN, American Samoa Ranking Member
NEAL DUNN, Florida MARK TAKANO, California
JOHN RUTHERFORD, Florida ANN MCLANE KUSTER, New Hampshire
CLAY HIGGINS, Louisiana BETO O'ROURKE, Texas
JENNIFER GONZALEZ-COLON, Puerto LUIS CORREA, California
Rico
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
----------
Tuesday, September 26, 2017
Page
Legislative Hearing On H.R. 93; H.R. 501; H.R. 1063; H.R. 1066;
H.R. 1943; H.R. 1972; H.R. 2147; H.R. 2225; H.R. 2327; And, A
Draft Bill To Make Certain Improvements In Va's Health
Professionals Educational Assistance Program................... 1
OPENING STATEMENTS
Honorable Brad Wenstrup, Chairman................................ 1
Honorable Julia Brownley, Ranking Member......................... 2
WITNESSES
Honorable Debbie Dingell, U.S. House of Representatives, 12th
District; Michigan............................................. 3
Prepared Statement........................................... 30
Honorable Beto O'Rourke, U.S. House of Representatives, 16th
Congressional District; Texas.................................. 5
Prepared Statement........................................... 31
Honorable Derek Kilmer, U.S. House of Representatives, 6th
Congressional District; Washington............................. 5
Prepared Statement........................................... 32
Honorable Steve King, U.S. House of Representatives, 4th
Congressional District; Iowa................................... 7
Prepared Statement........................................... 33
Honorable Lloyd Smucker, U.S. House of Representatives, 16th
Congressional District; Pennsylvania........................... 9
Prepared Statement........................................... 34
Honorable Steve Stivers, U.S. House of Representatives, 15th
Congressional District; Ohio................................... 10
Prepared Statement........................................... 35
Honorable Ron DeSantis, U.S. House of Representatives, 6th
Congressional District; Florida................................ 12
Prepared Statement........................................... 36
Honorable Mike Coffman, U.S. House of Representatives, 6th
Congressional District; Colorado............................... 13
Prepared Statement........................................... 36
Honorable John Rutherford, U.S. House of Representatives, 4th
Congressional District; Florida................................ 14
Prepared Statement........................................... 37
Keronica Richardson, Assistant Director of Women and Minority
Veterans Outreach, National Security Division, The American
Legion......................................................... 16
Prepared Statement........................................... 38
Amy Webb, National Legislative Policy Advisor, AMVETS............ 17
Prepared Statement........................................... 44
Harold Kudler M.D., Acting Assistant Deputy Under Secretary for
Health for Patient Care Services, Veterans Health
Administration, U.S. Department of Veterans Affairs............ 19
Prepared Statement........................................... 48
Accompanied by:
Catherine Biggs-Silvers, Executive Director for Mission,
Planning, and Analysis, Human Resources and
Administration, U.S. Department of Veterans Affairs
Rick Weidman, Executive Director for Policy & Government Affairs,
Vietnam Veterans of America, Prepared Statement only........... 56
STATEMENTS FOR THE RECORD
David J. Shulkin, M.D............................................ 58
Blinded Veterans Association (BVA)............................... 59
Disabled American Veterans (DAV)................................. 62
Justice For Vets................................................. 69
Make A Difference America........................................ 72
Paralyzed Veterans of America (PVA).............................. 73
Veterans of Foreign Wars of The United States (VFW).............. 77
LEGISLATIVE HEARING ON H.R. 93; H.R. 501; H.R. 1063; H.R. 1066; H.R.
1943; H.R. 1972; H.R. 2147; H.R. 2225; H.R. 2327; AND, A DRAFT BILL TO
MAKE CERTAIN IMPROVEMENTS IN VA'S HEALTH PROFESSIONALS EDUCATIONAL
ASSISTANCE PROGRAM
----------
Tuesday, September 26, 2017
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Disability Assistance
and Memorial Affairs,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 10:00 a.m., in
Room 334, Cannon House Office Building, Hon. Brad Wenstrup,
[Chairman of the Subcommittee] presiding.
Present: Representatives Wenstrup, Bilirakis, Radewagen,
Dunn, Rutherford, Higgins, Brownley, Takano, Kuster, O'Rourke,
and Correa.
Also present: Representative Coffman.
OPENING STATEMENT OF BRAD WENSTRUP, CHAIRMAN
Mr. Wenstrup. Good morning and thank you all for joining us
today.
Before we begin, I would like to ask unanimous consent for
our colleague and fellow Member Representative Coffman from
Colorado to sit on the dais and participate in today's
proceedings.
Without objection, so ordered.
It is a pleasure to be here this morning with all of you to
discuss ten pieces of pending legislation that would impact our
Nation's veterans and the care provided to them by the
Department of Veterans Affairs.
I am grateful to my colleagues who sponsor the bills on our
agenda for their hard work and leadership and for being here
this morning to testify about their proposals. I am also
grateful to our witnesses from VA and from the veterans'
service organization community, as well as those stakeholders
and advocates who provide statements for the record, for their
insightful comments, thoughtful recommendations, and ongoing
efforts on behalf of veterans and their families.
The agenda for today's hearing includes bills that would
help the VA health care system become a more transparent,
streamlined, well-staffed, patient-centered, accountable, and
innovative organization. While I look forward to examining all
the legislation we are considering this morning, I am
particularly interested in Representative Rutherford's draft
bill to strengthen VA's recruitment and retention programs.
Previous legislation of mine to improve VA's ability to
hire high-quality employees was signed into law as part of a
larger VA bill in August. However, VA's staffing shortages and
workforce retention issues are complex and will not be fully
overcome without strong efforts to improve VA's ability to
identify talented clinicians early in their medical careers,
recruit them during or straight out of residency, and bring
them quickly on board to begin serving veteran patients and
bolstering the strength of the VA health care system.
Representative Rutherford's bill would do that and I look
forward to discussing it, and the many other bills before us
this morning.
I now yield to Ranking Member Brownley for any opening
statement that she may have.
OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER
Ms. Brownley. Thank you, Mr. Chairman.
And thank you to all of today's witnesses for participating
in our legislative hearing, and particularly to all of the
Members who are here representing very, very good bills. So
thank you for that.
I will say right up front that unfortunately I will be
unable to remain for the entire hearing. I have a constituent
testifying at the T&I Committee and I need to be there for my
constituent. I sit on the T&I Committee. Mr. Takano has kindly
agreed to sit in for me to finish out today's hearing.
We have a number of important bills on the agenda for today
and I want to thank my colleagues for offering their
legislation to improve the care and services we provide to
veterans.
After reading the witnesses' prepared statements ahead of
today's hearing, I would also like to extend a special thank
you to each of the VSOs for supporting my legislation, H.R. 93,
that will ensure women veterans have access to gender-specific
services at VA facilities.
The Women Veteran Equal Access to Quality Care Act will
increase access to health care for the every-growing population
of women veterans enrolled in VA care by requiring the
Department to offer gender-specific services at each of its
medical facilities. This legislation is critical to ensure that
women veterans receive the equal access to health care that
they have earned.
Almost 10 percent of the total veteran population, over 2
million veterans are women, and the VA projects that this
percentage will continue to rise. In the years since 9/11, more
American women have served our country in uniform than ever
before. Nearly 280,000 women have served in Iraq and
Afghanistan and through their service have earned the full
range of health care services provided by the VA. We must
ensure that our Nation's women veterans have access to the full
range of health care services that they need, including
dedicated women's health providers and gender-specific care.
I am also eager to hear from our witnesses about the two
pieces of legislation related to service dog therapy on the
agenda today. Both the PAWS Act and the Veteran Dog Training
Therapy Act serve as important discussion points in ensuring VA
is exploring the efficacy of alternative forms of treatment,
especially treatments that have seemingly obvious benefits. I
have yet to meet a veteran assigned a service dog that did not
appreciate the assistance and therapy offered by the dog.
We must continue to look at these complementary and
alternative treatments that help veterans cope with the
invisible wounds of war. I welcome the input of the VA and our
VSOs, so that we can continue to work together to develop the
best legislation that will achieve this purpose.
Mr. Chairman, thank you for the opportunity to discuss the
legislation in front of the Committee today and I yield back.
Mr. Wenstrup. Thank you, Ms. Brownley.
I am honored to be joined this morning by several of my
colleagues who are going to be testifying about the bills on
our agenda that they have sponsored. I appreciate you all
taking time out of your morning to be here with us and for your
work to help our veterans.
With us this morning is Congresswoman Debbie Dingell from
Michigan; Congressman Beto O'Rourke from Texas; Congressman
Derek Kilmer from Washington; Congressman Steve King from Iowa;
Congressman Lloyd Smucker from Pennsylvania; Congressman Mike
Coffman from Colorado; Congressman Steve Stivers from Ohio;
Congressman Ron DeSantis from Florida; and Congressman John
Rutherford from Florida as well.
Congresswoman Dingell, we will begin with you. You are now
recognized for 5 minutes.
OPENING STATEMENT OF HONORABLE DEBBIE DINGELL
Mrs. Dingell. Thank you, Mr. Chairman.
Chairman Wenstrup, Ranking Member Brownley, thank you for
your tireless dedication--and all the Members of this
Subcommittee and Full Committee, thank you for your tireless
dedication to our veterans and allowing me to testify in
support of my legislation, H.R. 501, the VA Transparency
Enhancement Act.
This bipartisan legislation, which I introduced with my
colleague Congressman Tim Walberg from Michigan, is a
commonsense measure we can take to improve transparency and the
quality of care for our veterans, and I urge the Committee to
consider this bill as soon as possible.
The bill would simply require the director of each VA
medical center to send quarterly reports to the Secretary on
the number of surgical infections at each facility and the
number of surgeries which were cancelled or transferred to
another hospital. The Secretary would then transmit these
reports to Congress and publish them on the Department's Web
site to help improve transparency.
This legislation is a direct response to an unfortunate
incident at a VA hospital in my district, which actually lasted
over a period of almost two years. The VA and our health care
system had a reoccurring problem with particulate matter
appearing on trays of surgical equipment that are supposed to
be sterile. In addition to raising the risk of infections, many
veterans had their surgeries cancelled or moved to a different
location. Cancelling or delaying a surgery could result in
adverse health for our veterans and we must know as soon as
possible if this is happening at VA facilities.
This is not the only instance of cancelled surgeries at a
VA hospital. In September 2015, the Star Tribune reported that
the Minneapolis Veteran Affairs Medical Center was forced to
postpone and reschedule dozens of surgical procedures after an
unidentified substance was found in sterilizing equipment.
As I dug into the issue, I learned that VA hospitals are
not required to publicly report on surgical infections and
cancellation rates as other hospitals do. The VA Transparency
Enhancement Act will help Congress and the veterans themselves
understand when, where, and why infections are happening or if
surgeries are being cancelled, so the VA and Congress can
effectively address the problem.
We should know as soon as possible if surgical infections
or cancellations are increasing at any VA hospital.
Other hospitals throughout the country are required to make
this data available and it is a transparent metric for all of
us to ensure our veterans are receiving quality health care.
Surgical infection rates are an important measurement and all
patients in any hospital have the right to know. This should be
critical for our veterans.
Improving transparency at the VA by requiring these
quarterly reports will help ensure we are doing everything we
can to give our veterans the care they deserve, and will help
policymakers and the VA staff craft an appropriate response to
help fix the problem.
The number-one priority for all of us is to ensure that
veterans receive the highest quality health care. We do not
want to see any more surgeries cancelled or delayed because of
unsterile equipment, but if it does happen again we must know
right away. We also need to know when people are having an
increased infection rate; that is a simple measurement of
quality of care.
The VA Transparency Enhancement Act is a good government
bill that represents a modest step to help improve confidence
in our VA health care system. By increasing transparency, we
can prevent bad outcomes for our veterans and identify problems
at the VA hospital sooner. Our responsibility as Members of
Congress is to be a voice and an advocate for veterans across
this country and serve our veterans as they have served us.
Thank you again for inviting me to testify and allowing me
to testify on this critical legislation. I thank the Chairman
and Ranking Member for holding this important hearing and do
hope that this bill will get marked up soon and moved to the
House floor for consideration.
Thank you, Mr. Chairman.
[The prepared statement of Debbie Dingell appears in the
Appendix]
Mr. Wenstrup. Well, thank you very much. I think those are
key components to quality assurance that exist in virtually
every hospital setting and it is the tool to manage adverse
trends and be able to nip those in the bud. So I appreciate you
bringing that forward.
Congressman O'Rourke, you are now recognized for 5 minutes.
OPENING STATEMENT OF HONORABLE BETO O'ROURKE
Mr. O'Rourke. Thank you, Chairman Wenstrup. I will be brief
in describing H.R. 1063, the Veteran Prescription Continuity
Act.
Essentially, what this does is it harmonizes the formulary
between DoD and the VA, so that if a servicemember is receiving
a prescription for their hypertension, pain control, sleep
disorder, or a psychiatric issue to include post-traumatic
stress disorder, that they can continue to receive that same
medication in the VA. Today, unfortunately, that is not the
case.
And if we want to make that transition from active service
to civilian life as a veteran as seamless and successful as
possible, then we need to make sure that those two formularies
are really one. This bill would do that. It has the support of
many veteran service organizations, for which I am grateful,
and is cosponsored by Representative Mike Coffman of Colorado,
to whom I am grateful as well.
So that's it. Thanks.
[The prepared statement of Beto O'Rourke appears in the
Appendix]
Mr. Wenstrup. I appreciate that as well, especially if
their medications are working that they don't have to change.
Congressman Kilmer, you are now recognized for 5 minutes.
OPENING STATEMENT OF HONORABLE DEREK KILMER
Mr. Kilmer. Thank you, Chairman and Ranking Member, and
Members of the Subcommittee. I appreciate the opportunity to
join you today to discuss how we can improve the operations of
the Veterans Administration, so that those who have served our
Nation actually get the care that they have earned.
I have the honor of representing more than 82,000 military
veterans, more than almost any other Member of my party, and
one of the largest concentrations in the House of
Representatives. In my region, we know that those who have
served and their families have made tremendous sacrifices for
us, and we know they have had our backs and part of our job is
to have theirs too.
And that means, if you fight for your country, you
shouldn't have to fight for a job when you come home. It means,
in the land of the free and the home of the brave, every brave
servicemember should have a home. And it means that anywhere in
this country, if you are a veteran, you should have access to
the benefits that you have earned.
That last point is what brings me here today. It is a
conversation we have been having for far too long. I have heard
in VA halls and the grocery store and from members of my
Veterans Advisory Council, why can't we fix the VA once and for
all? Why does it take so long to see a practitioner? Why do
folks in smaller towns have to travel so far to get served?
These questions have arisen because of the inability of
veterans to schedule appointments, the difficulty to build a
community-based outpatient clinic in my district, and other
issues. And they are symptoms of a larger problem: systemic
management challenges at the VA.
I appreciate all that this Committee and this Congress have
done to deliver answers to veterans like those that I
represent. I am glad that we have passed legislation seeking
information, providing enhanced authorities and funding, and
calling for accountability, but we also know that there is more
to do.
In 2013, I partnered with then Ranking Member Brown and
eventually Chairman Miller to request the Government
Accountability Office to conduct a management review of the
Veterans Health Administration. In our minds, this would help
us get to the root of the problem. And the GAO team dove in and
what started with three reports on our organizational
structure, human capital, and information technology has
doubled. These findings have begun to see the light of day and
are accompanied by specific solutions to fix the problems that
the GAO found.
One of the key findings that stood out is that, after a
number of reviews from both within and outside the VA, there
was a clear menu of recommendations to fix things for the
better. These specific recommendations included clarifying
different responsibilities between local and national
facilities, evaluating if core duties were being met, and
improving services, planning, and communications, but the GAO
found that these recommendations were never implemented. That
is not fair to veterans, it is not fair to the staff that
conducted these reviews, and, frankly, it is not fair to
taxpayers who paid for them.
On top of that, the Veterans Health Administration
struggles to implement new policies and procedures due to a
severe lack of clarity regarding the roles, missions, and
accountability of senior leaders and organizations within the
agency. The scale of the VA is so large that we need to go
beyond position descriptions and office missions. There has to
be clear, transparent, and enforced relationships between the
leaders and the layers of the VA.
How can we expect leaders and staff at more local levels to
seek opportunities for collaboration and efficiency if there is
not a clear understanding of how they are supposed to work
together to care for veterans? We need all of the oars in the
water rowing in the same direction, rather than the oars out of
the water, beating each other over the head.
And that is why I introduced the VA Management Alignment
Act, to make sure that we follow through on the GAO
recommendations. This bill simply requests that the Secretary
of the VA provide a report to Congress within 180 days on the
organizational structure of the VA. Specifically, the bill
would require the Secretary to outline the roles,
responsibilities, and accountability measures of senior leaders
and branches of the VA informed by existing recommendations on
the matter, and to provide Congress with a series of
legislative options to assist the Secretary in realizing
positive change.
Before coming to Congress, I worked as a management
consultant for McKinsey & Company and then worked in economic
development, and my experience in both roles led me to
understand that good management requires clarity from the top.
To do that, we need to better measure outcomes, we need to work
collaboratively with the administration to set an environment
for success, and this bipartisan bill, which was drafted in
consultation with the GAO and consistent with their
recommendations, meets both of those tests.
It is also important to note that the VA Management
Alignment Act is supported by the American Legion and the
American Federation of Government Employees. I am grateful that
the largest veterans service organization and the Federal
employees union has joined me in this effort.
I know this is a legislative hearing and not a markup, and
I would just request that we continue to work together to move
this policy forward. I am with you in the effort to improve the
VA and to turn words into deeds. And, again, I appreciate the
opportunity to join you today and look forward to working with
you to honor the service and sacrifices of our Nation's
veterans.
Thank you.
[The prepared statement of Derek Kilmer appears in the
Appendix]
Mr. Wenstrup. Thank you very much. I appreciate your deep
dive into some of the issues with GAO and seeking solutions.
Thanks again.
Mr. Kilmer. Thank you.
Mr. Wenstrup. Congressman King, you are now recognized for
5 minutes.
OPENING STATEMENT OF HONORABLE STEVE KING
Mr. King. Thank you, Mr. Chairman, and good morning, and
Ranking Member and Members of the Committee.
I am Steve King from Iowa and I represent the 4th District,
and I am honored to testify before you today in support of my
bill, H.R. 1943. The designated title is Restoring Maximum
Mobility to Our Nation's Veterans Act of 2017.
This critical legislation aims to ensure that our Nation's
veterans with service-connected disabilities are not simply
afforded a wheelchair, but are instead equipped with the very
best wheelchair, one that affords maximum achievability of
mobility and in the activities of daily life.
The ability to pursue life to the fullest possible degree,
even in the face of disability, is critical to ensuring that
our Nation's veterans are as healthy as possible in body, in
mind, emotions, and spirit. And the statistics prove the truth
of that statement. An average of 20 veterans die each day due
to suicide and six of them have been receiving VA service, the
veterans and VHA services, I should say, in the two preceding
years leading up to the tragic decision to commit suicide. In
my home state of Iowa, there were 75 veteran suicides in 2014
alone. We mourn these lives and they were lost unnecessarily
many of them, and we find it unthinkable that these trends
should continue.
But according to current practice, when determining which
wheelchair is best equipped for a particular veteran, a VA
clinician will take into account medical diagnosis, prognosis,
functional abilities, limitations, goals, and ambitions.
Evaluation of those mobility accesses include a number of
medical evaluations, but these capacities in response are to
effort, quality, speed and mobility, and overall function. That
really gives them enough latitude, except the VA
recommendations clarify in addition that, quote, ``motorized
and power equipment or equipment for personal mobility intended
solely for recreational leisure activity should not be
provided. Motorized and power equipment designed for
recreational leisure activities do not typically support a
rehabilitative goal.''
That is their opinion and I think this Congress has an
opportunity now to weigh in on how we really want to take care
of our veterans. And in view of the suicide rates and a number
of other observations, how can motorized and power equipment
designed for recreational leisure activities not support a
rehabilitative goal?
According to a study made available by the National Center
for Biotechnical Information, which operates under the NIH,
quote, ``Leisure activities are defined as preferred and
enjoyable activities participated in during one's free time,
and characterized as representing freedom and providing
intrinsic satisfaction. Individuals can recover from stress,
restore social and physical resources through leisure
activities. Leisure activities with others may provide social
support and in turn mediate the stress-health relationship,
enrich meaning of life, recovery from stress, and restoration
of social and physical resources,'' close quote.
This description will sound accurate to anyone who has
found this kind of rest and solace.
And I think that I will allow the rest of my prepared text
into the record or ask that it be included into the record, but
I want to tell a couple narratives into this on how this came
together for me. And each year for a number of years, a decade
or more, I have hosted the Bud Day Pheasant Hunt. Bud Day at
the time of his passing about three or four years ago was the
most decorated living American hero. He had 70-some Federal
medals, including the Medal of Honor, which he received as a
POW in North Vietnam. He was my hunting buddy and my friend.
In that hunt, we would welcome Jack Zimmerman, a double
amputee who had lost his legs at the hip and the use of most of
his right arm and some of the use of his left arm. He hunted in
a track chair with us. He had to shoot left-handed because his
left hand was the only one that could operate the trigger and
his right forearm he used to hold up the gun. But as he is
tracking down through the field, I noticed that he only could
shoot between 12 o'clock and 3 o'clock, because he has to shoot
left-handed and he can't turn. I have hunted ducks from a
canoe, I know what that's like. I'm 9 o'clock to 12 o'clock
from a canoe.
And so I started watching Jack. And he was limited and he
couldn't rotate the chair, he couldn't rotate the seat in the
chair, and you've got one second to get turned when a bird gets
up. He loves to hunt and fish and outdoors. So I wanted him to
have a rotating table that could turn in one second. I saw him
going down the hill and that chair would push down to where he
had to fight to keep from falling out of the chair. And I sit
on dozers and equipment on side hills that now automatically
level the seat. When you sit on the side, it will turn it this
way; when you're going downhill, it turns you back to level;
when you're going uphill, it sets you level. Jack can have that
and every veteran that wants to hunt should have something like
that.
And so we need to remember that these wheelchairs are
archaic and there is a lot of progress that will be made, let's
make sure we provide that for our veterans.
Thank you, Mr. Chairman, and I yield back the balance of my
time.
[The prepared statement of Steve King appears in the
Appendix]
Mr. Wenstrup. Thank you. I appreciate your interest in
getting the best care for our patients and the decision-making
process being between the physician and the patient.
Congressman Smucker, you are now recognized for 5 minutes.
OPENING STATEMENT OF HONORABLE LLOYD SMUCKER
Mr. Smucker. Thank you, Chairman Wenstrup, for the
invitation to participate today. I would like to thank you,
Ranking Member Brownley, and Members of the Subcommittee for
the opportunity to testify before the Committee on legislation
entitled the VA Billing Accountability Act.
In August of this year, the Veterans Affairs Office of
Inspector General reported that in the fiscal year 2015, of
roughly 15.4 million bills that the Veterans Health
Administration issued during 2015, approximate 1.7 million of
those were improper bills for the treatment of service-
connected conditions.
To put this in perspective, the Veterans Health
Administration collected a staggering 13.9 million from our
Nation's veterans inappropriately. That is simply unacceptable.
Our servicemen and women should not be responsible to pay when
there are errors or delays by the Department of Veterans
Affairs.
For more than a decade, the Department has failed to
address its broken medical billing system that leaves our
Nation's veterans to pick up an inaccurate or expensive bill.
That is why I introduced the bipartisan VA Billing
Accountability Act to relieve veterans of financial burdens
caused by delays at the VA.
My congressional district is home to more than 38,000
veterans, all of them deserve the highest quality medical care
and the assurance from the VA that they will not be forced to
foot the bill for the mistakes made by the VA bureaucrats.
To address this ongoing issue, my bill authorizes the VA to
waive veterans' copayments if a veteran received a copayment
bill more than 120 days after they received care at the VA or
if they have received care at a non-VA facility after 18
months.
The VA Billing Accountability Act also holds the VA
accountable by giving the Secretary of the VA the authority to
get rid of the requirement that veterans make a copayment if
the VA does not abide by the billing timing mandates.
To ensure accountability, my bill requires the Secretary of
Veterans Affairs to review the agency's copayment billing
controls and notification systems to see if there are better
solutions that can monitor and prevent erroneous bills within
180 days after enactment of this legislation. It is imperative
that the Department of Veterans Affairs prioritizes improving
its internal billing procedures.
Our Nation's veterans and their families have sacrificed so
much in defense of our Nation, we should be making it easier,
not harder, for them to transition to post-military life. That
starts with making sure that the VA not only delivers quality
health care, but also timely bills that our veterans can count
on.
Thank you again for the opportunity to testify before the
Committee today and for all the work that the Members of this
Committee do to ensure quality and affordable care for our
Nation's veterans.
I yield back.
[The prepared statement of Lloyd Smucker appears in the
Appendix]
Mr. Wenstrup. Well, thank you very much. There is no doubt
that the billing process in the VA is in need of some help as
we move forward.
Congressman Stivers, you are now recognized for 5 minutes.
OPENING STATEMENT OF HONORABLE STEVE STIVERS
Mr. Stivers. Thank you, Chairman Wenstrup and Ranking
Member Brownley for holding this very important hearing and
giving me the opportunity to testify on the Veteran Dog
Training Therapy Act.
I want to thank my cosponsor, Tim Walz from Minnesota, for
his support on this important bill. It is a bipartisan bill
that can help us with the devastating mental health crisis
facing many of our veterans.
You know, when veterans return home, many of them are
struggling with visible, physical wounds; however, it is the
invisible wounds that our veterans suffer that are sometimes
overlooked. This includes post-traumatic stress, depression,
and other mental health-related issues.
Today, I want to discuss a few of the ways that this
bipartisan bill can help our Nation's veterans in a unique way
and build on the already-proven benefits of therapy dogs. First
and foremost, therapy dogs work. Anybody who has ever had a pet
understands the calming presence that they can be. We have a
bunch of therapy dogs in the room today and, you know, it just
kind of warms your heart just to look around and see what they
are doing for our veterans.
We have so many veterans who are struggling with service-
connected mental health issues and having the presence of the
service dog can make all the difference in the world for them,
and there is scientific evidence to back it up. A Kaiser
Permanente study showed that veterans who have service dogs
have fewer symptoms of post-traumatic stress, depression,
anxiety, have better interpersonal relationships, and lowered
risk of substance abuse and overall better mental health.
Dog training therapy can clearly make a difference and we
are losing too many veterans every day to suicide, I believe
this is something that can really make a difference. The pilot
program that this bill establishes would have the Department of
Veterans Affairs Secretary contract with local therapeutic dog
training organizations to help veterans who are seeking
treatment learn the art and science of dog training. So they
get to bond with the dog, they get to actually train with the
dog, there is real therapeutic benefit there. Upon completion,
the dog would be provided to a disabled veteran. And, you know,
obviously, hopefully it would be those veterans who trained
them, but we want to work with the Committee to make sure that
that is something that we can have happen.
The Compassionate Innovation Office at the Veterans Health
Administration would be responsible for managing the program,
ensuring only the best organizations who are certified and
specialize in service dog training receive contracts. The bill
establishes a Director of Therapeutic Service Dog Training, who
would have a background in social services, experience in
teaching and experience with service dogs, and at least one
year of experience working with veterans dealing with post-
traumatic stress.
The unique part of this legislation will help veterans work
with other veterans who are struggling. We know the value of
veteran-on-veteran engagement in assisting our servicemen and
women. This legislation adds preference to the pilot dogs for
contracting with the veterans who have graduated from post-
traumatic stress treatment programs and service dog training
certification to conduct the training.
This is just another way that we can help engage other
veterans and help work on post-traumatic stress, make
connections between veterans.
We are working and want to continue to work with the staff
to put a pay-for in the bill. The pay-for that we had last year
got taken away and used in another bill that the Committee did,
which we appreciate and it was a good pay-for. We want to make
sure that we work with the Committee with this year's pay-for
and make it appropriate. Right now the bill does not have a
pay-for in it, but we want to work with you to find a pay-for
that you think is appropriate and the right thing to do.
The Veteran Dog Training Therapy Act is bipartisan, it
establishes a pilot program to measure real outcomes of
connecting veterans to therapeutic training and interaction
with service dogs, and gives veterans the opportunity to help
other veterans. I hope that you can support this bill. It is
supported by numerous organizations: The Paralyzed Veterans of
America, Iraq and Afghanistan Veterans of America, the VFW.
More ever, this legislation was passed last year out of
this Committee, included in a bigger bill, and unfortunately
the Senate didn't get this portion of the bill done. So we are
looking forward to working with you to bringing the benefit of
therapy dogs to our veterans and to help our mental health
issues.
Thank you for allowing me to testify and I hope you will
all consider this legislation.
I yield back the balance of my time.
[The prepared statement of Steve Stivers appears in the
Appendix]
Mr. Wenstrup. Well, thank you. Thank you, General Stivers,
for your firsthand insights on the issues that our troops face.
Congressman DeSantis, you are now recognized for 5 minutes.
OPENIG STATEMENT OF HONORABLE RON DESANTIS
Mr. DeSantis. Well, thank you, Chairman. Thank you, Ranking
Member Brownley.
I will submit my statement for the record, the prepared
remarks. You know, I would just say that we have I think a wide
acknowledgment that the suicide rate among veterans is
appallingly high. There are obviously a number of factors that
go into that. I think there is a broad agreement that post-
traumatic stress for veterans and all of our veterans, but
particularly some of the post-9/11 veterans who have done
multiple deployments in very difficult circumstances, you know,
that that is a problem that we need to address and that the
VA's prescription for that typically is counseling and
prescribing drugs, which can be helpful, but doesn't really
answer the call for all the veterans. So you have a lot of
veterans who go through the VA suffering from really
significant post-traumatic stress; they do some counseling,
they do drugs, and then they are still symptomatic and
sometimes they're even worse off.
And so how can you deal with that problem? And what you
have seen throughout our country is a number of organizations
that have taken it up upon themselves to harness the use of
service dogs. And these are not just dogs that are just pulled
off the street and given new veterans. I mean, they go through
training programs so that the dogs understand the symptoms of
PTS when the veterans are in circumstances where this is
triggered, whether it is in public or whether it is having
nightmares. The service dog understands that and can respond
accordingly. And so what that ends up doing is that allows
these veterans to get back into society and function.
So we have a number of people who have endorsed, you know,
our bill who have some great stories to tell. I mean, what our
bill would basically do is have the VA recognize this as a
possibility, write grants to some of the organizations that are
accredited and that have been proven to do a good job. And if
you look at the cost of, you know, the service dog, the
training, the veterinary care, even traveling the veteran to go
and pick up the dog, if you end having a veteran where that
works well and they stop using some of the prescription drugs,
that is actually going to save a lot of money. I mean, we are
doing it to save lives, but it really will, it is a bargain in
many respects.
And so we have got almost 200 cosponsors on this. It is
definitely a bipartisan bill, been endorsed by the major
veterans organizations. But I have just had a number of
veterans come up to me who, you know, had gone through the VA
treatment and were not doing well. And I have had a number tell
me, look, I was lucky enough to get a service dog through this
organization or through a family friend, or however they got
referred, and if I didn't have that, you know, I don't think I
would be here today, because they were suicidal.
I have in the crowd here one of the guy who has really
pushed for this named Cole Lyle, who is a Marine, former
Marine, and he, you know, can tell you about he was in the
dumps, he had a service dog and, you know, went to school. He
is now up here, he has worked on the Hill, he is doing all
kinds of things.
So the results are there for us to see. There is more
medical research now coming out that is showing that this is a
positive effect, declining use of drugs, and a lot of the good
indicators. So I appreciate the Committee's interest in this
issue.
I think that this bill, the pilot program, it is only five
years, it is not a lot of money overall, but I think you will
see real results. And I think the VA then--and I give Secretary
Shulkin credit, he said, look, we can't wait, if this can work,
we've got to do it. So I think what will happen is that will
really open up even more possibilities so that we can get that
suicide rate down, so that we can get veterans who are
suffering from post-traumatic stress back on their feet and
back to being productive members of society because, when they
are, they do an awful lot of good in society too even after
their military service.
So I appreciate you giving me the time to say a few words
about this bill and I yield back the balance of my time.
[The prepared statement of Ron DeSantis appears in the
Appendix]
Mr. Wenstrup. Well, thank you, and I appreciate that you as
a veteran are continuing to advocate on behalf of our veterans.
Mr. Coffman, you are now recognized for 5 minutes.
OPENING STATEMENT OF HONORABLE MIKE COFFMAN
Mr. Coffman. Thank you, Mr. Chairman.
My bill, H.R. 2147, the Veterans Treatment Court
Improvement Act, builds upon an existing and successful program
that connects veterans who go into the criminal justice system
with a VA representative in these Veterans Treatment Courts,
and they are Veterans Justice Outreach Specialists. This is to
keep veterans who may have substance abuse issues, may have
mental health issues oftentimes related to their military
service, to keep them out of jail. And so I was very suspicious
of whether or not these programs actually work and so I went to
one of the Veterans Courts, Treatment Courts to actually
witness it. And what was amazing to me was that what it did was
it touched on something in their lives where they were
successful, something in their lives where they held something
in common, and that was they all were successful at one point
in time in the military. They got through basic combat training
in the Army, they got through boot camp in the Army, basic in
the Air Force and the Navy. And the judge in the court that I
went to in Adams County, Colorado, the prosecutor was a Marine
Corps combat veteran from Vietnam, and I think that to see the
pride in these veterans come out in the court.
And it is amazing, in the 18th Judicial District in the
State of Colorado, they have a 74-percent success rate, which
is much higher; the rate of recidivism normally is the vast
majority re-offend.
So you have a representative from the VA who is there to
make appointments, make mental health appointments, substance
abuse appointments right on the spot for these veterans who are
periodically required to show up for these court proceedings.
And so in effect what this bill asks is an additional 50 VIO
Specialists.
And so I just want to say how impressed I am with this
program, how it keeps our veterans out of the criminal justice
system in terms of being incarcerated, gets them back into
being contributing members of society, and I just think this is
a very important program and would urge the passage of the
bill.
And with that, Mr. Chairman, I yield back.
[The prepared statement of Mike Coffman appears in the
Appendix]
Mr. Wenstrup. Thank you. I know that in my home county the
Veterans Treatment Court has been very successful and includes
mentoring from a veteran of similar background, and we have
seen very good results with that and I appreciate that.
Mr. Coffman. Mr. Chairman, if I could for one second?
Mr. Wenstrup. Yes.
Mr. Coffman. That is another point is that there are
mentors that are associated with the program and I did fail to
mention that. I think they are not generally with the VA, they
are volunteers that do that. There is again one VA employee
associated with the court that we discussed here. And, you
know, to be able to where they don't have to navigate the
bureaucracy of the VA, to have somebody right there that will
set up that mental health appointment, that will set up that
substance abuse appointment for that veteran is so important.
This is such a tremendous savings to the taxpayers of the
United States by keeping these veterans from being incarcerated
and keeping them on as taxpayers.
I yield back, Mr. Chairman.
Mr. Wenstrup. Thank you.
Mr. Rutherford, you are now recognized for 5 minutes.
OPENING STATEMENT OF HON. JOHN RUTHERFORD
Mr. Rutherford. Chairman Wenstrup, Ranking Member Takano,
and fellow Members of the Subcommittee, I want to thank you for
this opportunity to speak on behalf of this draft legislation
that would improve the Health Professional Education Assistance
Program at the VA.
This Subcommittee has frequently heard testimony regarding
the high number of physician vacancies at the VA and the
negative impact that this has on the care of our Nation's
veterans. And currently the VA has several programs to address
recruitment in their profession ranks, including the Education
Debt Repayment Program and the Health Professions Scholarship
Program. And while these programs have improved recruitment,
physician remains at the top of VA's critical mission shortage
with the current estimate of physician vacancies to be 3500.
One way to ensure that the VA is long-termed staffed with
qualified providers is to recruit those who are currently in
medical school or in residency and assist in their educational
expenses in exchange for their service within the VA system.
As we as a Congress work with our partners in the
Administration and in our communities to improve care and
decrease wait times, I believe it is critical that the VA has
the tools to recruit and retain providers in areas that are
desperately needed throughout the system.
This draft legislation really makes three primary
improvements to the program.
First, it requires the VA to provide a minimum total of 50
2-to-4-year scholarships annually for students studying to
become physicians or dentists any time the shortage of these
professions is 500 or greater. These students will then be
obligated to provide clinical service at a VA facility for 18
months for each year of scholarship support.
Second, the legislation requires the VA to create a pilot
program to fund two scholarships at each of the five Teague-
Cranston Act medical schools for veterans who qualify for
admission to those medical schools. The schools that
participate in this program will each receive two seats in each
class for the veteran recipients of those scholarships. The
veterans are obligated to provide clinical service at a VA
facility for a minimum of 4 years in exchange for the
scholarship.
Third, and finally, it standardizes and increases the VA
Loan Repayment Program for newly graduated medical students or
those currently in residency who will be training in
specialties deemed as shortages in VHA. The loan payments will
be a maximum of $40,000 per year with a maximum total of
$160,000.
Following completion of residency training, the loan
recipients would be obligated to provide clinical service at a
VA facility for 1 year for each $40,000 of loan repayment, but
in no case fewer than 2 years. The current program varies among
the various VISNs and is not actually adequately competitive,
quite frankly.
So the VA has made many impactful changes in recent years,
but it is important that we consider ways, alternative ways
that the VA can attract talent on the front end to improve the
system long term. A key part of this is attracting young talent
and getting that to come into the system and compete. To do
that, we are going to have to compete with the private sector.
In closing, I would like to thank the Chairman, the Ranking
Member, my colleagues on the Committee, and the Subcommittee
staff for their commitment to this and other pieces of
legislation that are under consideration today that would
continue to improve our VA health care system.
Thank you. I yield back.
[The prepared statement of Honorable Rutherford appears in
the Appendix]
Mr. Wenstrup. Thank you, and I appreciate that premise. It
is something that has been very successful within the military
as far as recruitment and gaining good medical providers, I
appreciate that.
If there are no questions of our two remaining panelists,
then we will move on to the second panel, and I will now
welcome our second panel to the witness table.
Joining is Dr. Harold Kudler, the Acting Assistant Deputy
Under Secretary for Health for Patient Care Services for the
Department of Veterans Affairs, who is accompanied by Catherine
Biggs-Silver, the Executive Director for Mission, Planning, and
Analysis for Human Resources and Administration; Keronica
Richardson, the Assistant Director of Women and Minority
Veterans Outreach for the National Security Division of The
American Legion; and Amy Webb, the National Legislative Policy
Advisor for AMVETS.
Thank you all for being here and for your advocacy on
behalf of our veterans, today and each and every day.
As soon as you get settled, we will begin with Mrs.
Richardson, and you are now recognized for 5 minutes.
STATEMENT OF KERONICA RICHARDSON
Ms. Richardson. Good morning, Chairman Wenstrup, Ranking
Member Brownley, and distinguished Members of the Subcommittee
on Health. On behalf of the National Commander Denise H. Rohan
and The American Legion family, we thank you for the
opportunity to testify on behalf of The American Legion.
The American Legion is the country's largest patriotic
wartime service organization to veterans, with over 2 million
members and serving every man and woman who have worn the
uniform for this country, we welcome the opportunity to speak
on behalf of our constituents.
I am Keronica Richardson, the Assistant Director of the
Women and Minority Veterans Outreach, and it is my duty and
honor to present The American Legion's position and we
appreciate this opportunity to testify and expand on these
important issues.
Since the American Revolution, women have volunteered to
serve in the U.S. military. In fact, according to the
Department of Veterans Affairs, the female veteran population
accounts for 10 percent of U.S. veterans and that number is
expected to grow to 15 percent by 2030.
Women veterans are significantly different than their male
counterparts; as such, the care that women veterans receive at
medical centers and community out-patient clinics should be
gender-specified. Although the VA has made some progress in
providing gender-specific services, more work needs to be done.
H.R. 93, Medical Services for Women Veterans, would amend Title
38 to provide increased access to care for women veterans at
the Department of Veterans Affairs.
To understand the need for this bill, some of the important
issues that female veterans encounter are obstacles in
receiving gender-specific health care in rural areas; the lack
of female providers for military sexual trauma, treatment, and
therapies; a full-time gynecologist on staff, the lack of a
full-time gynecologist on staff; and female veterans are more
likely than their male counterparts to be referred to an
outside VA system for specialty care.
If enacted, H.R. 93 will require the VA to meet the health
care needs of women veterans across the VA health care system.
When the VA is unable to meet their needs, the Secretary may
enter into contracts with third-party organizations to provide
the necessary services. The American Legion supports this bill
and stands ready to assist in however we can help expand the
health care needs of women veterans.
Shifting focus to H.R. 2327, the PAWS Act of 2017, we feel
that it is important to make service dogs accessible to
veterans wanting an alternative post-traumatic stress disorder
treatment. Currently, the Department of Veterans Affairs does
not fund service dogs or recognize the use of service therapy
dogs as a possible method for veterans suffering from PTSD.
There have been multiple studies proving that service dogs
can provide many different forms of mental healing to veterans
suffering from the invisible wounds of war. Service dogs can
act as an effective complementary therapy treatment, especially
for those veterans who suffer on a daily basis from the
physical and psychological wounds of war.
PTSD has become an epidemic and the VA has estimated that
between 11 and 20 percent of veterans who served in Afghanistan
or Iraq have PTSD. While the VA continues to stall on their
dog-based therapy studies, veterans are being denied
alternative forms of treatment.
The American Legion supports H.R. 2327 because it allows
for an alternative treatment to injured veterans suffering from
traumatic brain injury or post-traumatic stress disorder.
Lastly, I would like to shift my focus to H.R. 1063, the
Veteran Prescription Continuity Act. This legislation will
require the VA to continue serving medications, supplying
medications prescribed to DoD health care providers while the
DoD health care provider determines that such pharmaceutical
agent is critical for transition out of the military. The
American Legion feels that this legislation serves in the best
interest of transitioning servicemembers and veterans by
allowing them the comfort in knowing that their medical
treatment will continue even after their military discharge.
The American Legion supports H.R. 1063.
Again, I would like to thank you for this opportunity to
testify and I welcome your questions.
[The prepared statement of Ms. Keronica Richardson appears
in the Appendix]
Mr. Wenstrup. Thank you.
Ms. Webb, you are now recognized for 5 minutes.
STATEMENT OF AMY WEBB
Ms. Webb. Good morning, Chairman Wenstrup, Ranking Member
Brownley, and Members of the Subcommittee. AMVETS is truly
pleased to be invited to testify today.
While AMVETS is on the record in support of all of the
bills and the discussion draft under consideration, I would
like to start by talking about the concerns or the cautionary
way in which we offer support for H.R. 2327, the PAWS Act.
AMVETS has long advocated for the pairing of well-trained
service dogs with veterans to assist the veteran with a myriad
of physical and emotional health issues. On its face, we
wholeheartedly support the PAWS Act, but, as mentioned in our
written statement, there are several stipulations to this
support.
First, it is vital that organizations that train the
service dogs are well vetted, and it seems that great care has
been taken in writing the bill to ensure this. We appreciate
the quality measures put in place, such as requiring that any
eligible organization is Assistance Dog International or ADI
accredited, and that it meets the Association of Service Dog
Providers for Military Veterans Service Dog Agency standards.
Per the ADI Web site, there are currently 65 accredited
programs in the country and of those just nine mention PTSD or
veterans. And in extrapolating the funding request for the
bill, it looks like the intention is to place about 80 dogs
with veterans per year for five years. Our hope is that the
limited number of accredited programs can meet the demand for
this wonderful pilot.
Second, it is also vital that veterans chosen to
participate in the pilot are very closely monitored, especially
in the first year of the pairing, which should be implemented
into the contact plan outlined in the bill. There should also
be some type of recourse for the veteran if they are not
getting a response to their questions or requests for follow-up
training, and recourse for the organization if the veteran does
not respond or keep their part of the contact agreement.
Veterans chosen for this pilot remain diagnosed with PTSD
after completing evidence-based treatment with no improvement.
It is well known that PTSD can manifest in sleep issues, losing
interest in activities that you used to enjoy, along with
depression. This can be as simple as losing interest in taking
a shower, going to the store to buy food, or going out with
family and friends. Having a service dog requires consistency
and work on the handler's part.
Our reasoning for suggesting very close follow-up stems
from the alarming issues that occurred in the first part of
VA's study on PTSD service dogs and the fact that AMVETS has
paired with an ADI accredited service dog organization for
nearly 30 years and they will not train PTSD service dogs.
AMVETS and this particular organization does believe that
dogs can be trained to perform concrete tasks to help a person
with PTSD in a heightened state of anxiety or in the midst of a
nightmare, but they do not employ a full-time psychiatrist and
therefore they do not feel they have the insight needed to
properly pair dogs or provide the follow-up. AMVETS wants to
ensure that all measures are proactively put in place to set
this pilot up to have as much of a positive impact that we know
that it can and we look forward to passage of this bill.
On a separate note, as an organization we have to mention
H.R. 2147, the Veterans Treatment Court Act. This bill goes
straight to the heart of our organization.
In 2008, our then National Commander J.P. Brown worked in
Buffalo, New York with Judge Russell on the country's first
Veterans Treatment Court. To this day, Commander Brown stays
highly involved with the Veterans Treatment Court he helped
found in his home state of Ohio. These courts reach out and
hold the proverbial hand of justice-involved veterans and guide
them down a better path. The results and percentages of
veterans that complete the 2-year program is quite incredible
and we wholeheartedly support this bill.
Lastly, AMVETS would like to comment on H.R. 501, the VA
Transparency Enhancement Act. This straightforward, bipartisan
bill requires VA to publicly report on post-surgical infections
and cancelled or transferred surgeries. The origin of this
bill, as we heard earlier, stems from an ongoing issue at the
Ann Arbor VA, and the intent is simply to provide veterans
knowledge and safe health care. The reporting requirement would
also alert Congress if something more needs to be done.
AMVETS members strongly support VA accountability and we
believe that transparency is part of being accountable. AMVETS
supports this bill and urges its passage.
Thank you again for the opportunity to speak on behalf of
AMVETS and I welcome any questions.
[The prepared statement of Amy Webb appears in the
Appendix]
Mr. Wenstrup. Thank you.
Dr. Kudler, you are now recognized for 5 minutes.
STATEMENT OF HAROLD KUDLER, M.D.
Dr. Kudler. Thank you and good morning, Chairman Wenstrup,
Ranking Member Brownley, and Members of the Subcommittee. Thank
you for inviting us to present our views on several bills that
would affect the Department of Veterans Affairs programs and
services.
Joining me today is Catherine Biggs-Silvers, Executive
Director of Management, Planning, and Analysis for VA's Human
Resources and Administration.
VA and Congress are closely aligned in what we want to
accomplish for veterans, their families and the Nation. In the
few instances where we're not in concurrences, it's generally a
matter of details. We see these bills as opportunities to
collaborate with you to work these details out.
We share Congress' concern about services for women
veterans, but because the language of H.R. 93 doesn't specify
what is meant by gender-specific, it may require more than you
intend.
The percentage of women veterans increases yearly across VA
and we have primary care services for all women in all our
medical centers, as well as women veterans comprehensive care
centers in more than half of our VA medical centers, 81 of
these in total. But we want to work with Congress to best meet
this growing need.
H.R. 501 would impose new reporting requirements regarding
surgical infections and cancelled or transferred surgeries.
Currently, each facility collects data on surgical infections,
but this information is not rolled up nationally. The VA
Surgical Quality Improvement Program, VASQIP, examines a
statistically significant sample, approximately 30 percent of
all complex surgeries completed across VA, to study surgical
infections. Nationally, 1.5 percent of VASQIP-assessed
surgeries are associated with infection.
There are no good comparators in the community because no
other system of our size and scale keeps such records, nor does
the Joint Commission require them to do so.
We do not support this bill because the VASQIP system
already addresses surgical infections and examining all
surgeries would siphon resources away from clinical care
without any appreciable improvement in quality. Furthermore, we
are concerned that the summaries called for could expose
veterans' protected personal information.
We would therefore like to discuss this bill further with
you to see if our current systems could satisfy your
objectives.
VA does not support H.R. 1063 because of unintended risks
and requirements. While continuity between DoD and VA care is
critically important, we are concerned that this bill as
currently written would tie clinician's hands and create the
potential for serious harm.
VA looks forward to working with Congress to ensure that
before any change in medication is made patients get an
individualized assessment, and have an opportunity to discuss
their needs and their concerns with VA clinical staff.
The VA supports H.R. 1066, which requires a report on VA's
organizational structure. We are already working to ensure that
we in VA are held accountable.
Regarding H.R. 1943, VA already provides whatever a veteran
needs for biking, driving, or other mobility issues, including
adaptive equipment. Access to this level of support is not
currently limited to service-connected injuries, as this bill
would require. But it depends only on medical necessity and on
the veteran's individual rehabilitation plan.
We agree with Congress that veterans have a right to know
whether they are going to be charged a copay in a timely
manner. Unfortunately, H.R. 1972 does not take into account the
multiple steps and stakeholders required to generate an
accurate bill. We place priority on giving the veteran an
accurate statement as quickly as possible and look forward to
working with Congress to align our timeframes in accomplishing
this.
Congress' support for VA's Veterans Justice Outreach
Program has had a major impact on homelessness and mental
health problems among veterans. H.R. 2147 would require VJO
Specialist hiring without providing the additional funds
needed. But VA is already working to hire and train more than
50 new VJO Specialists using funds prioritized for exactly this
purpose rather than to require new offsets, which would harm
other programs.
H.R. 2225 proposes a five-year pilot for veteran training
of service dogs. However, both DoD and VA are already piloting
similar programs. We do not believe that creating yet another
program would add significant value.
VA is already helping veterans obtain service dogs when
that best supports their recovery. However, H.R. 2327 specifies
a funding strategy which would predictably undermine
statutorily required VA functions.
Mr. Chairman, this concludes my prepared statement.
We look forward to working with the Subcommittee to achieve
our shared goals. My colleague and I would be pleased to answer
any questions which you or other Members of the Subcommittee
may have.
Thank you.
[The prepared statement of Dr. Harold Kudler appears in the
Appendix]
Mr. Wenstrup. Thank you.
I am going to yield myself some time for questions before
we go to the others.
Dr. Kudler, I would say that I think the more data you have
on infection and infection control is important. You know, our
troops when they come from all parts of the country, they come
together and they go to common places, but then when they come
back as veterans they are all over the country. And if you want
to follow trends and where that infection maybe came from, you
have to look at it nationally, because now our troops are all
across the country.
So I think we can take a look at that. I understand some of
your concerns, but I think that is important data to collect
and try and find the origin and cause of certain infections, if
indeed it came from their military service especially and where
the common origin is. They don't all come back to the same VA
hospital when they leave. So I think that is important.
But I do have a question for you on women's health
especially. But, you know, a VA medical facility may not have a
large enough female population to be able to recruit and retain
a woman's health provider or OB/GYN because of the low volume,
so how do you plan to engage in that and be able to provide
that opportunity for our women?
Dr. Kudler. Well, we have been training 500 clinicians a
year in women's health in order to try to meet that need. We
have been, as you say, looking to work with communities and
under Choice we can do a great deal more of that. And under
Choice as we imagine in the future even more, not just to meet
the needs that we identify, but to meet the convenience and the
desires of women veterans in their own communities.
We need to scale this. We are growing at about 6 percent
per year in women veterans, and women veterans do have
different needs and different ways they would like to use
services. One thing that is really interesting about women
veterans and VA is when they do use VA, they tend to use more
of our services than the men do, and I think that reflects back
to women are smarter and speak up for their own health better
than men do.
The bottom line is, we need to work together with you to
figure out how to scale this and also how to pay for it.
Mr. Wenstrup. Thank you.
And in the same vein, Ms. Richardson and Ms. Webb, what are
your feelings today at the current state of VA services for
women?
Ms. Richardson. Keronica from The American Legion. At this
current moment, I feel that the VA has made improvements. There
are some gender-specific services available; however, there is
still a lot of work that needs to be done. As I mentioned,
there are still not any on-site gynecologists, there are still
issues in rural areas about not being able to have the gender-
specific services available. Even on a smaller scale not having
sanitary items in the restrooms or not having the privacy
curtains at the VA utilized when female veterans are present.
So I think there is still room for growth.
Mr. Wenstrup. Thank you.
Ms. Webb?
Ms. Webb. Yes, I agree that over the years a lot of
progress has been made in each facility, the development of the
Women Veteran Program managers at every facility, but there is
a lot of work to be done. You know, each woman needs to be able
to go in and feel not only welcome, recognized, but have
someone that knows her specific health care needs. It is a
priority.
Mr. Wenstrup. Thank you.
Mr. Takano, you are now recognized for 5 minutes.
Mr. Takano. Thank you, Mr. Chairman.
I have long said that we need to improve the human
resources function of the VA and the co-chairs of the
Commission on Care testified before this Committee that they
agreed that we needed to improve the human resource function.
I support Representative Kilmer's work to improve
accountability at the VA with H.R. 1066, the VA Management
Alignment Act of 2017. The VA has said that they are working to
improve accountability, but I think Mr. Kilmer's legislation
helps expedite the process.
Now, can any of the VSOs who are present today expound on
how you see Representative Kilmer's legislation helping to
improve accountability at the VA?
Ms. Webb. Well, I believe that it is, you know, very
important to have each department take a really good look at
what they are doing and streamline functions and make sure that
every role, you know, is working at its full capacity. And that
if there are cost-saving measures and downsizing, or if they
need to bring in more staff on the other side of it, it is just
always a good business practice to do such things and it does
speak to them being accountable for what each department is
doing and you can't be accountable if you don't know what's
going on.
Mr. Takano. Great.
The American Legion, anything to add?
Ms. Richardson. I don't have anything to add to that. I
think she covered exactly how The American Legion feels on that
stance as well. We just feel like being accountable would allow
them to have the service provider or the veteran more informed
and make more informed decisions about whichever VA that they
decide to choose from.
Mr. Takano. Wonderful.
Ms. Richardson. Other than that, we don't have any more
stance.
Mr. Takano. Well, moving on to a different topic, having
reviewed the written testimony from the VSOs, I noted there was
broad support for the Veterans Treatment Court Improvement Act
of 2017, and based on what you have heard from your members,
why is this legislation so important?
Ms. Webb. Well, a lot of people have post-deployment
readjustment issues and the whole point is that, you know,
sometimes they misbehave or sometimes there are undiagnosed
mental health issues, or perhaps they have gotten into drugs,
and instead of just throwing someone away into the jail system
or into the criminal justice system, you know, these courts,
the mentorship is a really big part of it, working with them.
They have to make a commitment to get through this program so
their charges can be dropped, and we hear time and time again,
that the ones that get through these programs, they lead
better, fuller lives, they don't know what they would have done
without that mentorship, and then many of them proceed to give
back.
Ms. Richardson. The American Legion's stance on that is
when you look at an overview of the Veterans Treatment Court,
it is a hybrid of veterans with drugs and mental illnesses that
relates back to PTSD.
So we definitely fully support the Veterans Treatment Court
because we feel it would give the veteran another opportunity
to readjust to society, so we support that bill.
Mr. Takano. Great. Thank you.
Dr. Kudler, accountability remains a key focus of this
Committee and as I just asked the VSOs about and their
testimony about 1066, you in your written testimony noted that
the VA is not waiting for legislation to improve the
Department's organizational structure and internal management,
and the VA has already taken aggressive steps to address these
areas. Can you provide some insight into these efforts?
Dr. Kudler. Yes. VA has taken on a modernization program
that exceeds the rest of the Federal agencies. We have been
working on it before it was ordered down from the White House
to be done by all agencies. And I think the real principle is
increasing accountability and transparency, and moving the
fulcrum of control from Washington closer to the point of
service. So that local facilities will have more
responsibility, but also more flexibility in how do you provide
service in Beckley, West Virginia versus New York City in
Manhattan or the Bronx.
It makes sense to answer veterans' needs in community
terms. But we also want the networks, which are large enough to
have more buying power and more centralized control and more
data to pull together, but also small enough to know regional
issues to then be able to roll that up and coordinate with
them. And we in central office will be there to offer support,
but not try to use a 3,000-mile screwdriver to adjust
everything that happens everywhere around the country. And this
I think is a key principle of where we are trying to go.
Mr. Takano. Thank you very much, Dr. Kudler.
And thank you, Mr. Chairman, my time is up.
Mr. Wenstrup. Mrs. Radewagen, you are now recognized for 5
minutes.
Mrs. Radewagen. Thank you, Mr. Chairman. And I want to
thank the panel for appearing today, thank you for your
service.
As everyone here is acutely aware, VA still has a
significant shortage of health care professionals despite
existing educational assistance programs. For example, in my
home district of American Samoa, we are currently facing
difficulties in finding physical therapists and other health
care specialists for our small VA clinic.
American Samoa is a remote area with no VA hospital of our
own and because of staffing problems we cannot even make use of
the limited facilities we do have.
So, Dr. Kudler, what can VA do to address staffing
shortfalls in remote areas like the U.S. Territories and how
can we ensure that once we have an adequate supply of trained
professionals they end up where they are needed most?
Dr. Kudler. Yes, thank you.
The citizens of American Samoa serve at a higher rate than
most other groups in the United States and they do have not the
3,000-mile screwdriver, but I am going to say probably more
like a 10,000-mile screwdriver of us trying to get in there and
fix things directly. But there are different ways that we can
work together.
For example, you mentioned physical therapy and I work with
the Physical Medicine Department in Durham, North Carolina to
help promote a rural physical therapy program that used a
point-to-point telehealth to actually do physical therapy. You
can provide equipment to help somebody increase their range of
motion and measure it within a micron of movement to work with
a physical therapist who isn't even on the same island where
you are. So it is just one of many possibilities.
Obviously, we need to hire more people, we need to make
transportation more available, we need to think about how do we
project our strength and our talent, and how do we also bring
people in when it meets their needs and it is their wish to be
brought in. I know not everybody wants to get on a plane and
fly to a remote location either for their care. So we have a
long way to go, but fortunately new tools are being developed
and we have to keep using innovation to apply them properly.
Mrs. Radewagen. Thank you.
Mr. Chairman, I yield back the balance of my time.
Mr. Wenstrup. Dr. Dunn, you are now recognized for 5
minutes.
Mr. Dunn. Thank you very much, Mr. Chairman.
Let me start out by saying to Ms. Webb, I am a life member
of AMVETS and I invite you to come see your chapter in Panama
City. Maybe when it is cold and nasty up here you will find the
time to do that.
Dr. Kudler, I want to turn my attention to the Health
Professionals Educational Assistance Program. I know you are
working on providing a formal view on the cost estimates of
this bill, when do you think that will be available?
Dr. Kudler. Well, we did get that bill a little bit later
and too late to prepare, but let me say as quickly as possible
and we are looking forward to responding, because--
Mr. Dunn. I am just looking for a timeframe.
Dr. Kudler. I would have to get that for you, sir; I don't
have it.
Mr. Dunn. Okay. We are anxious to have your thoughts on it,
because we think it may help.
Do you agree on the estimate of the shortage in the VA of
medical professionals that Congressman Rutherford mentioned,
3500?
Dr. Kudler. There is a national medical shortage--
Mr. Dunn. There is.
Dr. Kudler [continued]. --and we are not gearing up to meet
it. And the VA as the largest employer of physicians, and
especially of psychiatrists and psychologists in America, is
really in need of any help we can get.
Mr. Dunn. I am just trying to quantify it. Is it about
3,500 in the VA nationwide?
Dr. Kudler. Oh, I would have to get that for you, sir.
Mr. Dunn. Okay. So we need a lot of data, it sounds like.
We can't fix a problem without data.
What is the attrition rate for medical professionals in the
VA annually?
Dr. Kudler. Once again, I would have to get that for you.
Mr. Dunn. Okay. So you get a sense of the data things we
are looking for. Do you know how many people, how many medical
professionals you hire in a year?
Dr. Kudler. I know that we are--
Mr. Dunn. Just roughly.
Dr. Kudler. In mental health, which is the area I work in,
I think we are now up in the last year about almost 900.
Mr. Dunn. Nine hundred in a year?
Dr. Kudler. Professionals, yes.
Mr. Dunn. Good, that is an important area.
Dr. Kudler. Psychologists, psychiatrists, licensed
professional counselors, social workers, all of whom are
employed in the mental health field in VA.
Mr. Dunn. How about the--do you know how many you
anticipate resigning or retiring in the next year?
Dr. Kudler. I really hesitate. I have got some numbers
kicking in my head, but I am not sure they are accurate, sir.
Mr. Dunn. How about how many of your scholarship programs
have been granted to physicians in the last X amount of time,
year, 2 years, whatever, anything you are familiar with?
Dr. Kudler. I am not aware of VA having a scholarship
program for physicians at this time. We do have under the Clay
Hunt Act medical debt reduction for psychiatrists and we are
fully engaging that, and we are spending every dollar that is
in there, we are matching every person that is in there.
Mr. Dunn. Yeah, I'm sure.
Dr. Kudler. That has been very effective.
Mr. Dunn. Let's turn our attention to H.R. 501, the
Transparency Enhancement Act. Do you have a feeling for the
number of surgeries performed in your system, systemwide in a
year?
Dr. Kudler. Sir, I wish I did, I do not.
Mr. Dunn. Okay. So that would be a really important number
for us to have when we are talking about infection rates.
I want to echo the Chairman's comments on tracking
infections that have started, you know, we picked up in some
other country and brought back with all the other problems we
bring back from those countries. So we need to have--I will say
I have built and operated at least a half a dozen surgery
centers in my career and worked at a number of hospitals too,
we had 100-percent surveillance on infection rates in all of
our hospitals and in our surgery centers, and I actually was
surprised to hear that the VA doesn't have 100-percent
tracking. Everybody else that I am aware of on the civilian
side is doing this already and they are doing it with far fewer
resources, honestly, per surgical case than the VA has. So, I
mean, we never considered or occurred to us that we were going
to be in the situation where we weren't reporting all of our
surgical infections.
And I think that the fact the VA, as you said, it is
burdensome to implement, it is just the cost of doing business.
Everybody else in the country is doing it. So I would urge you
to reconsider that and get on board with the, you know, 100-
percent surveillance rate and the reporting nationally. You are
a hospital system that takes people from all over the world and
treats them all over the country.
So I just want to turn my attention now in my diminishing
seconds here and applaud my friend and fellow Floridian
Representative Rutherford for his educational enhancement bill
that he has advanced. We really feel like this has worked for
the military. I went through the military on a health
professional scholarship and I think that this kind of program
for the VA is a jolly good thing.
Thank you. I yield back my time, Mr. Chairman.
Mr. Wenstrup. If I may add to the point that you made, Dr.
Dunn, is even our outpatient facilities we assured that we
followed up with the surgeon to say were there any adverse
problems with the patient's care. Was there a post-operative
infection? Was there any type of complication? Which is more
challenging when they are not in the hospital where you can
collect that data as they are sort of a captive audience, but
we made sure that we captured all that information because it
is imperative to the quality and to follow trends?
So I think we really need to consider that and I hope the
VA would change their position on where we are going with that
data that I think is very valuable and needed.
Did you want to make a comment, sir?
Dr. Kudler. May I clarify that every hospital in the VA
system does track its own data on infection, but rolling it up
using the VASQIP system, we look nationally, we use a 30-
percent sample of incision infections within 30 days, which is
different than bio surveillance if people bring communicable
diseases home, which I absolutely agree is a vital national
issue.
Mr. Wenstrup. And that is why I think we need the data
nationwide and not just a sample. Thirty percent seems like a
pretty small sample for the opportunity to miss something
important that may exist. But we will talk more about that, I
am sure.
Mr. Higgins, you are now recognized for 5 minutes.
Mr. Higgins. Thank you, Mr. Chairman. And I thank the panel
for appearing, your service to your country, and I recognize
and appreciate the presence of the many VSOs represented in the
audience and the concerned citizens.
Dr. Kudler, you stated that the VA is already working to
hire more than 50 additional Veterans Justice Outreach
Specialists to provide Treatment Court services to justice-
involved veterans or VA courts. As a police officer for 14
years, I understand the importance of addressing the root
causes of misbehavior and crime, and I appreciate the VA's
commitment to our veterans in this area.
How many of the 50 new VJO Specialists has the VA hired
thus far, sir, are you aware?
Dr. Kudler. I am not sure how many have been hired so far,
but I can assure you we have no problem hiring and training
this staff; we will hire them expeditiously.
Mr. Higgins. Thank you.
Additionally, you had highlighted concerns regarding
funding that other bills may result in a reduction of funding
for other programs. How is the VA funding the 50 new positions?
Dr. Kudler. We prioritized this as critically important for
our mission and therefore found that money in other funds. And
what concerns us about the bill as currently written is it
would have a similar number, but it is a zero-sum game, we
would have taken funds from still another program and it does
come to a lot. We believe that other veterans would suffer.
The current new 50, 51 actually will bring us to 312
Veterans Justice Outreach Specialists in VA, which we feel
right now would match the available Veterans Courts around the
country. We would continue to scale as those numbers grew.
Mr. Higgins. Thank you, sir. That brings me to my real
question.
Within my own district, I represent the 3rd District of
Louisiana, we have the highest density of population of
veterans in the State of Louisiana. I am humbled and honored to
represent 133,000 veterans in my district. We are attempting to
set up VA courts in our district, jurisdictional authorities
across the district, and it is quite difficult, it is quite
difficult. Where a VA court, a diversion court does not exist
in this manner, it is quite challenging to establish within the
judicial system, at least those that we are encountering within
my own district.
Would we as representatives of the citizens that we serve
in an effort to set up a VA diversion court within the judicial
systems to help our veterans navigate criminal issues as they
encounter them, is there a process, sir, within the VA where
you can help us set this up? I would certainly, you know,
humbly raise my hand and ask for that assistance.
Dr. Kudler. We would be very glad to work with you. I have
helped set up Veterans Courts and worked with law enforcement
Mecklenburg County, that's Charlotte, North Carolina, I know it
is a challenge. You need a judge who is ready and willing to
take this up, prosecutors, defense. You need local law
enforcement to sign on, because they play a critical role in
this. We would be glad to work with you. And also SAMHSA, in
the past at least, has provided grants for communities to
develop this capacity.
So we would be glad to work with you on doing this
together.
Mr. Higgins. Would I be able to communicate with you
directly, sir, about that? I represent ten parishes of
Louisiana. We don't have counties, because we are Louisiana.
But that is ten jurisdictional districts and you are talking
about ten seated judges and it is quite challenging. And I
would like to communicate with you after this event, sir, so
perhaps you can give me a hand.
Dr. Kudler. It would be a pleasure. We have been involved
in many communities of all sizes and shapes and I am sure that
we could be of help. I look forward to it.
Mr. Higgins. And I look forward to that ongoing
conversation.
Mr. Chairman, thank you. I yield the balance of my time.
Mr. Wenstrup. Mr. Rutherford, you are now recognized for 5
minutes.
Mr. Rutherford. Thank you, Mr. Chairman.
Dr. Kudler, I would like to talk a little bit about the
Veterans Prescription Continuity Act. And I was glad to hear
your testimony when you asserted that medical necessity, not
formulary status, drives prescription decisions. Do you have an
idea how many requests for off-formulary prescriptions were
filed last year and what percentage were actually approved?
Dr. Kudler. You know, as a VA clinician who many times did
ask for non-formulary prescriptions, I was pretty lucky in
mine. I couldn't tell you nationally where that stands now, but
when it comes to people transferring from DoD, we always give
the benefit of the doubt to that this might be exactly the
regimen this person needs.
When it comes to mental health, some time ago working with
Congress we have established that we will continue these
medications. For example, if someone came to us on Lexapro
Escitalopram, which is more expensive and was non-formulary at
that time, it is now generic, we were going to continue to
provide that and not change to say Citalopram, one of the other
medicines that can be used. But in mental health, we have not
only decided we are going with what DoD did, we have been
measuring the outcomes, and we found generally very good
outcomes in these groups.
What we worry about and one specific thing is opiates and
perhaps opiates plus a benzodiazepine. And if a patient came to
me from DoD and was on a medicine for pain, and unfortunately
military service often generates chronic pain, but was also
getting a benzodiazepine and they said, well, Doctor, aren't
you going to sign off on this script, I would say, well, within
my practice that would be a very bad idea, but let's sit and
talk about it. So I think what is critical and you captured it,
sir, is we would figure out what is clinically appropriate, not
have our hands bound and not have the veteran's hands bound. I
could make somebody happy saying I am not going to touch
anything, sir, but I would be endangering them and I don't
think it would be ethically and certainly not medically
appropriate.
Mr. Rutherford. And I presume the VSOs all agree with the
concept that it needs to be medical necessity, not formulary,
or what is on the formulary.
But, Dr. Kudler, you also in your statement said that this
act would usurp a prescriber's professional responsibility and
that would carry for the patient-provider relationship and also
for the overall strength of the VA health care system some
implications. Can you talk a little more about that, because
I--make me understand that part?
Dr. Kudler. Well, what I mean by that, you know, I learned
how to drive in New York City and I learned how to practice
medicine in Brooklyn, and the rule of thumb was the same, you
practice, you drive like everyone else was crazy. You are
responsible, you are this person's doctor, you cannot take for
granted what another doctor writes, even if you like and
respect that person. And you have a professional responsibility
to make your own clinical decision and stand by it. This does
not mean be high-handed with the patient. Part of being a
doctor is collaborating with a patient, because you don't get
any compliance and they may not take any medicine you write
unless you and the patient have a rapport, an understanding, a
trust.
So what I was trying to get at there is simply, when I say
this is my patient, I have a responsibility to make my own
assessment, make my own decisions, but then collaborate with
the patient to see if we can agree on this.
And by the way, if the patient says no way on earth am I
doing that, I am not going to settle for simply being right, I
am going to work out something we can both agree on.
Mr. Rutherford. But, Doctor, I think the issue that is
trying to be captured here is exactly what you were--I don't
think the sponsor of this bill would disagree with what you
just said. The challenge, though, is as they transferred from
DoD to VA there is that time that it takes you to evaluate, to
determine what the medical necessity needs are of that
particular patient. Because, as you said, I'm not just going to
take somebody else's word for it, I am actually going to, you
know, do my job and make those decisions for myself, formulary
and otherwise, but surely you must understand that that is
going to take some time.
So there is a delay between coming from DoD over to VA, you
know, and I don't think that that continuity of care until you
as the doctor make an informed decision--look, even the doctor
that was treating them in DoD may at some point change the
formulary because their needs change. Can you address that?
Dr. Kudler. You know, I think that gets at the core issue,
which is the continuity of care between DoD and VA, and we have
to address that as a critical area where people fall between
the cracks, that might be one day or it might be five years,
and we have to create a warm handoff between our agencies which
would include this. We developed that for traumatic brain
injury years ago where if you were coming say out of the
Richmond VA for our polytrauma program, I would actually sit in
Richmond and talk over a telehealth hookup with your doctors in
Landstuhl and we would work this out together.
Mr. Rutherford. Right.
Dr. Kudler. We need to create that continuity and I think
that is a missing element in this bill. But I have got to tell
you this, we are working--and this was the Secretary's demand
and he is absolutely right--same-day assessment in primary care
and mental health. And I don't see a reason why if you have a
mental health issue say, you shouldn't be able to walk into a
VA and get a clinical assessment on that spot, on that day, and
review your medicines and confront issues.
Mr. Rutherford. Thank you, Mr. Chairman. I yield back.
Mr. Wenstrup. Thank you. I appreciate that was a good
conversation, and the handoff is important and how we can
facilitate that. No one wants there to be a gap, no one wants
there to be someone who falls through the cracks, but how do we
assure that there isn't that situation.
I want to thank you all once again for being here today,
and if there are no further questions, the second panel is now
excused.
And I ask unanimous consent that all Members have five
legislative days to revise and extend their remarks and include
extraneous material.
Without objection, so ordered.
I would like to again thank you all, our witnesses and the
audience members for joining us here this morning.
This hearing is now adjourned.
[Whereupon, at 11:31 a.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Honorable Debbie Dingell
Chairman Wenstrup, Ranking Member Brownley, thank you for inviting
me to appear before you today. The important work of this committee is
invaluable to bettering the lives of all those who have served and the
families at their sides. Thank you for your tireless dedication to
serving our veterans.
As you know, today's hearing includes bipartisan legislation
introduced by Congressman Tim Walberg (R-MI) and I that aims to add
enhanced transparency requirements at VA hospitals nationwide. Our
bill, H.R. 501, the VA Transparency Enhancement Act, is a commonsense
measure we can take to improve overall quality of care for veterans.
The bill simply requires the Department of Veterans Affairs to
report quarterly to Congress on the number of patients who contracted
an infection as a result of a surgery and report the number of
surgeries cancelled or transferred by the VA. It would also require the
VA to publish these reports on the Department's website for all our
veterans, their families, and the public to have and understand.
While the VA currently provides completed and pending appointment
data from local VA medical facilities to the public monthly, the VA
does not publically release data on rates of surgical infection or
cancelled or transferred surgeries. Patients have a right to see
surgical infection rates and other issues impacting quality of care at
VA hospitals. Improving transparency at the VA will help ensure we are
meeting the quality standards we owe our veterans.
The VA Transparency Enhancement Act will also help Congress
understand when, where, and why infections are happening or surgeries
are cancelled so we can respond to changing conditions more
effectively. Should surgical infection or cancellation rates rise at
any VA hospital, Congress and the public need to know about it as soon
as possible. As policymakers we need to understand whether cancelled
surgeries are affecting the health of a veteran. Ensuring our veterans
have access to timely, quality health care is a critical responsibility
of the Congress, and this is one more important step to ensure they do.
In late 2015, my office and Congressman Walberg became aware of a
contamination issue at the VA Ann Arbor Healthcare System after
particulate matter was observed on sterile surgical equipment. This led
to surgeries for veterans being intermittently cancelled or moved to
different hospitals. For many months the issue persisted putting great
stress and uncertainty on our veterans who were scheduled for
operations.
The staff at the Ann Arbor VA is a dedicated group of individuals.
This issue came to light because they were doing their job inspecting
surgical instruments and discovered the problem. To be clear, it does
not appear that the contamination issue caused any infections or harm
to a patient-but, for us, this remains a concern for any future cases.
Throughout this problem we remained in constant communication with
Ann Arbor VA leadership. In the process, we learned that VA hospitals
are not required to report on surgical infection and cancellation rates
as other hospitals do.
This is not the only instance of cancelled surgeries at a VA
hospital. In September 2015, the Star Tribune reported that the
Minneapolis Veterans Affairs Medical Center was forced to postpone and
reschedule dozens of surgical procedures after an ``an unidentified
substance'' was found in sterilizing equipment. \1\
---------------------------------------------------------------------------
\1\ Brunswick, Mark, ``Minneapolis VA shuts down surgeries over
unidentified substance,'' Star Tribune, September 23, 2015, http://
www.startribune.com /minneapolis-va-hospital-shuts-down-surgeries-
after-a-substance-is-found-in-sterilization-equipment /328878601/
---------------------------------------------------------------------------
We do not want to see this happen again in Michigan or any state,
which is why we took action and introduced this bill. We believe it is
important that, like other hospitals, the VA be open and transparent
and report the number of patients that have acquired surgical
infections while receiving care at the VA, and the number of surgeries
that have been canceled or moved to another hospital.
The number one priority for all of us is to ensure that veterans
receive the highest quality health care. By increasing transparency we
can prevent the worst scenarios for our veterans and identify
problematic VA hospitals sooner. Our responsibility as Members of
Congress is to be a voice and advocate for veterans all across this
country, and serve our veterans as well as they have served us.
Thank you again for inviting me to testify before this committee on
legislation that will improve VA transparency and patient care for all
our veterans. We urge every member of the committee to support this
legislation and we stand ready to work with you in any way to move this
bipartisan bill out of this committee for consideration on the House
floor. At this time, I look forward to answering any questions the
committee may have.
Prepared Statement of Honorable Beto O'Rourke
CONCERNING
H.R. 1063, THE VETERAN PRESCRIPTION CONTINUITY ACT
Than you Chairman Wenstrup, Ranking Member Brownley, and members of
the Subcommittee. I appreciate the opportunity to join you today to
discuss how we can improve care for our veterans as they transition out
of the military.
Our nation asks much of its service members. We ask them to uproot
their families, put themselves in harm's way, and endure pain and
suffering. As members of the Veterans' Affairs Committee, we have an
obligation to ensure that our service members and their families
receive the best care possible when they leave the service. With as
many as 20 veterans committing suicide a day, we are failing to fulfill
that obligation.
We may not be able to solve all of the Department of Veteran
Affair's problems today, but we can take meaningful steps towards
improving the care our veterans receive. One common sense measure to
achieve this is my legislation before the Committee today, the Veterans
Prescription Continuity Act. In the past, the pharmaceutical agent
formularies used by the Department of Defense (DoD) and Veterans Health
Administration (VHA) had numerous differences. This meant that a
service member may not have been able to receive the same DoD
prescribed medication when he or she enters the VHA system.
Section 715 of the FY2016 National Defense Authorization Act (NDAA;
Public Law 114-92) included a provision that attempted to improve
prescription medication continuity when service members left the DoD
health care system and entered the VHA system. This section required
the Secretary of Defense and Secretary of Veterans Affairs to establish
a joint formulary for prescription medications, with the intended goal
to ensure veterans would receive the same medication under the VHA as
they were prescribed during their service.
Unfortunately, this section has shortcomings. It only accounts for
certain medications. It did not cover some common, widely used drugs
available to the DoD but not the VA as well as new or emergent
medications for pain control, sleep disorders, and psychiatric
conditions (including post-traumatic stress). Additionally, it did not
require the DoD and VHA to regularly update their formularies to ensure
they matched in the future.
My legislation, the Veteran Prescription Continuity Act, will fix
these shortcomings. It will allow transitioning service members the
ability to retain their current regimen of pharmaceutical agents under
their VA health care provider, even if it is not on the VA's formulary.
It will require regular updates between the DoD and VA formularies and
allow the VA to prescribe medications not on their formulary between
these updates.
Transitioning out of the military is a challenging task. Doing so
while being forced to change medications increases the stress and
burden on our service members and does not represent the best possible
care we can give them. I thank my colleague, Mr. Coffman of Colorado,
for his partnership with me to enact this common sense legislation.
Together, we are taking steps towards improving our nation's care for
its veterans.
It is also important to note that the Veterans Prescription
Continuity Act is supported by fourteen veteran service organizations
that are a part of the National Military and Veterans Alliance. We have
worked hand in hand with these organizations to create this common
sense legislation.
I appreciate the opportunity to speak before you today and look
forward to continuing this committee's work in improving the care for
our veterans.
Prepared Statement of Honorable Derek Kilmer
CONCERNING
H.R. 1066, THE VA MANAGEMENT ALIGNMENT ACT
Than you Chairman Wenstrup, Ranking Member Brownley, and members of
the Subcommittee. I appreciate the opportunity to join you today to
discuss how we can improve the operations of the Veterans
Administration so those who have served our nation actually get the
care they have earned.
I have the honor of representing more than 82,000 veterans, more
than most any other member of my party and one of the largest
concentrations in the House of Representatives. In my region we know
that those who have served, and their families, have made tremendous
sacrifices for us. We know they have had our backs. And we understand
we should have theirs too. That means if you fight for your country you
shouldn't have to fight for a job. In the land of the free and the home
of the brave, every veteran should have a home. And anywhere in our
country if you are a veteran, you should have access to the benefits
you've earned.
That last point is what brings me here today. It's a conversation
we've been having for far too long. I've heard it in VA halls, in the
grocery story, and from members of my Veterans Advisory Council - why
can't we fix the VA once and for all? Why does it take so long to see a
practitioner, why do folks in smaller towns have to travel so far to
get served? These questions have arisen because of the inability of
veterans to schedule appointments, the difficulty to build a new
Community Based Outpatient Clinic (CBOC) in my district, and other
issues. And they are symptoms of a larger problem - systemic management
challenges at the VA.
I appreciate all this committee and Congress has done to deliver
answers to veterans like those I represent. I'm glad we've passed
legislation seeking information, providing enhanced authorities,
funding, and calling for accountability. But we all know there is more
work to do.
In 2013, I partnered with then Ranking Member Brown and eventually
Chairman Miller to request the Government Accountability Office (GAO)
conduct a management review of the Veterans Health Administration. In
our minds, this would help us get to the root of the problem.
The GAO team dove in, and what started with three reports on
organizational structure, human capital, and information technology has
expanded to more than six. These findings have begun to see the light
of day and are accompanied by specific solutions to fix the problems
GAO found.
One of the key findings that stood out is that - after a number of
reviews from both within and outside the VA - there was a clear menu of
recommendations to fix things for the better. These specific
recommendations included clarifying different responsibilities between
local and national facilities, evaluating if core duties were being
met, and improving services, planning, and communications. But the GAO
found these recommendations were never implemented.
That is not fair to veterans, the staff that conducted the reviews,
or the taxpayers who paid for them.
Moreover, the VHA struggles to implement new policies and
procedures due to a severe lack of clarity regarding the roles,
missions, and accountability of senior leaders and organizations within
the agency. The scale of the VA is so large that we need to go beyond
position descriptions and office missions. There has to be a clear,
transparent, and enforced relationship between the leaders and layers
of the VA. How can we expect leaders and staff at more local levels to
seek opportunities for collaboration and efficiency if there is not a
clear understanding of how they are supposed to work together to care
for veterans? We need all the rowers in the boat paddling in the same
direction - not beating each other over the heads.
I introduced the VA Management Alignment Act to make sure we follow
through on the GAO findings. This bill simply requests the Secretary of
VA to provide a report to Congress within 180 days on the
organizational structure of the VA. Specifically, the bill would
require the Secretary to outline the roles, responsibilities, and
accountability measures of senior leaders and branches of the VA
informed by existing recommendations on the matter, and to provide
Congress with a series of legislative options to assist the Secretary
in realizing positive change.
Before coming to Congress, I worked as a management consultant to
large private sector companies and for a county wide economic
development agency. My experience in both roles led me to understand
that good management requires clarity from the top. To do that we need
to better measure outcomes. We need to work collaboratively with the
administration to set an environment for success. This bipartisan bill,
which was drafted in consultation with GAO, meets both of those tests.
It is also important to note that the VA Management Alignment Act
is supported by the American Legion and the American Federation of
Government Employees. I am grateful that the largest veterans' service
organization and the federal employee union have joined me in this
effort.
As this is a legislative hearing and not a markup, I request that
we continue to work together to move this policy forward. I am with you
in the effort to improve the VA and turn our words into deeds.
Again, I appreciate the opportunity to join you here today and look
forward to working with you honor the service and sacrifices of our
nation's veterans.
Prepared Statement of Honorable Steve King
Good Morning Chairman Wenstrup, Ranking Member Brownley, and
Members of the Committee. I am Congressman Steve King. I represent the
Fourth District of Iowa, and I am truly honored to testify before you
today in support of my bill, H.R. 1943, the Restoring Maximum Mobility
to Our Nation's Veterans Act of 2017. This critical legislation aims to
ensure that our nation's veterans with service-connected disabilities
are not simply afforded a wheelchair, but are equipped with the very
best wheelchair-one that affords maximum achievable mobility and
function in the activities of daily life.
The ability to pursue life to the fullest possible degree, even in
the face of disability, is critical to ensuring that our nation's
veterans are as healthy as possible-in body, mind, emotions and spirit.
And the statistics prove the truth of that statement. Statistics
demonstrate that an average of 20 veterans die by suicide each day in
our nation. Six of each 20 are recent users of Veterans Health
Administration (VHA) services in the two preceding years leading up to
the tragic decision to commit suicide. In my home state of Iowa, there
were 75 veteran suicides in 2014 alone. We mourn these precious lives
that were lost unnecessarily, and find it unthinkable that these trends
should continue. We must do more, and we must provide better services,
care and support that our nation's veterans need and deserve.
According to current practice, when determining which wheelchair is
best equipped for a particular veteran, a VA clinician will take into
account medical diagnoses, prognosis, functional abilities,
limitations, goals, and ambitions. Evaluation of mobility assesses
musculoskeletal, neuromuscular, pulmonary, and cardiovascular
capacities and response, effort, quality and speed of mobility, and
overall function. However, the VHA recommendations clarify that
``Motorized and power equipment or equipment for personal mobility
intended solely for a recreational leisure activity should not be
provided.Motorized and power equipment designed for recreational
leisure activities do not typically support a rehabilitative goal.''
In view of suicide rates among our nation's veterans, how can
motorized and power equipment designed for recreational leisure
activities not support a rehabilitative goal? According to a study made
available by the National Center for Biotechnology Information, which
operates under the National Institutes of Health (NIH), ``.leisure
activities are defined as preferred and enjoyable activities
participated in during one's free time, and characterized as
representing freedom and providing intrinsic satisfaction. Individuals
can recover from stress; restore social and physical resources through
leisure activities. Leisure activities with others may provide social
support and, in turn, mediate the stress-health relationship, enrich
meaning of life, recovery from stress, and restoration of social and
physical resources.''
This description will sound accurate to anyone who has found rest,
solace and rejuvenation in a preferred recreational activity. As
someone who enjoys the outdoors, hunting, fishing and travel, I
certainly can appreciate the importance of recreation to a healthy
life. And as this reality affects our nation's disabled veterans, I
have seen first-hand the benefit of recreation to their health. I have
had the honor of hunting with my friend, Army Specialist Jack
Zimmerman. Jack is a remarkable man and decorated veteran who lost both
of his legs as a result of life-altering injuries caused by an
improvised explosive device. After his injury, Jack had a long
rehabilitation in front him. And he had to deal with trials that he
simply should not have had to during that time, including the VA
issuing multiple inadequate wheelchairs to him. As an outdoorsman, Jack
needed a chair that could navigate uneven terrain without the risk of
tipping over. Jack was made aware of an off-road powered-track
wheelchair that could offer a heightened level of normalcy and
enjoyment to his life. He contacted the VA to acquire one and waited
months without success.
Jack's wife ultimately was able to procure a powered-track
wheelchair from an outside organization called the Independence Fund,
which provides resources and tools that enable veterans to work through
their physical, mental and emotional wounds and regain their
independence. I am grateful for the Independence Fund and other
organizations that make it their mission to provide for our veterans.
But our veterans should not have to rely on such groups to do for them
what their nation should. They fought for this nation and they should
be cared for by this nation.
In the aftermath of Iraq and Afghanistan, we have strived in
Congress to halt veteran suicide. We have worked to ensure that every
veteran has access to the health care and services they need. Sadly,
the somber statistics demonstrate that we have far to go to adequately
take care of our veterans. That's why I champion H.R. 1943, which
amends Section 1701 of Title 38 of the United Code to ensure
wheelchairs provided to our veterans include ``enhanced power
wheelchairs, multi-environmental wheelchairs, track wheelchairs, stair-
climbing wheelchairs, and other power-driven mobility devices.'' This
legislation ensures that the Secretary of Veterans Affairs may provide
a wheelchair to a veteran because the wheelchair restores an ability
that relates exclusively to participation in a recreational activity.
Prepared Statement of Honorable Lloyd Smucker
Chairman Wenstrup, Ranking Member Brownley, and Members of the
Subcommittee, I thank you for the opportunity to testify before the
committee on my legislation, the VA Billing Accountability Act.
On August 9, 2017, the Veterans Affairs Office of Inspector General
reported that in Fiscal Year 2015, of roughly 15.4 million bills the
Veterans Health Administration issued during 2015 approximately 1.7
million were improper bills for the treatment of service-connected
conditions. To put this into perspective, the Veterans Health
Administration collected a staggering $13.9 million from our nation's
veterans inappropriately. This is simply unacceptable.
Our service men and women should not have to pay for errors or
delays by the Department of Veterans Affairs (VA). For more than a
decade, the Department of Veterans Affairs has failed to address its
broken medical-billing system that leaves our nation's veterans to pick
up an inaccurate and expensive bill. That is why I introduced the
bipartisan VA Billing Accountability Act to relieve veterans of
financial burdens caused by delays at the VA.
My congressional district is home to more than 38,000 veterans--all
of them deserve the highest quality medical care and the assurance from
the VA that they will not be forced to foot the bill for the mistakes
made by VA bureaucrats.
To address this ongoing issue, my bill authorizes the VA to waive
veterans' co-payments if a veteran received a co-payment bill more than
120 days after they received care at the VA or 18 months after they
received care at a non-VA facility.
The VA Billing Accountability Act also holds the VA accountable by
giving the Secretary of the VA the authority to get rid of the
requirement that veterans make a co-payment if the VA does not abide by
the billing timing mandates.
To ensure accountability my bill requires the Secretary of Veterans
Affairs to review the agency's copayment billing controls and
notification systems to see if there are solutions that can better
monitor and prevent erroneous bills within 180 days after enactment of
this legislation. It is imperative that the Department of Veterans
Affairs prioritizes improving its internal billing procedures.
Our nation's veterans and their families have sacrificed so much in
defense of our nation. We should be making it easier, not harder, for
them to transition to post-military life. That starts with making sure
that the VA not only delivers quality health care, but also timely
bills that our veterans can count on.
Thank you again for the opportunity to testify before the committee
today, and for all the work that the members of this committee do to
ensure quality and affordable care for our nation's veterans.
I yield back.
Prepared Statement of Honorable Steve Stivers
Testimony Before the House Committee on Veterans' Affairs,
Subcommittee on Health: Veterans Dog Training Therapy Act
Thank you Chairman Wenstrup and Ranking Member Brownley for holding
this hearing today, and for giving me the opportunity to testify on
behalf of my bill, the Veterans Dog Training Therapy Act. I also want
to thank the co-sponsor of this bill, Congressman Tim Walz (D-MN), for
his support.
We face a devastating mental health crisis in this country - one
that has particularly affected our veterans' community. When veterans
return home, many struggle with visible, physical wounds. However, the
invisible wounds our veterans suffer with are often overlooked. This is
includes Posttraumatic Stress Disorder (PTSD), depression, and other
mental health related issues from their service. It is just as
important that we find ways to help veterans address mental health
related issues, as it is their physical wounds.
Today, I want to discuss a few of the ways that this bipartisan
bill can help our nation's veterans in a unique way, and build on the
already proven benefits therapy dogs can be to veterans.
Therapy Dogs Work
First and foremost, therapy dogs work. Anyone who has a dog as a
pet knows how much of a calming presence they can be. For veterans
struggling with service-connected mental health issues, having this
presence can make all of the difference.
In fact, research by Kaiser Permanente has shown that veterans who
have these companion dogs show fewer symptoms of PTSD, depression,
anxiety, have better interpersonal relationships, a lowered risk of
substance abuse, and better overall mental health. Therapy dogs can
clearly make a difference, and as we are losing veterans every day to
suicide, it is critical we pursue any strategy to help more veterans
receive the help they need and deserve.
The Pilot Program
The Veterans Dog Therapy Training Act would establish a pilot
program at the Department of Veterans Affairs (VA) in which the
Secretary will contract with local therapeutic dog training
organizations, and help veterans seeking treatment to learn the art and
science of dog training. Upon completion, the program will graduate the
animal to go home with their veteran.
The Compassionate Innovation office at the Veterans Health
Administration will be responsible for managing the program and
ensuring that only the best organizations who are certified and
specialize in companion animal training receive contracts. This bill
also establishes a director of therapeutic service dog training who has
a background in social services, experience in teaching others to train
companion dogs, and at least one year of experience working with
veterans or service members dealing with PTSD.
Additionally, this legislation will receive oversight from
Congress. The Secretary of the VA will be required to collect data on
the program to determine the effectiveness for those participating and
their mental health outcomes and report back to Congress.
Veterans Helping Veterans
A unique part of this legislation is it will help facilitate
veterans to help other veterans who are struggling. We know how
valuable, veteran on veteran engagement is to assisting our service men
and women and, my legislation adds a preference to the pilot program
for contracting with veterans who have graduated from PTSD treatment
programs and companion dog training certifications to conduct the
training. Only other veterans truly understand the struggles of
returning home, and the benefits a companion dog can provide. This is
just one more way we can help veterans coping with PTSD make
connections to other veterans who are in need.
I believe therapy dogs can make a real difference in the lives of
veterans struggling with service-related mental health issues. The
Veterans Dog Training Therapy Act is bipartisan, establishes a program
to measure the real outcomes of connecting veterans to therapy dogs,
and gives veterans the opportunity to help other veterans. This bill
has the support of organizations such as the Paralyzed Veterans of
America, Iraq and Afghanistan Veterans of America (IAVA), Veterans of
Foreign Wars (VFW), and Disabled American Veterans (DAV). Moreover,
this legislation is proven to have support - the Veterans Dog Training
Therapy Act passed the House of Representatives during the 114th
Congress.
I want to thank the Committee again for inviting me to testify
today, and I encourage all of the Members of the Committee to consider
this legislation.
Prepared Statement of Honorable Ron DeSantis
Chairman Wenstrup, Ranking Member Brownley, thank you for the
opportunity to testify this morning. I request that my statement be
accepted for the record.
Addressing service-connected disabilities is a critical part of the
United States' commitment to the men and women who risk their lives
through military service. Honoring our commitment includes safeguarding
mental health, yet far too often combat wounds that go beyond the
physical go ignored.
According to the most recent Department of Veterans Affairs (VA)
analysis of veteran suicide, ``Suicide Among Veterans and Other
Americans,'' an average of 20 veterans died by suicide each day.
The VA must be more effective in its treatment of our soldiers who
struggle with mental health disorders, including post-traumatic stress
disorder (PTS), to reduce the veteran suicide rate.
For this reason, I reintroduced HR 2327, the Puppies Assisting
Wounded Servicemembers (PAWS) Act, to direct the Secretary of the VA to
carry out a 5-year pilot program to provide grants to select
organizations that pair veterans suffering from severe PTS with the
service dogs critical to their recovery.
In order to be eligible for a VA grant for a service dog pairing,
the organization must either be an Assistance Dog International
accredited organization that also meets specific criteria listed in the
measure, or meet the Association of Service Dog Providers for Military
Veterans Service Dog Agency Standards, which cater to the needs of
veterans with PTS.
To be eligible for participation in the pilot, the veteran must
have completed traditional therapies for PTS and remain symptomatic. A
VA medical provider or clinical team must determine that the veteran is
an appropriate candidate for the program, and the veteran shall see the
VA medical provider at least every 6 months to remain eligible.
The pilot is capped at $10,000,000 for the 5-year period covering
2018-2023 and entirely offset with funds from the VA Office of Human
Resources and Administration, which has demonstrated inappropriate
conference planning and spending in the past.
Prior to reintroduction, my staff and I worked with House Committee
on Veterans' Affairs Committee staff, as well as U.S. Department of
Veterans Affairs personnel who would be involved with implementing the
pilot once it launches and U.S. Government Accountability Office
employees who would evaluate its success, to improve language from last
Congress. We appreciate the Committee's willingness to work with us to
revise language and the support from outside organizations to help move
this measure.
An ongoing study conducted by a Purdue University research team
revealed in February 2017 that service dogs contribute significantly to
emotional and psychosocial well-being. Furthermore, on March 7, 2017,
Veterans Affairs Secretary David Shulkin testified at a House hearing
on the use of service dogs for veterans who have PTS or other emotional
disorders, stating, ``[I] think it's common sense that service dogs
help.we hear it every day from veterans.I'm not willing to wait because
there are people out there today suffering.''
I am not willing to wait either. The urgency of veteran suicide
rates demands that we immediately explore the option of pairing service
dogs with veterans suffering from mental health disorders.
I look forward to continuing to work with the Committee to
accomplish this goal.
Thank you again for the opportunity to testify. I welcome your
questions.
Prepared Statement of Honorable Mike Coffman
Mr. Chairman, I would like to begin by thanking you for including
my bill in today's legislative hearing. To our witnesses, thank you for
your testimony, and for ensuring Congress and the American public
better understand the challenges facing our veterans today.
While many veterans successfully readjust and transition back to
civilian life after their military service, unfortunately, some do not.
Often due to undiagnosed or untreated issues related to their service,
veterans find themselves involved in the criminal justice system.
My bill, H.R. 2147 - the Veterans Treatment Court Improvement Act,
builds upon an existing and successful program that works with criminal
justice involved veterans and connects them with the services they
need.
Mr. Chairman, Veterans Treatment Courts (VTCs) were created to be
dedicated to veteran offenders specifically. These specialty,
diversionary courts take veterans out from the regular criminal justice
process to address the underlying issues, such as post-traumatic stress
disorder (PTSD) or substance abuse.
The VA provides Veteran Justice Outreach (VJO) Specialists who are
licensed social workers operating through VA Medical Centers as part of
the VJO Program. These VJO Specialists link veterans to available VA
services and treatment, and monitor the veteran's progress in the
Veteran Treatment Courts.
This successful model avoids the unnecessary incarceration of
veterans with mental illness, assesses their health and social needs,
and then helps develop a rehabilitation treatment program specific to
the veteran's needs.
In my district, the 18th Judicial Veterans Treatment Court has a
74% success rate for those who have participated in their program.
Clearly, this program works.
Mr. Chairman, there are more than 260 VJO Specialists in 167 VA
Medical Centers nationwide. However, the VA currently lacks a
sufficient number of VJO Specialists to meet the demand for their
services. This means numerous veterans cannot avail themselves of the
opportunity to enter the Veteran Treatment Courts and succeed in
rehabilitating themselves.
My bill, H.R. 2147, will help the VA to better meet the demands of
the program and to serve many more veterans by authorizing the VA
Secretary to hire 50 additional VJO Specialists. H.R. 2147 also
requires the VA Secretary to identify an offset, and requires the VA
and GAO to report to Congress on the implementation of this bill.
Mr. Chairman, our veterans have served us - now let us serve those
veterans who need our help. As a Marine Combat Veteran, I like to live
by the rule that we never leave anyone behind, and the Veterans
Treatment Court Improvement Act makes sure that we do not forget those
who bravely served our country in their time of need.
Mr. Chairman, thank you for allowing me to testify today on behalf
of my legislation and I yield back the remainder of my time.
Prepared Statement of Honorable John Rutherford
Draft legislation to improve the VA Health Professionals Educational
Assistance Program
Chairman Wenstrup, Ranking Member Brownley, fellow members of the
Subcommittee - thank you for the opportunity to speak on behalf of this
draft legislation that would improve the Health Professional
Educational Assistance Program at the VA.
This Subcommittee has frequently heard testimony regarding the high
number of physician vacancies at the VA and the negative impact this
has on the care of our nation's veterans. Currently, the VA has several
programs to address recruitment in their profession ranks, including
the Education Debt Repayment Program (RDRP) and the Health Professions
Scholarship Program (HPSP). While these programs have improved
recruitment, ``physician'' remains the top VA mission critical
shortage, with the current estimate for physician vacancies to be
3,500. One way to ensure that the VA is long term staffed with
qualified providers is to recruit those who are currently in medical
school or are in residency and assist in their education expenses in
exchange for their service within the VA system.
As we as a Congress work with our partners in the Administration
and in our communities to improve care and decrease wait times, I
believe it is critical that the VA has the tools to recruit and retain
providers in areas that are desperately needed throughout the system.
This draft legislation makes three primary improvements to these
programs.
First, it requires the VA to provide a minimum total of fifty 2 to
4 year scholarships annually for students studying to become physicians
or dentists while the shortage of these professions is 500 or greater.
These students will then be obligated to provide clinical service at a
VA facility for 18 months for each year of scholarship support.
Second, this legislation requires the VA to create a pilot program
to fund two scholarships at each of the five Teague-Cranston Act
medical schools for veterans who qualify for admission to those medical
schools. The schools that participate in this program will each reserve
two seats in each class for the veteran recipients of these
scholarships. The veterans are obligated to provide clinical service at
a VA facility for a minimum of 4 years in exchange for the scholarship.
Third, it standardizes and increases the VA loan repayment program
for newly graduated medical students or those currently in residency
who will be training in specialties deemed as shortages in VHA. The
loan payments will be a maximum of $40,000 per year with a maximum
total of $160,000. Following completion of residency training, the loan
recipients will be obligated to provide clinical service at a VA
facility for a year for each $40,000 of loan repayment, but in no case
fewer than two years. The current program varies among the VISNs and is
not adequately competitive.
The VA has made many impactful changes in recent years, but it is
important that we consider ways the VA can attract talent on the front
end to improve the system long term. A key part of this is attracting
young talent that will come into the system and compete with the
private sector.
In closing, I would like to thank the Chairman, the Ranking Member,
my colleagues on the Committee, and the Subcommittee staff for their
commitment to this and the other pieces of legislation under
consideration today that would continue to improve the VA health
system.
Congressman John Rutherford represents the 4th Congressional
district of Florida. Prior to being elected in 2016, Congressman
Rutherford served as the Sheriff of Duval County for 12 years where he
led initiatives to reduce crime in Jacksonville to a 40-year low. He
serves on the House Committee on Homeland Security, the House Judiciary
Committee, and the House Committee on Veterans' Affairs.
Prepared Statement of Keronica Richardson
----------------------------------------------------------------------------------------------------------------
Section Title Page Position
----------------------------------------------------------------------------------------------------------------
H.R. 93 To amend title 38, United States Code, to provide Support
for increased access to Department of Veterans
Affairs medical care for women veterans.
----------------------------------------------------------------------------------------------------------------
H.R. 501 VA Transparency Enhancement Act of 2017 Support
----------------------------------------------------------------------------------------------------------------
H.R. 1063 Veteran Prescription Continuity Act Support
----------------------------------------------------------------------------------------------------------------
H.R. 1066 VA Management Alignment Act of 2017 Support
----------------------------------------------------------------------------------------------------------------
H.R. 1972 VA Billing Accountability Act Support
----------------------------------------------------------------------------------------------------------------
H.R. 2147 Veterans Treatment Court Improvement t of 2017 Support
----------------------------------------------------------------------------------------------------------------
H.R. 2225 Veterans Dog Training Therapy Act Support
----------------------------------------------------------------------------------------------------------------
H.R.2327 PAWS Act of 2017 Support
DRAFT BILL To amend title 38, United States Code, to make No Position
certain improvements in the Health Professionals
Educational Assistance Program of the Department of
Veterans Affairs, and for other purposes.
----------------------------------------------------------------------------------------------------------------
Chairman Wenstrup, Ranking Member Brownley and distinguished
members of the Subcommittee on Health; on behalf of National Commander
Denise H. Rohan and The American Legion, the country's largest
patriotic wartime service organization for veterans, comprising over 2
million members and serving every man and woman who has worn the
uniform for this country, we thank you for the opportunity to testify
on behalf of The American Legion's positions on the following pending
and draft legislation.
H.R. 93
To amend title 38, United States Code, to provide for increased
access to Department of Veterans Affairs medical care for women
veterans.
According to the Department of Veterans Affairs (VA), the female
veteran population accounts for 10 percent of U.S. veterans, and that
number is expected to grow to 15 percent by 2030. This population
experiences distinctive challenges such as access to female-specific
medical care, the greater likelihood for homelessness, and higher
unemployment rates than male veterans. \1\
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\1\ http://www.blogs.va.gov/VAntage/40134/
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In 2013, The American Legion conducted fifteen ``System Worth
Saving'' site visits focusing on women veterans healthcare. Based on
these visits, the following key findings were identified: \2\
---------------------------------------------------------------------------
\2\ https:// www.legion.org/sites/ legion.org/files/legion/
publications/ 2013-SWS-Report-WEB.pdf
Women veterans do not identify themselves as veterans
and/or do not know what benefits they are eligible to receive;
VA medical center facilities do not have a baseline, one-
year, two-year, or five-year plan to close the gap between the
catchment area, enrollment numbers, and actual users among women
veterans;
Additional research is needed to determine the purpose,
goals, and effectiveness of the three VA women models of care on
overall outreach;
Communication and coordination of women veterans health
services are substandard;
Women veterans do not receive their mammogram results in
a timely manner;
Many VA facilities do not offer inpatient/residential
mental health programs for women veterans; and
VA's legislative authority for the child care pilot
program is due to expire by the end of September 2017.
If enacted, H.R. 93 will require the VA to meet the healthcare
needs of women veterans across the VA healthcare system. When the VA is
unable to meet their needs, the Secretary may enter into contracts with
third-party organizations to provide the services required.
Using resolution 147, Women Veterans, The American Legion supports
any legislation that provides full comprehensive health services for
women veterans department-wide, including, but not limited to:
increasing treatment areas and diagnostic capabilities for female
veteran health issues, improved coordination of maternity care, and
increase the availability of female therapists/female group therapy to
better enable treatment of Post-Traumatic Stress Disorder from combat
and MST in women veterans. \3\
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\3\ The American Legion Resolution No. 147 (2016): Women Veterans
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The American Legion Supports H.R. 93
H.R. 501 - VA Transparency Enhancement Act of 2017
To require increased reporting regarding certain surgeries
scheduled at medical facilities of the Department of Veterans Affairs,
and for other purposes.
During a study by the Environment of Care and Safety Review of the
operating room at the Edward Hines Jr. VA Hospital in Hines, IL, the
Department of Veterans Affairs (VA) Office of Inspector General (OIG)
found that surgery infections are often caused by improper temperature
and humidity control in the emergency room \4\suite. \5\
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\4\ https://www.va.gov/oig/pubs/VAOIG-13-02315-332.pdf
\5\ https://www.va.gov/oig/pubs/VAOIG-13-02315-332.pdf
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The Association of periOperative Registered Nurses recommends a
temperature range in an operating room between 68°F and 73°F.
This is to prevent hyperthermia, surgical site infections, longer
hospital stays, and other negative outcomes. Additionally, the
recommended humidity range in an operating room is 20 percent to 60
percent. This is to reduce infections and prevent the development of
mold and mildew in anesthetizing locations.
H.R. 501 would require the VA to track and submit findings
regarding complications due to surgery infections to the Secretary of
VA. The American Legion knows that it is pertinent to the safety of
future veterans utilizing these hospitals for the VA to track specific
outcomes regarding surgeries. This legislation would require these
outcomes be made public so that individuals can make the best-informed
decision regarding their medical treatments at different VA locations.
These metrics will also help Congress and veteran service organizations
understand which VA hospitals are having more problems with surgery
infection complications and find ways to address these issues.
Using resolution 377, Support Veterans Quality of life, The
American Legion supports any legislation that will enhance, promote,
restore or preserve benefits for veterans and their dependents,
including, but not limited to the following: timely access to quality
VA health care, timely decisions on claims and receipt of earned
benefits, and final resting places in national shrines and with lasting
tributes that commemorates their service. \6\
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\6\ The American Legion Resolution No. 377 (2016): Support Veterans
Quality of Life Resolution
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The American Legion Supports H.R. 501
H.R. 1063 - Veteran Prescription Continuity Act
To ensure that an individual who is transitioning from receiving
medical treatment furnished by the Secretary of Defense to medical
treatment furnished by the Secretary of Veterans Affairs receives the
pharmaceutical agents required for such transition.
In late 2014, the Department of Veterans Affairs (VA) conducted an
evaluation of medical prescriptions for 2,000 Department of Defense
(DoD) servicemembers entering the VA system for the first time. The
study included individuals taking mental health or pain medication. The
goal of the assessment was to evaluate the extent to which mental
health medications and opioid analgesics active at the time of DoD
separation were changed versus continued unchanged upon entering the VA
system, as well as the reason for any changes (clinical vs.
administrative). \7\
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\7\ https://www.pbm.va.gov/vacenterformedicationsafety/
othervasafetyprojects/ DoD--VA--Medication--Continuation--Report.pdf
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The study found that some veterans had their medication switched
due to differences between the VA and DoD drug formularies. The current
prescription drug formularies used by the DoD and VA have several
differences, meaning that certain prescription drugs are unavailable to
transitioning servicemembers once they start receiving care from the
VA. As a result, there are occasions when transitioning servicemembers
are forced to abruptly change their prescription drug regimen during an
already arduous transition period.
This legislation would require the VA to continue supplying
medications prescribed by a DoD healthcare provider when the DoD
healthcare provider determines that such pharmaceutical agent is
critical for such transition.
Using Resolution 377, Support Veterans Quality of Life Resolution,
The American Legion supports any legislation that will enhance,
promote, restore or preserve benefits for veterans and their
dependents, including, but not limited to, the following: timely access
to quality VA health care, timely decisions on claims and receipt of
earned benefits, and final resting places in national shrines and with
lasting tributes that commemorates their service. \8\
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\8\ The American Legion Resolution No. 377 (2016): Support Veterans
Quality of Life Resolution
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The American Legion Supports H.R. 1063
H.R. 1066 - VA Management Alignment Act of 2017
To direct the Secretary of Veterans Affairs to submit to the
Committees on Veterans' Affairs of the Senate and the House of
Representatives a report regarding the organizational structure of the
Department of Veterans Affairs, and for other purposes.
The American Legion has been at the forefront of efforts to both
increase accountability at Department of Veterans Affairs and improve
timely access to quality VA health care for veterans. We have been
rightly critical of past management failures and recognize the need to
assist VA, Congress, and other stakeholders to address these problems.
In 2015, VA health care was added to the Government Accountability
Office (GAO) high-risk list because of concerns about VA's ability to
ensure the timeliness, cost-effectiveness, quality, and safety of
veterans' health care. In testimony delivered to the Senate Veterans
Affairs Committee on March 15, 2017, GAO stated that insufficient
progress has been made to address the concerns that led to high-risk
designation. \9\
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\9\ https://www.gao.gov/assets/690/683381.pdf
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In May 2017, VA Secretary Shulkin delivered his diagnosis of the
department noting a long road toward recovery. He offered an assessment
on the ``State of VA,'' outlining 13 areas where the department needs
to improve and the legislative and administrative fixes it needs in
order to see progress. Shulkin reiterated his belief that the
department's central office is too large and unwieldy.
Another GAO report released in September 2016 found that the VA has
been slow to make changes after the 2014 wait-time scandal and that VA
does not have a process for following through with the recommendations
that it receives or to effectively make changes \10\. The report also
states that without a process, there is ``little assurance'' the
delivery of health care will improve. It goes on to say the VA cannot
confirm that it is holding leaders accountable for making improvements.
\11\
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\10\ https://www.gao.gov/mobile/products/GAO-16-803
\11\ http://www.gao.gov/assets/690/680054.pdf
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The VA Management Alignment Act was introduced in response to this
report to help address the issue. The measure would require the VA
secretary to submit plans to the House and Senate veterans committees
within 180 days after the bill goes into effect, detailing the roles
and responsibilities of VA executives and spelling out how they would
improve veterans' access to treatment.
The American Legion Resolution No. 3: Department of Veterans
Affairs Accountability urges Congress to pass legislation to improve
accountability at VA. \12\ The VA Management Alignment Act of 2017
would provide the agency and Congress with a new perspective on how to
address VA's management challenges and is consistent with ongoing
efforts to improve VA's ability to ensure the timeliness, cost-
effectiveness, quality, and safety of veterans' health care.
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\12\ The American Legion Resolution No. 3 (2016): Department of
Veterans Affairs Accountability
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The American Legion supports H.R. 1066
H.R. 1972 - VA Billing Accountability Act
To amend title 38, United States Code, to authorize the Secretary
of Veterans Affairs to waive the requirement of certain veterans to
make copayments for hospital care and medical services in the case of
an error by the Department of Veterans Affairs, and for other purposes.
While many veterans qualify for free healthcare services based on a
Department of Veterans Affairs compensable service-connected condition
or other special eligibilities, most veterans are required to complete
a financial assessment or means test at the time of enrollment to
determine if they qualify for free health care services. Veterans whose
income exceeds VA income limits, as well as those who choose not to
complete the financial assessment at the time of enrollment, must agree
to pay required copays for health care services to become eligible for
VA healthcare services. VA is also authorized to recover the reasonable
cost of medical care furnished to a veteran for the treatment of a non-
service-connected (NSC) disability or condition when the veteran or VA
is eligible to receive payment for such treatment from a third-party.
After enrollment, if a veteran's medical care appears to qualify
for billing under reimbursable insurance and co-payment, the charges
for co-payments will be placed on hold for 90 days, pending payment
from the third-party payer. If no payment is received within 90 days,
the charges will automatically be released and a statement generated to
the veteran. VA will provide sufficient information about first party
copayment debts to veteran patients reminding them of their
responsibilities to pay their share of debts created as a result of
medical services rendered as inpatient, outpatient, extended care, or
medication. VA will follow up with the debtor until the debt is
resolved.
VA currently has multiple options available to help make copay
charges more affordable, or to eliminate them:
Repayment Plan: A veteran has the right to establish a
monthly repayment plan at any time during their enrollment in VA health
care if they cannot pay their debt in full.
Waiver Request: A veteran also has the right to request a
waiver of part or all of the debt. If the waiver is granted the veteran
is not required to pay the amount waived.
Compromise: A veteran has the right to request a
compromise. A compromise means a veteran proposes a lesser amount as
full settlement of the debt.
H.R. 1972 would authorize the VA to waive the requirement that a
veteran makes copayments for medications, hospital care, nursing home
care, and medical services if:
An error committed by the VA or a VA employee was the
cause of delaying copayment notification to the veteran, and
The veteran received such notification later than 120
days (18 months in the case of a non-VA facility) after the date on
which the veteran received the care or services.
In requiring a veteran to make a copayment for care or services
provided at a VA or a non-VA medical facility, this bill would require
VA to notify the veteran not later than 120 days (18 months in the case
of a non-VA facility) after the date on which the veteran received the
care or services. If the VA does not provide notification by such date,
it may not collect the payment, including through a third-party entity,
unless the veteran is provided with:
information about applying for a waiver and establishing
a payment plan with the VA, and
an opportunity to make a waiver or establish a payment
plan.
Finally, H.R. 1972 would require the VA to review and improve its
copayment billing internal controls and notification procedures.
The VA Billing Accountability Act of 2017, by setting forth
specific and immediate billing requirements, so our nation's veterans
are not receiving unbilled co-payments for VA care in an untimely
manner, sometimes from years past, will help bring more stability and
financial security to their post-military lives.
Through Resolution No. 377: Support for Veteran Quality of Life,
The American Legion supports any legislative proposal that urges
Congress and the Department of Veterans Affairs to enact legislation
and programs within the VA that will enhance, promote, restore or
preserve benefits for veterans and their dependents, including, but not
limited to the following: timely access to quality VA health care;
timely decisions on claims and receipt of earned benefits; and final
resting places in national shrines and with lasting tributes that
commemorate their service. \13\
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\13\ The American Legion Resolution No. 377 (2016): Support for
Veteran Quality of Life
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The American Legion supports H.R. 1972
H.R. 2147 - Veterans Treatment Court Improvement Act of 2017
To require the Secretary of Veterans Affairs to hire additional
Veterans Justice Outreach Specialists to provide treatment court
services to justice-involved veterans, and for other purposes.
The Veterans Court Improvement Act of 2017 recognizes the
importance of Veteran Justice Outreach Specialists providing services
to veterans as well as the importance of Veteran Treatment Courts. This
legislation would assure our nation's veterans, who are in the criminal
justice system, have access to services and resources they need to be
productive members of society. With this bill, Congress validates that
this unique population will be best served within their communities by
providing sufficient resources to these courts.
When veterans return from combat, some turn to drugs or alcohol to
cope with mental health issues related to Post Traumatic Stress
Disorder (PTSD) and/or Traumatic Brain Injury (TBI). Thus, many
returning veterans are entering the criminal justice system to face
charges stemming from these issues. In 2008, a judge in Buffalo, NY,
created the first Veterans Treatment Court after seeing an increase in
veterans' hearings on his dockets. Veteran Treatment Courts are a
hybrid of drug and mental health courts. They have evolved out of the
growing need for a treatment court model designed specifically for
justice-involved veterans to maximize efficiency and economize
resources while making use of the distinct military culture consistent
among veterans.
Through Resolution No. 145: Veterans Treatment Courts, The American
Legion supports any legislation that establishes a separate program
office within Department of Veterans Affairs Central Office with an
increased program budget and hiring of staff to expand the Veterans
Justice Outreach program and policies. \14\ The resolution specifically
calls for continuing to fund and expand Veterans Treatment Courts and
hire more staff to expand the Veterans Justice Outreach program and
policies.
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\14\ The American Legion Resolution No. 145 (2016): Veteran
Treatment Courts
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The American Legion supports H.R. 2147
H.R. 2225 - Veterans Dog Training Therapy Act
To direct the Secretary of Veterans Affairs to carry out a pilot
program on dog training therapy.
Since 1991, the United States has been at war, and as a result,
thousands of soldiers have returned home with mental and physical
injuries. In 2009, Congress amended Title 38, United States Code Sec.
1714 by authorizing the Department of Veteran Affairs to extend
benefits for the upkeep of service dogs used primarily for the aid of
persons with physical disabilities and psychological wounds.
This bill directs the VA to carry out a five-year pilot program to
assess the effectiveness of addressing veterans' post-deployment mental
health and post-traumatic stress disorder symptoms through the
therapeutic medium of training service dogs for veterans with
disabilities.
Through Resolution No. 160: Complementary and Alternative Medicine,
The American Legion supports any legislation that provides oversight
and funding to the Department of Veterans Affairs for innovative,
evidence-based, complementary and alternative medicine (CAM) in
treating various illnesses and disabilities. \15\
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\15\ The American Legion Resolution No. 160 (2016): Complementary
and Alternative Medicine
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The American Legion supports H.R. 2225
H.R.2327 - PAWS Act of 2017
To direct the Secretary of Veterans Affairs to make grants to
eligible organizations to provide service dogs to veterans with severe
post-traumatic stress disorder, and for other purposes.
The Puppies Assisting Wounded Servicemembers Act of 2017 (PAWS Act)
makes service dogs accessible to veterans wanting an alternative post-
traumatic stress disorder (PTSD) treatment option possible for veterans
open to this type of treatment. Currently, the Department of Veterans
Affairs does not fund service dogs or recognize the use of therapy
service dogs as a possible method to treat veterans suffering from
PTSD. There have been multiple studies proving that service dogs can
provide many different forms of mental healing to veterans suffering
from physically invisible wounds of war.
H.R. 2327 would create a five-year $10 million pilot program that
pairs veterans who served on active duty in the Armed Forces on or
after September 11, 2001, with eligible therapy service dogs if they
have been diagnosed with PTSD severe enough to warrant treatment.
Eligible veterans must have also completed an evidence-based treatment
program and remain significantly symptomatic by clinical standards.
The American Legion supports this legislation because it allows for
an alternative form of treatment to injured veterans returning home
from war with Traumatic Brain Injury (TBI) and PTSD. Service dogs can
act as an effective complementary therapy treatment component,
especially for those veterans who suffer on a daily basis from the
physical and psychological wounds of war. PTSD has become an epidemic,
and the VA has estimated that between 11 and 20 percent of veterans who
served in Afghanistan or Iraq have PTSD \16\. While the VA continues to
stall with their dog-based therapy studies, veterans are being denied
alternative forms of treatment. As the VA is continually accused of
over-prescribing veterans, and as veteran continue to complain about
overprescription, it is time that the VA, and the Federal government,
look at alternative options. \17\
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\16\ https://medlineplus.gov/magazine/issues/winter09/articles/
winter09pg10-14.html
\17\ http://www.npr.org/sections/health-shots/2014/07/11/330178170/
veterans-kick-the-prescription-pill-habit-against-doctors-orders
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Through Resolution No. 160: Complementary and Alternative Medicine,
The American Legion supports any legislation that provides oversight
and funding to the Department of Veterans Affairs for innovative,
evidence-based, complementary and alternative medicine (CAM) in
treating various illnesses and disabilities. \18\
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\18\ The American Legion Resolution No. 160 (2016): Complementary
and Alternative Medicine
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The American Legion supports H.R. 2327.
DRAFT BILL
To amend title 38, United States Code, to make certain improvements
in the Health Professionals Educational Assistance Program of the
Department of Veterans Affairs, and for other purposes.
The provisions of this draft bill fall outside the scope of
established resolutions of The American Legion. As a large, grassroots
organization, The American Legion takes positions on legislation based
on resolutions passed by our membership. With no resolutions addressing
the provisions of the legislation, The American Legion is researching
the material and working with our membership to determine the course of
action that best serves veterans.
The American Legion has no current position on this Draft Bill.
Conclusion
As always, The American Legion thanks this subcommittee for the
opportunity to elucidate the position of the over 2 million veteran
members of this organization. For additional information regarding this
testimony, please contact The American Legion Deputy Director of the
Legislative Division, Derek Fronabarger, at (202) 861-2700 or
[email protected].
Prepared Statement of Amy Webb
On
``Pending Health Care Legislation''
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
H.R. 93 to Provide Increased Access to Department of Support
Veterans Affairs Medical Care for Women Veterans
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H.R. 501 VA Transparency Enhancement Act of 2017 Support
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H.R. 1063 Veteran Prescription Continuity Act Support
----------------------------------------------------------------------------------------------------------------
H.R. 1066 VA Management Alignment Act of 2017 Support
----------------------------------------------------------------------------------------------------------------
H.R. 1943 Restoring Maximum Mobility to Our Nation's Support
Veterans Act of 2017
----------------------------------------------------------------------------------------------------------------
H.R. 1972 VA Billing Accountability Act Support
----------------------------------------------------------------------------------------------------------------
H.R. 2147 Veterans Treatment Court Improvement Act of Support
2017
----------------------------------------------------------------------------------------------------------------
H.R. 2225 Veterans Dog Training Therapy Act Support
----------------------------------------------------------------------------------------------------------------
H.R. 2327 PAWS Act of 2017 Support
----------------------------------------------------------------------------------------------------------------
Draft to Make Certain Improvements to VA's HPEAP Support
----------------------------------------------------------------------------------------------------------------
Chairman Wenstrup, Ranking Member Brownley, and all members of the
committee; thank you for the opportunity to testify on behalf of
AMVETS' 250,000 members. We are particularly thankful for your efforts
to address some of the most challenging and longstanding veteran health
care issues. We appreciate the dedication of your staff members who are
working diligently to formulate policies that ensure we are taking care
of our Nation's veterans.
H.R. 93: Provide Increased Access to Department of Veterans Affairs
Medical Care for Women Veterans
AMVETS supports H.R. 93
H.R. 93 ensures that gender specific services are continuously
available at every VA medical center and community based outpatient
clinic.
This bill is strongly aligned with our National Resolution on Women
Veterans Health care which states, in part, that AMVETS urges DoD and
VA to enhance their programs to ensure that women veterans receive
high-quality, comprehensive primary and mental health care services in
a safe and sensitive environment at every VA health care facility.
H.R. 501 VA Transparency Enhancement Act of 2017
AMVETS supports H.R. 501
This bill increases reporting requirements from VA medical
facilities regarding post-surgical infections, and cancelled or
transferred surgeries.
AMVETS has a National Resolution on VA Accountability, and we
believe that transparency is equally important. Any measure which seeks
to improve the health care and health outcomes of veterans is something
that we not only support, but advocate for as part of our
organizational mission.
H.R. 1063 Veteran Prescription Continuity Act
AMVETS supports H.R. 1063
H.R. 1063 improves the care of individuals transferring from
receiving treatment from the Department of Defense to the Department of
Veterans Affairs by ensuring that any pharmaceuticals the patient is
taking at the time of transfer that are not listed on the Joint Uniform
Formulary for Transition of Care would be able to still be prescribed
until such point where it was deemed they were no longer needed.
AMVETS believes it is imperative to offer servicemembers
transitioning into veteran status the continuity of care that medical
professionals believe is in their best interest. Allowing the
continuation of needed medication, whether or not it is listed in the
Joint Uniform Formulary, is something that is important and we urge
passage of this bill.
H.R. 1066 VA Management Alignment Act of 2017
AMVETS supports H.R. 1066
H.R. 1066 increases the reporting requirements of the Department of
Veterans Affairs related to the roles, responsibilities and
accountability of the departments and its key leaders and staff.
This bill falls well under our National Resolution on VA
Accountability. As VA works to ensure that those in all levels of
employment are upholding their commitments and dedication to serving
veterans, we encourage this type of reporting so that the different
roles of different departments can be adjusted and enhanced to better
serve those who have stood up to serve this country. This is VA's
purported mission and we support all levels of improved excellence.
H.R. 1943 Restoring Maximum Mobility to Our Nation's Veterans Act of
2017
AMVETS supports H.R. 1943
This bill ensures that veterans with a service-connected disability
may be furnished a wheelchair to restore an ability to participate in
recreational activities and clarifies that wheelchairs furnished to
these veterans should be intended to help the veteran achieve mobility
and function in the activities of daily life and employment in addition
to recreation.
AMVETS supports this bill as it falls in line with our National
Resolution on Prosthetics and Sensory Aids, and we also support in the
spirit of encouraging veterans of all abilities to be as active as they
are able. From VA's sports clinics to its wheelchair games, it is quite
evident that when veterans realize that they are capable of
participation and involvement in actives they were not sure was
possible after being injured or wounded, that it improves their
physical and mental health.
H.R. 1972 VA Billing Accountability Act
AMVETS supports H.R. 1972
H.R. 1972 waives the requirement of certain veterans to make
copayments for VA medical care, and prescriptions if the Department
made errors in properly notifying the veteran that a payment was
required, and if the notification was received more than three months
after the date of service. It will be required that the veteran is
given information on how to apply for a waiver, or to establish a
payment plan. For medical care received outside of VA, the veteran must
be notified of a payment due within 18 months of service.
AMVETS supports this protective measure of veterans, who should not
be held liable if VA is not properly billing its patients, whether they
receive care within or outside of the VA health care system.
H.R. 2147 Veterans Treatment Court Improvement Act of 2017
AMVETS supports H.R. 2147
H.R. 2147 would require the Secretary of VA to hire additional
Veterans Justice Outreach (VJO) Specialists, and AMVETS
enthusiastically supports this bill. Many veterans have specific needs
and challenges related to their military service. AMVETS has been
involved with veteran treatment courts since their inception - starting
with our then Commander J.P. Brown who worked with Judge Russell in
Buffalo New York who in January of 2008 created and began presiding
over the nation's first Veterans Treatment Court. Commander Brown took
that knowledge and spearheaded the creation of a veteran treatment
court in his home state of Ohio where about 100 veterans have since
gone through the system. Of those, only four have had to leave due to
noncompliance. The 96 others have completed two years of treatment
which combines VA services, Social Services, veteran and family
counseling, and four mental health agencies. The veteran is also paired
with a mentor. The court itself acts just like a regular court, and if
the veteran client pleads guilty and completes the 2-year program, then
the charges are dropped. It is a key legislative priority of ours to
see these courts expanded and we appreciate that the bill would add
more VJO Specialists. There are many solid systems in place to help
veterans, but they will not properly function without adequate
staffing.
H.R. 2225 Veterans Dog Training Therapy Act
AMVETS supports H.R. 2225
H.R. 2225 creates a five-year pilot program to study the
effectiveness of treating post-deployment mental health symptoms by
having eligible veterans learn how to train service dogs through the
VHA's Center for Compassionate Innovation's Recreation Therapy Service.
VA would be required to establish and hire a director of therapeutic
service dog training who has a background in social services;
experience teaching others to train service dogs in a vocational
setting; and a minimum of a year working in a clinical setting with
veterans or those on active duty with PTSD. In choosing dog training
instructors, there would be preference given to veterans who have
graduated from PTSD or other residential treatment programs and who are
certified in service dog training.
Veterans participating in the pilot would do so in conjunction with
VA's vocational rehabilitation Compensated Work Therapy program. Non-
governmental entities would be contracted to perform the assessments of
the pilot which include how stigma is reduced, improvements to
emotional regulation and patience, reintegrating into the community,
improving sleep patterns and instilling a sense of purpose.
The intent of this bill is in line with our National Resolution on
VA mental health care that strongly recommends Congress appropriate
more dedicated funding for mental health care and related programs and
services. AMVETS is also a strong proponent of the benefits of service
dogs, and believes that veterans in this pilot program would benefit by
being in the leadership position to help train these canines that can
change and better the lives of the fellow veterans they end up being
paired with.
H.R. 2327 PAWS Act of 2017
AMVETS Supports H.R. 2327
The Puppies Assisting Wounded Servicemembers Act creates a five-
year pilot program assessing the benefits of pairing a service dog with
veterans suffering from severe PTSD, in an effort to reduce the
concerning veteran suicide rate. The VA would provide $25,000 to
eligible organizations for the procurement and training of each service
dog paired with a veteran in addition to any necessary hardware, travel
expenses for the veteran to obtain the service dog, or any potential
replacement service dog, and a veterinary health insurance policy for
the life of the dog.
In order for a veteran to be eligible for the pilot they must be
enrolled in VA healthcare and have completed an established evidence-
based treatment for PTSD without suitable improvement so as they still
remain diagnosed under the PTSD checklist (PCL-5) and their mental
health care provider determines that they may potentially benefit from
a service dog. Once accepted into the pilot, in order to remain
eligible the veteran needs to maintain their relationship with their
mental health care provider, and have office visits at least every six
months to determine whether the veteran is benefitting from being
paired with a service dog. If it is determined that the veteran is not
benefitting than the eligible organization that provided the dog will
decide how best to ensure the safety of the dog and the veteran.
While the VA does not compensate veterans for the care of service
dogs that assist veterans with PTSD as they do for some other
conditions, they remain in the midst of a $12-million-dollar study to
measure the cost and mental health benefits of pairing well-trained
service dogs with veterans diagnosed with PTSD. The study also aims to
compare service dogs and emotional support dogs in how they assist
veterans with PTSD. Unfortunately, the study has been beset by many
setbacks, including improper pairing of poorly trained dogs with
veterans, and for being slow in acquiring and pairing dogs with
veterans. After undergoing a pause and reorganization, the VA study
picked back up in 2015 and according to the VA's Office of Research and
Development website, ``VA researchers are studying whether Veterans
with PTSD can benefit from the use of service dogs or emotional support
dogs. The study, being overseen by VA's Cooperative Studies Program, is
enrolling 230 Veterans with PTSD from Atlanta, Iowa City, and Portland.
To date, there is ample evidence on the benefits of service dogs for
people with physical disabilities, but very little such evidence in the
area of mental health.'' This particular study is set to be complete in
2018.
AMVETS has long seen the importance of well-trained and well-paired
service dogs, and the impact this relationship has on individuals and
veterans with physical and emotional illnesses or wounds. Service dogs
can perform specific tasks to assist with the symptoms of PTSD such as
learning commands to help secure space, turn on lights, sweep a room
prior to a veteran entering and bark if anyone is present, to wake them
up during a nightmare, remind them to take medication, and pick up on
stress cues and offer calming support.
The AMVETS Ladies Auxiliary has worked with ADI accredited ``Paws
with a Cause'' as its National Community Service program for nearly
thirty years in a consistent effort to help veterans with visible and
invisible wounds obtain a service dog to enhance their daily
functioning. Through this partnership, AMVETS has seen firsthand the
marked benefits to a veteran's quality of life when paired with a well-
trained service dog.
The intent of this bill is in line with our National Resolution on
VA mental health care that strongly recommends Congress appropriate
more dedicated funding for mental health care and related programs and
services. While AMVETS supports passage of the PAWS Act, it is with the
stipulation that great care, consult, and oversight occur when awarding
a contract to an organization that trains the service dogs; in choosing
veterans who are able to manage the continued care and training the dog
will require; in closely following those who are part of the pilot
program; and in setting expectations for how quickly the veteran can
obtain a dog. Fully trained service dogs are quite rarely immediately
available, but once paired with a receptive and willing owner, the
benefits can be extraordinarily rewarding. AMVETS looks forward to
providing any assistance needed to properly choose organizations that
provide trained animals that can effectively support veterans with
PTSD.
Discussion Draft: Make Certain Improvements to VA's HPEAP
AMVETS supports the discussion draft
This measure will improve the VA's Health Professionals Educational
Assistance Program (HPEAP) by offering additional scholarships to those
seeking to become a physician or dentist, and stipulates varying
degrees of commitment to working full time at a VA medical facility in
return for the scholarship, in addition to repayment parameters should
the individual not meet the requirements of the scholarship.
In addition this measure would create a VA Specialty Loan Repayment
Program in order to repay the loans of certain VHA physicians who are
eligible to be board certified in areas that are deemed to be most
needed in the areas of recruitment and retention.
Lastly, it would establish a veterans healing veterans pilot
program to fund the educations of ten eligible veterans who have
separated from the military within ten years, and who are not eligible
for other educational assistance. They must apply for admission to one
of five Teague-Cranston medical schools for 2019 and would be chosen
for being veterans with the highest admissions rankings. If each of the
five schools do not receive or award the two scholarships, then another
school may award an additional scholarship in order for ten total
scholarships to be awarded.
Quality recruitment and retention of high performing physicians and
dentists at VA has been a longstanding and complex challenge. We
believe that this measures offers offer some excellent solutions to
this issue, albeit rather short term with the repayment in the form of
time committed to working in VA rather short-term. We hope that in the
interim VA is able to strengthen its ability to retain physicians long-
term in the way of comparable compensation to the private sector, and
internal organizational processes across the board that speak to VA's
stated core values of: Integrity, Commitment, Advocacy, Respect,
Excellence (``I CARE'').
Prepared Statement of Harold Kudler, M.D.
Good morning, Chairman Wenstrup, Ranking Member Brownley, and
Members of the Subcommittee. Thank you for inviting us here today to
present our views on several bills that would affect the Department of
Veterans Affairs' (VA or Department) programs and services. Joining me
today is Ms. Catherine Biggs-Silvers, Executive Director, for Mission,
Planning, and Analysis, Human Resources and Administration. Due to the
timing of the hearing, VA is unable to provide views on the draft bill,
to make certain improvement in the Health Professionals Educational
Assistance Program of the Department of Veterans Affairs. These views
are currently being drafted and we will forward them to you as soon as
they are available.
H.R 93 Medical Services for Women Veterans
H.R. 93 would add section 1720H to Title 38, United States Code
(U.S.C.), requiring the Secretary to ensure that gender specific
services are continuously available at every VA medical center (VAMC)
and community-based outpatient clinic (CBOC). It also would allow the
Secretary to employ appropriate staff and enter into such contracts as
may be needed to meet current and expected future demand for these
services.
We appreciate the intent of this proposal and would like to work
with the Committee to further clarify the scope of this bill. We
strongly believe that every Veteran should receive care specific to his
or her needs, but we caution that the language as written could be
broader than intended. For example, the term ``gender specific
services'' is undefined, and could apply to both men and women
Veterans. It is also unclear if this is intended to refer to gender-
specific primary care services for women or more advanced services such
as obstetrics and gynecology (for women) or urology (for men). We also
note that the bill as written would require these services be
continuously available at every VAMC and CBOC. This could potentially
have significant resource implications depending upon the intended
effect. We would greatly appreciate the opportunity to meet with the
Committee further to discuss these and other issues to improve this
legislation.
Given the unclear scope of the legislation, we are unable to
provide a cost estimate for this bill at this time but note that it
could have significant resource implications depending on the intended
effect.
H.R 501 VA Transparency Enhancement Act of 2017
H.R. 501 would impose new reporting requirements on medical center
directors and the Secretary. It would require each VAMC Director to
file a quarterly report to the Secretary providing specific data
related to surgical infections and cancelled or transferred surgeries.
Within 60 days of the end of each calendar quarter, the Secretary would
be required to report to Congress and publish online the reports
submitted by the VAMC Directors and a summary on those reports.
We do not support this bill because portions of it are unnecessary
and others would be burdensome to implement. Currently, each facility
collects data on surgical infections locally, but this information is
not gathered nationally. The VA Surgical Quality Improvement Program
(VASQIP) examines a portion of all surgeries (approximately 30 percent)
completed within VA to identify surgical infections, and nationally,
approximately 1.5 percent of VASQIP assessed surgeries result in
infections within 30 days of the procedure. Examining all surgeries
could significantly increase our demand for resources without
generating an appreciable improvement in quality.
We are concerned about the intended result of the summaries of
surgical infections, which could implicate patient privacy information.
We would appreciate the opportunity to discuss this further with the
Committee to resolve these concerns while ensuring the Committee has
the information it needs to perform its oversight functions.
We currently collect information on cancelled surgeries (including
both the number and the reasons for such cancellations) and can provide
this information as needed, both locally and nationally. It would be
more difficult to gather information on transferred surgeries, as our
systems do not collect this information now. We note that section
2(a)(2)(C) directs VA to provide information on the number of
additional days each such patient had to wait for surgery because of
cancellation or transfer, but we caution that there are a number of
reasons for cancellations and transfers, some of which are patient-
driven and others that may be clinically necessary, and that this
information would therefore not necessarily be helpful. Some surgeries
may be cancelled and never performed, either because they were elective
or because of intervening circumstances. We would also like to discuss
this provision further with the Committee to see if currently available
information may satisfy the objective of this provision.
VA estimates the cost of the legislation would be $18 million in
fiscal year (FY) 2018, $97 million over five years, and $209 million
over 10 years.
H.R 1063 Veteran Prescription Continuity Act
H.R. 1063 would amend Section 715 of the National Defense
Authorization Act for Fiscal Year 2016 (Public Law 114-92) by adding a
new subsection (c). The Secretary would be required to provide any
pharmaceutical agent not included in the joint uniform formulary for VA
and the Department of Defense (DoD) to an individual who is
transitioning from receiving treatment from DoD to receiving treatment
from VA, if a DoD health care provider determines that such
pharmaceutical agent is critical for such a transition. VA would be
required to furnish these pharmaceutical agents beginning on the date
on which the individual enrolls in the VA health care system and ending
on the date on which a VA provider determines the agent is no longer
required by the individual.
We do not support this bill. When filling prescriptions, the
Veteran's medical necessity drives the utilization of medications, not
the formulary status of a medication. Fundamentally, we are concerned
that the legislation would usurp a prescriber's professional
responsibility to ensure a medication, whether a controlled substance
or not, started by another provider continues to be safe and effective.
We have a long-standing practice of continuing medications that are
clinically needed for transitioning Servicemembers, and we have
strengthened this further with a policy articulating this requirement
in 2015 (VHA Directive 2014-02, issued January 20, 2015). Further, as
required by Congress, VA and DoD have developed a process for annually
reviewing the Continuity of Care Drug List, and we recently completed
this review earlier this summer. VA's Center for Medication Safety has
collaborated with DoD and performed two studies that have validated
that our policies are working and that transitioning Servicemembers and
new Veterans are receiving the medications they clinically need. The VA
Center for Medication Safety is assessing the financial impact of the
Continuity of Care Drug List, as required by Congress.
DoD has no requirements in law to address the opioid crisis
currently affecting the country. While section 715 required a joint
formulary, there is no requirement for VA and DoD to adhere to the same
protections and metrics for opioid prescriptions. We recommend that if
Congress is interested in legislating in this area, this is an area
that could produce significant improvements in the safety and well-
being of Veterans and Servicemembers alike. We would be happy to work
with the Committee on this initiative. We also recommend that Congress
enact legislation requiring DoD to notify VA immediately for any
patients on high-risk medications who are transitioning out of military
service. There currently is no mechanism for sharing this information,
which introduces the potential for gaps in clinical care and patient
safety.
The bill is intended to ensure that patients maintain continuity of
their prescription medications as they transition from DoD to VA, but
as written, this legislation could obligate providers and pharmacists
to furnish medications in ways that could violate other provisions of
law or professional responsibility. For example, if a Servicemember
received a prescription for a controlled substance, and such a
prescription requires either routine monitoring or additional
screening, a VA pharmacist or provider could be forced to decide which
law to comply with and which to violate. As another example, if a
Servicemember received a prescription for a controlled substance, then
sought additional prescriptions for the same substance from several
private providers, a VA pharmacist would know this by checking the
Prescription Drug Monitoring Program; ordinarily, VA pharmacists would
not fill that prescription, but this bill could require them to do so.
VA providers and pharmacists are trained to review prescriptions
carefully to ensure that patient safety is the top priority, and we are
concerned that this legislation, while well-intended, could impede that
objective.
We note as a technical manner that, as written, proposed section
715(c)(2)(B) would require a VA health care provider to determine that
the Veteran does not require a pharmaceutical agent. This would
preclude a non-Department provider authorized to furnish care and
services to Veterans from making this determination. Given the
continuing discussion regarding the future of Care in the Community, we
note this language may affect some Veterans differently based upon who
furnishes their care.
We are unable to provide a cost estimate for this bill given the
uncertainty regarding how many transitioning Servicemembers would be
affected, which medications VA would have to provide, how much those
medications would cost, and how long it would take for VA to make a
clinical determination regarding the continued need for that
medication.
H.R. 1066 VA Management Alignment Act of 2017
H.R. 1066 would require, within 180 days of enactment of this Act,
the Secretary to report to Congress on the roles, responsibility, and
accountability of elements and individuals within VA. In creating the
report, the Secretary would be required to utilize the results of the
Independent Assessment of the Health Care Delivery Systems and
Management Process established by section 201 of the Veterans Access,
Choice, and Accountability Act of 2014 (Public Law 113-146), any study
or report by the Commission on Care established by section 202 of
Public Law 113-146, and other studies or reports. The Secretary's
report to Congress would also have to specify clearly delineated roles
and responsibilities to optimize the organizational effectiveness and
accountability of each administration, staff office, or staff
organization, their subordinate organizations, and key leaders of the
Department.
VA supports the intent of this bill. The Secretary has made
improving accountability within VA, including ensuring that the
Department is well-organized and well-functioning, one of his highest
priorities, and our current efforts are achieving the intended results
of this legislation. We are not waiting for legislation to improve VA's
organizational structure and internal management-we are taking
aggressive steps now to ensure that VA is responsive to Veterans' needs
while being a good steward of taxpayer dollars.
We do not expect this legislation would result in any appreciable
costs.
H.R 1943 Restoring Maximum Mobility to Our Nation's Veterans Act of
2017
H.R. 1943 would amend 38 U.S.C. Sec. 1701 by adding a new
paragraph (11) defining the term ``wheelchair''. This term would
include enhanced power wheelchairs, multi-environmental wheelchairs,
track wheelchairs, stair-climbing wheelchairs, and other power-driven
mobility devices. It would also add a new subparagraph (2) to 38 U.S.C.
Sec. 1712(c) to require the Secretary to ensure that each wheelchair
provided under this title to a Veteran because of a service-connected
disability restores the maximum achievable mobility and function in the
activities of daily life, employment, and recreation for the Veteran.
The Secretary would be authorized to furnish a wheelchair in order to
restore an ability that relates exclusively to participation in a
recreational activity.
We generally support the proposed changes to section 1701, but have
concerns with a few of the types of wheelchairs identified. For
example, track wheelchairs and stair-climbing wheelchairs are not
currently cleared by the Food and Drug Administration (FDA) for use,
and as a result, we do not believe it is appropriate to prescribe or
furnish such equipment to Veterans. We currently furnish FDA-cleared
wheelchairs, and in the event that other wheelchairs are cleared by FDA
in the future, we would be able to furnish such wheelchairs at that
time. Similarly, we are concerned about the breadth of the term ``other
power-driven mobility devices'', which could include any number of
items that have no valid medical necessity.
Regarding the proposed changes to section 1712, we note that the
language would limit eligibility to Veterans who are furnished a
wheelchair because of a service-connected disability. VA currently
provides wheelchairs to Veterans, regardless of their service-connected
status, as long as they are enrolled in VA health care and the
wheelchair is determined to be medically necessary. We do not
distinguish between Veterans with service-connected disabilities and
those without when making determinations regarding which prosthetic
devices the Veteran needs; we only consider their medical necessity. In
this context, we do not believe these amendments are needed because we
already furnish these services. We recommend that the language
requiring the Secretary to ensure that each wheelchair restores the
maximum achievable mobility and function in the activities of
``employment'' and ``recreation'' be removed, as this could potentially
create an open-ended obligation. We believe it is sufficient for a
Veteran's clinical needs that the wheelchair restore the maximum
achievable mobility and function in the activities of daily life.
We note there is some ambiguity in terms of the intent and effect
of the second sentence in proposed 1712(c)(2), and we would appreciate
the opportunity to discuss this further with the Committee to provide
any technical assistance that may be required.
Because the intended scope of the certain provisions of the bill is
unclear, we cannot estimate the cost of this legislation to the
Department but note that it could have significant resource
implications.
H.R 1972 VA Billing Accountability Act
H.R. 1972 would amend sections 1710(f)(3) and 1722A, and add a new
section 1709C to title 38, U.S.C., that would require VA to notify
Veterans of their copayment requirements no later than 120 days after
the date of care or services provided at VA medical facilities, and no
later than 18 months after the date of care or services provided at
non-VA facilities. If VA does not provide such notice, VA could not
collect the copayment, including through a third-party entity, unless
VA provided the Veteran: (1) information on applying for a waiver and
establishing a payment plan, and (2) an opportunity to make a waiver or
establish a payment plan. The Secretary would be authorized to waive
the copayment requirement in cases where notification to the Veteran
was delayed because of an error committed by VA, a VA employee, or a
non-VA facility (if applicable), and the Veteran received notification
beyond the specified timeframes. H.R. 1972 would also require VA, no
later than 180 days after enactment, to review and improve its
copayment billing internal controls and notification procedures,
including pursuant to the provisions of the bill.
VA supports the intent of H.R. 1972 to prevent delays in the
release of copayment charges due to operational error, avoid undue
burden to Veterans, and improve VA's copayment billing procedures.
However, we are concerned that the 120-day time period proposed in the
bill could adversely affect some Veterans. Further, it is not clear
what specific copayment billing issues the bill would address.
We note that copayments are automatically generated by VA's
integrated billing system. Moreover, VA ensures that every Veteran is
given the notice of rights and the opportunity to request a waiver or
compromise, and to establish a repayment plan for copayment charges.
This information is included with every copayment billing statement
that VA sends to a Veteran. As a service to Veterans, VA holds
copayment bills until a Veteran's other health insurance (OHI) is
billed and either pays or denies the claim. This allows VA potentially
to offset the Veteran's copayment charges with payment received from
the OHI, reducing the Veteran's liability. When a Veteran has OHI, the
copayment charge is placed on hold for 90 days while the OHI is billed.
If no payment is received within 90 days, the charges will
automatically be released and a statement generated to the Veteran. If
a balance remains after an OHI payment is applied to the copayment
debt, the bill for the remaining balance is released to the Veteran and
he or she receives it within a variable timeframe that ranges from 70
to 150 days depending on when the OHI payment is made - a timeframe
that can exceed the proposed 120-day standard in H.R. 1972. Requiring
all copayment bills to be issued within 120 days could adversely affect
some Veterans whose OHI payments are delayed, as they would be notified
of a copayment and billed when they would ordinarily not incur any
personal liability. We note that less than 10 percent of copayment
bills currently are submitted more than 120 days from the date of
service, but in these cases, requiring copayment bills be issued could
produce confusion among Veterans, result in greater out-of-pocket costs
for these Veterans, and increase VA's administrative burden in
implementing this change. VA financial policy for medical care debts
specifies that Veterans who do not have OHI should have the opportunity
to satisfy copayment obligations at the Agent Cashier's office prior to
leaving the medical facility. Otherwise, the record of service is
prepared and the copayment is released for billing on the Veteran's
next scheduled monthly billing statement, which is normally received
anywhere from 14 to 42 days after the date of service. The timeliness
of OHI payments to VA is one of the biggest factors affecting the
timeliness of copayment bills issued by VA to Veterans.
Copayment bills may also be generated following income verification
under 38 U.S.C. Sec. 5317, which authorizes VA to validate certain
Veterans' reported income with the Internal Revenue Service (IRS) and
Social Security Administration information. This validation begins 18
months after the calendar year in which that income is reported due to
receipt of data, upon completion of tax processing, from the IRS. If VA
identifies unreported income, VA has authority to generate copayment
billings as a result of this verification process. VA also refunds
copayments, when appropriate, as a result of this income verification
process. The timeframe associated with this process exceeds the 120-day
standard proposed in H.R. 1972. We also note that private sector
billing industry standards allow for billing up to 12 to 18 months
after services are rendered - also exceeding the proposed 120-day
timeframe.
H.R. 1972 does not specify what constitutes an error, what would
justify a waiver, and whether the waivers and payment plans authorized
under the bill would differ from those currently authorized in
applicable statutes and regulations. VA has existing procedures under
38 U.S.C. Sec. 5302 to waive collection in cases where the Secretary
determines that recovery would be against equity and good conscience.
In these instances, an application for relief must generally be made
180 days from the date of notification of the indebtedness.
We note that VA copayment requirements under 38 U.S.C. Sec.
1710(f)-(g), 38 U.S.C. Sec. 1722A, and 38 U.S.C. Sec. 1710B (which is
not referenced in H.R. 1972, but requires copayments of certain
Veterans for extended care services) apply regardless of whether the
care or services was provided in a VA facility or authorized by VA in a
non-VA facility. Therefore, the 120-day timeframe that would be added
in section 1710(f)(3)(G)(ii) and section 1722A(c)(2) by the bill may be
read as applying to care or services in both VA and non-VA facilities.
We note that the Department is close to submitting its plan for the
future of community care, the Veteran Coordinated Access & Rewarding
Experiences (CARE) Act, which will include proposed amendments to its
practices concerning the recovery or collection of reasonable charges
from other parties for certain care and services. We recommend the
Subcommittee forbear further consideration of HR 1972 until VA has
submitted the Veteran CARE Act and the Subcommittee can consider how
this bill would be affected by the Department's proposal.
If copayment billings delayed beyond 120 days from date of service
are waived, VA estimates a 5-year revenue loss of $282 million and a
10-year revenue loss of $562.8 million from the First Party Inpatient/
Outpatient and Pharmacy Medical Care Collection Fund.
H.R 2147 Veterans Treatment Court Improvement Act of 2017
H.R. 2147 would require VA to hire additional Veterans Justice
Outreach (VJO) Specialists to provide treatment court services to
justice-involved Veterans. Specifically, H.R. 2147 would require that
VA hire not less than 50 VJO Specialists and place each such VJO
Specialist at an eligible VA medical center (VAMC). The bill would
require that the total number of VJO Specialists employed by the
Department not be less than the sum of (a) the VJO Specialists employed
on the day before the enactment of this provision; and (b) the number
of VJO Specialists to be hired under this bill. The bill would require
that the Secretary prioritize placement of the VJO Specialists at
facilities that will create an affiliation with a Veterans treatment
court that is established on or after the date of enactment of the
bill, or one that was established prior to enactment but is not fully
staffed with VJO Specialists. The bill would require the Secretary to
submit a report to Congress on the progress and effects of implementing
these provisions within one year, with new reports submitted annually
after that. The bill would also require the Comptroller General to
submit to Congress a report on the implementation of this authority and
the effectiveness of the VJO Program. The bill would authorize to be
appropriated $5.5 million for each of fiscal years 2017 through 2027,
and would require the Secretary to submit to Congress a report that
identifies such legislative or administrative actions that would result
in reduction in expenditures by the Department that are equal to or
greater than the amounts authorized to be appropriated.
VA supports the intent of this bill and is already working to hire
more than the 50 additional VJO Specialists within the next year.
However, the bill could ultimately result in a reduction of $5.5
million in funding to other programs (including possibly programs for
homeless Veterans). Because of this potential reduction in funding, VA
does not support the legislation as drafted. Demand for VJO Specialists
has grown considerably over the past several years, partly as a result
of the adoption of the Veterans Treatment Court model in new
jurisdictions. Limited VJO staff resources have affected VA's ability
to partner effectively with Veterans Treatment Courts, especially those
newly established.
We note that provisions of section 2(e) of the bill concerning the
authorization of appropriations may not accomplish the intended
objective. We understand this provision is intended to ensure that the
Secretary identifies offsets to fund the program required by this bill.
However, this provision would violate the Recommendations Clause, U.S.
Const. art. II, Sec. 3, by requiring the Secretary to recommend
legislative actions regardless of whether the Secretary judges such
legislation ``necessary and expedient.'' To comply with the
Constitution, such recommendations should be discretionary rather than
mandatory. Moreover, the bill only requires the Secretary to report to
Congress on legislative or administrative actions that would result in
a reduction of expenditures equal to or greater than $5.5 million. To
the extent that the Secretary identifies legislative actions that would
result in a reduction of expenditures, there is no guarantee that
Congress would take such actions. We further note that the offsets
would likely affect adversely VA's ability to implement and run other
programs, which could result in delays in the provision of benefits,
healthcare, and other critical services to Veterans and other
beneficiaries. Ultimately, we do not believe this is an appropriate
mechanism for funding the program required by this section.
We also note that the definition of ``local criminal justice
system'' in section 2(f)(3) of the bill would not include Federal
courts. We understand there are some Federal district courts that have
Veterans treatment courts, and these would not be supported under this
bill.
While we estimate the hiring of 50 additional VJO Specialists would
cost $5.5 million in FY 2018, because the bill would require VA to
identify offsets, we believe the ultimate cost would be $0 in FY 2018
and over both 5 and 10 years, if these offsets, some of which may
require legislation, can be implemented. We again caution that the
costs for implementation would involve reductions to other VA programs.
H.R 2225 Veterans Dog Training Therapy Act
H.R. 2225 would require the Secretary, within 120 days of
enactment, to commence a 5-year pilot program under which the Secretary
enters into a contract with one or more non-government entities for the
purpose of assessing the effectiveness of addressing post-deployment
mental health and post-traumatic stress disorder (PTSD) symptoms
through a therapeutic medium of training service dogs for Veterans with
disabilities. The bill would require the Secretary to enter into
contracts with non-government entities located in close proximity to a
minimum of three and not more than five VA medical centers. The bill
requires that the non-government entities be certified in the training
and handling of service dogs and have a training area that meets
certain enumerated specifications.
The bill would require each pilot program site to employ at least
one person with clinical experience related to mental health, and to
have certified service dog training instructors with preference given
to Veterans who have graduated from a residential treatment program and
are adequately certified in service dog training. In addition, the bill
would require VA to collect data to determine how effectively the
program assists Veterans in various areas such as reducing stigma
associated with PTSD, improving emotional regulation, and improving
patience. Not later than one year after the date of commencement of the
pilot program and annually thereafter, VA would be required to submit
to Congress a report regarding the number of participating Veterans, a
description of the services carried out by the pilot program, the
effects of pilot program participation in various areas relating to the
participating Veterans' health and well-being, and recommendations with
respect to extension or expansion of the pilot program.
VA supports the identification of effective treatment modalities to
address PTSD and other post-deployment mental health symptoms; however,
VA does not support the specific provisions in H.R. 2225 because VA has
significant concerns about the proposed legislation. Although anecdotal
evidence has been offered to show the benefits of participating in such
a dog training therapy program, there is no published scientific
evidence to date that shows that such a program benefits PTSD patients
specifically or that such a resource-intensive program is any better
than other therapies known to be effective in alleviating PTSD
symptoms. By propagating a yet unproven therapy, the bill may result in
unintended and negative consequences for the Veterans who would be
participating in this unsubstantiated treatment regime. Also, the pilot
program would be duplicative of a DoD study of this same therapy
program at the Uniformed Services University of Health Sciences. In
addition, the service dog training therapy program currently in place
at the Palo Alto VAMC is organized as part of an integrated set of
services provided for their in-patient Trauma Recovery Program and is
not offered as a stand-alone program or as an outpatient service. VA
has no prior experience in offering or managing such a program as an
outpatient program.
We note the bill would require this program be carried out through
the Center for Compassionate Innovation of the Veterans Health
Administration (VHA) of the Department of Veterans Affairs. We
recommend against including such specific language identifying a
particular organization as the lead for implementation, particularly
given the nature of this work and the involvement of multiple offices
within VHA.
The bill would require that each contract entered into under
subsection (a) shall provide that the nongovernmental entity shall
employ at least one person with clinical experience related to mental
health. It is unclear what role this person is intended to fill.
The bill would also make a number of restrictive stipulations
regarding the structure and operation of the pilot program. For
instance, contractor service dog trainers would be required to be
certified, but there is currently no national certification program for
service dog trainers. The bill would require the contractor to
preferentially hire Veterans who have graduated from a PTSD or other
residential treatment program and received ``adequate certification in
service dog training.'' However, programs at the Palo Alto VAMC and DoD
sites do not provide adequate training to qualify a Veteran as a dog
trainer, and they focus on basic commands rather than the advance tasks
required by service dogs. The legislation would also require
establishing a VA director of therapeutic service dog training who is
experienced in teaching others to train service dogs in a vocational
setting, has a background in social services, and has at least one year
of experience working with Veterans or active duty military members
with PTSD in a clinical setting. These criteria would severely reduce
the number of eligible candidates.
VA also notes that, if any service dogs successfully trained
through the program for Veterans with disabilities are to be eligible
to participate in VA's service dog medical benefit program, the non-
government entities chosen would have to be accredited by Assistance
Dog International. Thus, the number of potential non-government entity
partners who could produce dogs eligible for VA's service dog medical
benefit program would be relatively limited.
VA estimates this bill would cost $3 million in FY 2018 and $14
million over five years.
H.R 2327 PAWS Act of 2017
H.R. 2327 would require the Secretary to carry out a pilot program
under which the Secretary provides a $25,000 grant to an eligible
organization for each Veteran referred to that organization for a
service dog pairing. Grantees would be required to provide for each
participating Veteran and service dog coverage of a commercially
available veterinary health insurance policy; hardware, or repairs or
replacements for hardware, that are clinically determined to be
required by the dog to perform the tasks necessary to assist the
Veteran with the diagnosed disorder of the Veteran; and payments for
travel expenses for the Veteran to obtain the dog. If the Veteran is
required to replace a service dog provided pursuant to a grant, the
Secretary would be required to pay the travel expenses for the Veteran
to obtain a new service dog, regardless of any other benefits the
Veteran is receiving for the first service dog.
To be eligible to receive a grant, an applicant would have to be a
nonprofit organization certified by Assistance Dogs International
(ADI), provide one-on-one training for each service dog and recipient
for 30 hours or more over 90 days or more, provide wellness
verifications from licensed veterinarians, ensure all service dogs pass
the American Kennel Club Community Canine test and the ADI Public
Access test prior to permanent placement, while also meeting other
requirements. VA would review and approve Veterans to participate in
this program based upon their application, and VA would have 90 days to
make an approval determination. Veterans would have to: be enrolled in
the VA health care system; have been treated and have completed an
established evidence-based treatment for PTSD; receive the
recommendation of a VA provider or team that the Veteran may
potentially benefit from a service dog; and agree to successfully
complete training provided by an eligible organization. Veterans would
have to see their provider at least every six months to determine,
based on a clinical evaluation of efficacy, whether they continue to
benefit from a service dog. Any improvement in symptoms as a result of
participation in the pilot program could not affect the eligibility of
the Veteran for any other benefit under the laws administered by the
Secretary.
The Secretary would be required to develop metrics and other
appropriate measurements to determine the efficacy of the program.
Within one year of enactment, the Comptroller General would be required
to brief Congress on the methodology established for the pilot program.
Ten million dollars ($10,000,000) would be authorized to be
appropriated for the period of FY 2018 through FY 2023 to carry out the
pilot program, and the amounts otherwise authorized to be appropriated
for VA's Office of Human Resources and Administration would be reduced
by the same amount over the same time period. The pilot program would
terminate on the date that is 5 years after the date of the enactment
of this Act, and any eligible Veteran in possession of a service dog
furnished under the pilot program as of the termination of the pilot
program may keep the service dog after the termination of the program
for the life of the dog.
As we previously stated, VA supports the identification of
effective treatment modalities to address PTSD and other post-
deployment mental health symptoms; however, we do not support the
specific provisions in H.R. 2327 because VA has significant concerns
about the proposed legislation. Again, there is no published scientific
evidence to date that shows that such a program benefits PTSD patients
specifically, or that such a resource-intensive program is any better
than other therapies known to be effective in alleviating PTSD
symptoms. By propagating a yet unproven therapy, the bill may result in
unintended and negative consequences for the Veterans who would be
participating in this unsubstantiated treatment regime. Also, the pilot
program would be duplicative of an existing VA research study on the
effectiveness of service dogs and emotional support dogs for Veterans
with PTSD.
We have several other concerns with this legislation. We note that
the bill refers in certain places to ``severe'' PTSD, but there are no
established diagnostic criteria to distinguish levels of severity of
PTSD.
In section 2 of the bill, Congressional findings are presented
concerning Veteran suicide, mental health disorders, and substance use
disorders. However, we note that there is no evidence to support that
the presence or possession of a service dog would result in the
reduction of any of these conditions or events. VA strongly agrees with
the need to focus on reducing Veteran suicide and in treating Veteran's
mental health conditions, but we do not believe the proposed bill would
be the best use of resources to that end. VA is aggressively pursuing
efforts to end Veteran suicide, but we cannot rely on the assumption
that service dogs will ensure the well-being of Veterans.
Under section 3(a) of the bill, grantees would receive $25,000 for
each Veteran referred to that organization for a service dog pairing.
We note that it is possible some organizations may be able to furnish
these services for less than $25,000. We recommend the language be
revised to state that grants may not exceed $25,000 to ensure that
Federal resources are not wasted. We would appreciate the opportunity
to conduct a cost analysis to ensure that we are the best stewards of
taxpayer dollars and that we maximize the potential use of our
resources.
Section 3(c)(1)(A)(ii) of the bill would require an organization to
provide, on average, one-on-one training for each service dog and
recipient for 30 hours or more over 90 days or more. If this refers
only to the pairing, this may be an appropriate amount of time, but if
this is intended to cover all of the training of the dog, this would be
inadequate.
The 90-day approval period for VA to determine a Veteran's
eligibility under section 3(d)(1) could present challenges in
implementation given the number of consultations or clinical visits
that may be required for some Veterans.
We are concerned about section 3(d)(2)(A), which could provide an
incentive for failing treatment and could interfere with other forms or
guidelines for evidence-based mental health treatment. Regarding
section 3(d)(2)(B), there is no clinical basis in existence for
providers to make a determination about whether a Veteran may benefit
from a service dog. This could make implementation more difficult and
result in variation across the system. We have similar concerns about
the requirement in section 3(d)(3) for the ongoing evaluation every 6
months to determine the clinical efficacy of whether the Veteran
continues to benefit from a service dog, as there are no recognized
means for making such determinations. In section 3(d)(4), the bill
clarifies what happens if the Veteran is no longer able or willing to
care for the service dog, but does not address what would happen if the
service dog were no longer able to fulfill its function.
We strongly oppose section 3(i) of this bill, which would reduce
the amounts authorized to be appropriated for VA's Office of Human
Resources and Administration (HRA) by $10 million between FY 2018 and
FY 2023. This reduction would have a devastating impact on our mission.
HRA's budget funds missions that are statutorily driven. A reduction of
this nature would have a cascading impact on all of the organizations
in VA, including health care delivery. HRA's budget funds staff office
rent for 10 buildings, security, U.S. mail, and other operational costs
for VA's Central Office campus. These are non-negotiable fixed costs,
and account for roughly half of the funds allocated to HRA as part of
the General Administration appropriation. The remaining funds are
allocated to payroll. Most of the services HRA provides to VA are
provided through Federal employees. VA has already conducted a
comprehensive review of HRA's organizational functions to reduce or
eliminate activities not required by law, and as a result, there are no
further programs that could be stopped based on a further reduction in
funds.
Under section 3(j), the authority to operate the program would end
5 years from the date of enactment. This length of time would further
limit the efficacy of this program. VA would be required to publish
regulations for this program (see 38 U.S.C. Sec. 501(d)), and in
addition, it takes on average approximately 18-24 months to train a
service dog. This would result in very little time in which Veterans
could receive service dogs and would likely not produce very many
service dogs that could be provided to Veterans.
We estimate the bill would cost $2 million in FY 2018 and $14
million over 5 years, but note that certain provisions in this
legislation could result in continuing costs beyond that time period.
Mr. Chairman, this concludes my prepared statement. My colleagues
and I would be pleased to answer any questions you or other members of
the Subcommittee may have.
Prepared Statement of Rick Weidman
Good morning, Chairman Wenstrup and other distinguished members of
the subcommittee. Vietnam Veterans of America (VVA) is pleased to have
the opportunity to appear here today to share our views concerning
pending legislation before this subcommittee.
H.R.501 - VA Transparency Enhancement Act of 2017, introduced by
Congresswoman Debbie Dingell, (D-MI-12). This bill requires
increased reporting regarding certain surgeries scheduled at
medical facilities of the Department of Veterans Affairs.
We have no objections to this bill.
H.R.93 - Introduced by Congresswoman Julia Brownley, (D-CA-26), would
provide for increased access to VA medical care for women veterans.
VVA has always championed quality health care for women veterans.
We continue our advocacy to secure appropriate facilities and resources
for the diagnosis, care, and treatment of women veterans throughout the
health care system. While the Department has made many improvements and
advancements over the past several years, some concerns remain.
Specifically, every woman veteran should have access to a VA primary
care provider who meets all her primary care needs, including gender-
specific care.
We support Ms. Brownley's bill as it addresses the need for such
gender-specific services at every VA Medical Center and Community-Based
Outpatient Clinic.
H.R.1063 - Veteran Prescription Continuity Act, introduced by
Congressman Beto O'Rourke (D-TX-16). This bill would ensure that an
individual who is transitioning from receiving medical treatment
furnished by the Department of Defense to medical treatment at a VA
facility receives a ``seamless transition'' of the pharmaceutical
agents provided by DoD yet may not be on the VA drug formulary.
The transition process is not necessarily as robust as it should
be. While VA and the DoD have collaborated for many years to improve
the transitioning process, gaps still remain, and too many veterans
still fall through the bureaucratic cracks. Oftentimes we hear of
veterans who have transitioned from the military health care system to
the VA health care system, not receiving the same medications, a
situation very much the case with mental health drugs. We believe that
every measure should be taken to ensure veterans have a safe,
transparent, and hassle-free transition.
VVA supports enactment of this bill.
H.R.1066 - VA Management Alignment Act of 2017, introduced by
Congressman Derek Kilmer (D-WA-6), which would direct the Secretary
of Veterans Affairs to submit to the Committees on Veterans'
Affairs of the Senate and the House of Representatives a report
regarding the organizational structure of the Department of
Veterans Affairs.
VA's organizational structure seems to undergo changes whenever
there is a change in leadership. This often leads to unnecessary
confusion, as well as questions as to who has responsibility and
accountability for a given task or program. Numerous studies and
reports on what an effective organizational structure might look like
have been developed, yet they wind up languishing on the shelf and
forgotten. Mr. Kilmer's bill directs the VA to utilize the results of
several recent reports to accomplish a restructuring and management
realignment. We believe this process should be as transparent as
possible.
VVA supports this bill.
H.R.1943 - Restoring Maximum Mobility to Our Nation's Veterans Act of
2017, introduced by Congressman Steve King, (R-IA-4), would require
the Secretary of Veterans Affairs to ensure that each wheelchair
furnished to a veteran because of a service-connected disability
restores the maximum achievable mobility in the activities of daily
life, employment, and recreation.
Restoring independence and mobility to a severely injured person
speeds his/her recovery mentally as well as physically. The Department
has many professional occupational and recreational therapists who
assist veterans every day to bring them closer to achieving those
goals. In fact, the Department has an adaptive sports program that is
very popular with the veteran community. In 2017 there were six events
for veterans to participate in. Similarly, DoD hosts the Wounded
Warrior Games, and veterans can participate in the Invictus Games and
Paralympics.
This bill would authorize the Secretary to furnish a wheelchair to
a veteran because the wheelchair restores an ability that relates
exclusively to participation in a recreational activity.
VVA supports this bill.
H.R.1972 - VA Billing Accountability Act, introduced by Congressman
Lloyd Smucker (R-PA-16), would authorize the VA Secretary to waive
the requirement that certain veterans make copayments for hospital
care and medical services in the case of an error by the
Department.
The VA has a history of billing problems. Veterans should not be
held responsible for making a payment due to the fault of the
Department. VVA supports the opportunity for veterans to apply for a
waiver or establish a payment plan for the purposes of paying
copayments as laid out in the legislation.
VVA has no objection to this bill.
H.R. 2147 - Veterans Treatment Court Improvement Act of 2017,
introduced by Congressman Mike Coffman (R-CO-6), would require the
Secretary of Veterans Affairs to hire 50 additional Veterans
Justice Outreach specialists to assist justice-involved veterans.
Today there are more than 360 Veterans Treatment Courts in
jurisdictions across the country, with scores more in various stages of
planning and implementation. The role of VJOs is critical to the
effective functioning of these courts. So, too, are VJOs key in
assisting veterans incarcerated in jails as well as prisons, arranging
for services and health care upon their release from confinement,
providing invaluable aid in helping eligible veterans find housing and
employment.
While it is a chronic complaint among many in government that they
are overworked, the reality is that the VA's VJOs are spread really
thin, considering all the treatment courts and correctional facilities
where their services are vitally needed. Considering that Mr. Coffman's
bill would appropriate $5,500,000 to hire additional VJOs not only for
FY'17 but for the next nine federal fiscal years as well, enactment of
this bill is certainly a step in the proverbial right direction. It is
also in essence companion legislation to Senator Jeff Flake's S. 946.
VVA applauds Congressman Coffman for introducing this legislation.
H.R. 2225 - Veterans Dog Training Therapy Act, introduced by
Congressman Steve Stivers (R-OH-15), would direct the Secretary of
Veterans Affairs to carry out a pilot program on dog training
therapy.
VVA has always recognized the importance of guide dogs trained to
assist visually impaired veterans and service dogs trained to assist
hearing impaired veterans or veterans with a spinal cord injury or
dysfunction or other chronic impairment that substantially limits
mobility.
Recognizing the expansion of alternative treatments for mental
health issues, Congress gave VA the authority in 2009 to provide
service dogs for the aid of veterans with mental illness. However, we
would like to emphasize that instead of a pilot program, or in
conjunction with the pilot program, what is really needed for dog
therapy and other alternative treatments is evidence-based
epidemiological research studies that would determine the efficacy of a
certain treatment. Currently, research is scarce on these types of
treatments and a well-designed study conducted by professionals could
be used to inform treatment protocols that are validated through such
research.
Still, VVA has no objection to the bill.
H.R. 2327 - PAWS Act of 2017, introduced by Congressman Ron DeSantis
(R-FL-6th). This bill would direct the VA Secretary to make grants
to eligible organizations to provide service dogs to veterans with
severe PTSD.
While our comments regarding H.R. 2225 apply as well to this bill,
we must object, however, to the offset in this bill that would take $10
million from the Office of Human Resources and Administration. It is
widely known that VA's HR office is understaffed and in need of
training. They can hardly afford to have that funding taken away from
them. It has been our long-standing argument that you do not take
funding from one program for veterans to fund another: you do not rob
Peter to pay Paul. If Congress cannot provide for the funding for PAWS,
VVA cannot support its enactment.
Draft bill: introduced by Congressman John Rutherford (R-FL-4), to make
improvements in the VA's Health Professional Educational Assistance
Program (HPEAP).
Section 2 of this bill would authorize the Secretary to award no
less than 50 scholarships to individuals who are enrolled in a program
to become a physician or dentist until the staffing shortage of
physicians and dentists in the Department is less than 500. In return,
the participant agrees to serve in the Veterans Health Administration
as a full-time employee. It further extends HPEAP to December 31, 2033.
Section 3 establishes the Specialty Education Loan Repayment
Program. In general, to be eligible an individual must have recently
graduated from an accredited medical or osteopathic school and matched
to a residency program in a certain medical specialty described in
title 38, owe money, and be a physician in training. In return, the
participant incurs an obligation to serve for a specified number of
years as a full-time clinical practice employee of VHA. The Secretary
may give preference to veteran applicants.
This legislation also authorizes the establishment of a pilot
program in which the VA funds the medical education of 10 eligible
veterans enrolled in the Teague-Cranston medical schools. The veterans
must have been discharged under honorable conditions in order to be
eligible for this program. In return, the veteran agrees to serve as a
full-time clinical practice employee in the VHA for four years.
VVA is well aware of the shortages in clinical staff throughout the
VA health system. This is a good first step in trying to alleviate that
shortage. However, this will take some time to implement and offers no
immediate succor for an increasingly serious staffing situation.
Also, we believe the VA would be well-served if they opened the
doors of service to veterans with an administratively rendered OTH
discharge. If a ``veteran'' is defined as one who is discharged under
other than dishonorable conditions, then OTH vets should not be
excluded from this program unless they were discharged for medical
malpractice, crimes involving patients, or other reasons that call into
question their integrity and hence, their ability to be the type of
employee valued by the VA and the veterans it serves.
The VHA - and Congress - must come to grips with the underlying
causes of the so-called access scandal that rocked the VA in 2014 (even
though the practice that was called into question had been going on for
decades): the serious shortage of qualified medical personnel willing
and able to work for the VA, and making less money than they might
otherwise earn in private practice. If a veteran with ``bad paper''
goes on to a career in medicine and is otherwise qualified, s/he should
be granted the opportunity to participate in this program.
VVA thanks you for this opportunity to present our views here
today. We will be pleased to respond to any questions you might care to
put to us.
Statements For The Record
DAVID J. SHULKIN, M.D.
The Honorable Brad Wenstrup
Chairman
House Committee on Veterans' Affairs
Subcommittee on health
United State House of Representatives
Washington, DC 20510
Dear Mr. Chairman:
The agenda for the House Committee on Veterans' Affairs'
Subcommittee on Health September 26, 2017, legislative hearing included
the draft bill to make certain improvements in VA's Health
Professionals Educational Assistance Act, for which the Department of
Veterans Affairs (VA) was unable to provide views in our testimony. We
are aware of the Committee's interest in receiving this information.
The enclosure expresses VA's views on this legislative initiative.
We appreciate the opportunity to comment on this legislation and
look forward to working with you and the other Committee Members on
these important legislative issues.
Sincerely,
David J. Shulkin, M.D.
Enclosure
Draft Bill, to amend title 38, United States, Code, to make certain
improvements in the Health Professional Educational Assistance
Program of the Department of Veterans Affairs, and for other
purposes
Section 2 of the draft bill, would require the VA to offer 50
scholarships to physicians and dentists in return for a service
obligation to practice at a VA facility.
Section 3, would amend the Health Educational Assistance Programs
to include the Specialty Education Loan Repayment Program (SLERP), an
education loan repayment program to attract physicians who are eligible
for board certification in medical specialties that are difficult for
recruitment and retention for employment in the VA.
Section 4, would require the VA to offer 10 additional scholarships
to Veterans attending a Teague Cranston Medical School in return for a
service obligation to practice at a VA facility.
VA supports sections 2 and 4, subject to the availability of funds,
as this is an excellent opportunity to recruit providers to fill
critical vacancies throughout the VA. VA estimates the cost for
sections 2 and 4 would be $45 million over five years and $98 million
over ten years.
VA supports the intent of section 3, but would like to work with
the Committee to further clarify the scope to enhance existing programs
and develop new programs to meet the hiring needs of VA. As written,
the language infers that only recent medical school graduates or those
in their initial year of residency who will not have declared a
subspecialty would be eligible, limiting VA's ability to attract more
experienced providers who would be eligible sooner. Furthermore, the
maximum award amount exceeds the maximum award amount authorized under
the Education Debt Reduction Program (EDRP), 38 U.S.C. Sec. 7683,
which limits education debt reductions payments to$24,000/year, not to
exceed $120,000). This creates disparity between physicians currently
employed within the VA or those eligible for permanent appointment and
recent medical school graduates or residents with less experience,
giving those with fewer qualifications a larger reimbursement.
VA is unclear regarding the eligibility requirement of ``[who are
eligible to be board-certified]'' and the requirement that program
candidates be ``.hired under section 7401.'' as individuals who have
recently completed medical school or are in the first year of residency
would not necessarily be a permanent VA employee.
Given the existing loan repayment authority for the EDRP, VA
recommends an alternative approach, such as a stipend program, to
attract medical residents and fellows with declared specialties (i.e.,
those in the final two years of residency or fellowship) to better meet
the recruitment and retention needs of VA.
As written, VA is unable to estimate the costs of this section and
would welcome the opportunity to discuss further. VA agrees with the
intent of the draft legislation, however as written this will not
fulfill the intent of the Committee. VA requests the opportunity to
have a discussion with the Committee to develop a stipend or other
program that will meet the intent of the legislation.
VA appreciates, through the proposed legislation, the opportunity
to recruit providers to fill critical vacancies throughout the VA.
BLINDED VETERANS ASSOCIATION (BVA)
Introduction
Thank you, Chairman Wenstrup, Ranking Member Brownley and members
of the Health Subcommittee, for the opportunity to participate in this
hearing. The comments that follow are submitted on behalf of the
Blinded Veterans Association, (BVA) the only Congressionally chartered
veteran service organization (VSO) exclusively dedicated to serving the
needs of blinded veterans and their families. There are several
significant pieces of legislation under consideration at this hearing,
and we appreciate the opportunity to comment on them. Our comments will
focus on three bills in particular: H.R.93; H.R.2225; and H.R.2327.
H.R. 93
Approximately 400 of BVA's current members are female veterans.
Most of these veterans are enrolled in the VA healthcare system. Many
of them have reported experiencing significant hardships due to the
lack of gender-specific medical services at the clinic where they
receive their healthcare. These veterans sometimes face insurmountable
barriers due to the lack of transportation options that would enable
them to get to an alternate facility where gender-specific treatment is
available. We, therefore, applaud the introduction of H.R. 93 and would
welcome the assistance it could bring to some of our female members.
H.R.2225
Many members and staff of the Blinded Veterans Association,
including this writer, have experienced firsthand the benefits a well-
trained dog can provide to a person with a disability. Those benefits
can be life changing. Therefore, we welcome efforts that will give
veterans with other disabilities opportunities to experience similar
benefits. Although we believe the sponsors of H.R.2225 intended to
design a program that could provide such opportunities to veterans who
struggle with PTSD, we are concerned that the effectiveness of the
pilot it seeks to establish could be undermined by numerous
shortcomings in the program's design. There are a number of questions
crucial to the effectiveness of this program that this legislation
leaves unanswered. First, although the bill directs the Secretary to
enter into contracts with entities ``certified in the training and
handling of service dogs,'' it does not specify what certification will
be acceptable. We believe this is an important oversight that should be
clarified. Working with quality training entities from the beginning
will give this program a greater chance for success. Since other
programs administered by the VA to support service dogs and their
handlers require that the dogs be trained by entities with ADI or IGDF
certification, we would be much more favorable to this legislation if
it further specified that the entities participating in this program
must be ADI certified. Alternatively, standards could be specified
related to the training methodologies, facilities, and dog care
practices expected of the contracting entities. This would give the VA
some criteria by which to evaluate entities seeking to participate in
the program, and determine whether they are likely to produce the
desired results.
Another key aspect of this pilot that this bill fails to consider
adequately involves the dogs. It seems to us that one of the criteria
contractors should be evaluated on is their ability to provide dogs
that are likely to be successfully trained to assist veterans
appropriately. The formal training is only one factor in determining
that success. How will the dogs be prepared for participation in this
program? For that matter, this legislation does not even discuss
provision of the dogs. Is it assumed that contractors will provide dogs
ready and available for training?
With regard to the training itself, there is no mention of what
tasks veterans will train dogs to do, or what tasks the dogs will be
trained to perform, by participating veterans, as part of their
therapy. This is a crucial omission, if the intended result is to have
trained dogs that could be placed with other veterans as working
service dogs. Activities that can provide veterans with high quality
therapy may not necessarily also produce well-trained dogs that can be
placed with other veterans and serve them as service dogs. We believe
that all of these issues should be addressed in order to provide the VA
with the greatest chance of designing a successful program. The
training itself should be designed in a manner that minimizes obstacles
and maximizes its chances of success. To do this, guidelines as to what
the VA should look for in training entities should be provided. The VA
is not currently involved in service dog training, so leaving such
matters unspecified creates risk of unintended consequences, missteps
by the VA and ultimately, design flaws that undermine the program's
ability to achieve its goal of serving veterans. It also undermines the
department's ability to assess the effectiveness of the program in
mitigating the veterans' disabilities.
It is also unclear whether this legislation anticipates that the
veterans who receive training will then be utilized as trainers by the
contracting entity during the pilot, or whether it anticipates an
additional phase of the program, established in the future, to give
these veterans an opportunity to utilize their newly-acquired skill.
Further there are no criteria here for the placement of dogs with other
veterans, and the nature and scope of follow-up services that will be
provided to them in order to insure their long-term success after
training.
The premise behind this bill, that giving veterans a practical
means of helping other veterans could restore the mental health of the
helpers, while assisting additional veterans, is laudable. However, we
are concerned that the program, as currently designed, is fraught with
myriad opportunities for things to go wrong that could undermine the
program's chances for success. It will also be difficult for VA to
assess the effectiveness of this program. We applaud the intent to get
help to veterans as quickly as possible in order to try to avert crises
that could otherwise occur, and we acknowledge the possibility that
this help could come in the form of a partnership with an animal begun
through a program such as this, we worry that the concern for creating
those partnerships as soon as possible could undermine the success of
those partnerships long-term. That being said, we would welcome an
opportunity to work with the offices of Rep. Stivers and Rep. Walz, and
other co-sponsors of this legislation, to address these issues. It is
our hope that the concerns that we believe currently undermine the
effectiveness of this bill can be remedied, so that a program that
gives additional veterans access to the benefits of partnership with
service dogs will follow.
H.R. 2327
There are many aspects of this bill that the Blinded Veterans
Association both welcomes and supports. However, once again, we have
several questions and serious concerns about the feasibility of the
project, as set forth in this legislation.
First, the general concern we have is with the offset being
proposed to fund this pilot. It is our understanding that VA's Office
of Human Resources is currently under staffed. Additionally, Secretary
Shulkin has been talking about department-wide efforts to ramp up
recruitment of personnel to deal with shortages of medical personnel
throughout the VA healthcare system, particularly within the mental
health field, whose professionals provide much-needed services to the
same veterans the authors of this bill are trying to help. We wonder
what impact reductions in funding for the VA Office of Human Resources
will have on that office's ability to provide administrative support to
VA's recruitment efforts.
The design of the pilot program itself looks reasonable. It is our
position that good training for both dogs and their users is essential
to the success of their partnership. We are not certain how well
developed the best practices are for training of dogs to assist people
who have PTSD, but there are well established standards of dog behavior
that should be included in any service dog training curriculum and we
are pleased to see them included in the requirements for covered
facilities here. The rush to get people paired with dogs as quickly as
possible, in hopes of mitigating their disability's negative impact on
quality of life is laudable and, we believe, generally well
intentioned. But we hope this will not be done at the expense of
careful and thorough training for both the dogs and their recipients.
To compromise here could add significantly to, rather than relieve an
individual's stress. It can and has also caused injuries to veterans,
dogs, and members of the public who inadvertently get caught up in
situations involving misbehaving, frightened or aggressive dogs.
Finally, we have some concerns about whether VA has the capacity to
administer a program of dog training and placement, such as the one
called for in this legislation. We worry that the process of
determining whether a facility and/or a veteran, is eligible to
participate in this program might be more involved than this
legislation appears to anticipate. It could easily require more than
making sure all the boxes are checked and all the right documents are
attached to the applications. Does the VA have staff with the expertise
to make these determinations beginning in 2018? Do the bill's authors
envision that some of the monies appropriated for this program would be
used to hire additional staff with the expertise to process these
applications? To make certain facilities are what and who they claim to
be? If someone falls short and doesn't follow through, will VA have the
capability of tracking and trying to redress the situation?
I raise the questions above because VA is already having trouble
communicating and consistently enforcing the policies they have in
place with regard to service dog access. We have received numerous
reports over the past couple of years of incidents involving apparently
untrained, or poorly trained dogs on VA property who act aggressively
toward VA employees, veterans who accidentally get too close to the
dog, or the service dogs of veterans with disabilities. Several of our
members have reported to us that they have been forced by repeated
encounters with aggressive dogs at VA medical centers to leave their
service dogs at home when they must go to those facilities for care.
Unfortunately, many of these dogs are presented to VA personnel as
service dogs who are needed by the person bringing them to the facility
to mitigate PTSD. Frequently, front line personnel are not equipped to,
or don't feel that they can, make a judgment as to whether an animal's
behavior is sufficiently inappropriate to deny access. Security and law
enforcement personnel who are called in response to incidents of dog
misbehavior commonly ignore it or claim there's nothing they can do.
Nobody wants to be the ``bad guy'' and risk wrongfully denying access
to a service dog, even though both the VA policy and the ADA
regulations clearly give agency and business operators the authority to
remove out-of-control or disruptive animals from their premises. We met
with Dr. Alaigh and other VHA leaders last month to discuss this
growing trend and ask the under-secretary to initiate a review of both
the current department policies and the means by which those policies
are communicated to VA personnel. We hope this will encourage the VA to
take action to clarify the access rights of service animal users,
regardless of disability, as well as the enforcement tools available to
security personnel who have reason to believe that a dog is being
fraudulently presented as a service animal or who encounter a dog that
is not under the control of its handler and poses a danger to other
people on the premises. This should include the standards of good
public behavior that the law allows the VA to expect as well as the
enforcement options that can be exercised when animals, or their
handlers, do not comply with those standards.
In summary, while we appreciate the intent of this legislation, and
we believe this program is a good one, we are not convinced that the VA
has the capacity to carry out this program in the manner prescribed, or
the funds to cover the cost of the program, within the time frame set
forth in the bill.
Conclusion
Each piece of legislation discussed above seeks to address critical
issues faced by a significant number of veterans today. We appreciate
the efforts of the bills' sponsors to address these critical issues,
and we appreciate the opportunity to discuss these issues with the
members of the Health Subcommittee. We hope this is the beginning of
continuing dialogue on this legislation, and will look forward to
working with committee members and staff to further address these
issues and help the VA find innovative ways to provide critical
assistance to veterans who have PTSD and post-deployment mental health
conditions.
DISABLED AMERICAN VETERANS (DAV)
SHURHONDA Y. LOVE
ASSISTANT NATIONAL LEGISLATIVE DIRECTOR
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting DAV (Disabled American Veterans) to testify
at this legislative hearing of the Subcommittee on Health. As you know,
DAV is a non-profit veterans service organization comprised of 1.3
million wartime service-disabled veterans that is dedicated to a single
purpose: empowering veterans to lead high-quality lives with respect
and dignity. DAV is pleased to offer our views on the bills under
consideration by the Subcommittee.
H.R. 93, a bill to provide increased access to VA care for women
veterans
This bill seeks to improve access to Department of Veterans Affairs
(VA) medical care for women veterans by ensuring that gender-specific
health care services are available at every medical center and
community-based outpatient clinic of the Department. It provides that
the Secretary, in consideration of women veterans' increased demand for
services and the projected growth in the population, may employ
personnel, or enter into such contracts as necessary to ensure
comprehensive gender-specific care is available to women veterans in
accordance with Veterans Health Administration (VHA) quality standards.
The number of women serving within the United States military
continues to rapidly increase. Women now comprise 15.5 percent of
active duty military, and 19.0 percent of the National Guard and
Reserves. As more women serve within the military, the number of women
seeking care from VHA will also grow. From 2005 to 2015, the number of
women enrolled in VA health care increased by 83.9 percent, translating
into more than 400,000 users of VHA care. With more than two million
women represented within the total veteran population, and the women
veterans' population projected to grow by 18,000 per year for the next
10 years, it is vitally important that VA is prepared to meet their
unique health care needs now and in the future.
Currently women veterans between the ages of 18 and 44 make up
approximately 42 percent of women users of VHA. This age group
represents a population of women within child bearing years that may
require maternity care. Women require routine breast care and
gynecological services throughout their lives; therefore, it is
important that VA is prepared to care for these women now and as they
age. Yet, in a recent Government Accounting Office report (GAO-17-52),
VHA data from fiscal year (FY) 2014 and 2015 shows about 27 percent of
VA medical centers and health care systems lacked an onsite
gynecologist.
DAV understands that some facilities may not have enough women
veterans seeking care to warrant a full time gynecologist onsite, but
it must have policies and procedures in place to ensure women seeking
care are able to receive the gender-specific services they need from a
qualified health care provider either in VA or in the community.
In addition to ensuring women veterans have access to gender-
specific care, like gynecology and other specialty services, women
veterans must also have access to primary care physicians that have
expertise in women's health. VHA Directive 1330.01, states that each VA
medical facility must ensure eligible women veterans have access to
high-quality, equitable, comprehensive medical care that includes but
is not limited to primary care. However, GAO points out 18 percent of
VA facilities are unable to provide women with a primary care provider
who is specially trained in the care of women.
In cases where VA is unable to provide health care services to
women veterans, the Veterans Choice Program is used to purchase care in
the community. Based on data contained in the GAO report, women
veterans utilize more non-VA outpatient care than men, which is
consistent with the inability to obtain basic gender-specific care,
forcing them out of VA to receive care in the community. However,
whenever possible we want women veterans to have the opportunity to get
their care in VA so they are afforded access to VA's specialized
services for veterans such as treatment for post-traumatic stress
disorder (PTSD), sexual trauma, and war-related injuries. Veterans
using VA care are frequently asked if they need supportive services for
homelessness or post-deployment mental health challenges such as
substance use disorder (SUD) or suicidal ideation. We want to ensure
women veterans also have access to this unique and specialized care
whenever possible. If care must be obtained from community providers,
there must be a plan to provide a seamless transition for that care.
DAV is pleased to support H.R. 93, which is consistent with DAV
resolutions 128 and 225, adopted at our most recent National
Convention. These resolutions call on VA to furnish quality primary
health care and gender-specific services necessary to meet the needs of
a growing population of women veterans, and to ensure that the
provision of health care services and specialized programs are
inclusive of gender-specific services. These services must be provided
to the same degree and extent that services are provided to eligible
male veterans.
H.R. 501, VA Transparency Enhancement Act of 2017
This measure would require increased reporting regarding certain
surgeries scheduled at VA medical facilities.
We note VA is not exempt from reporting hospital-acquired
infections in VA hospitals in its annual Facility Quality and Safety
Report. The first of such reports containing details at the VA facility
level was issued in 2008. Moreover, subsequent to this bill's
introduction, VA made available to the public through its website those
measures, analysis and comparison on those aspects of health care
quality and patient safety this bill requires and many other quality of
care measures applicable for all its VA facilities.
More specifically, the results of Healthcare Associated Infection
measures and Surgical Complications based on Agency for Healthcare
Research and Quality (AHRQ) Patient Safety Indicators (PSIs) for VA
facilities can be found here: http://www.accesstocare.va.gov/
Healthcare/HospitalCompareData. As an example, information for Ann
Arbor VA Medical Center is here: http://www.accesstocare.va.gov/
Healthcare/HospitalData/506
While DAV has no resolution to support the particular approach
proposed by this legislation, we urge the Subcommittee to consider
focusing the resources and efforts that would otherwise be needed to
meet these reporting requirements towards directly addressing veterans
medical care needs as well as identifying and correcting known
deficiencies at VA facilities.
H.R. 1063, Veteran Prescription Continuity Act
This measure would amend the FY 2016 National Defense Authorization
Act (NDAA) to direct VA to furnish an individual, who is transitioning
care settings from the Department of Defense (DoD) to VA, any
pharmaceutical agent not included in the joint uniform formulary if a
DoD health care provider determines that the pharmaceutical agent is
critical for the transition.
We urge the Subcommittee to strengthen this bill with regards to
section (c)(2)(B). Specifically, the proposed language does not
recognize or provide for consideration of a holistic, patient-centered
approach for changing or discontinuing medications.
DAV recognizes chronic and severe pain as one of the most prevalent
reasons individuals, including wounded, injured and ill veterans, seek
health care and that chronic pain is closely linked with depression and
other mental health challenges, including suicidal ideation.
The delegates to our most recent National Convention adopted
Resolution No. 116, which highlights the failure of some VA providers
to adhere to Department's own Pain Management Opioid Safety Guide. This
guide calls for certain resources such as ``[i]ncreased options for
monthly (or more) face to face and/or Telehealth visits, case
management and a structured communication between primary care (or
whoever is tapering the opioids) and mental health or SUD clinicians''
be in place when a VA clinician decides to taper or discontinue
opioids.
All too often we hear from veterans these supportive resources are
not offered or provided to veteran patients when their pain medication
is significantly reduced or abruptly discontinued. This paternalistic
approach that harms severely ill and injured DAV members as well as the
patient-provider relationship may be reinforced by section (c)(2)(B) of
this bill or the lack of a provision requiring a patient-centered
holistic approach.
For example, in VA's Pain Management Opioid Safety Guide,
healthcare providers are cautioned when ``[a] decision is [made] to
taper opioids, the pace of opioid taper should be individualized with a
risk benefit analysis.''
Our resolution calls for, among other things, pain management that
ensures severely disabled veterans with chronic pain who have used
prescribed pain medications over long periods be managed in a patient-
centered environment, with balanced regard for both patient safety and
humane alternatives to the use and reduction of controlled substances,
and while under VA care receive their prescribed medications in a
timely fashion.
Mr. Chairman, DAV supports H.R. 1063 as it will be beneficial for
veterans who have an effective, established medical regimen for
treatment of psychiatric, pain or sleep issues and for transitioning
service members whose medications are effective for them. We recommend
the bill be amended to address medications such as benzodiazepines,
stimulants and opioids that can be effective in the short-term, but
detrimental if continued to be taken in the long-term. We believe VA
providers should have the option of initiative tapers or changing these
medications when appropriate but the bill should also propose a
balanced decision-making process between the clinician and the patient
when determining which pharmaceutical agent is deemed ``critical for
such transition'' in a manner that mitigates harm at a vulnerable point
in the patient's treatment-the space between care settings.
H.R. 1066, VA Management Alignment Act of 2017
This bill would require the VA to prepare and submit a report to
the Senate and House Committees on Veterans' Affairs that details the
roles, responsibilities and accountability requirements for key leaders
and offices within the Department. In producing this report, VA would
utilize the results of the Independent Assessment mandated by the
Choice Act, the final report of the Commission on Care, and other
relevant reports related to improving VA's organization and governance.
The report should also include recommendations for any legislation VA
considers necessary and appropriate to strengthen its organization,
management and governance structure.
DAV does not have a resolution from our membership specific to this
bill but recognizing that better organization and management of VA
could improve the delivery of benefits and services to veterans, we
have no objection to its enactment.
H.R. 1943, Restoring Maximum Mobility to Our Nation's Veterans Act of
2017
This bill seeks to expand the term ``wheelchair'' to include
enhanced power wheelchairs, multi-environmental wheelchairs, track
wheelchairs, and other power-driven mobility devices. It further seeks
to ensure that a veteran prescribed a wheelchair under the provisions
of this bill due to a service connected disability receive any chair
that restores the maximum achievable mobility and function in their
activities of daily life, employment, and recreation.
VHA provides care to thousands of veterans who require wheelchairs
due to disabilities, age or infirmity. For these veterans, wheelchairs
are an extension of the body that restore functionality, enhance
independence, and even allow them to engage in preferred recreational
activities. VA research and clinical experience show that physical
activity is important to maintaining good health, speeding recovery and
improving overall quality of life. Wheelchairs, for persons with
disabilities who have lost the ability to ambulate on their own, allow
many veterans to freely participate and engage actively with their
families and in their communities, and are critical to overall
wellbeing.
Younger veterans, and veterans that are active in rehabilitative
sports, or outdoor activities may require the use of more than one type
of wheelchair to maintain or enhance their quality of life. These
veterans should have every opportunity to receive the type of
wheelchair appropriate for the activities in which they participate.
Some veterans may require multiple chairs in order to navigate
different terrain such as beaches or wooded areas, just as veterans
with lower limb amputations may require different prosthetic devices to
shower, swim or run. The preventive and therapeutic value of sports,
fitness and recreation, are key factors in VA's extensive
rehabilitation program. Participation in recreational activities is
also beneficial to veterans helping many to overcome or mitigate the
physical and emotional impact of severe disabilities.
H.R. 1943 is in line with DAV Resolution No. 178, which calls for
VA to deliver high quality cutting-edge prosthetic items to help
injured, ill and wounded veterans recover, regain mobility and achieve
maximum independence, to the extent possible, in all areas of their
life. While assuring veterans of the highest quality wheelchairs and
prosthetics in accord with their individual needs, VA must also access
and assure veterans' safety. We believe that all specialized devices
should meet appropriate and similar standards and criteria for FDA-
approved wheelchairs. There may be some instances in which a veteran
requests a wheelchair that has not been FDA approved. The request for
prescriptions for such wheelchairs should be determined on a case-by-
case basis.
H.R. 1972, VA Billing Accountability Act
This measure would require VA waive a veteran's copay requirement
if, due to an error by the Department, its copayment notification was
received by the veteran after 120 days from the date the veteran
received VA medications, hospital care, nursing home care, or medical
services.
As the Subcommittee is aware, VA's antiquated systems supporting
collections for first-party copayments and third-party reimbursements
requires manual intervention making the process prone to human error.
VA's Consolidated Patient Account Centers must rectify these mistakes
and subsequently bill co-payments weeks to months after veterans
receive care.
We support the intent of this legislation based on DAV Resolution
No. 115, which calls for legislation to eliminate or reduce VA health
care out-of-pocket costs for service-connected disabled veterans.
In addition, we urge the Subcommittee to further strengthen this
important bill by including a provision to extend the waiver to VA-
furnished extended care services under title 38, United States Code,
Section 1710B.
H.R. 2147, Veterans Treatment Court Improvement Act of 2017
This measure requires the VA to hire additional Veterans Justice
Outreach (VJO) specialists to ensure veterans have greater access to
effective and tailored treatment. VA created the VJO program to engage
justice-involved veterans in specialty treatment courts and provide
timely access to VA's specialized services. The veterans' treatment
court model removes veterans from the regular criminal justice process
and helps to address conditions that are prevalent among veterans,
including traumatic brain injury, PTSD, and SUDs. In a veterans'
treatment court, the presiding judge works alongside the veteran and
the VJO specialist to establish a structured rehabilitation program
that is tailored to the specific needs of that veteran.
The bill would authorize $5.5 million for each fiscal year
beginning in FY 2017 through 2027 to hire a minimum of 50 additional
VJO Specialists. Funding priority would be given to VA facilities that
work with newly established or existing but understaffed veterans'
treatment courts. VA would be required to annually report on the
implementation of the bill and its effect on the VJO program. The
Government Accountability Office is also required to review and report
on the implementation of the bill and the overall effectiveness of the
VJO program for justice-involved veterans.
DAV supports H.R. 2147 based on DAV Resolution No. 105, calling for
the continued growth of veterans' treatment courts. We recognize the
importance of this unique program as years of experience from the
veterans' courts now in existence nationwide has produced a
statistically significant reduction of recidivism rates among veterans
compared to persons in other treatment courts and individuals not
involved in any sort of alternative or diversionary treatment options.
We also recognize that veterans in general deeply value their military
experiences and share a unique bond with their peers. In our opinion,
veterans' treatment courts build upon this bond by enabling veterans to
proceed through the treatment court process with people who are
similarly situated and by pairing veterans with veteran mentors. We are
pleased to inform you that DAV members across the country strongly
support this program and many volunteer to serve as mentors.
We hope this measure receives favorable consideration, and ask the
Subcommittee to further strengthen this bill. We join with other
organizations who have voiced concern for section 2(e) of the bill that
calls for the identification of offsets to fund the increase in VJOs.
We believe that Congress should appropriate new funds rather than
reallocate funds that may adversely affect other programs and/or
benefits currently utilized by ill and injured veterans.
Further, the DAV has concerns with section 2(f)(3) of the bill that
defines the ``local criminal justice system'' as law enforcement,
jails, and state and local courts. This limits the scope of the bill
and precludes Federal Courts such as the Judicial District Veterans
Courts. These Federal court cases make up 2.2 percent of the overall
veteran cases in our justice system. Therefore, we ask that the bill be
amended to include Federal courts so that all justice-involved veterans
can be served by the program.
Finally, we urge that a provision be added in section 2(d)(2)(B) of
this bill, which currently directs the Government Accountability Office
to submit to Congress a report on the implementation of this section
and the effectiveness of the Veterans Justice Outreach Program. We
suggest the report should include an evaluation of the sufficiency of
VJO staffing levels in meeting current demand and the impact of
existing staffing levels on the effectiveness of the program.
DAV thanks the bill sponsor for his strong advocacy on behalf of
justice-involved veterans and we are committed to working with all
interested parties to enact this important measure.
H.R. 2225, Veterans Dog Training Therapy Act
This bill would require the Secretary of Veterans Affairs to
establish a five-year dog training therapy pilot program, with one or
more non-governmental entities certified in the training and handling
of service dogs. The pilot would assess the effectiveness of addressing
post-deployment mental health and PTSD symptoms through the training of
service dogs for veterans with disabilities.
The Center for Compassionate Innovation, in collaboration with
Recreation Therapy Services of the Department, under the direction of a
certified recreational therapist with sufficient administrative
experience, would help oversee the program. It would also establish a
new director of therapeutic service dog training.
The measure mandates the pilot program be located in close
proximity to at least three but not more than five medical centers of
the Department. The Secretary would provide, to the one or more non-
government entities entering into contract, access to a training area
in VA that is appropriate for educating veterans with mental health
conditions, in-service dog training and handling through lecture and
hands-on experience. Each contract awardee would be required to: employ
at least one person with clinical experience related to mental health;
ensure participating veterans receive training from certified service
dog training instructors; include practical hands-on training and
grooming of service dogs; and ensure that each service dog
participating in the training pilot program is taught all essential
commands for service dogs. In hiring dog trainers, awardees would give
preference to veterans who have successfully completed PTSD treatment
and who are certified in service dog training.
Pilot program participants could include veterans who are enrolled
in VA's Compensated Work Therapy (CWT) program and the Secretary would
be required to determine if veterans would be selected or volunteer for
participation in the dog training pilot program.
Additionally, the Secretary would be required to collect data to
determine the effectiveness of the program by assessing the reduction
of stress associated with a veteran's PTSD, including the improvement
of emotional regulation, and other standard measures. VA would also be
required to submit a report to Congress not later than one year after
the commencement of the pilot program, and each year thereafter, to
include information about the number of veterans participating in the
program; services provided in the program; and measures to demonstrate
effectiveness of program in improving participants' PTSD
symptomatology, family dynamics, pain management, and general
wellbeing. In addition, the Secretary would be required to make a
recommendation to Congress about extending or expanding the pilot
program.
Although DAV has no specific resolution approved by our membership
relating to the training of service dogs that would authorize DAV to
formally support this measure, we recognize that many veterans report
that service animals have immensely improved their quality of life by
promoting their recovery, helping them reestablish their independence
and assisting them to better cope with stressful situations and
facilitate reintegration into their communities. For these reasons, we
have no objection to the passage of this bill.
However, VA's Cooperative Studies Program is currently overseeing
comprehensive multi-site research on the benefits of service dogs, to
determine the efficacy of the types of therapy in improving activity
and quality of life for veterans with PTSD. We understand this research
is due to be completed in April of 2020. While we would like to ensure
the effectiveness of trained therapy dogs for veterans with mental
health conditions before VA makes significant investments in training
or acquiring and maintaining service dogs for veterans, DAV is
supportive of innovative non-traditional therapies and expanded mental
health treatment options for veterans in accordance with DAV Resolution
Nos. 019, 128 and 245.
H.R. 2327, Puppies Assisting Wounded Servicemembers Act of 2017 (PAWS
Act of 2017)
If enacted, this bill would create a five-year pilot program and
pair eligible veterans suffering from the most severe levels of PTSD
with service dogs. Participants would be required to be enrolled in the
VHA and have a medical determination by a Department health care
provider, indicating that the veteran may benefit from having a service
dog. Participants must have completed a course of evidence-based
treatment for PTSD, yet remain significantly symptomatic prior to
entering the program. Once approved for participation in the pilot,
veterans would then be referred to an accredited dog assistance
organization to be paired with a service dog.
Service dogs must pass the American Kennel Club Community Canine
Test and the Assistance Dogs International (ADI) Public Access Test
prior to placement with the veteran. Follow-up support service for the
life of the dog, to include a contact plan, should be offered to the
veteran. If at any point the veteran is no longer able or willing to
care for the service dog, the organization providing the dog, and the
veteran shall determine the appropriate course of action.
Organizations participating in the pilot must be nonprofit
organizations that provide trained service dogs, certified by ADI. They
must be able to provide one-on-one training, provide a wellness
verification from a licensed veterinarian for each dog, and provide an
in-house residential facility or other accommodations where the veteran
may stay while receiving training with their new service dog.
Participating organizations would be provided a grant in the amount of
$25,000 for each veteran referred to that organization for service dog
pairing. Offsets from the VA's office of Human Resources and
Administration (HR), will be reduced for FY 2018 through 2023, by $10
million per year in support of this pilot program.
At the conclusion of the five-year program, the Comptroller of the
United States shall provide Congress a briefing on the methodology
established for the pilot program, and a report on the results of the
pilot program.
While DAV supports the intent of this bill, and recognizes that
trained guide dogs and other trained service dogs can play a
significant role in maintaining functionality and promoting maximal
independence for individuals with disabilities, we are concerned with
the $10 million proposed offset for FY 2018-2023 from VA's HR
department. This department is already facing significant difficulties
in filling critical employee vacancies, and this offset would likely
impede VA's ability to attract, hire and retain high quality personnel
necessary to fulfill VA's primary mission; the provision of high
quality health care and benefits services to veterans.
Furthermore, as noted above, such a significant investment of
resources, and funds in a program that has not yet been shown to be an
efficacious intervention in the treatment of veterans with PTSD may not
prove to be an investment in the best interest of the veterans it seeks
to aid. We understand that VA is currently conducting a legislatively
mandated study at its Palo Alto facility, the Paws for Purple Hearts
study to determine the efficacy of the use this nontraditional
application of service dogs, acting as companions to veterans with
PTSD. DAV encourages VA to complete its current research, and resolve
the overarching question of whether service dogs are an efficacious
therapy intervention for veterans with PTSD.
Finally, DAV notes that only providing service dogs to veterans
with PTSD, while excluding veterans with other severe mental health
conditions raises questions of equity to this benefit. DAV's resolution
019, adopted at our most recent National Convention, calls for VA to
complete its plan to conduct research and expansion of ongoing model
programs to determine the most efficacious use of guide and service
dogs in defined populations; in particular, veterans with mental health
conditions. While we support the intent of this bill, and have no
objection to its passage, we do again note our concerns with the
proposed offset in the legislation.
Discussion Draft, to make certain improvements in the Health
Professionals Educational Assistance Program of the VA
Mr. Chairman, we were also asked to make any comments on a draft
bill to improve the Health Professionals Educational Assistance Program
(HPEAP). DAV recently approved two resolutions that allow us to support
this draft measure. DAV Resolution 177 specifically supports
scholarships for mental health practitioners who practice in VHA
facilities and DAV Resolution 228, which supports effective
recruitment, retention and development of the VA health care system
workforce.
Section 2 of this bill would amend the HPEAP and require the
Secretary to offer not less than 50 scholarships for physicians and
dentists when VHA reports staff shortages of at least 500 positions. In
years in which VHA reports fewer than 500 unfilled physician and
dentist positions, the Secretary would offer scholarships representing
at least 10 percent of the vacancies. Professionals awarded these
scholarships would be required to serve in VHA for 18 months for each
school year the scholarship was awarded. The Secretary would be
authorized to give preference to veterans in awarding scholarships. In
addition, the HPEAP would be extended from December 31, 2019 until
December 31, 2033.
Section 3 of the bill would create a new program under Chapter 76-
the Specialty Education Loan Repayment Program. This program would be
specifically targeted at medical specialties that the Secretary
determines VHA has difficulty recruiting or retaining providers and
could be used alone or in tandem with the HPEAP or other tools. The
program would authorize the Secretary to provide up to $40,000
annually, for no more than four years, for a total of no more than
$160,000 per provider to assist with tuition, educational expenses and
reasonable living expenses. In return it would require the health
professional to serve in VHA for 12 months for each $40,000 VHA
provides under the program.
Section 4 of the bill would establish a pilot program-Veterans
Healing Veterans Medical Access and Scholarship Program. This program
would require the Secretary to select two veterans to whom VA would
award scholarships at each of the five Teague-Cranston medical schools.
Veterans selected must have been honorably discharged from the military
within the past decade and be able to meet the requirements for medical
school admission.
VA has identified staffing shortages for physicians for many years.
DAV is aware that VHA requires new recruitment tools to meet increasing
demand for care as well as quality and timeliness standards. Many VHA
facilities serve in areas the Health Resources and Services
Administration has designated as ``health professional shortage areas''
or medically underserved areas. VHA medical professional shortages will
be exacerbated by the estimated 40 percent of the VHA workforce
expected to retire in the next few years and the national shortage of
physicians overall. In addition, the federal government has not been
successful in recruiting younger employees. The recent Commission on
Care noted that individuals younger than thirty years old accounted for
only six percent of the federal government's employees as opposed to 23
percent of the civilian workforce.
The efficiency of talent management processes in VHA programs has
also been called into question. VHA loses approximately 13 percent of
its applicants in the hiring process, which many reports, including the
Independent Assessment required under the Veterans Access Choice and
Accountability Act of 2014, have found are slow and cumbersome compared
to the processes used by many private health care organizations today.
In addition, government pay rates are often not competitive with the
private sector.
There are many reasons VHA struggles with quickly filling critical
health professional staff positions and all of these issues must be
addressed if VA is to become the employer of choice. This draft bill
would provide a way for the Department to attract professionals
entering into medical careers at the beginning of the production
pipeline, rather than the end when individuals with highly sought after
skills have many more options. Use of these tools also requires the
Secretary and VHA to determine and assess future workforce needs more
systemically. DAV supports this draft measure, which we believe would
assist VHA in becoming a more competitive employer of physicians and
dentists, particularly for providers in scarce medical specialties
ultimately leading to more timely care of our nation's ill and injured
veterans.
Mr. Chairman, this concludes my testimony. DAV would be pleased to
respond to any questions from you or Subcommittee members concerning
our views on the bills under consideration today.
JUSTICE FOR VETS
H.R. 2147 Veterans Treatment Court Improvement Act of 2017
Statement of Judge Robert Russell, Buffalo, New York
To Chairman Wenstrup, Ranking Member Brownley, and distinguished
Members of the Subcommittee, I am honored to have the opportunity to
submit my testimony in support of H.R. 2147 Veterans Treatment Court
Improvement Act of 2017 and respectfully request my statement be
entered into the record.
In 2007, while serving as presiding judge over the drug court and
mental health court in Buffalo, New York, I began to see an increase in
the number of veterans appearing on our dockets struggling with
substance use disorders, mental health disorders and trauma. Drug court
is the most successful justice intervention for offenders with a
substance use disorder and is proven to significantly reduce drug abuse
and crime while saving money. Mental health courts were established in
the mid-nineties to apply the drug court model to cases involving
individuals with an underlying mental health condition. Despite the
proven success of these interventions, I became concerned that not
enough was being done to connect veterans in crisis with the
appropriate treatment and services.
One day during our mental health court docket, I called the case of
a Vietnam veteran who, to that point, had not been progressing in his
treatment or with the help being offered by the court, and who
struggled to communicate with the court team. In a moment of
exasperation, I asked one member of my staff and a county employee,
both Vietnam veterans, to go out in the hall and talk to him. The three
Vietnam veterans met for over thirty minutes. The next time I called
the case, the man walked up to the bench, stood at parade rest, and
held his head high. I asked him if he had any comments, and he looked
me in the eye and said yes, he would try harder and would work with the
court and treatment.
This profound experience became the inspiration for what would
become the first veterans treatment court in the nation. It helped us
recognize two things. First, the camaraderie that exists between men
and women who served in the military can be motivational and
therapeutic. Surrounding veterans with other veterans is crucial to
breaking through the warrior mentality that can make accepting help
difficult. Second, it is critical to link veterans with the specific
resources they earned through their service and which are uniquely
suited for their individual needs.
Together, my staff and I decided that more must be done to serve
our justice-involved veterans. I went to our local VA medical hospital
and asked the director if they would allow a staff person to come to
our court so they could immediately engage with veterans coming through
the program. I told him our program could refer veterans to treatment
at the hospital, and ensure compliance with said treatment through
regular court appearances and supervision. He agreed. This became the
impetus for the Veterans Justice Outreach (VJO) program.
Veterans Treatment Courts
In January 2008, we launched the Buffalo Veterans Treatment Court.
This veterans-only docket is an alternative to incarceration for
veterans whose involvement in the justice system is rooted in a
substance use or mental health disorder, often both. While maintaining
the traditional partnerships and practices of our highly successful
drug court - judge, prosecutor, defense, probation, law enforcement,
case manager - the veterans treatment court interdisciplinary team
includes representatives from the Department of Veterans Affairs -
including the Veterans Health Administration and the Veterans Benefit
Administration - as well as State Department/Commission of Veterans
Affairs, Vet Centers, community mental health and substance use
treatment providers, veterans service organizations, and volunteer
veteran mentors.
Veterans in the program receive structure, supervision, and
treatment surrounded by other veterans and being connected to veteran
specific local, state and federal resources.
Almost immediately after launching our program, we became inundated
with requests from other jurisdictions seeing the same increases of
justice-involved veterans. This was the beginning of a movement that
has grown to include today more than 350 operational veterans treatment
court programs serving approximately 15,000 justice-involved veterans a
year.
Veterans treatment courts are now considered the most innovative
and successful intervention for justice-involved veterans diagnosed
with substance use and/or mental health disorders. Through a
coordinated effort that promotes accountability, structure, and
treatment, veterans treatment courts connect veterans in crisis with
the benefits and services they earned. This approach saves money,
reduces future crime, and ensures that veterans have the opportunity
for freedom and recovery.
The Role of the VJO
Veterans treatment courts simply could not exist without the VA's
Veterans Justice Outreach program. Approximately 80 percent of veterans
in the Buffalo Veterans Treatment Court qualify for VA benefits. This
is consistent with other programs across the country. The VJO
representative in court helps determine eligibility, assists with
expediting or following up on the status of a VA Veteran Health
Identification Card, provides necessary information for placement,
educates enrolled participants about services that are available,
provides ongoing support in connecting enrolled participants to
treatment in the VA healthcare system and/or other community health
systems and communicates directly with the court to ensure treatment
referral and engagement - two of the most important indicators of
treatment success.
For example, a Marine combat veteran (one-tour Afghanistan/one-tour
Iraq) enters veterans treatment court after becoming addicted to
prescription drugs to cope with undiagnosed PTSD. The veteran is
unemployed and sleeping on friends' couches because his wife has left
him. He has only been out of the military for eight months and is not
enrolled in the VA.
During his first session in veterans treatment court, the VJO
confirms his eligibility and enrolls the veteran in the VA. The VJO
schedules the veteran to receive therapy for PTSD and coordinates with
the court to secure inpatient treatment for his substance use disorder.
While it ordinarily might take weeks or months for this veteran to
receive treatment, he is getting help within days. The VJO monitors the
veteran's progress in treatment and reports back to treatment court
team weekly. The VJO helps the veteran explore other benefits offered
through the VA. The veteran receives a service-connection disability
rating from the VA that helps pay for living expenses. The veteran then
applies and qualifies for VA's Vocational Rehabilitation and Employment
(VR&E) and enrolls in college.
This example is not unique, it is the type of success occurring in
veterans treatment courts across the country; success that would not be
possible without the presence of the VA in court.
Since 2008, I have travelled the country as faculty for Justice For
Vets, a division of the non-profit National Association of Drug Court
Professionals dedicated to the training and expansion of veterans
treatment courts. Justice For Vets has trained more than 227 of the
more than 350 operational programs nationwide. The comprehensive
Justice For Vets training brings together all stakeholders necessary to
implement and sustain a veterans treatment court, including VJO and
other VA personnel.
The most common issue we encounter from jurisdictions seeking to
establish a program is not knowing how to liaise with the VA. In my
experience, the inability of a jurisdiction to coordinate directly with
a VJO is the most significant mitigating factor in efforts to create a
veterans treatment court.
These concerns are alleviated by the presence of a VJO.
Unfortunately, many communities do not have access to a VJO, or the VJO
assigned to their region cannot fully engage with the court due to the
large area they cover; one VJO in Upstate New York is responsible for
eight counties alone. The VJO program has been crucial to the growth
and success of veterans treatment courts and is also one of most
effective programs at VA.
The VJO program has one of the highest rates of treatment referral
and engagement in the VA. A 2014 study of the program states, ``among
veterans who had a mental health or substance use disorder, 97% entered
mental health or substance use disorder outpatient or residential
treatment or received pharmacotherapy for alcohol or opioid use
disorders.[T]he rate of treatment engagement, defined as six or more
mental health outpatient visits, or six or more substance use disorder
outpatient visits, or any mental health or substance use disorder
residential treatment, was 79%.''
In 2016, the Government Accountability Office recommended the VA
expand the VJO program to help keep up with demand, which is precisely
what this bill aims to do.
Justice-Involved Veterans
It is important to note veterans are incarcerated at significantly
lower rates than non-veterans, and the number of veterans in jails and
prisons decreased between 2004 and 2012 (Bureau of Justice Statistics
[BJS], 2015). But there is a startling lack of data on the intersection
of veterans and the justice system and too often veterans are not
identified upon entry to the system or reentry to their community. What
we do know suggests substance use disorders and mental health disorders
are a significant factor in justice involvement.
In March 2014, The Washington Post released a report finding that
more than half of the 2.6 million American veterans of the wars in Iraq
and Afghanistan struggle with physical or mental health problems
stemming from their service, and feel disconnected from civilian life
(Chandrasekaren, 2014). The RAND Center estimates about 1 in 5 veterans
of the wars in Iraq and Afghanistan has post traumatic stress disorder
(PTSD) or significant mental health needs (Tanielian & Jaycox, 2008).
The Substance Abuse and Mental Health Services Administration (SAMHSA)
estimates 1 in 15 veterans had a substance use disorder in 2014
(SAMHSA, 2015).
Left untreated, these issues put veterans at significant risk for
involvement with the justice system. Historically, there is no
comprehensive effort to ensure the justice system responds sufficiently
to the unique clinical needs some veterans face. Justice-involved
veterans are scattered throughout the justice system, making it
difficult to coordinate effective treatment interventions. Until
veterans treatment courts, the VA had little to no contact with
justice-involved veterans.
Veterans Treatment Courts: Unprecedented Success
Veterans treatment courts are now considered the most successful
intervention for veterans in our justice system. In Buffalo, we have
`graduated' 240 veterans, with less than 10 percent recidivism rate
amongst these graduates.
Nationally, the numbers are just as impressive. Recently, Community
Mental Health Journal released the first published study on veterans
treatment courts and concluded participating veterans experienced
significant improvement with depression, PTSD, and substance use, as
well as with critical social issues including housing, emotional well-
being, relationships, and overall functioning. The study further
concluded that veterans who receive trauma-specific treatment and
mentoring not only experienced better clinical outcomes, they reported
feeling more socially connected (Knudsen & Wingenfeld, 2016). Much of
this success can be attributed to the VJO program. A national study of
more than 22,000 veterans in the VJO program found that veterans
treatment court participants had better housing and employment outcomes
as compared to other justice-involved veterans.
These outcomes are crucial for ensuring long-term success.
The Future
Veterans treatment courts continue to be the fastest growing
treatment court model in the United States. Thanks to the rise of
veterans treatment courts and the role and engagement of VJOs in local
justice systems, jurisdictions from coast to coast learned the
importance of identifying veterans at the earliest possible contact
with the justice system, assessing them for substance use or mental
health disorders and diverting them to evidence-based treatment. The
progress is monumental but in order to ensure existing programs remain
faithful to the veterans treatment court model--and new programs are
established with the proper policies and procedures in place--training
and VJO involvement is absolutely necessary.
Veterans treatment courts combine criminal justice and the VA in a
way that has never been done. Programs that launch without proper
training or coordination with the VA run the risk of doing more harm
than good. Justice For Vets is doing all it can to meet the urgent and
growing need for training but more support is needed.
The men and women of the United States military safeguard our
freedom. It is this nation's collective responsibility to treat the
wounds-visible and invisible-of those who suffer as a result of their
service.
The Veterans Treatment Court Improvement Act of 2017 is a critical
step in meeting the urgent and growing need, and ensuring out nation
delivers its promise to our veterans. I want to thank Chairman Wenstrup
and Ranking Member Brownley for conducting a hearing on this important
piece of legislation, and urge the swift passage of the bill.
References
Aos, S., Miller, M., & Drake, E. (2006). Evidence-based public
policy options to reduce future prison construction, criminal justice
costs, and crime rates. Olympia, WA: Washington State Institute for
Public Policy; Carey, S. M., Finigan, M., Crumpton, D., & Waller, M.
(2006). California drug courts: Outcomes, costs and promising
practices: An overview of phase II in a statewide study. Journal of
Psychoactive Drugs, SARC Supplement 3, 345-356; Finigan, M., Carey, S.
M., & Cox, A. (2007). The impact of a The Bureau of Justice Statistics.
(2015, December 7). Veterans in Prison and Jail, 2011-2012. Retrieved
from http://www.bjs.gov/index.cfm?ty=pbdetail&iid=5479
Aos et al. (2006). Evidence-based public policy options to reduce
future prison construction, criminal justice costs, and crime rates.
Olympia: Washington State Institute for Public Policy; Lattimer (2006).
A meta-analytic examination of drug treatment courts: Do they reduce
recidivism? Canada Dept. of Justice; Lowenkamp et al. (2005). Are drug
courts effective: A meta-analytic review. Journal of Community
Corrections, Fall, 5-28; Shaffer (2006). Reconsidering drug court
effectiveness: A meta-analytic review. Las Vegas, NV: Dept. of Criminal
Justice, University of Nevada; Wilson,et al. (2006). A systematic
review of drug court effects on recidivism. Journal of Experimental
Criminology, 2, 459-487.
Chandrasekaren, R. (2014, March 29). Pain and Pride: A nationwide
poll of Iraq and Afghanistan veterans reveals the profound and enduring
effects of war on the 2.6 million who have served. The Washington Post.
Retrieved from http://www.washingtonpost.com/sf/national/2014/03/29/a-
legacy-of-pride-and-pain/
mature drug court over 10 years of operation: Recidivism and costs.
Portland, OR: NPC
Finlay, A. K., Rosenthal, J., Blue-Howells, J., Clark, S., Van
Campen, J., & Harris, A. H. S. (2015). Veterans Justice Outreach
Program: Connecting Veterans with Veterans Health Administration Mental
Health and Substance Use Disorder Treatment [Fact Sheet 2015-000b].
Menlo Park, CA: Center for Innovation to Implementation.
Finley, Andrea K., Smelson, David, Sawh, Leon, McGuire, Jim,
Rosenthal, Joel, Blue-Howells, Jessica, Timko, Christine, Binswanger,
Ingrid, Frayne, Susan M., Blodgett, Janet C., Bowe, Tom, Clark, Sean
C., Harris, Alex H.S. (2014). U.S. Department of Veterans Affairs
Veterans Justice Outreach Program: Connecting Justice-Involved Veterans
With Mental Health and Substance Use Disorder Treatment. Criminal
Justice Policy Review. DOI: 10.1177/0887403414562601.
Knudsen, K.J. & Wingenfeld, S. (2016) A Specialized Treatment Court
for Veterans with Trauma Exposure: Implications for the Field.
Community Mental Health Journal, 52:127.
Research; Loman, L. A. (2004). A cost-benefit analysis of the St.
Louis City Adult Felony Drug Court. St. Louis, MO: Institute of Applied
Research; Barnoski, R,. & Aos, S. (2003). Washington State's drug
courts for adult defendants: Outcome evaluation and cost-benefit
analysis. Olympia, WA: Washington State Institute for Public Policy;
Logan, T. K., Hoyt, W., McCollister, K. E., French, M. T., Leukefeld,
C., & Minton, L. (2004). Economic evaluation of drug court:
Methodology, results, and policy implications. Evaluation & Program
Planning, 27, 381-396.
National Center for Veterans Analysis and Statistics. (n.d.).
Veteran Population. Retrieved from http://www.va.gov/vetdata/veteran--
population.asp
Substance Abuse and Mental Health Administration. (2015, May 7). 1
in 15 veterans had a substance use disorder in the past year. Retrieved
from http://www.samhsa.gov/data/sites/default/files/report--1969/
Spotlight-1969.pdf
Tanielian, T. & Jaycox, L.H. (2008) Invisible Wounds of War:
Psychological and Cognitive Injuries, Their Consequences, and Services
to Assist Recovery. Retrieved from http://www.rand.org/pubs/monographs/
MG720.html
MAKE A DIFFERENCE AMERICA
Wisdom, courage and compassion.
These three words describe unique attributes of the men and women
that are and have been members of the armed services of the United
States of America.
America's military is the greatest protective force in the world.
There are many elements that contribute to making our military the best
including leading edge technology, seasoned leadership and dedicated
personnel. However, I believe that the overwhelming reason for our
success is the manner in which we conduct ourselves.
As American citizens and as Americans in the military, we care
deeply about the people of the world. No matter what their country,
origin, culture or tradition, we care. America will never be defeated
with a military like ours that conducts itself with wisdom, courage and
compassion. Our military also serves as an ambassador to the people of
the world. Average citizens in foreign countries learn about America
through their interaction with our service members. For this reason
America and its citizens are respected around the world; whether or not
their leaders agree.
As citizens, knowing what our military does for us, we want to be
confident that America is ensuring that our veterans are receiving the
care that they have earned. Our men and women in the military have
protected us and when necessary, sacrificed for us. It is our
obligation to address their concerns even if they say they will ``tough
it out and not complain''.
HR1943 was initiated by an average citizen that asked the question,
``Why are organizations like the Gary Sinise Foundation, Independence
Fund and Wounded Warriors providing track wheelchairs to our veterans
with private funds? Shouldn't the VA be providing them?''.
After talking to members of the House and Senate, it was determined
that Congress thought that the VA was providing the track wheelchairs
to our veterans. That conclusion prompted us to commission a research
project to determine if the VA actually had the authority to provide
powered track wheelchairs to service-disabled veterans for recreational
purposes. The research found a statement in the VHA Prosthetic Clinical
Management Program (PCMP) which states that ``Motorized and power
equipment or equipment for personal mobility intended solely for a
recreational leisure activity should not be provided.''
Now knowing the ``root cause'' for service-disabled veterans being
denied powered mobility devices for recreational purposes by the VA, we
had the credibility to approach members of Congress with the facts.
Once we had the research information organized in a digestible form, it
wasn't long before Congressman Steve King (IA), a long time veteran
supporter, agreed that the regulations needed changing and offered to
introduce our initiative as a bill.
On April 05, 2017, HR 1943 was introduced by Congressman King. This
was a great day for our country. HR1943 is not just a bill, it is a
bill that came about the way our Founding Fathers intended, by citizens
of our country using the legislative tools we were provided to make
changes in the law.
Of course, we are only at the beginning of the process; taking
little steps at a time. However, it has been a pleasurable experience
so far and has shown that one citizen can make a difference and
together there is nothing we cannot change.
I want to thank the Veterans Affairs Committee for selecting HR1943
as one of the bills to be reviewed at the hearing scheduled for
September 26, 2017. This will be one more important step in the process
of providing changes to our laws that will make the lives of our
disabled-veterans as whole as possible.
Dave Meister
PARALYZED VETERANS OF AMERICA (PVA)
CONCERNING
PENDING LEGISLATION
Chairman Wenstrup, Ranking Member Brownley, and members of the
Subcommittee, Paralyzed Veterans of America (PVA) would like to thank
you for the opportunity to present our views on the broad array of
pending legislation impacting the Department of Veterans Affairs (VA)
that is before the Subcommittee. No group of veterans understand the
full scope of care provided by the VA better than PVA's members-
veterans who have incurred a spinal cord injury or disease. Most PVA
members depend on VA for 100 percent of their care and are the most
vulnerable when access to health care, and other challenges, impact
quality of care. These important bills will help ensure that veterans
receive timely, quality health care and benefits services.
H.R. 93, ``to amend title 38, United States Code, to provide for
increased access to Department of Veterans Affairs medical care for
women veterans''
PVA supports H.R. 93, to amend title 38, United States Code, to
provide for increased access to Department of Veterans Affairs (VA)
medical care for women veterans. The bill would ensure gender specific
services are continuously available at every VA medical center and
community based outpatient clinic.
As of 2016, women comprise nearly 10 percent of the total veteran
population. That percentage is expected to rise. VA has made strides in
recent years to meet the needs of women veterans, by providing basic
reproductive health services, preventative screenings and provider
training on women's health issues. However, nearly a third of VA
medical centers still lack providers for gynecological services and
refer women veterans to community providers.
The great advantage for a patient of the VA health care system over
other networks in the United States is the care coordination provided
amongst its comprehensive services. For too many women veterans, their
care is fractured between their VA medical center, and a bevy of
community care providers. They have to worry about record sharing,
prescription data, and if VA will pay the provider on time before
receiving a bill themselves. For most male veterans at VA, these basic
health services are quickly and readily available. All veterans deserve
to benefit from the hallmark of the VA system. The number of women
enrolling at VA continues to rise. VA must have systems and providers
in place to address their unique needs. This legislation would require
VA facilities hire or contract with the needed providers.
H.R. 501, the VA Transparency Enhancement Act of 2017
PVA generally supports H.R. 501, the ``VA Transparency Enhancement
Act of 2017.'' The bill seeks to increase availability of information
regarding the prevalence of surgical infections, cancellations, and
transfers. The bill would require quarterly reports to the Committees
on Veterans' Affairs of the House and Senate, and a public release on
VA's website. Currently, VA provides the monthly completed and pending
appointment data from local VA medical facilities. VA does not
publically release data on rates of infection or cancelled or
transferred surgeries. Hospitals that receive reimbursement from the
Centers for Medicare and Medicaid Services (CMS) must report a variety
of quality measures to the National Healthcare Safety Network,
including surgical infections. This legislation will bring VA in line
to be qualitatively compared to the private sector.
H.R. 1063, the ``Veteran Prescription Continuity Act''
PVA supports H.R. 1063, the ``Veteran Prescription Continuity
Act.'' This bill would ensure a service member transitioning from
Department of Defense to Department of Veterans Affairs while receiving
medical treatment is able to maintain their prescription regimen if not
included in the joint uniform formulary.
Currently, there is no guarantee a patient transitioning to VA can
be prescribed the same drug as prescribed by DOD. The only exception is
medication for post-traumatic stress or chronic pain. This bill would
have VA offer what DOD prescribed until the veteran's provider
determines it is no longer necessary. This is a logical accommodation
for a service member in transition. Ensuring there is a seamless
handoff between systems is of the utmost importance.
H.R. 1066, the ``VA Management Alignment Act of 2017"
PVA supports H.R. 1066, the ``VA Management Alignment Act of
2017.'' This legislation would direct VA to submit to Congress a report
on the organizational structure of VA and the means to improve such
structure to improve access to quality care. GAO reports have revealed
VA has not implemented the recommendations for managerial and
structural improvement. The report required by this bill would spell
out the roles and responsibilities for senior staff and organizational
units within VA and how they work together to promote efficiency and
accountability, as well as any legislative recommendations to improve
access to care.
H.R. 1943, the ``Restoring Maximum Mobility to Our Nation's Veterans
Act of 2017"
PVA generally supports H.R. 1943, the ``Restoring Maximum Mobility
to Our Nation's Veterans Act of 2017.'' The bill would amend title 38,
USC, to require VA to ensure each wheelchair, furnished to a veteran
with a service connected disability restores the maximum achievable
mobility in activities of daily living, employment, and recreation. The
bill would amend `wheelchair' to include `enhanced power wheelchairs,
multi-environmental wheelchairs, track wheelchairs, stair-climbing
wheelchairs, and other power-driven devices.' The bill would allow the
Secretary to furnish a wheelchair to a veteran because the wheelchair
restores an ability that relates exclusively to participation in a
recreational activity.
PVA supports this bill provided such wheelchairs meet all
International Organization for Standardization (ISO) criteria and FDA
requirements for wheelchairs. The existing regulations and standards
will ensure the veteran is using equipment that has been rigidly tested
to meet all safety, mechanical and software parameters. This is a
difficult standard for many of the mentioned devices, such as tracked
vehicles. Our primary concern is the veteran's safety and well-being.
We would not encourage VA to furnish veterans with spinal cord injuries
an off road ``wheelchair'' that could roll over. And there are general
safety concerns for these recreational vehicles and the operation of
gasoline motors.
H.R. 1972, the ``VA Billing Accountability Act''
PVA supports H.R. 1972, the ``VA Billing Accountability Act.'' This
bill would authorize the Secretary of Veterans Affairs to waive the
requirement of certain veterans to make copayments for hospital care
and medical services in the case of an error by the VA. Many VA Medical
Centers struggle to send billing statements for co-payments to veterans
in a timely manner. For some veterans this means being sent a bill
years after the service. H.R. 1972 would mandate that a veteran receive
their bill within 120 days from receiving care at a VA Medical Center
and within 18 months if seen at a non-VA facility. Further, the bill
grants the Secretary the authority to waive the co-payment altogether
if these billing timelines are not adhered to. If the bill is sent
after the required time VA must notify the veteran of the option to
receive a waiver or create a payment plan before the payment can be
collected. Veterans and their families should not be burdened with
unknown debts resulting from mistakes in VA's own processes.
H.R. 2147, the ``Veterans Treatment Court Improvement Act of 2017"
PVA firmly believes in the rule of law and that anyone convicted of
a crime should be held accountable. Our criminal justice system,
though, has long recognized the existence of aggravating and mitigating
circumstances that play an important role in influencing the
administration of penalties. While advocacy before a sentencing judge
following conviction is critical, prosecutorial discretion is also
vast. Veterans Justice Outreach Specialists can help veterans use their
honorable service, as well as mitigating circumstances arising from
that service, to ensure both the prosecutor and judge see more than
just a rap sheet when making decisions.
If the specialist demonstrates that the veteran is entitled to
health care or disability benefits, the judge or prosecutor might be
able to fashion a sentence or plea offer that incorporates utilization
of these services in lieu of imposing solely punitive sanctions. It
could also lead to an outright deferment of prosecution conditioned on
the veteran exploring and obtaining all services available to him or
her. This scenario is especially enticing to the judicial system given
the constant struggle to find resources, particularly for in-patient
substance abuse rehabilitation programs and mental health care.
For some veterans, this path might help them avoid being
permanently stigmatized with a criminal conviction. For others, it
might be the ticket that lifts them out of homelessness and the
corresponding criminal recidivism, specifically with petty and/or
vagrancy crimes. It is no secret that some veterans go years before
realizing they were entitled to certain benefits that might have helped
them avoid poverty and dejection. A court order pointing the veteran to
the Department of Veterans Affairs can sometimes turn into a life-
changing event. At the least, more veterans touched by this program
will re-engage productively with society. That is a goal worth
pursuing.
H.R. 2225, the ``Veterans Dog Training Therapy Act''
PVA supports H.R. 2225, the ``Veterans Dog Training Therapy Act.''
This legislation would require the Department of Veterans Affairs (VA)
to contract with certified non-government entities to test the
effectiveness of addressing veterans' post-deployment mental health and
post-traumatic stress disorder (PTSD) symptoms through training service
dogs for fellow veterans with disabilities.
PVA knows that service animals provide tremendous benefits for many
veterans living with disabilities. The benefits of service animals are
multi-faceted. Service animals promote independence for veterans with
disabilities and help them to break down barriers in their communities.
Many PVA members have personally experienced these benefits.
``The Veterans Dog Training Therapy Act'' will allow VA to explore
potential therapies for veterans with certain mental health issues to
include training of service animals. Not only could this provide
additional treatment options for veterans living with PTSD and other
similar conditions but it will provide highly trained service animals
for veterans living with disabilities. This pilot program would be
located at VA medical centers and administered by VA's Center for
Compassionate Innovation. We believe that this construct will provide
the conditions that lead to effectively trained service animals for
veterans with disabilities.
H.R. 2327, the ``Puppies Assisting Wounded Servicemembers (PAWS) Act of
2017"
PVA generally supports H.R. 2327, the ``Puppies Assisting Wounded
Servicemembers (PAWS) Act of 2017,'' to provide service animals to
veterans who need them. If enacted, this legislation would direct the
VA to carry out a pilot program to provide service dogs to certain
veterans with severe post-traumatic stress disorder (PTSD). Service
animals provide crucial assistance to many veterans living with
catastrophic disabilities. The benefits of using a service animal are
multi-faceted. Service animals promote independence and help to break
down societal barriers. Many members of Paralyzed Veterans have
personally experienced these benefits.
Through the PAWS Act, VA will provide grants to service animal
organizations to assist veterans referred by VA who have PTSD. This
pilot program will provide service dogs to veterans with PTSD who have
completed evidence-based treatment for PTSD but who continue to have a
PTSD diagnosis. We support efforts to increase access to service
animals for veterans with disabilities. It is our hope that this
program will be funded. However, we strongly discourage it be done by
offsetting resources for VA's Office of Human Resources and
Administration, which could derail VA's efforts to hire and retain
qualified personnel.
Additionally, the bill as written does not appropriately reflect
the fact that the VA currently does not provide service animals to any
veteran directly. Service animals are provided to veterans by
organizations responsible for the training and provision of service
animals, not the VA. The VA currently bares no direct cost when it
comes to providing service animals. As it is, we are not aware of a
demonstrated need for VA to be the procurer of service animals.
Additionally, this bill would have the VA provide service dogs only to
veterans with PTSD, excluding veterans with other mental health
conditions and physical disabilities who would also benefit.
VA provides veterinary health insurance and other ancillary
benefits to service animals used for veterans with physical
disabilities. While this bill would make PTSD service dogs eligible for
existing benefits, (something VA currently has the authority to do) it
goes a step beyond by charging VA with procuring a trained, capable
dog. We are concerned that creating a new process to place service dogs
with veterans with PTSD confuses the process among veterans with other
needs.
Draft legislation to ``make certain improvements in VA's Health
Professionals Educational Assistance Program''
PVA supports the draft legislation to make certain improvements in
VA's Health Professionals Educational Assistance Program. The bill
would designate at least fifty scholarships to medical or dental
students. The goal is to award such scholarships until the Secretary
determines the staffing shortage of these providers is less than 500.
The recipient of the scholarship agrees to serve as a full-time
employee in VHA for a period of obligated service of 18 months of each
school year or part thereof that the scholarship was provided. The bill
would also establish within VA a Specialty Education Loan Repayment
Program. The purpose is to incentivize medical residents to work at
VHA, particularly in specialties where recruitment and retention have
proven difficult. This bill would allow for the Secretary to waive
maximum loan repayment caps established under the Specialty Education
Loan Repayment Program and pay the total amount of the principal and
interest on a participant's loan. The participant's obligated service
would be determined on a scale of the amounts repaid. Additionally,
Section 4 of the bill would establish a pilot program to fund the
medical education of ten eligible veterans throughout the Teague-
Cranston medical schools.
Given the critical shortage of health care providers VA must be
able to pursue the means to recruit and retain new residents. The
majority of providers at VA and throughout the United States will soon
retire and there are not enough poised to take their place. And with an
aging patient population and uncertain healthcare landscape, these
challenges require quick action
That potential health care students are reluctant to commit to
medical school, or new residents are hesitant to take a post in an
underserved community, should come as no surprise. The cost burden of
their education and training is an overwhelming prospect and debt is
all but guaranteed. No matter how eager to serve, or desirous of giving
back to veterans a new resident may be, a career at an understaffed VA
may not be a tenable choice. By providing scholarships to cover the
cost of medical school or paying off loans, in exchange for a period of
service, VA would become an obvious choice. Removing the financial
barriers encourages the best and the brightest to make their mark at
VA. Additionally, such programs would cultivate a culture of commitment
by those unburdened by debt and revive areas too long stressed by
continuous shortages. VA must be given the resources to address this
current and looming crisis. The health and wellbeing of our nation's
veterans depend on it.
VETERANS OF FOREIGN WARS OF THE UNITED STATES (VFW)
KAYDA KELEHER, ASSOCIATE DIRECTOR
NATIONAL LEGISLATIVE SERVICE
Chairman Wenstrup, Ranking Member Brownley and members of the
Subcommittee, on behalf of the women and men of the Veterans of Foreign
Wars of the United States (VFW) and its Auxiliary, thank you for the
opportunity to provide our remarks on legislation pending before this
subcommittee.
H.R. 93, to provide for increased access to Department of Veterans
Affairs medical care for women veterans.
The VFW supports this legislation which would ensure gender-
specific health care services maintain continuous availability within
Department of Veterans Affairs (VA). It would also authorize VA to
provide women veterans community care options when VA is unable to
provide gender-specific care at its medical facilities.
Estimated to grow to the size of the entire active duty military by
the year 2030, women veterans are the fastest growing cohort of the
veterans' community. It is absolutely imperative that VA provides
necessary access and employ personnel trained to provide gender-
specific health care.
H.R. 501, VA Transparency Enhancement Act of 2017
The VFW agrees with the intent of this legislation, but has
concerns with some of its requirements. The VFW firmly believes VA must
maintain agency transparency and be held accountable when necessary.
Yet Congress must not put undue burdens on VA. The VFW does not believe
it necessary to overstretch the already scarce resources it is given,
which are intended for delivering health care and service to veterans,
on superfluous reporting requirements.
Health care associated infections are currently tracked by the
Centers for Disease Control and Prevention (CDC) National Healthcare
Safety Network (NHSN). More than 17,000 medical facilities within the
United States currently submit surgical site infections data for public
reporting to CDC NHSN for patients who are 18 years old or older. Most
of this data is transferred by the medical facilities electronic health
record systems directly to CDC.
With this in mind, the VFW has concerns with this legislation that
would require a quarterly report of surgical site infections, as well
as cancelled or transferred surgeries. First, a quarterly report is
unnecessarily frequent and unusual when compared to other health care
systems. Aside from the logistics of preparing a quarterly report--
disseminating and analyzing it--any report made publicly available
should be posted alongside similar reports of other non-VA facilities.
This would help keep the information organized and easily comparable to
the rest of America's health care sector. Also, a report strictly
showcasing the number of surgical site infections without a comparison
to the number of total surgeries per surgical site would be unusable,
except for promoting unintended concern and distrust of VA.
H.R. 1063, Veteran Prescription Continuity Act
The VFW supports this legislation which would ensure veterans
transitioning from the Department of Defense (DOD) to VA have access to
the same medical care and treatment, specifically pharmaceuticals, as
they did before transitioning out of DOD. Making sure pharmaceuticals
that are medically necessary and have a crucial effect on the quality
of veterans' lives are available is an absolute must. Both DOD and VA
must ensure their formularies match for medications of high prevalence
and necessity for service members and veterans. This is particularly
true for pharmaceuticals specific to both chronic pain and mental
health.
H.R. 1066, VA Management Alignment Act of 2017
The VFW agrees with the intent of this legislation, but does not
support it. This bill would require the Secretary of VA to submit a
report outlining the current organizational structure within VA, and
how it should strive to work together between different offices and
departments.
VA has developed the Functional Organization Manual, which was
updated this year. This manual covers VA's organizational structure,
missions, functions, activities and authorities. This legislation would
require the Secretary to use VA resources for an independent assessment
striving for the same results, while also specifying how each office
should work with other offices within VA. This legislation is also
unclear as to whether it would require VA to evaluate all 300,000
positions within VA or specifically VA's Central Office. While it is of
utmost importance that VA continues striving to improve structural
organization and working relationships within the department, it is
increasingly redundant to continue demanding reports on already
conducted studies.
H.R. 1943, Restoring Maximum Mobility to Our Nation's Veterans Act of
2017
The VFW supports the intent of this legislation, but has concerns
as currently written.
Members of the VFW have vocalized concerns and barriers faced in
trying to receive the prosthetics necessary to live functional, high
quality lives. Whether they need an additional prosthetic limb for
recreational activities or cultural purposes, veterans have earned
them. While it may not be rampant, some members who have been fortunate
enough not to lose a limb still need the assistance of a wheelchair.
We believe all service-connected veterans in need of wheelchairs
deserve one from VA. Mobility and functionality are crucial for the
mental well-being of our nation's veterans. With this said, VA must
work to ensure all veterans in need of a wheelchair have one which
meets the requirements of both the International Organization for
Standardization criteria, as well as the U.S. Food and Drug
Administration. These regulations standardize requirements to ensure
veterans are using wheelchairs that have been tested for safety, and
mechanical and software perimeters.
While technology keeps improving, it must also continue to meet
industry standards for the safety of our veterans who are bound to
wheelchairs. Many new models of wheelchairs do not meet these standards
and can cost more than a car. Congress must ensure VA resources are
spent smartly on safe medical equipment.
H.R. 1972, VA Billing Accountability Act
The VFW supports this legislation to provide the Secretary of VA
with the authority to waive certain veterans from copayment
requirements for hospital care and medical services in the case of an
error by VA.
At this time, VA has the authority to waive copayment requirements
for hospital and medical services both inside and outside VA. This
legislation would codify that authority. While authorizing VA to waive
debts if VA employees fail to provide timely notice to veterans is a
step toward the right direction, the VFW would urge the subcommittee to
require VA to waive debts for veterans when VA is unable to provide
timely notice. Veterans must hot be held liable because VA sent them
untimely bills that do not contain information for waivers or payment
plans.
H.R. 2147, Veterans Treatment Court Improvement Act of 2017
The VFW strongly supports this legislation which would require VA
to hire more Veterans Justice Outreach Specialists to provide treatment
court services to justice-involved veterans.
According to the most recent data from the Bureau of Justice
statistics, over 130,000 veterans are incarcerated in state and federal
prisons, representing approximately eight percent of the total prison
population. While the VFW realizes veterans who are convicted of crimes
must suffer the consequences, we also recognize that having veteran
advocates or individuals to represent them before sentencing and act in
their best interests is invaluable.
Increasing the amount of Veterans Justice Outreach Specialists will
help our justice-involved veterans navigate the legal system, and
hopefully attain outcomes that are best suited for each individual
veteran. Also, by providing veterans struggling with legal issues, it
allows VA and the justice system to more directly assist veterans
struggling with substance abuse issues related to mental health
conditions from their service.
H.R. 2225, Veterans Dog Training Therapy Act
The VFW supports this legislation which would carry out a pilot
program for dog training therapy at several VA facilities.
With such a high ratio of veterans who have defended our nation
being diagnosed with post-traumatic stress disorder (PTSD), VA must
provide veterans mental health care options that work best for them.
Recent studies show service dogs provide positive health care outcomes
in veterans with PTSD. Such studies illustrate a reduction in symptoms
from the PTSD Checklist, lowered effects of anxiety and depression
disorders, as well as a reduced need for psychopharmaceutical
prescriptions. Veterans who have service dogs also experience an
increased participation in social settings, as well as overall
satisfaction with life. The VFW supports continued efforts to evaluate
the efficacy of using service dogs to treat PTSD and other mental
health conditions. Currently, VA in Oregon has already developed the
program on which this legislation is modeled. Basing legislation on a
currently functioning program ensures an easy transition and proper
implementation of the pilot program in more VA facilities.
For more than a decade, research into the benefits of providing
service dogs to veterans struggling with their mental health has
garnered attention. Given promising research in both the private sector
as well as VA, VFW members have consistently reported on the benefits
they experienced from having a service dog.
This legislation would ensure more veterans are provided the
opportunity to receive a service dog for combat-related mental health
conditions. This opportunity would be provided at a VA medical center,
administered by VA's Center for Compassionate Innovation, with
experienced and qualified staff training the dogs and veterans.
Veterans would not need to travel for this benefit, and they would have
access to VA's veterinary insurance. It would also have the potential
to advance and positively affect ongoing studies of service dogs by
collecting essential data. Many studies and anecdotal notes have found
veterans with service dogs decrease their use of medications such as
opioids for chronic pain linked to PTSD. This collection of data would
be invaluable in knowing the likelihood of medication decreases,
emotional well-being and improvements of service dog owners as well as
sleep patterns.
H.R. 2327, Puppies Assisting Wounded Servicemembers Act of 2017
The VFW supports the intent of this legislation. This legislation
would provide grants to eligible private sector organizations to
provide service dogs to veterans with severe PTSD.
Studying the benefits of providing service dogs to veterans
struggling with mental health disorders after the military is
absolutely crucial. With that said, the VFW knows that not all combat
veterans return home with PTSD. There is a wide range of behavioral
health issues veterans may struggle with, from mental illness to
psychosocial disorders. This pilot program would limit access to
service dogs only for veterans with severe PTSD. These veterans would
have to travel for their service dog training, which would be
reimbursed by VA. While this is not always a barrier, travel outside VA
may be a barrier to some veterans. Legislating that the pilot must be
performed by private organizations outside VA adds a possible barrier
to veterans in need. This legislation would also only require one
report within nine months of the pilot program ending. This would limit
the ability of VA and Congress to oversee the progress and benefits of
the outcomes for participating veterans. Also, with more than 40,000
employment vacancies within VA, the VFW is concerned this legislation's
offset could have unintended consequences for VA's Human Resources
trying to fill those much needed positions.
The VFW strongly supports the continuance of care this legislation
would require to maintain eligibility of canine health insurance.
Continuance of care is crucial to successfully overcoming any illness,
whether it is physical or mental. With VA only maintaining coverage of
the service dogs if the veteran continues to see their physician or
mental health care provider at least once a quarter--unlike other
service dog bills--this legislation would ensure more consistent and
open communication between the medical provider and veteran.
Draft Bill, to make certain improvements in VA's Health Professionals
Educational Assistance Program.
The VFW Supports the draft legislation and has recommendations to
improve it, which we hope the subcommittee considers before advancing
it.
This legislation would make improvements to scholarship and
educational assistance programs provided by VA in an attempt to address
provider shortages within the department. These position vacancies in
VA must be properly addressed, and the VFW supports the idea of
providing education incentives to attract more high quality VA
employees. Section 2 of this draft bill is specific in designating
scholarships specifically for physicians and dentists. There is zero
doubt VA needs physicians and dentists, but this section must include
scholarship opportunities for psychologists and students working toward
their Master of Social Work. The entire country has a shortage of
mental health care providers, and psychiatrists are not the ones
providing talk therapy and the majority of mental health testing/
screening for patients. By not including psychologists and therapists
in section 2, this legislation would be proving a disservice to VA in
the form of not addressing veterans' mental health needs and access to
care.
The second alarming issue the VFW has concerns with is in Section
4. This section would provide a full-ride scholarship to certain
veterans who qualify and choose to attend a Teague-Cranston medical
school. This scholarship is not tied to any other education benefit
eligibility for title 38 or title 10 of the United States Code. Yet
this legislation specifically shuns certain veterans with bad paper
discharges. Eligible veterans would only include those discharged not
more than 10 years before they apply, and only those with an honorable
or a general discharge. The VFW firmly believes this criteria must be
more open and inclusive.
Mr. Chairman, Ranking Member, this concludes my testimony. The
Veterans of Foreign Wars sincerely appreciates the opportunity to
provide views on these important bills, and I am prepared to take any
questions you or the subcommittee members may have.