[Senate Hearing 112-668]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 112-668

 
               HEARING ON HEALTH AND BENEFITS LEGISLATION

=======================================================================

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                      ONE HUNDRED TWELFTH CONGRESS

                             SECOND SESSION

                               __________

                             JUNE 27, 2012

                               __________

       Printed for the use of the Committee on Veterans' Affairs


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                     COMMITTEE ON VETERANS' AFFAIRS

                   Patty Murray, Washington, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Daniel K. Akaka, Hawaii              Johnny Isakson, Georgia
Bernard Sanders, (I) Vermont         Roger F. Wicker, Mississippi
Sherrod Brown, Ohio                  Mike Johanns, Nebraska
Jim Webb, Virginia                   Scott P. Brown, Massachusetts
Jon Tester, Montana                  Jerry Moran, Kansas
Mark Begich, Alaska                  John Boozman, Arkansas
                       Kim Lipsky, Staff Director
                 Lupe Wissel, Republican Staff Director



                            C O N T E N T S

                              ----------                              

                             June 27, 2012
                                SENATORS

                                                                   Page
Murray, Hon. Patty, Chairman, U.S. Senator from Washington.......     1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North 
  Carolina.......................................................     3
Brown, Hon. Scott P., U.S. Senator from Massachusetts............     4
Boozman, Hon. John, U.S. Senator from Arkansas...................     5

                               WITNESSES

Heller, Hon. Dean, U.S. Senator from Nevada......................     7
Ayotte, Hon. Kelly, U.S. Senator from New Hampshire..............     9
Franken, Hon. Al, U.S. Senator from Minnesota....................    11
Wyden, Hon. Ron, U.S. Senator from Oregon........................    13
    Prepared statement...........................................    15
Boxer, Hon. Barbara, U.S. Senator from California................    16
Portman, Hon. Rob, U.S. Senator from Ohio........................    17
Agarwal, Madhulika, M.D., M.P.H., Deputy Under Secretary for 
  Health for Policy and Services, Veterans Health Administration.    20
        and
Murphy, Thomas, Director, Compensation Service, Veterans Benefits 
  Administration, U.S. Department of Veterans' Affairs; 
  accompanied by William Schoenhard, Deputy Under Secretary for 
  Health for Operations and Management, Veterans Health 
  Administration; Jane Claire Joyner, Office of General Counsel; 
  and Richard Hipolit, Office of General Counsel.................    21
    Joint prepared statement.....................................    22
    Additional views.............................................    36
    Response to posthearing questions submitted by:
      Hon. Patty Murray..........................................    56
      Hon. Scott P. Brown........................................    60
    Fast Letters.................................................    69
Keil, Tracy, Caregiver and Spouse of OIF Veteran.................    79
    Prepared statement...........................................    82
Edney, Mark Thomas, MD, OIF Veteran, Member, Legislative Affairs 
  Committee of the American Urological Association...............    84
    Prepared statement...........................................    87
Ansley, Heather, M.S.W., Vice President of Veterans Policy, 
  VetsFirst......................................................    90
    Prepared statement...........................................    92
Ilem, Joy J., Deputy National Legislative Director, Disabled 
  American Veterans..............................................    97
    Prepared statement...........................................    98

                                APPENDIX

Cleland, Max, Secretary, American Battle Monuments Commission; 
  prepared statement.............................................   113
American Society for Reproductive Medicine (ASMR); prepared 
  statement......................................................   114
Beeler, Nathaniel, Avon, IN; letter..............................   115
Zampieri, Thomas, Ph.D., Director of Government Relations, 
  Blinded Veterans Association (BVA); prepared statement.........   117
Kasold, Hon. Bruce E., Chief Judge, U.S. Court of Appeals for 
  Veterans Claims; prepared statement............................   118
Wright, Dennis L., Captain, U.S. Navy (ret.), Chairman, Clark 
  Veterans Cemetery Restoration Association; letter..............   120
National Coalition for Homeless Veterans; letter.................   122
Paralyzed Veterans of America (PVA); prepared statement..........   125
Collura, Barbara, President, Resolve; letter.....................   132
Sims, Ron, Seattle, WA; prepared statement.......................   134
Klein, Morris, Esq., Attorney at Law, Bethesda, Maryland, and 
  Lois Zerrer, Zerrer Elder Law Office, LLC, Springfield, 
  Missouri, on Behalf of the Special Needs Alliance; prepared 
  statement......................................................   137
Bhagwati, Anu, Executive Director, Service Women's Action 
  Network; prepared statement....................................   139
Huebner, Charles, United States Olympic Committee; prepared 
  statement......................................................   141
Ansley, Heather L., Esq., M.S.W., Vice President of Veterans 
  Policy, VetsFirst; letter......................................   144
Wright, Dennis L., Captain, U.S. Navy (ret.), Chairman, Clark 
  Veterans Cemetery Restoration Association (CVCRA); letter......   145
Wounded Warrior Project (WWP); prepared statement................   147

            Submitted by Senator Barbara Boxer of California

AMVETS Department of California Service Foundation; letter.......   150
Hampton, Brian A., Maj. USAR (ret.), President, Center for 
  American Homeless Veterans, Inc.; prepared statement...........   152
California Association of Veteran Service Agencies; letter.......   153
The National Coalition for Homeless Veterans; letter.............   154
Blecker, Michael, Executive Director, Swords to Plowshares; 
  letter.........................................................   155
Kelley, Raymond C., Director, National Legislative Service, VFW; 
  letter.........................................................   156

               Submitted by Senator Dean Heller of Nevada

Wong, Fang A., National Commander, The American Legion; letter...   157
Gornick, Matt, Policy Assistant Director, National Coalition for 
  Homeless Veterans; letter......................................   158


               HEARING ON HEALTH AND BENEFITS LEGISLATION

                              ----------                              


                        WEDNESDAY, JUNE 27, 2012

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:04 a.m., in 
room 124, Dirksen Senate Office Building, Hon. Patty Murray, 
Chairman of the Committee, presiding.
    Present: Senators Murray, Burr, Isakson, Brown of 
Massachusetts and Boozman.
    Also present: Senators Heller, Ayotte, Franken, Wyden, 
Boxer, and Portman.

                STATEMENT OF HON. PATTY MURRAY, 
                  U.S. SENATOR FROM WASHINGTON

    Chairman Murray. Good morning. Thank you, and welcome all 
of you to this hearing of the Veteran Affairs' Committee this 
morning as we examine health and benefits legislation that is 
before our Committee.
    We have a number of Senators who are here who want to 
testify about their legislation. I will make an opening 
statement, then Senator Burr, and if we have any other 
Committee Members we will allow them to give theirs, then turn 
to other Senators. So, thank you all for being here.
    Like our hearing 2 weeks ago on economic opportunity and 
transition legislation, today's agenda is ambitious and 
reflects important work by the Members on both sides of the 
aisle. I wanted to briefly highlight two of my bills that are 
on the agenda.
    The Mental Health ACCESS Act of 2012 is sweeping 
legislation that improves how VA provides mental health care. I 
think it is fitting actually that we are here considering this 
legislation on National PTSD Awareness Day.
    Over the past year, this Committee has repeatedly examined 
the alarming rate of suicide and the mental health crisis in 
our military and veterans' populations. We know our 
servicemembers and veterans have faced unprecedented 
challenges, multiple deployments, difficulty finding a job when 
they come home, and isolation in their communities. Some have 
faced tough times reintegrating into family life, with loved 
ones trying to relate but not knowing how.
    These are the challenges our servicemembers and veterans 
know all too well. But even as they turn to us for help, we are 
losing the battle. Time and time again, we have lost 
servicemembers and veterans to suicide. We are losing more 
servicemembers to suicide than we are to combat, and every 80 
minutes a veteran takes his or her own life. On average this 
year, we have lost a servicemember to suicide once every day.
    But while the Departments of Defense and Veterans' Affairs 
have taken important steps toward addressing this crisis, we 
know there is a lot more that needs be done. We know that any 
solution depends upon reducing the wait times and improving 
access to mental health care, ensuring proper diagnosis, and 
achieving true coordination of care and information between the 
Departments.
    The Mental Health ACCESS Act would expand eligibility for 
VA mental health services to family members of veterans. It 
would require VA to offer peer support services at all medical 
centers and create opportunities to train more veterans to 
provide peer services, and this bill will require VA to 
establish accurate and reliable measures for mental health 
services.
    This Committee has held multiple hearings on VA mental 
health care, and we heard repeatedly about the incredibly long 
wait times to get into care. It is often only on the brink of 
crisis that a veteran seeks care. If they are told ``sorry, we 
are too busy to help you,'' we have lost the opportunity to 
help, and that is not acceptable.
    Without accurate measures, VA does not know the unmet 
needs. Without a credible staffing model, VA cannot deploy its 
personnel and resources effectively.
    The other bill I want to mention today is S. 3313. It is 
the Women Veterans and Other Health Care Improvement Act of 
2012, which builds upon previous law to improve VA services for 
women veterans and veterans with families.
    This bill will create a child-care pilot program for 
veterans seeking readjustment counseling at Vet Centers and 
increase outreach to women veterans. We know that as more of 
our men and women return from Afghanistan, the VA will be 
called upon to provide care for our most severely wounded 
veterans. After suffering life-changing injuries on the 
battlefield, these veterans now face a future forever changed.
    Between 2003 and 2011, we know that more than 600 
servicemembers experienced blast injuries that caused trauma to 
their reproductive or urinary tracts in Iraq and Afghanistan. 
Even more have experienced other injuries, like spinal cord 
injuries.
    Many of these veterans dream of 1 day starting a family. 
But with the injuries they have sustained on the battlefield 
that may not be possible without some extra help. While the 
Department of Defense and TRICARE are now able to provide 
advanced fertility treatment to injured servicemembers, today 
the VA can only provide limited treatment. VA's services do not 
even begin to meet the needs of our most seriously injured 
veterans and their families.
    So, my bill will help make real the dream of starting a 
family by authorizing the VA to provide advanced fertility 
treatment to severely wounded veterans. By authorizing these 
treatments, we will bring VA services in line with what DOD and 
TRICARE already provide. It is the right thing to do, and it is 
what our veterans deserve.
    I look forward to our second panel today where we have some 
very compelling testimony from families that have been impacted 
by these injuries.
    So, I look forward to hearing from our VA witnesses and all 
of our Committee Members and those Senators that are here today 
to talk about their legislation.
    With that, I will turn it over to the Ranking Member, 
Senator Burr.
    Senator Burr. Thank you, Chairman Murray; and I also 
welcome our witnesses today. I would also like to welcome 
Senator Wyden, who just introduced a bill in the last couple of 
weeks together, which he will testify on today. And I welcome 
the rest of my colleagues who are here that I expect to do a 
similar thing.
    Before turning to today's agenda, I want to say a few words 
about the Caring for Camp Lejeune Veterans Act, which would 
provide health care for veterans and their families who were 
stationed at Camp Lejeune when the water was contaminated with 
known or probable known carcinogens.
    I am very pleased that we have made progress on this bill 
in recent weeks, and I hope it will soon pass so that we can 
finally provide these veterans and their families with the care 
they need and deserve.
    As we consider other bills today--particularly any that 
create or expand programs--we should start by looking at how 
well existing programs are working and identify any gaps and 
inefficiencies. That should help us focus on changes that are 
truly needed and avoid creating any more duplicative and 
overlapping programs that can end up frustrating veterans and 
their families.
    Also, with the fiscal challenges facing our Nation, we need 
to know the cost of these bills; and for any that will move 
forward, we must find ways to pay for them.
    With all that in mind, I look forward to a productive 
discussion about the bills on today's agenda. To start with, I 
would like to mention several of those bills that I have 
cosponsored.
    One is S. 1707, which would end the unfair process that 
strips veterans and their families of the rights to own 
firearms if VA believes they need help with their finances.
    Under this bill, the Second Amendment rights of a VA 
beneficiary could not be taken away unless a judicial authority 
finds that the individual is dangerous. This would put the 
decision about Constitutional rights in an appropriate forum 
and base it on relevant questions.
    Another bill, S. 2045, would require judges of the Court of 
Appeals for Veterans' Claims to live within 50 miles of the 
Court's office, a requirement that already applies to other 
Federal judges.
    This should increase the efficiency and effectiveness of 
the Court by encouraging the judges to be present and 
personally engaged on a daily basis. It would also emphasize 
that the judges must be totally committed to the Court's 
important work.
    Then, S. 3084 would reform VA's Veterans' Integrated 
Service Networks or the acronym we all know, VISNs. In 1995, 
the veterans' health care system was divided into 22 geographic 
areas. It now is divided into 21 VISNs. Each VISN has its own 
headquarters with a limited management structure to support the 
medical facilities in that region. Since then, there has been a 
huge growth in staff at the VISN headquarters and increasing 
duplication in the duties they carry out.
    So, this bill would consolidate the boundaries of nine 
VISNs, move some oversight functions away from VISN management, 
and limit the number of employees at each VISN headquarters. 
All of this should make these networks more efficient and 
should allow resources to be reallocated to direct patient 
care.
    One other, S. 3202, is a bill Chairman Murray and I 
introduced to give VA the tools to help ensure that veterans 
and servicemembers are laid to rest with dignity and respect. 
By granting VA the authority to purchase caskets or urns when 
they otherwise would not be provided, veterans buried in 
national cemeteries can be laid to rest in a manner befitting 
their service.
    Finally, S. 3270 would create a ``look-back'' period so VA 
could consider whether someone applying for need-based pensions 
has recently transferred away assets. As the Government 
Accountability Office highlighted, there is an entire industry 
aimed at convincing veterans to move assets around in order to 
qualify for need-based pension benefits.
    That practice not only undermines the integrity of the 
pension program but can leave elderly veterans without any 
adequate resources in their greatest time of need. So, this 
bill aims to strengthen VA's pension program, while 
discouraging companies from preying on elderly veterans.
    Madam Chairman, all of these bills would provide 
commonsense solutions to real issues affecting our Nation's 
veterans, their families, and their survivors. I look forward 
to working with you and with our colleagues to see that these 
and other worthwhile bills that are on today's agenda soon 
become law.
    Again, I want to stress how important this hearing is, and 
I want to thank you for your help with Camp Lejeune 
legislation.
    Chairman Murray. Of course, thank you very much, Senator 
Burr. We have three Committee Members present. If any of you 
would like to offer an opening statement before we turn to our 
visiting Senators; Senator Isakson, Senator Brown, do you have 
an opening statements?

               STATEMENT OF HON. SCOTT P. BROWN, 
                U.S. SENATOR FROM MASSACHUSETTS

    Senator Brown of Massachusetts. Yes, I do.
    Thank you, Madam Chair. I am bouncing back and forth 
between HSGAC and this. I appreciate the opportunity.
    I want to say thank you, Senator Burr, for working on Camp 
Lejeune. It is something I am a cosponsor of. I have many 
Massachusetts families affected by that too. So, I appreciate 
your efforts and, Madam Chair, your willingness to move forward 
on that in a positive manner.
    As we know, we introduced a bill last week with Senator 
Burr, Housing for Families of Ill and Injured Veterans. It is 
pretty simple. It gives the VA the authority to award grants to 
the Fisher House Foundation for the construction of additional 
temporary lodging facilities similar to the ones which 
currently exist and that many people are aware are.
    There is even a Fisher House in Washington State, Madam 
Chair, as you are probably aware of, and today there are 21 
States and additional projects are already planned in nine 
other States.
    If you have been to Walter Reed or visited a VA medical 
center back home, you know the critical role that that facility 
plays in helping troops and their families navigate the 
difficult and often painful road to recovery.
    Our Fisher Houses in Massachusetts are an incredible asset 
for the family seeking care in our State and thankfully these 
homes create, as you all know, an instant community of support 
for our families.
    Unfortunately, the reality is that private and corporate 
charitable contributions are declining. There is a real concern 
about what is going to happen with a lot of the so-called 
deduction opportunities if charitable deductions is going to be 
one of those on the chopping block, and this has prevented 
Fisher House from producing the amount of homes required by VA 
for the foreseeable future even as demand continues to rise.
    In fact, Secretary Shinseki identified 19 medical centers 
that desperately need a Fisher House. On the other hand, the 
DOD budget is about $4 million annually to the Fisher House 
Foundation to cover the cost, and my point is I do think it is 
reasonable for the VA like DOD to put some skin in the game. 
Our bill gives the authority to do just that.
    I would also like to just make a quick reference to the 
Women's Homeless Veterans Act that Senators Heller and Burr 
recently introduced, and I was proud to cosponsor as well.
    This Committee held a hearing back in March to learn more 
about what the VA was doing on this epidemic, and we heard from 
Ms. Sandra Strickland and learned firsthand about her personal 
experiences. She testified that she was hung up on by folks at 
the VA and felt bad that VA did not go above and beyond to 
address their current needs. What is worse it is not an 
isolated case. We reference that from the GAO report.
    So, I want to obviously thank those Senators Heller and 
Burr, and I am hopeful that we will be able to move these 
matters forward.
    As I mentioned, I am back and forth between hearings, and I 
am going to hopefully come back and testify. If not, I will 
offer questions for the record.
    Thank you, Madam Chair.
    Chairman Murray. Thank you very much.
    Senator Boozman.

                STATEMENT OF HON. JOHN BOOZMAN, 
                   U.S. SENATOR FROM ARKANSAS

    Senator Boozman. Thank you, Madam Chair, and thank you, 
Ranking Member Burr, for holding this important hearing 
regarding legislation to improve the health care and benefits 
that each individual of our all volunteer force has earned 
through their sacrifice.
    I also appreciate that you have included several bipartisan 
bills in which we have been working to improve our veterans 
benefits and quality-of-life. I would really like to just take 
a few minutes to say a few words about some of this.
    First off, I want to thank Senator Franken for his hard 
work, and I want to say that I echo the sentiments that he is 
going to be expressing in a little bit.
    With so many of our veterans living in rural areas, our 
Nation has seen fit to invest significant amount of money to 
improve the accessibility and quality of the health care that 
they receive. While the research of VA Office of Rural Health 
Strategic Plan is a little step in the right direction, I think 
it is so important for us to have a clear path forward to 
improve health care for our rural veterans.
    So, I would associate again myself with Mr. Franken's 
sentiments and thank him for his continued partnership and hard 
work in addressing the issue.
    Another important bill that we have been working on is 
S. 3206 to extend Paralympic Integrated Adaptive Sports 
Program. I would also like to take this opportunity to thank 
Senator Begich for his assistance and hard work with the bill 
and so many others, many of which we will hear today, that he 
has been such a great partner on the Committee and together we 
have been able to raise awareness about the several key issues 
to help our veterans and advance legislation through Congress. 
So again, thanks to him and his staff.
    S. 3206 would reauthorize this program that despite only 
being operational for about 18 months is already serving 
wounded warriors in more than under 50 communities in 42 States 
and has collaborated with 53 VA medical centers to provide 
adaptive sports programs for our disabled veterans right in 
their communities. More than 500 partner organizations have 
come together to help provide this important service to 
thousands of our disabled veterans that have leveraged these 
Federal dollars with their own funds and expertise. This type 
of activity is so important to our wounded warriors in 
improving quality-of-life, health, self-esteem, socialization.
    Now with our recent overseas engagements winding down, it 
is more important than ever that this valued program remain in 
place with no interruption in its authorization which would 
lapse at the end of the next fiscal year under current law.
    Another bill that is important that I have been working 
with Senator Baucus on, to whom I am grateful for his efforts 
on this issue, is S. 1838. This is simple legislation, a nearly 
identical companion of which has already passed the full House 
is part of H.R. 2074.
    It would create a pilot program in which the VA would 
examine the feasibility of the service-dog training activities 
as therapies in mental health rehab programs.
    Too often many of our veterans must rely on pharmacological 
therapies for seen and unseen injuries. This is not all bad, 
but I think we need to examine alternatives to this, which is 
why I am being very supportive of programs like Rivers of 
Recovery, which recently expanded into Arkansas and that 
teaches recreational therapy through fly fishing.
    This dog-training program could be a four-way win by 
providing therapy, teaching potential vocational skills as dog 
trainers, providing highly-trained service dogs for veterans in 
need, and providing a pathway for the rescue of shelter dogs 
that meet the criteria for the service.
    For all of these reasons, I think that this modest pilot 
program is worthy of examination.
    I have also been working with Senator Begich on S. 3094, 
which is a commonsense adjustment to the definition of homeless 
veterans so that it includes veterans who are fleeing domestic 
violence situations.
    With such an increasing percentage of our veterans 
population being women, this Committee has been hard at work to 
improve programs and benefits to meet their needs; and while it 
is not only women who could fall under this adjustment, it is 
important that we get our veterans the benefits and assistance 
they need when they need them and this simple adjustment would 
help ensure that that happens.
    Finally, I would like to express my strong support for 
S. 1707, the Veteran Second Amendment Protection Act. I have 
been strongly advocating for this legislation for the past few 
Congresses, and it is high time that we have got this done.
    This bill would protect the Second Amendment rights of our 
veterans who served in uniform. Right now if a veteran is 
assigned a fiduciary to administer their benefits, they can be 
automatically deemed adjudicated as mentally defective by a 
nameless and faceless bureaucrat and be denied their Second 
Amendment rights.
    There is nothing just about this. So this legislation would 
require that a judge or a magistrate make this determination. I 
think it is commonsense and Congress should move this bill 
forward.
    So, again, thank you all very much for bringing all of 
these things forward. We appreciate your hard work.
    Chairman Murray. Thank you very much. We do have a number 
of Senators who are here to testify about the legislation. We 
welcome all of them. I will call on them in order of their 
appearance beginning with Senator Heller.

                STATEMENT OF HON. DEAN HELLER, 
                    U.S. SENATOR FROM NEVADA

    Senator Heller. Good morning. Thank you, Madam Chairwoman 
and Ranking Member Burr, for the opportunity for me to 
introduce this legislation, Senate bill 3308, the Homeless 
Women's Veterans Act, before the Committee today; and I 
appreciate your hard work and effort on behalf of the Nation's 
veterans.
    I know everybody here shares the same concerns about 
homeless veterans as I do. A couple of weeks ago I met with a 
constituent of mine, Dan Lyons, who walked from Reno, Nevada, 
to Washington, DC, to raise support for homeless veterans. A 6-
month, 2800-mile journey.
    He began walking on January 3, recording about 25 miles 
each day. This former Marine Corps veteran who served in 
Vietnam battled treacherous weather. He battled snakes and 
long, lonely miles just for the chance to sit down and ask that 
we do more to help struggling veterans.
    All too often we see clearly what is wrong with this 
society, and I think Dan reminds us of all that is right, and I 
am proud to tell his story as we discuss legislation helping 
homeless veterans. I commend his steadfast determination in 
raising awareness for those who keep us safe, and I share his 
commitment in helping veterans in need.
    Too many of our Nation's heroes are coming home from 
overseas to their homes underwater and high unemployment in 
their communities. This economy has left far too many veterans 
without work and in too many instances without a place to live; 
and while a number of veterans have fallen on tough times 
financially, some have also had difficulty adjusting to 
civilian life.
    Today there are over 100,000 veterans on America's streets, 
roughly 16 percent of the homeless adult population. Congress 
has established numerous programs to provide services to 
homeless veterans facing economic hardship.
    One program, the Grant and Per Diem Program has provided 
construction costs, transportation costs, and counseling to 
thousands of veterans and has been successful in combating 
homelessness among veterans.
    While these programs provide significant assistance to our 
Nation's veterans, there are still too many without a place to 
call home. Of particular concern is the growing number of 
homeless female veterans.
    In 1990, women made up 4 percent of all veterans. Today 
that number has doubled to 8 percent, amounting to almost 1.8 
million women. As the demographics of our Armed Services have 
changed throughout the years so too have the needs of homeless 
veterans.
    Many homeless shelters today were never designed to serve 
the needs of female veterans or homeless veterans with 
children. The funding provided by Congress specifically 
dedicated to this growing population is simply not enough to 
ensure they have a safe and secure place to stay, nor do 
existing programs allow the VA to be reimbursed for services 
provided to children of homeless veterans.
    Shelters should not have to make the untenable decision to 
either lose money or deny services to children. For these 
reasons, I join with Ranking Member Burr to introduce the 
Women's Homeless Veterans Act. I do appreciate the support of 
my friend, Senator Brown from Massachusetts, for his support on 
this legislation also.
    This commonsense legislation increases the percentage of 
funding allocated for homeless women veterans as well as 
providing the VA with the ability to reimburse shelters for 
services provided to children.
    Under this bill, at least 15 percent of funds allocated to 
the Grand Per Diem account must be directed to the special-
needs program to greater meet the needs of homeless women 
veterans. The current program does not provide an amount that 
is reflective of this growing population.
    The increased resources could be used to construct wings at 
homeless shelters that are designed specifically for the 
security and safety needs of women and children or provide more 
counseling or other rehabilitative services for female 
veterans.
    The bill also clarifies that the VA can reimburse the cost 
of dependents of veterans, ensuring that shelters providing 
services will not have to turn children of veterans away. 
Ensuring that all of our veterans and their children have a 
safe and secure place to stay is the least that we can do.
    I urge my colleagues to support this legislation to improve 
the lives of our Nation's bravest. When they have sacrificed so 
much for our country to preserve and protect our freedoms, we 
should at least ensure that their needs are met when they fall 
on hard times. I am proud that both The American Legion and the 
National Coalition of Homeless Veterans have joined in support 
of this legislation and ask that their letters of support be 
entered to into the record.

    [The letters are included in the Appendix.]

    I thank Chairman Murray and Ranking Member Burr for holding 
this important hearing. I am deeply appreciative of the 
Committee's time and look forward to continuing this important 
discussion.
    And as a finishing point, Dan Lyons, who walked for 6 
months, did take the train home. [Laughter.]
    Thank you.
    Chairman Murray. Thank you very much, Senator Heller.
    Senator Ayotte.

                STATEMENT OF HON. KELLY AYOTTE, 
                U.S. SENATOR FROM NEW HAMPSHIRE

    Senator Ayotte. Thank you Madam Chair and Ranking Member 
Burr for convening this hearing today.
    I appreciate the opportunity to testify before this 
distinguished Committee regarding the Remembering America's 
Forgotten Veterans Cemetery Act of 2012, which is S. 2320, 
which Senator Begich and I introduced earlier this year and 
which several Members of this Committee are cosponsoring. I 
would like to personally recognize and thank the Members of 
this Committee that are cosponsoring my bill who are Senators 
Akaka, Brown, Isakson and Wicker.
    From Normandy to Panama, America's veterans' cemeteries 
serve as a reminder of the extraordinary sacrifice thousands of 
brave American men and women have made on distant battlefields 
to protect our country.
    Maintaining America's veterans' cemeteries is a well-
recognized responsibility of the Federal Government, and we 
have a moral obligation to make sure that these cemeteries are 
properly cared for.
    One of those cemeteries is the Clark Veterans Cemetery in 
the Philippines which contains the remains of more than 8,300 
United States servicemembers and their dependents.
    In 1991, the United States abandoned Clark Air Force Base 
in the wake of a volcanic eruption; after 90 years of 
maintaining custodianship, the United States also unfortunately 
abandoned the graves of these brave Americans, leaving them 
unattended under a thick layer of ash.
    Over the next few years, the condition of the cemetery 
worsened, leaving the graves of our courageous veterans in an 
unacceptable state. Before you and also on the Committee 
Members' iPads are pictures of what happened to the Clark 
Veterans Cemetery, and you can see from these pictures that no 
men or women or their dependents who have served our country 
admirably should they be left, their remains, in a cemetery 
that is in this condition and not cared for by our government.
    Private volunteers became so concerned about the state of 
this cemetery that they volunteered and attempted to honor our 
servicemembers and their families buried there by maintaining 
the cemetery at their own expense, and I want to thank the 
Clark Veterans Cemetery Restoration Association and its 
president, Denis Wright, for volunteering their own time and 
resources to attempt to right this wrong and to give the 
servicemembers buried at Clark the dignity that they deserve.
    While these private citizens deserve our gratitude, the 
United States government has a moral responsibility to care for 
our veterans' cemeteries that honor the remains of those who 
have bravely served our country.
    For almost a century, the United States government cared 
for those buried at the Clark Veterans Cemetery in the 
Philippines. Now, it is time for the United States to resume 
its responsibilities.
    Our legislation would accomplish this by requiring the 
American Battle Monuments Commission to restore, operate, and 
maintain Clark Veterans Cemetery to honor the courageous 
Americans that are buried there.
    In fact, Senate Resolution 481, which passed the Senate by 
voice vote on June 5, concluded that the United States 
government should designate an appropriate United States entity 
to be responsible for the ongoing maintenance of Clark Veterans 
Cemetery.
    Military cemeteries are managed by three Federal agencies, 
the American Battle Monuments Commission and the Department of 
Veterans Affairs National Cemetery Administration, and those in 
the United States and Puerto Rico that is the agency that 
maintains our cemeteries; and military departments also manage 
cemeteries that are located on military installations.
    Of these three Federal agencies, the American Battle 
Monuments Commission, which is responsible for designing, 
constructing, operating, and maintaining permanent American 
cemeteries in foreign countries, is the most appropriate agency 
to assume responsibility for the Clark Veterans Cemetery 
because the Cemetery is a permanent American cemetery in a 
foreign country.
    Although the American Battle Monuments Commission focuses 
much of its efforts on historical cemeteries and monuments in 
Europe, the Commission also maintains a Corozal American 
Cemetery in Panama, which is very, very similar to the Clark 
Veterans Cemetery.
    I am very pleased that the military coalition, which 
represents 34 military veterans and uniformed services 
organizations totaling nearly 5.5 million members, and the 
National Military Veterans Alliance, which represents 3.5 
million members in our country, as well as The American Legion, 
the Military Officers Association, and others have written 
endorsement letters or passed resolutions supporting this 
legislation. Millions of current and former servicemembers and 
dozens of service organizations have spoken.
    They all agree. We must do the right thing for Clark 
Veterans Cemetery. Madam Chair, I would ask that these letters 
be submitted for the record.
    Chairman Murray. The information will be included in the 
record.
    Senator Ayotte. The American veterans buried in Clark 
Veterans Cemetery deserve a dignified and well-maintained final 
resting place. There is no reason that the brave servicemembers 
buried at Clark should be deprived of the honor that they have 
earned and that veterans at other cemeteries are afforded. It 
is time for the United States government to fulfill its 
responsibility to care for this sacred ground.
    Again, I would like to thank you, Madam Chair, and Ranking 
Member Burr, for agreeing to hold this hearing. I am optimistic 
that we can move forward on this legislation and ensure that 
the United States government fulfills its responsibility to 
honor the final resting ground of those who have sacrificed and 
made the alternate sacrifice many of them for our country.
    Chairman Murray. Thank you very much for your statement.

    [The letters are included in the Appendix.]

    Chairman Murray. We will turn to Senator Franken.

                 STATEMENT OF HON. AL FRANKEN, 
                  U.S. SENATOR FROM MINNESOTA

    Senator Franken. Thank you, Madam Chairwoman.
    Chairwoman Murray and Ranking Member Burr, Members of the 
Committee, thank you for the opportunity to testify on behalf 
of the Rural Veterans' Health Care Improvement Act.
    I apologize. I am going to have to leave immediately 
following my testimony today.
    I am very pleased to be working together with Senator 
Boozman on this legislation. His commitment to our Nation's 
veterans, like his unflappable disposition, is well known and 
undisputed. I am honored that he is the lead sponsor of this 
legislation which was considerably improved through his work on 
it.
    The purpose of our legislation is very straightforward and 
very important: to improve access to quality health care for 
our Nation's veterans living in rural areas.
    Like many States, Minnesota has a great many veterans who 
live in rural areas. Nationwide over 40 percent of all veterans 
enrolled in the VA system live in rural areas. That presents a 
challenge to accessing quality health care through the VA.
    To address this challenge, the VA created the Office of 
Rural Health or ORH in 2007. Congress has provided over $1 
billion in support of ORH through fiscal year 2012. That is a 
significant investment.
    But the reality and the results are not yet where they need 
to be. The funds that Congress has provided have enabled the 
Office of Rural Health to undertake hundreds of initiatives 
throughout the country.
    Unfortunately, there has been no coherent strategic plan 
for those hundreds of initiatives, and I think this speaks to 
the Ranking Member's opening statement about making sure that 
we are not wasting money and that we are not having duplicative 
plans but we are having well-thought-out, strategically-
thought-out responses to these needs.
    As a result, improvements in veterans' access to health 
care in rural areas has been piecemeal and uneven. Last year, a 
VA Inspector General found that ORH lacked reasonable assurance 
that a majority of its funds, this is amounting to $273 million 
in fiscal years 2009 and 2010, actually no assurance that they 
actually improved access to and quality of care for rural 
veterans. That is a failure. It fails our veterans and it fails 
the public that funds VA's programs.
    When we are talking about that much money and such an 
important mission, we are not going to let VA muddle through. 
We are going to demand that they get it right, and they get it 
right now.
    The ORH has an essential goal, to bring quality health care 
to veterans in rural areas. To achieve that, the VA needs to 
undertake careful, strategic planning, including the careful 
stewardship of taxpayer resources. That is the purpose of our 
legislation, which requires the VA to produce a strong and 
comprehensive strategic plan for ORH.
    Now, I appreciate that VA has taken some steps to address 
problems identified by the Inspector General's report, but 
these steps are simply not enough.
    First, the strategic plan that the VA put out, which was 
already out when the IG made its findings does not move beyond 
the piecemeal approach ORH has been taking and does not develop 
a comprehensive strategy.
    The research of the ORH plan, as Senator Boozman said in 
his opening, the research of the ORH plan that VA issued late 
last year was an improvement over the initial plan, but not yet 
enough of an improvement.
    Second, while some of the features required by our 
legislation are included in the plan that VA put out others are 
not. If ORH is to be successful, it needs to address all of the 
important goals and objectives we have identified in the 
legislation.
    The Disabled American Veterans in their testimony note a 
couple of these areas. The full and effective use of mobile 
outpatient clinics and the provision and coordination of care 
for women veterans in rural areas.
    I will add another just by way of example. I believe you 
will not find the word emergency or emergencies in the VA's 
current plan. Yet, the VA Inspector General has again and again 
reported the difficulties that many veterans in rural areas 
face trying to get care in an emergency.
    Understandably, many rural clinics are not equipped to 
handle many types of emergencies including heart attacks, 
strokes, and mental health emergencies. They simply go beyond 
the capacity of these relatively small clinics. But we know 
that emergencies will happen, and we need to be prepared.
    To address this, our legislation will require VA to ensure 
that all rural health care providers are actually identifying 
their clinical capacity and have a contingency plan for how 
they handle emergencies that exceed that capacity.
    That way, if a veteran shows up with a mental health 
emergency, for example, he or she will really get the best care 
possible in addressing that emergencies. We cannot have 
veterans committing suicide or suffering intense psychological 
anguish because they could not get care.
    I have also heard some Minnesota County veterans' services 
officers about veterans who get taken to a hospital for a heart 
attack because the VA clinic does not have an emergency room 
and then have real trouble getting reimbursed, getting it 
covered. They have to pay for it themselves. The coordination 
of care that our bill promotes will also make that situation 
far less likely.
    Finally, finally, our bill brings much-needed 
accountability to the VA's Office of Rural Health. I appreciate 
that VA wants ORH to achieve its mission. This legislation will 
make that happen and happen faster. I would also note that the 
Appropriations Committee in its report accompanying the 
military construction/VA appropriations express its belief, 
quote, that ``the VA must do more to plan for and provide 
quality health care to veterans living in rural and highly 
rural areas.''
    ORH is dedicated to the provision of health care to rural 
veterans, and the Congress has provided substantial funds for 
that very important purpose. But thus far the results have not 
been good enough and this speaks so clearly, I think, to what 
the Ranking Member said in his opening.
    Our legislation will ensure that the VA improves access to 
care for rural veterans so they can get the excellent health 
care that they deserve. We owe them nothing less. Thank you.
    Chairman Murray. Thank you, Senator Franken.
    With that, we will turn now to Senator Wyden.

                 STATEMENT OF HON. RON WYDEN, 
                    U.S. SENATOR FROM OREGON

    Senator Wyden. Thank you, Madam Chair.
    Madam Chair, I would ask first that my statement, my 
statement's entirety could be put in the record and perhaps I 
could just summarize. I know you have additional colleagues who 
are waiting to testify.
    Chairman Murray. Absolutely. Every Senator's statement will 
be printed in the record.
    Senator Wyden. Thank you, Madam Chair, and first of all, 
Madam Chair, as your Pacific Northwest neighbor, let me just 
thank you for the extraordinary advocacy that you have brought 
to the cause of veterans. I get to see it, and most recently 
the work that you are doing now to up the ante in the fight 
against PTSD is extraordinarily important. I want you to know I 
appreciate it and want to help.
    And to Senator Burr, my friend, we have worked together for 
a lot of years on these kinds of issues, and you have just been 
tireless and a terrific partner, and I thank you for it.
    Madam Chair, what Senator Burr and I are sponsoring is 
S. 3270. This is a piece of legislation that comes about as a 
result of a lengthy undercover investigation done by the 
Government Accountability Office. It was done on behalf of 
Senator Burr, yourself, and several of us from the Senate Aging 
Committee.
    So, lots of times around here you cannot get one Committee 
to agree. We have now been able to get two committees to work 
together in a bipartisan way.
    The heart of the problem and what the GAO found, and I 
started looking at some of these senior abuses, you know, years 
ago when I was codirector of the Oregon Gray Panthers and the 
Senior Citizens Law Program, is they really uncovered some of 
the sleaziest practices in terms of older veterans that I have 
seen in the years that I have spent working in this field.
    What it essentially involves is a program called Aid and 
Attendance. This program is essentially a lifeline for the 
poorest and most vulnerable who have served our country. It is 
for very sick veterans, folks who are no longer able to care 
for themselves and do not have the resources to pay for their 
care.
    What you have is essentially several hundred financial 
firms. They are called pension poachers, and we see them around 
the country basically trying to find ways to either talk these 
vulnerable veterans out all their resources or tie up their 
assets in a way that is good for the financial firm.
    These case, just to highlight, that we saw in our hearings 
was one from Montana. A veteran there was referred by the 
management of the retirement home to one of these pension 
poaching companies from Mississippi for assistance with the Aid 
and Attendance benefit.
    So, what the poachers did was charge the veteran a very 
substantial sum, $2,500, to fill out the application paperwork 
that they essentially can get for free, and it was eventually 
filed with the VA but it was denied because the paperwork was 
never actually signed by the veteran.
    What the poachers did, however, and this is a very common 
kind of practice, is to get the veteran's signature on a power 
of attorney and that way they can tie up their assets in one of 
these corporations that are located out of State.
    That has been a special magnet for these pension poachers. 
They try to sell these inappropriate financial instruments, 
deferred annuity, certain types of trusts. That way they can, 
in effect, benefit while the veteran's money, in effect, 
becomes unusable during the veteran's lifetime.
    So, what the Government Accountability Office recommended, 
you know, Madam Chair, was the establishment of a look-back 
approach similar to what has been used for years with Medicaid 
or Social Security.
    This would take away the incentive for the pension poacher 
to target older veterans. Senator Burr and I have joined in 
sponsoring this bill. It is legislation that would, in effect, 
implement the recommendations from the Government 
Accountability Office that come from this undercover 
investigation.
    For colleagues who would like to see the tapes of this 
undercover inquiry, Senator Burr and I can make it available to 
you. But I will tell you that having worked in this field now 
for many years and going back to the days with Gray Panthers 
and always watching how unfortunately there are some people out 
there who try to rip off older people and here they are ripping 
off older veterans.
    This is some of the sleaziest stuff I have ever seen. We 
ought to take away the incentive to rip off the people who 
desperately need this benefit.
    My sense is in this kind of financial climate, and the 
Chair of the Committee did important work on the Super 
Committee, if people keep ripping off this program, people are 
going to say, well, maybe this is something we should not have 
any longer.
    Senator Burr and I want to make sure that this program 
remains for the most needy and most vulnerable and that is why 
I very much appreciate the chance to come here.
    I know Senator Boxer and Senator Portman are waiting. If 
the rest of my remarks could be put into the record, I would 
very much appreciate it.
    Chairman Murray. We will do that. Thank you very much, 
Senator Wyden.
    Senator Wyden. Thank you, Madam Chair, Senator Burr.
    [The prepared statement of Senator Wyden follows:]
     Prepared Statement of Hon. Ron Wyden, U.S. Senator from Oregon
    Chairman Murray and Senator Burr, I want to thank you for allowing 
me the time to appear before the Committee on Veterans' Affairs today.
    The legislation that I'm here today to discuss is the result of the 
great bipartisan efforts of the two of you and well as this Committee 
and the Senate Committee on Aging. I think this demonstrates the 
importance of this issue.
    Senator Burr, you especially have been a relentless driving force 
behind this bill, and I'm honored to have introduced it with you.
    As you'll recall, a few weeks ago the Senate Special Committee on 
Aging held an investigative hearing on scams targeting elderly veterans 
using a specific VA pension as a lure.
    The Aging Committee found that some financial planners, lawyers and 
others are using the VA's ``enhanced pension with aid and attendance,'' 
or simply, Aid and Attendance, to enrich themselves at our veterans' 
and taxpayers' expense.
    What makes this even worse is the fact that Aid and Attendance was 
specifically designed to help infirm and impoverished elderly veterans, 
so many of the victims of these pension poachers are the ones who can 
afford it least.
    At the hearing, the Government Accountability Office testified 
about the undercover investigation they conducted at the request of 
Senators Murray, Burr, Kohl and I. They found versions of this scam 
nationwide, with over two hundred pension poaching companies in 
operation.
    GAO's recommendation to Congress was the establishment of a look-
back period, similar to Medicaid or Social Security, to take away the 
incentive for the Pension Poachers to target elderly veterans, and 
preserve this benefit for the veterans it is intended to help.
    This recommendation has been echoed by veterans' advocacy groups 
and the VA itself.
    Senator Burr and I authored S. 3270, which would provide this look-
back. We worked closely with the VA and other experts to ensure our 
bill fixes the problem, but does not create collateral damage like an 
increased backlog of claims.
    We knew we had to drain the swamp and get rid of these pension 
poachers, but we also had to ensure the benefits our veterans need 
would be accessible quickly and without excessive red tape.
    We also didn't want to inadvertently punish veterans who were 
misled by the false or inaccurate promises, so we've included specific 
waiver authority to address this.
    ``Aid and Attendance'' is an invaluable lifeline for many veterans. 
This program is for the very sick--veterans who are no longer able to 
care for themselves and who do not have the resources to pay for care. 
It is a benefit intended to ensure that those who served their nation 
with honor can live out their final days in dignity.
    I believe the bill that Senator Burr and I have introduced, which 
already has strong bipartisan support, will preserve the Aid and 
Attendance benefit, while protecting our veterans from pension poachers 
who are driven only by greed.
    I'm pleased to announce we've received formal support from AMVETS, 
recognizing the importance of this legislation in protecting our 
veterans.
    We've also received a letter from the Assisted Living Federation of 
America, supporting this bill and pledging to help in the development 
of industry best practices to further ensure veterans are treated with 
the integrity they deserve.
    I hope that this Committee will support this legislation, and help 
put an end to the malicious practices of these pension poachers.

    Chairman Murray, Thank you again for the time to speak this 
morning. I truly appreciate your consideration of such an important 
matter.

    Chairman Murray. Senator Boxer.

               STATEMENT OF HON. BARBARA BOXER, 
                  U.S. SENATOR FROM CALIFORNIA

    Senator Boxer. Madam Chairman, Ranking Member Burr, and 
Members of the Committee, my friends, you know, I am in the 
middle of some very interesting negotiations right now that are 
looking good; but even though that is the case, I want you to 
know how honored I am to be sitting here listening to my 
colleagues come forward with such good ideas, and to have this 
forum is such an honor.
    I just want to say, I am in awe of the Chairman for the 
work she is doing and the Ranking Member beside her, and to 
serve with the Ranking Member as the Chair of the Military 
Families Caucus is a great honor.
    So, I come here and I will stick within the time limit 
because I know how much work you have to do, and that you have 
to hear from a lot of people. I came here to talk to you about 
the epidemic of veteran homelessness and to offer an idea that 
does not cost any money that I think would be terrific 
involving the American people in fighting this epidemic.
    You know, I would say probably all of those in this room--I 
certainly hope all of us in this room--have safe, comfortable, 
permanent homes to live in, and we take it for granted. Yet 
every night 67,500 of our Nation's veterans are homeless. 
Again, 67,500 of our veterans are homeless. This is inexcusable 
because no veteran should ever have to spend the night on the 
streets, and I know we all agree with that.
    Ensuring that our veterans have safe, stable housing is 
also a smart thing to do because research has shown that a home 
is the very foundation on which a veteran can build and sustain 
a successful life.
    In my homestate of California I met a veteran, Holbert Lee. 
When Mr. Lee returned home from Vietnam, he ended up addicted 
to drugs and homeless on the streets of San Francisco.
    We have an organization there called Swords to Plowshares, 
and they helped him turn his life around, Madam Chairman. With 
the help of a housing voucher and VA support services, Mr. Lee 
now has a home to call his own; and today as a vocational 
specialist at the San Francisco VA. He is working to assist 
other veterans.
    Holbert Lee is a success story and proof of what can happen 
when we end a cycle of homelessness. But there are too many 
more men and women who we have not reached.
    Now, our government announced a goal to end veterans' 
homelessness by 2015, and I would like to think when we 
announce a goal like that we mean it. This is not just 
something we throw out but yet Secretary Shinseki admitted, 
quote, while we are not where we need to be just yet, we have 
movement, but it is too early to begin high-fiving one another.
    It is clear from those words that we have a long way to go. 
So, I introduced S. 1806, the Check the Box for Homeless 
Veterans' Act of 2011. Very straightforward. It creates a 
check-off box on the annual Federal tax return. Taxpayers can 
decide to make a voluntary contribution of one dollar or more 
to support programs that prevent and combat veterans' 
homelessness.
    The donations are deposited in a new homeless veterans' 
assistance fund established at the Treasury that can only be 
used to supplement Congressionally appropriated funds for these 
various programs to help veterans.
    Now, let me be very clear. These funds in the check-off box 
will not be allowed by law to replace any budgeted dollars. 
There needs to be a maintenance of effort but they would be 
used to supplement those dollars.
    So, colleagues, I want to say, well, before I do my real 
close, I want to place in my record with your permission, Madam 
Chair, letters of support from the Veterans Foreign Wars, from 
the National Coalition for Homeless Veterans, from Team AMVETS, 
from the Center for American Homeless Veterans, Inc., and from 
the California Association of Veterans Services, and Swords to 
Plowshares. Might I put those in the record?
    Chairman Murray. We will do that.

    [The letters are included in the Appendix.]

    Senator Boxer. And I think if you read these letters, they 
strongly support this approach.
    So, in conclusion, I would say that our veterans have given 
so much. You are dealing with this every day and a lot of them 
suffer and they suffer mightily and having a home is the least 
we can do, and I think that all Americans want a chance to 
help. They feel sometimes helpless but with a dollar and a 
check off if every American paying, you know, their taxes did 
that we could do something special.
    I hope you will consider this. I will work with you to make 
it happen. I thank you for your dedication.
    Chairman Murray. Thank you very much.
    We will turn to Senator Portman.

              STATEMENT OF THE HON. ROB PORTMAN, 
                     U.S. SENATOR FROM OHIO

    Senator Portman. Thank you, Madam Chair, I appreciate it. I 
got used to calling you Madam Chair in another little Committee 
we served on.
    Chairman Murray. I remember it.
    Senator Portman. This one is more super than that one was.
    [Laughter.]
    Chairman Murray. And I agree.
    Senator Portman. Thank you what you do every day for our 
veterans, and Ranking Member Burr, I was just with him in North 
Carolina recently, another champion for our veterans. Senator 
Isakson and Senator Boozman who testified on the floor last 
night about veterans.
    I am here to ask you to support this bill, S. 2244, the 
Veterans Missing America Act. It has been a privilege to work 
with my colleague, Senator Begich, on this, and it helps bring 
light to a critical issue that many of us are becoming aware 
of.
    At funeral homes and mortuaries all across this great 
country, thousands of veterans ashes and remains go abandoned, 
unclaimed; and in response to these unfortunate circumstances, 
a handful of veterans service volunteers began this project 
called Missing in America Project. It is a terrific group of 
volunteers who have been very active in my homestate of Ohio, 
and I am sure in many of your States.
    Regrettably, when individuals pass away, and there is no 
next of kin identified, the remains sometimes stay at funeral 
homes or mortuaries, without anyone laying them to rest, 
indefinitely.
    Of the hundreds of thousands of unclaimed remains in this 
country, it is estimated that over 10,000 are remains of our 
veterans. The Missing America Project tries to identify anyone 
who is a veteran among those unclaimed remains and then provide 
a proper burial and funeral.
    Sometimes these dedicated volunteers have run into 
bureaucracy and complications because they tried to do that. It 
is a noble cause but, due to limitations on third-party 
involvement, it has become difficult for them.
    So, this legislation attempts to address these 
complications, recognizing their tireless work and dedication 
and in cooperation with numerous veterans service organizations 
have put together a legislative approach here that we think 
will help identify unclaimed remains and ensure that the 
Department of Veterans Affairs will work with these volunteers 
to see every veteran receives the respect that they deserve.
    As I mentioned, in Ohio we have taken a leadership role on 
this. Despite some of these roadblocks we are talking about we 
are trying to fix today, the Department of Veterans Affairs in 
Ohio, along with these volunteers from the Missing America 
Project, have had an initial burial of 10 veterans at the 
Dayton National Cemetery in May of this year.
    These were veterans of World War I, World War II, and 
Korea; and in this case, the remains had been at funeral homes 
for between 15 and 25 years.
    It was a very moving ceremony. There were a few hundred 
people who showed up to pay their respects, none of whom knew 
the veterans but they were there to pay their respects for 
their service to our country.
    Although we have had some successes like those, the work of 
these volunteers is encumbered by the Department of Veterans 
Affairs next-of-kin requirements. The bill, therefore, directs 
the Secretary of Veterans Affairs to work with veterans service 
organizations to assist entities in identifying veterans 
eligible for burial in a national cemetery.
    If the remains are of an eligible veteran, the Secretary of 
the Department of Veterans Affairs is then required to provide 
the burial benefits already authorized to that veteran.
    It is important to note to this Committee that since we 
introduced the legislation with Senator Begich in March and 
along with our counterparts in the House, there is companion 
legislation in the House, we have worked closely with the 
Department of Veterans' Affairs to ensure the measure is 
appropriately worded to meet the sheer intent that we have; and 
through those discussions and their technical suggestions, we 
have amended the language including refining the burial 
eligibility criteria to ensure that benefits are provided to 
qualifying veterans.
    We stand ready to submit these technical amendments and 
refinements to the Committee during your markup of the bill. 
Our intent is to add no new spending through this provision and 
we will work with the Committee very closely and, of course, 
with the Department to achieve that goal.
    I am proud to say that the National Association of State 
Directors of Veterans Affairs has expressed support for the 
Missing America Project and has urged our Nation's leaders to 
take action. Additionally, this effort has the support of the 
National Funeral Directors Association and The American Legion.
    Those who gave their life in service to our country deserve 
an honorable burial, and this bill is a step toward ensuring 
that eligible veterans do receive that burial in a national 
cemetery given the respect that they rightly deserve.
    Thank you very much for the opportunity to testify on that 
this morning, and I look forward to working with the Committee 
on this going forward along with all of the other good work 
that you are doing.
    While I am here, Madam Chair, I would also like to thank 
you for having S. 3238 on the docket this morning. This measure 
would designate the Department of Veterans Affairs Community 
Based Outpatient Clinic in Mansfield, Ohio, in the name of 
Private First Class David F. Winder. I am pleased to cosponsor 
this measure along with Senator Sherrod Brown as we seek to 
honor this Metal of Honor recipient from Vietnam who provided 
medical aid to his soldiers in Vietnam and died in doing so.
    So again, thank you for your help on both of these 
important pieces of legislation, and I look forward to working 
with the Committee further.
    Chairman Murray. OK. Thank you very much.
    I will just let all the Senators know who have been 
testifying today that we are going to be working with them and 
their staff and the Administration on all of these bills.
    As Senator Burr mentioned, we do have to pay for all of the 
legislation that comes before this Committee. So, we have a lot 
of work to do, but we will be scheduling a markup on all of 
these pieces of legislation toward the middle of July, and I 
will be working with Senator Burr on that. So, thank you very 
much.
    At this time then, I would like to welcome and introduce 
our first panel. From the Department of Veterans Affairs, we 
have Dr. Madhulika Agarwal, the Deputy Under Secretary for 
Health Policy and Services at the Veterans Health 
Administration.
    Also joining us today from the VA is Thomas Murphy, 
Director of the Compensation Service at the Veterans Benefits 
Administration. Accompanying Dr. Agarwal and Mr. Murphy is 
Deputy Under Secretary for Health for Operations and Management 
at the Veterans Health Administration William Schoenhard, as 
well as Jane Claire Joyner and Richard Hipolit from the Office 
of General Counsel.
    We appreciate all of you being here today.
    The Department's full statement will be entered into the 
record and, Dr. Agarwal, please begin.

  STATEMENT OF MADHULIKA AGARWAL, DEPUTY UNDER SECRETARY FOR 
  HEALTH POLICY AND SERVICES, VETERANS HEALTH ADMINISTRATION, 
              U.S. DEPARTMENT OF VETERANS AFFAIRS

    Dr. Agarwal. Chairman Murray, Ranking Member Burr, and 
other Members of the Committee, thank you for the opportunity 
to address the health care bills on today's docket.
    My colleague, Mr. Murphy, will address the VBA bills under 
consideration. I will highlight some of the critical issues 
that are themes of many of the bills on the agenda and a 
detailed discussion of these bills can be found in my written 
statement.
    First, Chairman Murray, thank you for your continued 
efforts to emphasize the health care needs of women veterans. I 
am proud of VA's efforts in improving women's health, and I 
know we can make further enhancements working with the 
Committee.
    Your bill, S. 3313, the Women's Veterans Health and Other 
Care Improvement Act, among other features includes 
reproductive health issues. The VA's goal is to restore the 
capabilities of veterans with disabilities to the greatest 
extent possible. VA does not yet have a position on S. 3313 but 
we have had productive discussions with your staff which we 
look forward to continuing.
    Second, several bills address programs for rural veterans. 
VA is committed to improving access and quality of health care 
for this population. My written testimony outlines what VA is 
doing to meet this challenge, including greater use of 
telehealth technologies and collaboration with other Federal 
and State agencies and community providers to provide more 
points of care.
    This work is especially important to increase access to 
mental health services for veterans in rural areas. We note in 
our testimony that some features of the bills would overlap 
with our current efforts. We will be glad to discuss how we can 
best advance the goals of the legislation before us.
    Third, while we do not have views today on S. 3340 
regarding the Mental Health ACCESS Act of 2012, we will follow-
up with the Committee as soon as possible.
    We fully recognize there is no more critical need than 
effective and timely mental health care. We strive to improve 
all facets of mental health services. To increase our capacity 
to meet current and future demand, we have launched a new 
hiring initiative to increase staff, and we will continue our 
efforts to increase access to quality mental health care.
    Fourth, we regret we do not have a position this morning on 
S. 3049 which expands the definition of homelessness. We will 
provide information on that to the Committee as soon as 
possible.
    Let me assure the Committee that whatever the technical 
considerations may be on a statutory definition, VA never would 
and never will turn away a homeless veteran who finds 
themselves on the street because they are fleeing domestic 
violence.
    Finally, turning to Ranking Member Burr's legislation on 
VISN reorganization, we have been working for the past year to 
review VISN operations.
    My written testimony describes these ongoing efforts, and 
we would like to brief the Committee in greater detail on these 
plans. We believe S. 3804 is too prescriptive in legislating 
particular boundaries and structures and Mr. Schoenhard will be 
glad to discuss this issue.
    Madam Chairman, this concludes my statement. Mr. Murphy 
will now address the pending VBA legislation and we will then 
be ready to answer your questions.
    Chairman Murray. Mr. Murphy.

  STATEMENT OF THOMAS MURPHY, DIRECTOR, COMPENSATION SERVICE, 
 VETERANS BENEFITS ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
   AFFAIRS; ACCOMPANIED BY WILLIAM SCHOENHARD, DEPUTY UNDER 
 SECRETARY FOR HEALTH FOR OPERATIONS AND MANAGEMENT, VETERANS 
 HEALTH ADMINISTRATION; JANE CLAIRE JOYNER, OFFICE OF GENERAL 
    COUNSEL; AND RICHARD HIPOLIT, OFFICE OF GENERAL COUNSEL

    Mr. Murphy. Chairman Murray, Ranking Member Burr, and other 
Members of the Committee, thank you for the additional time to 
comment on the extensive agenda before us today. As Dr. Agarwal 
did, I will only touch on a few highlights, as you have our 
detailed testimony for the record.
    VA wholeheartedly supports Senate Bill 2259, the Veterans 
Cost of Living Adjustment Act. It would express in a tangible 
way this Nation's gratitude for the sacrifices made by our 
service-disabled veterans and their surviving spouses and 
children and would ensure that the value of their well-deserved 
benefits will keep pace with the increased cost of living.
    Two bills on the agenda concern the burial needs of the 
indigent veterans whose remains are unclaimed. Senate Bill 
2244, the Veterans Missing in America Act and Senate Bill 3202, 
the Dignified Burial of Veterans Act.
    VA appreciates the Committee's continued attention to 
ensure that these veterans, including, no doubt, homeless 
veterans, are honored and are not forgotten. We look forward to 
continuing to work with you to ensure that all veterans receive 
dignified and respectful burials, which they earned through our 
service to our Nation.
    We are supportive of these efforts and welcome discussions 
with the Committee on those few points in the testimony where 
he recommend improvements in the bill.
    For Senate Bill 1707, the Veterans Second Amendment 
Protection Act, we appreciate the objectives of this 
legislation to protect the firearms rights of veterans 
determined by VA to be unable to manage their own financial 
affairs.
    VA determinations of mental incompetency are based 
generally on whether a person lacks the mental capacity to 
manage his or her own financial affairs due to injury or 
disease. We believe that there are adequate protections in the 
law now such that a veteran with a determination of 
incompetency has two procedures available to make a showing to 
restore his or her ability to purchase a firearm.
    In the interest of time, I will then herein refer the 
Committee to my written statement. I would be happy to answer 
any questions you or the Members of the Committee may have.
    [The prepared joint statement of Dr. Agarwal and Mr. Murphy 
follows:]

Prepared Statement of Dr. Madhulika Agarwal, Deputy Under Secretary for 
 Health for Policy and Services, Veterans Health Administration, U.S. 
                     Department of Veterans Affairs

    Chairman Murray, Ranking Member Burr, and other Members of the 
Committee, I am pleased to provide the views of the Department of 
Veterans Affairs (VA) on pending legislation. Joining me today are Tom 
Murphy, Director, Compensation Service, Veterans Benefits 
Administration; William Schoenhard, Deputy Under Secretary for Health 
for Operations and Management, Veterans Health Administration; Jane 
Clare Joyner, Deputy Assistant General Counsel; and Richard Hipolit, 
Assistant General Counsel.
    VA regrets not having sufficient time to formulate views for 
S. 1391; S. 3049; S. 3206; S. 3270; S. 3238; S. 3282; S. 3308; S. 3309; 
S. 3313; S. 3316; S. 3324; S. 3336; a draft bill to amend title 38, 
United States Code, to improve the multifamily transitional housing 
loan program of the Department of Veterans Affairs; and a draft bill 
entitled the ``Mental Health Access to Continued Care and Enhancement 
of Support Services Act of 2012'' or ``Mental Health ACCESS Act of 
2012.'' VA will provide views for these bills at a later date.
              s. 1264--veteran voting support act of 2011
    VA has a tradition of successfully supporting and facilitating 
Veteran voting, without disrupting the delivery of health care and 
services to Veterans. Facilities use posters and flyers to emphasize 
the issue of voting to patients and visitors, and VA volunteers assist 
Veterans in registering to vote. VA facilitates transportation to the 
polls for Veterans to vote, using VA resources and volunteers. VA 
tracks these voter registration and facilitation activities.
    The Department's voter assistance policy (VHA Directive 2008-053) 
focuses on Veterans who are inpatients at VHA facilities. Under this 
directive, Veterans staying at VA facilities are currently provided the 
same type and level of assistance and support that would be required 
under the bill. During the 2008 election cycle more than 9,000 posters 
were placed at VA facilities, more than 225,000 flyers were provided to 
new inpatients through their welcome packets and comfort kits, and 
1,100 volunteers were recruited specifically to provide voter 
information and assistance to Veterans. VA also partnered with non-
partisan groups to conduct more than 80 informational ``voter drives.'' 
As a result, close to more than 5,900 inpatients received assistance in 
registering to vote. While not a principal focus, voter assistance does 
reach Veterans using outpatient services as well.
    Section 3 of this bill would require VA to provide a ``mail voter 
registration application'' to each Veteran seeking enrollment in VA 
health care and to all enrolled Veterans any time there is a change in 
enrollment status or address. It would also require VA to provide 
assistance with voter registration to Veterans unless they refuse such 
assistance, and would require VA to accept completed voter registration 
forms and transmit them to the appropriate state election official 
within 10 days of receipt (unless they are received within 5 days of 
the registration deadline, in which case they must be sent within 5 
days). Section 3 also would prohibit VA from influencing Veterans or 
displaying any political preference and would prohibit VA's use of this 
information for any purpose other than voter registration. The bill 
would allow anyone aggrieved to provide notice of the violation to the 
facility director or the Secretary and would require the director or 
the Secretary to respond within 20 days. If a violation is not 
corrected within 90 days, the aggrieved person may provide written 
notice to the Attorney General and Election Assistance Commission. 
Section 3 also authorizes the Attorney General to bring a civil action 
for violations.
    Section 4 would require VA, consistent with state and local laws, 
to assist Veterans residing in VA facilities with absentee balloting. 
Section 5 would require the Secretary to permit nonpartisan 
organizations to provide voter registration information and assistance 
at Department health care facilities, subject to reasonable 
limitations.
    Section 6 would similarly prevent VA from prohibiting any election-
administration official from providing voter information to Veterans at 
any VA facility. Moreover, it would require VA to provide reasonable 
access to VA health care facilities to state and local election 
officials for providing nonpartisan voter registration services. 
Section 7 would require VA to submit an annual report to Congress on 
the agency's compliance with this Act as well as the number of Veterans 
served by VA's health care system, the number of Veterans who requested 
information or assistance with voter registration, the number who 
received information or assistance, and information regarding notices 
of violations.
    As noted previously, VA is committed to helping Veterans exercise 
their right to vote, and, especially in recent years, has increased the 
non-partisan assistance provided to Veterans. While VA applauds the 
bill's goals, it opposes S. 1264 as it is overly burdensome and, in 
some respects, duplicates the agency's existing voter assistance 
efforts.
    As described above, Section 3 of the bill would require VA to 
provide a voter registration application form to each Veteran who seeks 
to enroll, and to enrolled Veterans any time there is a change in the 
enrollment status of that Veteran, or a change in the address of the 
Veteran. As VA facilities treat patients from multiple jurisdictions 
under a national system, implementing these requirements would be 
extraordinarily complicated. Under this national system, Veterans have 
the ability to use VA facilities not necessarily in their home 
jurisdiction. It would require VA to keep and apply authoritative 
information on elections, voter registration deadlines, and voter 
registration requirements in all 50 states.
    The multi-jurisdictional nature of VA also creates complications 
for providing the assistance with absentee ballots outlined in Section 
4 of S. 1264; however, Section 4 is limited to Veteran inpatients, 
those residing in Community Living Centers, and domiciliaries.
    This bill would also require the Secretary to permit nonpartisan 
organizations to provide voter assistance at facilities of the VA 
health care system. In addition, S. 1264 provides that the Secretary 
shall not prohibit any election official from providing voting 
information to Veterans at any facility of the Department of Veterans 
Affairs. Though the legislation allows VA to set reasonable time, place 
and manner restrictions on visits by election officials and nonpartisan 
groups, it is not clear that VA could entirely exclude election 
officials from certain facilities. There are some places within VA, 
such as National Cemeteries, psychiatric facilities, and Vet Centers, 
which are not appropriate locations for voter information and 
assistance activities from outside entities. Moreover, the definition 
of election official is overly broad as it could be interpreted to 
include volunteer ``election judges'' or ``election monitors'' who are 
assigned by campaigns or political parties to watch polling locations 
for irregularities on the day of an election. Directive 2008-053 
currently provides nonpartisan organizations and election officials 
access to VA health care facilities for the purpose of providing voter 
information and assistance.
    The costs for the requirements of this bill are significant. They 
include an initial mail-out to approximately 8.2 million enrollees at a 
cost of $5.3 million and estimated recurring costs of $1.2 million 
annually. VHA would have to create a Voter Assistance Program in VA 
Central Office and in the field to support the proposed legislation. VA 
estimates the entire cost of implementing S. 1264 would be $26.0 
million in FY 2013, $6.1 million in FY 2014, $113.3 million over 5 
years, and $242.4 million over 10 years.

    S. 1631--A BILL TO AUTHORIZE THE ESTABLISHMENT OF A CENTER FOR 
     TECHNICAL ASSISTANCE FOR NON-DEPARTMENT HEALTH CARE PROVIDERS 
               FURNISHING CARE TO VETERANS IN RURAL AREAS

    Section 1(a) of S. 1631 would authorize the Secretary of Veterans 
Affairs to establish a center responsible for providing technical 
assistance to non-VA health providers who furnish care to Veterans in 
rural areas. Were the Secretary to exercise this authority, section 
1(b) of the bill would permit VA to refer to the center as the ``Rural 
Veterans Health Care Technical Assistance Center'' (the ``Center''). It 
would also require the Secretary to appoint a Director for the Center 
from candidates who are qualified to carry out the duties of the 
position and who possess significant knowledge and experience working 
for, or with, a non-VA health care provider that furnishes care to 
Veterans in rural areas.
    Section 1(c) of S. 1631 would require the Secretary of Veterans 
Affairs to select the location of the Center and, in doing so, to give 
preference to a location that meets a set of detailed criteria relating 
to available infrastructure and a high number of Veterans in rural and 
highly rural areas, among other factors.
    Section 1(d) of S. 1631 would require the Center to carry out the 
following tasks:

     Develop and disseminate information, educational 
materials, training programs, technical assistance and materials, and 
other tools (1) to improve access to health care services for Veterans 
in rural areas and (2) to otherwise improve health care provided to 
Veterans by non-VA health care providers;
     Improve collaboration on health care matters, including 
the exchange of health information, for Veterans receiving health care 
from both VA and non-VA providers serving rural populations;
     Establish and maintain Internet-based information on 
mechanisms to improve health care for Veterans in rural areas 
(including practical models, best practices, research results, and 
other appropriate information);
     Work with existing Government offices and agencies, 
including those specified in the bill, on programs, activities, and 
other mechanisms to improve health care for rural Veterans;
     Track and monitor fee expenditures incurred by VA in using 
non-VA health care providers to serve rural populations; and
     Evaluate the Center through the use of an independent 
entity that is experienced and knowledgeable about rural health care 
matters, non-VA providers serving rural populations, and VA programs 
and services.

    Finally, section 1(e) of S. 1631 would authorize the Center, in 
discharging its functions, to enter into partnerships with: (1) persons 
and entities that have demonstrated expertise in the provision of 
education and technical assistance to Veterans in rural areas; (2) 
health care providers serving rural populations; and (3) persons and 
entities seeking to enter into contracts with the Federal Government in 
matters relating to functions of the Center (including the provision of 
education and technical assistance relating to telehealth, 
reimbursement for health care, improvement of quality of care, and 
contracting with the Federal Government).
    VA appreciates the aims of this legislation, but does not support 
S. 1631. VA's Office of Rural Health (ORH) currently supports a number 
of programs and initiatives that are accomplishing many of the 
activities proposed for the Center for Technical Assistance. 
Specifically, ORH currently funds ``The Health and Resource Initiative 
for Veterans Everywhere (THRIVE) On-Line,'' a collaboration with 
Stanford University School of Medicine, eCampus Rural Health, and VA 
Palo Alto Health Care Systems. THRIVE also partners with multiple VA 
services and community agencies. Participating VA staff are from a 
number of complementary Department programs, such as mobile medical, 
homeless outreach, Operation Enduring Freedom/Operation Iraqi Freedom/
Operation New Dawn (OEF/OIF/OND), women's outreach, and incarcerated 
Veterans re-entry teams. Successful partnerships have been established 
with local homeless shelters, employment agencies, and county health 
clinics. THRIVE On-Line also provides technical assistance, materials, 
and other tools to VA and non-VA providers alike, to improve the health 
care of our Veterans in rural areas.
    In addition, ORH currently funds three Veterans Rural Health 
Resource Centers (VRHRCs). These centers function as field-based 
clinical laboratories for demonstration projects. A number of these 
projects are focused on developing models of care as well as innovative 
clinical practices and systems of care for rural Veterans. The VRHRC--
Western Region is located in Salt Lake City, Utah. Much of the work of 
this center focuses on outreach, access issues, and the special needs 
of Native American Veterans and aging Veterans. One of its major 
efforts has been to establish an outreach program to build partnerships 
with community agencies and organizations that serve rural communities. 
Through these partnerships, rural Veterans receive information about, 
and assistance in identifying, VA benefits for which they may be 
eligible. The VRHRC--Central Region is located in Iowa City, Iowa. This 
center focuses on evaluating rural health programs and piloting new 
strategies to help Veterans overcome identified barriers to access to 
(quality) care. The VRHRC--Eastern Region has three locations: 
Gainesville, Florida; Togus, Maine; and White River Junction, Vermont. 
Their collective focus is on developing models to deliver specialty 
care and services to rural areas and on educating and training VA's 
next generation of rural health care providers. VRHRC staff members 
also serve as rural health experts for VA providers Nation-wide, and 
they provide training and education services to both VA and non-VA 
providers caring for rural Veterans.
    ORH also funds and oversees Veterans Integrated Service Network 
(VISN) Rural Consultants (VRCs). There is a VRC in each VISN that 
serves as the primary interface for ORH, the VISN, and the community 
regarding rural activities. The VRCs work closely with internal and 
external stakeholders to introduce, implement, and evaluate ORH-funded 
projects. The VRCs are also instrumental in conducting outreach to 
develop strong partnerships with community members, state agencies, 
rural health providers, and special interest groups. Since being 
established, ORH has funded well over 500 projects across the VA health 
care system. These projects cover a myriad of areas, such as education, 
home-based primary care, long-term care, mental health, case 
management, telehealth, primary care, and specialty care. ORH also 
funds ``Project Access Received Closer to Home (ARCH),'' which is a 3-
year pilot program to provide health care services to rural Veterans 
through contractual arrangements with non-VA care providers.
    VA has also recently drafted a memorandum of understanding (MOU) 
between the Department of Veterans Affairs (VA's Office of Rural 
Health) and the Department of Health and Human Services (Offices of the 
National Coordinator for Health IT and Rural Health Policy) to ensure 
interoperability between VA and rural health care providers to allow 
and promote the effective exchange of health information.
    Information on practical models, best practices, research results, 
and other appropriate information on mechanisms to improve health care 
for Veterans in rural areas, is already available on the ORH Web site 
at http://www.ruralhealth.va.gov/, at THRIVE On-Line, http://
ruralhealth.stanford.edu/, and on the VA Internet at http://
www.va.gov/.
    As to the bill's requirement to monitor and track fee expenditures 
in this area, the VHA Support Service Center (VSSC) already tracks all 
fee expenditures down to the Veterans' Zip Code in the ``Non-VA Care 
Cube.''
    In sum, S. 1631 is duplicative of VA's on-going efforts to improve 
access to quality health care for Veterans residing in rural areas. VA 
has committed considerable resources not only to ORH and other affected 
VA program offices but also to our collaborative projects with other 
Government Departments and Agencies. To date, these and related efforts 
have proven, and continue to prove, successful in developing models of 
care, providing education to VA and non-VA providers through the 
Internet, establishing an MOU for health information exchange, and 
developing innovative clinical activities and systems of care. As we 
continue to monitor, expand, and improve our efforts in this area, we 
will be glad to keep the Committee advised of our activities and 
progress.
    VA estimates the costs associated with enactment of S. 1631 to be 
$2.1 million for FY 2013, $11.7 million over a 5-year period, and $25.8 
million over a 10-year period.

       S. 1705--TO DESIGNATE THE DEPARTMENT OF VETERANS AFFAIRS 
                     MEDICAL CENTER IN SPOKANE, WA

    S. 1705 would designate the Veterans Affairs Medical Center in 
Spokane, Washington as the ``Mann-Grandstaff Department of Veterans 
Affairs Medical Center.'' VA defers to Congress in the naming of this 
facility.

           S. 1707--VETERANS SECOND AMENDMENT PROTECTION ACT

    S. 1707, the ``Veterans Second Amendment Protection Act,'' would 
provide that a person who is mentally incapacitated, deemed mentally 
incompetent, or unconscious for an extended period will not be 
considered adjudicated as a ``mental defective'' for purposes of the 
Brady Handgun Violence Prevention Act in the absence of an order or 
finding by a judge, magistrate, or other judicial authority that such 
person is a danger to himself, herself, or others. The bill would have 
the effect of excluding VA determinations of incompetency from the 
coverage of the Brady Handgun Violence Prevention Act.
    We understand and appreciate the objective of this legislation to 
protect the firearms rights of veterans determined by VA to be unable 
manage their own financial affairs. VA determinations of mental 
incompetency are based generally on whether a person because of injury 
or disease lacks the mental capacity to manage his or her own financial 
affairs. We believe adequate protections can be provided to these 
veterans under current statutory authority. Under the NICS Improvement 
Amendments Act of 2007 (NIAA), there are two ways that individuals 
subject to an incompetency determination by VA can have their firearms 
rights restored: First, a person who has been adjudicated by VA as 
unable to manage his or her own affairs can reopen the issue based on 
new evidence and have the determination reversed. When this occurs, VA 
is obligated to notify the Department of Justice to remove the 
individual's name from the roster of those barred from possessing and 
purchasing firearms. Second, even if a person remains adjudicated 
incompetent by VA for purposes of handling his or her own finances, he 
or she is entitled to petition VA to have firearms rights restored on 
the basis that the individual poses no threat to public safety. 
Although VA has admittedly been slow in implementing this relief 
program, we now have relief procedures in place, and we are fully 
committed going forward to implement this program in a timely and 
effective manner in order to fully protect the rights of our 
beneficiaries.
    We also note that the reliance on an administrative incompetency 
determination as a basis for prohibiting an individual from possessing 
or obtaining firearms under Federal law is not unique to VA or 
veterans. Under the applicable Federal regulations implementing the 
Brady Handgun Violence Prevention Act, any person determined by a 
lawful authority to lack the mental capacity to manage his or her own 
affairs is subject to the same prohibition. By exempting certain VA 
mental health determinations that would otherwise prohibit a person 
from possessing or obtaining firearms under Federal law, the 
legislation would create a different standard for veterans and their 
survivors than that applicable to the rest of the population and could 
raise public safety issues.
    The enactment of S. 1707 would not impose any costs on VA.

  S. 1755--COVERAGE UNDER DEPARTMENT OF VETERANS AFFAIRS BENEFICIARY 
  TRAVEL PROGRAM OF CERTAIN DISABLED VETERANS FOR TRAVEL FOR CERTAIN 
                  SPECIAL DISABILITIES REHABILITATION.

    S. 1755 would amend VA's beneficiary travel statute to ensure 
beneficiary travel eligibility for Veterans with vision impairment, 
Veterans with spinal cord injury or disorder, and Veterans with double 
or multiple amputations whose travel is in connection with inpatient 
care in a VA special disabilities rehabilitation program.
    This legislation could be construed to apply for travel of 
specified Veterans only in connection with their inpatient care in 
special rehabilitation program centers, and would apply only to 
Veterans with the specified medical conditions who are not otherwise 
eligible for beneficiary travel under 38 U.S.C. Sec. 111. VA provides 
rehabilitation for many injuries and diseases at numerous specialized 
centers, including programs for Closed and Traumatic Brain Injury 
(CBI+TBI), Post Traumatic Stress Disorder (PTSD), other mental health 
issues, Parkinson's Disease, Multiple Sclerosis, Epilepsy, War Related 
Injury (WRIIC), Pain Management, and various addictions. In addition, 
many of VA's specialized treatment centers, including blind, SCI, and 
amputee centers, provide rehabilitation--both initial and ongoing--on 
an outpatient basis using on and off-station lodging. This legislation 
clearly would not apply to travel for those specified Veterans 
receiving care on an outpatient basis and thus would provide disparate 
travel eligibility to a limited group of Veterans. Therefore, VA does 
not support S. 1755 as written.
    VA does support expansion of travel benefits to a larger group of 
Veterans (including blind, SCI, and amputees) and those with other 
special needs who may not be otherwise eligible for VA travel benefits. 
VA welcomes the opportunity to work with the Committee to craft 
appropriate language as well as ensure that resources are available to 
support any travel eligibility increase that might impact upon 
provision of VA health care.
    VA estimates that the total cost for S. 1755 would be $3 million 
during FY 2013, $17.6 million over 5 years and $43.1 million over 10 
years. This estimate is based on workload projections for inpatient 
services at specialized SCI, Blind, and Amputee centers.

 S. 1799--ACCESS TO APPROPRIATE IMMUNIZATIONS FOR VETERANS ACT OF 2011

    S. 1799 would amend the definition of ``preventive health 
services'' in 38 U.S.C. 1701 to include the term ``recommended adult 
immunization schedule'' and define it to mean the schedule established 
by the Advisory Committee on Immunization Practices (ACIP). S. 1799 
would also amend section 1706 of title 38, to require the Secretary to 
develop quality measures and metrics to ensure that Veterans receive 
immunizations on schedule. These metrics would be required to include 
targets for compliance and, to the extent possible, should be 
consistent and implemented concurrently with the metrics for influenza 
and pneumococcal vaccinations. The bill would require that these 
quality standards be established via notice and comment rulemaking. 
S. 1799 would also require that details regarding immunization 
schedules and quality metrics be included in the annual preventative 
services report required by 38 U.S.C. 1704. VA notes that the effective 
dates under this proposal would be retroactive to July 1, 2011 for the 
publication of the proposed measures and metrics and January 1, 2012 
for the implementation of the measures and metrics.
    VA does not support this legislation, as VA now provides prevention 
immunizations at no cost to the Veteran. In addition, VHA is 
represented as an ex-officio member of the ACIP and follows its 
recommendations. VHA is also an ex-officio member of the Department of 
Health and Human Services (HHS) National Vaccine Advisory Committee.
    VA develops clinical preventive services guidance statements on 
immunizations in accordance with ACIP recommendations (VHA Handbook 
1120.05). All ACIP-recommended vaccines are available to Veterans at VA 
medical facilities. These vaccines currently include: hepatitis A, 
hepatitis B, human papillomavirus, influenza, measles/mumps/rubella, 
meningococcal, pneumococcal, tetanus/diphtheria/pertussis, tetanus/
diphtheria, varicella, and zoster. As the recommendations change, VHA 
policy reflects those changes. The delivery of preventive care that 
includes vaccinations has been well established in the VHA Performance 
Measurement system for more than 10 years with targets that are 
appropriate for the type of preventive service or vaccine. VA updates 
the performance measures to reflect changes in medical practice over 
time.
    Adding the statutory requirement for regulations to the development 
of targets would be burdensome and lengthy. Moreover, the process does 
not allow for nimble and quick changes as new research or medical 
findings surrounding a vaccine come to light. Because the clinical 
indications and population size for vaccines vary by vaccine, blanket 
monitoring performance of all vaccines can be cost prohibitive and may 
not have a substantial positive clinical impact at the population 
level.
    VA estimates the costs associated with enactment of S. 1799 to be 
as follows: $654,000 for FY 2013; $3.5 million over a 5-year period; 
and $7.7 million over a 10-year period.

    S. 1806--DESIGNATION OF CONTRIBUTIONS TO THE HOMELESS VETERANS 
                            ASSISTANCE FUND

    S. 1806 would amend the Internal Revenue Code of 1986 to establish 
in the Treasury a trust fund known as the ``Homeless Veterans 
Assistance Fund,'' and would allow taxpayers to designate a specified 
portion (not less than $1) of any overpayment of tax to be paid over to 
the Homeless Veterans Assistance Fund. Amounts in the Fund would ``be 
available, as provided in appropriations Acts, to supplement funds 
appropriated to the Department of Veterans Affairs [(VA)], the 
Department of Labor [(Labor)] Veterans Employment and Training Service, 
and the Department of Housing and Urban Development [(HUD)] for the 
purpose of providing services to homeless veterans.'' S. 1806 would 
require that in the President's annual budget submission for fiscal 
year 2013 and each year thereafter, VA, Labor, and HUD include a 
description of the use of the funds from the Homeless Veterans 
Assistance Fund from the previous fiscal year and proposed use of such 
funds for the next fiscal year.
    While S. 1806 is well-intended, VA is opposed to its enactment. VA 
views its services to homeless Veterans as an obligation of the Nation, 
earned by those Veterans by their service. That is also reflected in 
Congress' enactment of laws to allow VA to provide these services. The 
Secretary has made clear that this is in fact one of VA's most 
important obligations. While we appreciate sincerely the motive of 
bringing this issue before the taxpayers, we believe the presence of a 
check-off could lead some to see these obligations as a discretionary 
charity. VA does involve charities and community organizations in its 
work, and they are vital. But VA prefers that all Federal funding come 
from affirmative appropriations taken by the Congress, rather than 
voluntary apportionments through the tax code.

         S. 1838--DEPARTMENT OF VETERANS AFFAIRS PILOT PROGRAM 
                        ON SERVICE DOG TRAINING

    S. 1838 would require the Secretary, within 120 days of enactment, 
to commence a pilot program for a 3-year period to assess the 
feasibility and advisability of using service-dog training activities 
to positively affect Veterans with post-deployment mental health and 
Post Traumatic Stress Disorder (PTSD) symptoms and produce specially 
trained service dogs for Veterans. The bill would require the Secretary 
to conduct the pilot program at one Department of Veterans Affairs (VA) 
medical center other than in the Department of Veterans Affairs Palo 
Alto health care system.
    The bill requires that the VA medical center selected as the 
program site have an established mental health rehabilitation program 
that includes a clinical focus on rehabilitation treatment of post-
deployment mental health disorders and PTSD and a demonstrated 
capability and capacity to incorporate service dog training activities 
into the rehabilitation program. In addition, the Secretary would be 
required to review and consider using recommendations published by 
experienced service dog trainers with regard to space, equipment and 
methodologies. In selecting the program site, the Secretary must give 
special consideration to Department of Veterans Affairs' medical 
centers located in States that the Secretary considers rural or highly 
rural. The pilot program must be administered through VA's Patient Care 
Services Office as a collaborative effort between the Rehabilitation 
Office and the Office of Mental Health Services. The national pilot 
program lead must be from Patient Care Services and have sufficient 
administrative experience to oversee the pilot program site.
    The bill also includes provisions concerning the service dogs 
themselves. The bill requires VA to ensure that each service dog in 
training is purpose-bred for this work with an adequate temperament, 
has a health clearance, and is age appropriate. Dogs in animal shelters 
or foster homes are not to be overlooked as candidates, but only if 
such dogs meet the service-dog candidate selection criteria under the 
bill. The Secretary must also ensure that each service dog in training 
is taught all basic commands and behaviors required of service dogs, 
that the service dog undergo public access training and receives 
additional training specifically tailored to address the mental health 
conditions or disabilities of the Veteran with whom the dog will be 
paired. In other words, that VA independently and internally train or 
produce service dogs for Veterans with mental health conditions or 
disabilities.
    Other provisions of the bill concern participation in the pilot and 
the actual instruction of the service dogs. Veterans diagnosed with 
PTSD or other post-deployment mental health conditions would be 
eligible to volunteer to participate. The Secretary would be required 
to give a hiring preference for service-dog training instructor 
positions to Veterans who have PTSD or some other mental health 
condition. The bill would also require the Secretary to provide or 
refer participants to business courses for managing a service-dog 
training business. In addition, the bill contemplates the Secretary 
providing ``professional support for all training under the pilot 
program.''
    VA would be required to collect data on the pilot program and 
determine the effectiveness of the program in positively affecting 
Veterans with PTSD or other post-deployment mental health condition 
symptoms. The data must also indicate the feasibility and advisability 
of expanding the pilot program to additional VA medical centers. VA 
would be required to submit an annual report to Congress following the 
end of the first year of the pilot program and each year thereafter to 
inform Congress about the details of the program and its effectiveness 
in specific areas. At the conclusion of the pilot program, the 
Secretary must submit to Congress a final report that includes 
recommendations with respect to the extension or expansion of the 
program.
    VA is not opposed to Veterans diagnosed with PTSD, or other post-
deployment mental health conditions, training service-dog candidates 
for persons with disabilities as a component of a treatment plan, so 
long as the determination of placement with a particular Veteran is 
made by the service-dog training program that acquires the VA service-
dog-in-training candidate and completes the final service-dog training.
    However, VA cannot support S. 1838 because as written the bill 
focuses on training of the dog as opposed to the therapeutic activities 
that such Animal Assisted Therapy or Animal Facilitated Therapy may 
provide the Veteran if appropriately administered as a component of a 
comprehensive mental health treatment program. It is also VA's opinion 
that a pilot is unnecessary as current efforts at the Palo Alto program 
focus on the training activity as part of the comprehensive treatment 
program which incorporates the training of dogs in basic obedience and 
preparing the dogs to complete the Canine Good Citizen (CGC) test. 
Establishing another pilot in addition to the existing Palo Alto 
program would be duplicative, unnecessary and fiscally inefficient.
    While excepted from consideration as the pilot program site in 
S. 1838, the Service Dog Training Program initiated in July 2008 at the 
Palo Alto Veterans Healthcare System (Menlo Park Division), in 
collaboration with Bergin University, is an example of a program where 
Veterans diagnosed with PTSD participate in the training of dogs as one 
activity in their comprehensive recovery program. The training of these 
dogs by Veterans participating in the PTSD Treatment Program includes 
basic obedience training, and the participation is designed to provide 
the Veterans with opportunities in skills development and community 
reintegration. The program provides a bridge to community involvement 
as a component of the dog-training activities. After completion of the 
basic obedience training program, the dogs that complete training are 
transitioned to an external Assistance Dogs International (ADI)-
accredited organization where they complete a rigorous training regimen 
to become service dogs and are paired with disabled Veterans.
    The Palo Alto program is not an example of VA independently 
training or producing service dogs for Veterans through all phases of 
training. The dogs involved in the Palo Alto program were actually 
trained to become service dogs by an external ADI-accredited 
organization, over an extended period of time and subject to ADI 
standards as adopted and applied by that organization. The Palo Alto 
program training focuses on basic obedience (e.g., commands such as 
``sit,'' ``stay,'' and ``heel'') and public access skills (sensitizing 
dogs to different environments) to prepare the dogs to become service 
dogs for disabled persons. That is because VA does not have the 
expertise, experience, or resources to develop independent training 
criteria or otherwise train or produce safe, high quality service dogs 
for Veterans. Such training is highly specialized and includes the 
training of the Veteran who is to receive the service dog. VA requires 
that a service dog candidate that is found to have the requisite 
ability to behave and learn skills at the service dog level, be 
``given'' to a service dog training organization that has the 
personnel, skills, and specialized abilities to pair the dog with a 
disabled person (in this case a disabled Veteran) and train the dog and 
Veteran on the specific tasks that the dog will perform for that 
individual Veteran. VA believes its reliance on the recognized 
expertise of a public or private organization is well-reasoned.
    It is unclear in S. 1838 whether subsection 1(d)(5)(C) is concerned 
with the volunteer Veteran participants who are training the dogs or 
the Veteran recipients of the dogs. Either interpretation is 
problematic. If subsection 1(d)(5)(C) is interpreted to refer to the 
Veterans with whom the dogs are paired to provide actual service dog 
services, rather than targeting the act of training as therapy and a 
component of a treatment plan for a particular Veteran, it would 
require VA to focus on determining what the dog's specialty will be or 
which category of disabled Veteran it will serve. In other words, the 
specialized training requirement shifts the goal to the successful 
training of the service dogs instead of the therapeutic benefit to the 
Veteran derived from the act of training the dog. Veterans would only 
be qualified to provide basic training. The advanced stages of 
specialized training must be turned over to accredited service dog 
training experts. The dogs' eventual roles or skills will depend on the 
outcome of this specialized training. If subsection 1(d)(5)(C) is 
intended to refer to the volunteer Veteran participants with whom the 
dogs are paired, it is equally inappropriate, as the dogs are not 
paired with a specific Veteran in the training process, but will almost 
certainly be trained by several Veterans who are participating in the 
residential program and who will work with the dogs as a team. Patients 
come and go based upon their individual clinical indications, and it is 
unlikely that all volunteer Veteran participants in the treatment/
rehabilitation program will be there for the length of time it takes to 
train a dog to enter a service-dog training program.
    Subsection 1(d)(6) states that in designing the program, the 
Secretary must provide professional support for all training under the 
pilot program. It is not clear whether this is a mandate that third 
party organizations actually conduct the training and that Veterans 
assist or that the bill allows for Veterans to in fact act as ``owner-
trainers'' with assistance of third parties.
    The requirement to give a hiring preference to Veterans who have 
PTSD or other mental health conditions may be counterproductive to the 
goals and objectives of the pilot program. VA understands the pilot is 
aimed at creating a therapeutic treatment modality that will help 
patients currently suffering from and in treatment for PTSD and post-
deployment mental health conditions. VA interprets the primary goal of 
the pilot to be finding better ways to improve the health of this 
Veteran population by exploring treatments, specifically Animal 
Assisted Therapy or Animal Facilitated Therapy that will prepare dogs 
to become service dogs for Veterans. For these reasons, it is 
critically important that the trainers selected be experts at their 
job, which is to train Veterans to train dogs as a component of 
treatment and as a member of the treatment team. It would be beneficial 
if they also appreciated the importance of serving Veterans and 
possessed a working knowledge of the needs of this Veteran population, 
but it is necessary not to confuse the role of the clinical staff with 
the role of the trainer which is that of training the Veteran to train 
the dog. The bill also envisions VA hiring trainers as employees. 
Allowing VA to contract for these services would afford VA more 
flexibility and access to already available training experts, 
particularly as there is no Government Service (GS) occupation training 
service dogs for disabled individuals. Although on the surface this 
sounds reasonable, should the program prove to be inappropriate for 
expansion/spread there would be no position available for a dog trainer 
in the system.
    VA is highly doubtful that the requirements of the bill can be 
accomplished within 120 days of the enactment. VA would have to 
establish selection criteria, advertise for sites (through a Request 
for Proposal), evaluate candidates and make selections. We are 
available to work with the Committee to provide advice on the 
components of what could be a workable program, and an appropriate 
mechanism to evaluate the current programs as to whether training 
service dogs is a clinically appropriate form of treatment based on 
information gleaned from the Palo Alto program and other related animal 
therapy programs currently in place within the VA.
    VA estimates the cost for the 3-year period of the pilot as 
follows: $635,281 in FY 2013; $658,151 in FY 2014; and $682,502 in FY 
2015 for a total of $1,975,934.

          S. 1849--RURAL VETERANS HEALTH CARE IMPROVEMENT ACT

    Section 2(a) of S. 1849 would require VA's Director of the Office 
of Rural Health (ORH) to develop a 5-year strategic plan for improving 
access to, and the quality of, health care services for Veterans in 
rural areas. In developing this plan, the Director would be required to 
consult with the Director of VA's Health Care Retention and Recruitment 
Office, VA's Office of Quality and Performance, and VA's Office of Care 
Coordination Services. It would also require the Director to develop 
this plan not later than 180 days after the date of enactment, with the 
5-year period beginning on the date of the plan's issuance.
    Section 2(b) of the bill would require the strategic plan to 
include the following elements:

     Goals and objectives for the recruitment and retention of 
VA health care personnel in rural areas;
     Goals and objectives for ensuring timeliness and improving 
quality in the delivery of VA health care services furnished to 
Veterans in rural areas through the use of contract providers and fee-
basis providers;
     Goals and objectives for the implementation, expansion, 
and enhanced use of VA telemedicine in rural areas (through 
coordination with other appropriate VA offices);
     Goals and objectives for ensuring the full and effective 
use of mobile outpatient clinics to provide health care services in 
rural areas;
     Procedures for soliciting from each VA facility that 
serves a rural area a statement of the facility's clinical capacity; 
its procedures in the event of a medical, surgical, or mental health 
emergency outside the scope of the facility's clinical capacity; and 
its procedures and mechanisms to provide (and coordinate) health care 
for women Veterans (including procedures and mechanisms for 
coordination with local hospitals and facilities, oversight of primary 
care and fee-basis care, and management of specialty care);
     Goals and objectives for modifying funding allocation 
mechanisms of the ORH to ensure that it distributes funds to 
Departmental components, to best achieve its goals and objectives in a 
timely manner;
     Goals and objectives for the coordination and sharing of 
resources between VA and the Department of Defense, Department of 
Health and Human Services, Indian Health Service, and other Federal 
agencies, as appropriate and prudent, to provide health care services 
to Veterans in rural areas;
     Specific milestones for the achievement of the goals and 
objectives developed for the plan; and
     Procedures for ensuring the effective implementation of 
the plan.

    Section 2(c) of the bill would require, not later than 90 days 
after the date of the plan's issuance, that the Secretary transmit the 
strategic plan to Congress (along with any comments or recommendations 
that the Secretary considers appropriate).
    VA does not believe that S. 1849 is necessary. VA's past and 
continuing efforts already provide a comprehensive approach to ensuring 
access to quality health care for Veterans in rural areas. 
Specifically, in 2010, VHA's ORH produced a 5-year strategic plan for 
fiscal years (FY) 2010-2014 to ensure that ORH programs and initiatives 
meet the health care needs of rural Veterans. That plan was refreshed 
in FY 2011, for FY 2012-2014, to better align ORH's resources with 
identified health care needs, especially in light of new technologies 
and delivery systems for rural Veterans.
    The plan was updated by a committee of stakeholders comprised of 
the following members: Veterans Rural Health Advisory Committee; 
Veterans Integrated Service Network (VISN) rural consultants; Veterans 
Rural Health Resource Centers; ORH; VA Medical Center Directors; VA's 
Office of Telehealth Services; VA's Office of Mental Health Services; 
VA's Office of Geriatrics and Extended Care, State VA Offices; VA's 
Office of Health Informatics; VA's Office of Academic Affiliations; VA 
Employee Education System; and VA's Healthcare Retention and 
Recruitment Office.
    The Committee updated each of the six ORH strategic goals in line 
with broadly agreed-upon initiatives (and associated action items) that 
respond to the specific findings of ORH's Nation-wide assessment to 
identify gaps in care at rural VA facilities and unmet clinical needs 
of rural Veterans. Input obtained at numerous town hall meetings and 
listening sessions also helped the Committee to better understand the 
perspective of rural Veterans and in particular the barriers that 
prevent them from accessing VA health care.
    The new initiatives included in the revised strategic plan include: 
an action plan to improve communications and outreach to rural areas; 
continued support of community-based outpatient clinics and outreach 
clinics; developing, implementing, and evaluating new models of 
specialty care; implementing and evaluating rural women's health care 
initiatives, increased collaboration and partnership with non VA 
community networks and providers, increasing student training 
opportunities in rural health; enhancing telehealth capabilities in 
rural areas; and increasing training for rural providers. We will 
continue to monitor implementation of these initiatives under the plan 
and revise them as necessary. ORH will also continue to evaluate its 
on-going programs, especially the host of pilot and demonstration 
projects that ORH currently funds across the VA health care system, to 
assess their effectiveness in delivering quality care to rural Veterans 
and improving those individuals' access to care.
    One ORH initiative is the ``Rural Health and Education Training 
Initiative.'' It will provide infrastructure support for up to five VA 
sites of care to establish rural health training and education programs 
for medical residents, dental, nursing, and allied health professions 
students from affiliated institutions. Under the program, these 
trainees will receive particular instruction on providing care to 
Veterans residing in rural areas. This will include instruction on the 
special challenges associated with providing health care in rural areas 
and how VA is working to overcome these challenges. Once they complete 
their training, VA hopes to recruit and retain them in rural VA health 
care positions throughout the country.
    ORH is also supporting an initiative to provide rural clergy with 
both information on VA benefits and services and local VA contact 
information. This initiative will also educate clergy-participants 
about post-deployment readjustment challenges, the spiritual and 
psychological effects of war-trauma on survivors, and the important 
role that religious institutions can play in helping to reduce the 
societal stigma associated with mental illness and to assist Veterans 
in their parishes and communities to obtain care and services for their 
mental health issues. It will also address other ways in which they, as 
vital community partners, can help support Veterans and their families.
    Finally, as discussed in connection with S. 1631, VA and the 
Department of Health and Human Services (HHS) are working on a 
memorandum of understanding (MOU) to address shortages in the rural 
Health IT workforce and the need for the effective exchange of health 
care information between VA providers and rural providers furnishing 
care to Veterans. The MOU will serve to:

     Increase the number of trained health IT and health 
information management professionals;
     Diversify training programs to meet a wider range of 
training needs;
     Reach out to potential workers and employers to inform 
them about career pathways in health information management and 
technology;
     Support employers in staffing health IT positions; and
     Examine ways to leverage existing resources to develop 
potential pilot sites for Health Information Exchange between rural 
providers and VHA.

    As indicated above, the 2010-2014 ORH strategic plan refresh will 
be re-evaluated periodically but at least on an annual basis to 
determine if additional initiatives or actions are needed. At the end 
of FY 2014, ORH will draft a new strategic plan based on its 
evaluations of the success of projects undertaken to date and up-dated 
assessments of the health care needs of Veterans residing in rural 
areas.
    VA estimates the costs associated with enactment of S. 1849 to be 
as follows: $215,000 for FY 2013; $368,000 over a 5-year period; and 
$768,000 over a 10-year period.
 s. 2045--to require judges on the united states court of appeals for 
 veterans claims to reside within 50 miles of the district of columbia
    S. 2045 would amend 38 U.S.C. 7255, to require that active judges 
of the U.S. Court of Appeals for Veterans Claims reside within 50 miles 
of the District of Columbia. This bill also would amend section 
7253(f)(1) to provide that violation of this residency requirement may 
be grounds for removal of a judge from the court. The absence of such a 
residency requirement in current law has not created difficulties for 
VA. Thus, VA perceives no need for this legislation.
    If enacted, S. 2045 would result in no costs or savings for VA.

            S. 2244--VETERANS MISSING IN AMERICA ACT OF 2012

    S. 2244, the ``Veterans Missing in America Act of 2012,'' would 
direct the Secretary to cooperate with Veterans Service Organizations 
to assist entities in possession of unclaimed or abandoned human 
remains in determining whether such remains are those of Veterans or 
other persons eligible for burial in a national cemetery. If unclaimed 
remains are identified as those of Veterans or other eligible persons, 
VA would provide for burial of the remains in a national cemetery and 
would cover the cost of preparation, transportation, and burial of the 
remains. The bill would further direct VA to establish a publicly 
accessible national database of such identified individuals.
    VA strongly supports the goal of ensuring that those who have 
earned the right to burial in a national cemetery are accorded that 
honor. VA commends organizations and volunteers who work to ensure that 
unclaimed and abandoned remains of our Nation's Veterans are identified 
and if eligible, receive a proper burial in a national cemetery. To 
ensure eligible Veterans receive burial in a national cemetery, VA 
currently works with States, counties, municipalities and private 
organizations to determine the eligibility of unclaimed and abandoned 
remains that are held at funeral homes or coroner's offices. In this 
regard, VA's National Cemetery Scheduling Office (NCSO) located in St. 
Louis, Missouri coordinates with Federal, State and local agencies to 
verify a deceased individual's military service and identity. NCSO also 
provides eligibility review assistance to entities such as the Missing 
In America Project (MIAP), to identify unclaimed remains and inter all 
eligible individuals. In FY 2011, NCSO processed 663 requests for 
burial eligibility determinations that were submitted by the MIAP, 
which works on behalf of entities, such as city and county coroners' 
offices, to ensure eligible Veterans receive proper burial. Currently, 
NCSO is working with the State of Oregon to identify unclaimed remains 
recently found in that state and determine eligibility for burial in a 
national cemetery.
    VA does not, however, support this bill in extending existing 
funeral and transportation benefits to certain non-Veterans and placing 
no cap on the amount of such payments. Section 3(b) would require VA to 
pay the cost of the burial, preparation, and transportation of the 
unclaimed or abandoned remains of any individual who is eligible for 
national cemetery burial when there are insufficient alternative 
resources to cover such expenses. Under current law, VA provides 
reimbursement benefits, up to maximum amounts specified by statute, for 
funeral and transportation costs associated with the burial of certain 
Veterans. However, not all Veterans who are eligible for burial in a 
national cemetery qualify for these benefits; for example, Veterans who 
were not in receipt of disability compensation at the time of death 
generally do not qualify for reimbursement of funeral or transportation 
costs. VA would support extending current funeral and transportation 
benefits under sections 2302(a)(2) and 2308 of title 38, United States 
Code, to all unclaimed remains of Veterans, subject to the same 
monetary caps generally applicable to such payments. However, VA does 
not support the current bill insofar as it would provide benefits for 
non-Veterans that are unavailable for many Veterans eligible for burial 
in a national cemetery and would lift the generally applicable monetary 
caps for this benefit.
    Section 3(c) of S. 2244 would direct VA to establish a database of 
the names of any Veterans or other individuals who are determined, 
under the identification process described in this bill, to be eligible 
for burial in a national cemetery. We believe this provision is 
unnecessary. Currently, VA maintains a publicly-accessible database, 
commonly known as the National Gravesite Locator (NGL), which already 
performs the functions proposed in the bill. The public can use the NGL 
to search for burial locations of Veterans and other individuals 
interred in VA National Cemeteries, State Veterans cemeteries, and 
various other military and Department of the Interior cemeteries. The 
NGL also provides information about Veterans buried in private 
cemeteries when the grave is marked with a Government-furnished 
headstone or marker. Names of Veterans or other individuals who are 
eligible for burial and whose remains are unclaimed or abandoned would 
be made available to the public through the NGL once they are interred. 
NCA continues to work to make this database even more accessible by 
implementation of a mobile application.
    S. 2244 would impose recurring costs on VA by extending entitlement 
to burial and transportation reimbursement benefits for a new category 
of individuals, without a monetary limit on the amount of such 
reimbursement. At this time, VA is unable to estimate the likely extent 
of those costs.

 S. 2259--VETERANS' COMPENSATION COST-OF-LIVING ADJUSTMENT ACT OF 2012

    S. 2259, the ``Veterans' Compensation Cost-of-Living Adjustment Act 
of 2012,'' would require VA to increase, effective December 1, 2012, 
the rates of disability compensation for service-disabled Veterans and 
the rates of dependency and indemnity compensation for survivors of 
Veterans. Current estimates suggest that the consumer price index will 
increase by 1.9 percent. This bill would increase these rates by the 
same percentage as the percentage by which Social Security benefits are 
increased effective December 1, 2012.
    VA wholeheartedly supports this bill, which is consistent with the 
President's FY 2013 budget request. It would express, in a tangible 
way, this Nation's gratitude for the sacrifices made by our service-
disabled Veterans and their surviving spouses and children and would 
ensure that the value of their well-deserved benefits will keep pace 
with the increased cost of living.
    VA estimates that this bill would result in first-year benefit 
costs of $772 million in FY 2013, 5-year benefit costs of $4.9 billion, 
and 10-year benefit costs of $10.9 billion. However, as annual cost-of-
living adjustments are assumed in the baseline for the Disability 
Compensation program, no PAYGO costs are associated with this proposal.

 S. 2320--REMEMBERING AMERICA'S FORGOTTEN VETERANS CEMETERY ACT OF 2012

    S. 2320, the ``Remembering America's Forgotten Veterans Cemetery 
Act of 2012,'' would direct the American Battle Monuments Commission to 
restore, operate, and maintain Clark Veterans Cemetery in the Republic 
of the Philippines, subject to the availability of appropriations. This 
bill would make Clark Veterans Cemetery a permanent cemetery under the 
auspices of the American Battle Monuments Commission, pursuant to 
section 2104 of title 36, United States Code.
    Because S. 2320 pertains to the American Battle Monuments 
Commission's authority under current chapter 21 of title 36 to allocate 
resources for the care and maintenance of military cemeteries and 
monuments in foreign countries, VA defers to the views of that 
Commission on this bill.

   S. 3052--NOTICE TO VETERANS OF AVAILABILITY OF SERVICES FROM VSOS

    S. 3052 would amend title 38 to require the Secretary of Veterans 
Affairs to provide Veterans who electronically file claims for VA 
benefits with notice that relevant services are available from 
Veterans' Service Organizations (VSOs). The bill would require the 
Veterans Benefits Administration (VBA) to notify each claimant who 
files a claim for benefits electronically that VSOs are available to 
provide services, and to provide a list of VSOs, and their Web site and 
contact information.
    S. 3052 is unnecessary, as VBA already provides notice to Veterans 
who file claims electronically that VSO representation is available. In 
addition, links to VSOs and private attorneys who offer representation 
on claims for VA benefits are currently available on VA's eBenefits Web 
site, which also contains a directory of all recognized VSOs with their 
contact information.
    S. 3052 would not impose any costs on VA.

                S. 3084--VISN REORGANIZATION ACT OF 2012

    Section 2 of S. 3084 would require VHA to consolidate its 21 
Veterans Integrated Service Networks (VISN) into 12 geographically 
defined VISNs, would require that each of the 12 VISN headquarters be 
co-located with a VA medical center, and would limit the number of 
employees at each VISN headquarters to 65 FTE. VA does not support 
section 2 for a number of reasons. By increasing the scope of 
responsibility and span of control of each VISN headquarters while 
reducing the number of employees at each, the legislation would impede 
VA's ability to implement the national goals of the Department. 
Currently, VISN headquarters are capable of providing assistance to 
supplement resource needs at facilities and are able to support 
transitions in staff within local facilities when there are personnel 
changes; with a responsibility for oversight of more facilities and 
fewer staff, the VISN headquarters would lose the opportunity to 
provide this sometimes essential service.
    VHA has already reviewed each VISN headquarters and is in the 
process of working with each to streamline operations, create 
efficiencies internal to each VISN, and to realign resources to 
facilities. This will achieve savings while not creating the negative 
outcomes of the restructuring and new organizations proposed in 
S. 3084. Current VHA plans are to reduce VISN staffing levels.
    VA currently maintains close relationships with other health care 
organizations, including those from other governmental, public, and 
private health care entities, when appropriate. The language appears to 
require VA to create new alliances with entities which may not be 
available or appropriate. VA's health care system has benefited from 
developing an expertise in the clinical and cultural needs and demands 
of Veterans. Requirements to further partner with other organizations 
could lead to distractions and unintended outcomes.
    This section's requirement that VISN budgets be balanced at the end 
of each fiscal year may have other unintended consequences. Currently, 
at the end of each fiscal year, each VISN's accounts must be balanced, 
and this is sometimes achieved by providing additional resources from 
VHA Central Office. Additional resources may be needed for a number of 
reasons, including greater than anticipated demand, a national disaster 
or emergency, new legal requirements enacted during the year, and other 
factors. By codifying a requirement that the VISN budget be balanced at 
the end of each fiscal year, VA may lose this flexibility to supplement 
VISNs with additional resources, and Veteran patient care would suffer 
as a result.
    Section 2 also requires the Department to identify and reduce 
duplication of functions in clinical, administrative, and operational 
processes and practices in VHA. We are already doing this by 
identifying best practices and consolidating functions where 
appropriate. Furthermore, while section 2 describes how the VISNs 
should be consolidated, it fails to clearly articulate the flow of 
leadership authority. In fact, by moving certain oversight 
responsibilities to regional centers, S. 3084 would create no clear 
lines of authority from VHA Central Office, regions, VISNs, to medical 
centers, actually producing less oversight and more confusion.
    Additionally, the proposed combination of VISNs simply combines 
VISNs to arrive at a reduction in the total number of Networks and 
employees without considering the underlying referral patterns within 
each VISN. The original VISN boundaries were drawn based upon local 
population health needs. Each VISN is charged with managing quality and 
access of health care while increasing the efficient delivery of 
population health. S. 3084 fails to take this into account in aligning 
VISN boundaries. For example, it is unclear why VISNs 19 and 20 should 
be consolidated, which would produce a single Network responsible for 
overseeing 12 states, 15 VA health care systems or medical centers, and 
a considerable land mass, while VISN 6, which oversees three states and 
eight health care systems or medical centers, remains its own entity. 
VA would appreciate the opportunity to review the Committee's criteria 
for determining these boundaries.
    Last, Section 2 of S. 3084 seems to assume that locating the 
management function off campus from a medical center represents an 
inefficient organizational approach. We believe that assumption is not 
valid for all cases. Currently, six VISNs (1, 2, 3, 20, 21, and 23) are 
co-located with a VA medical center; the legislation's requirement for 
co-location with a VA medical center would require either construction 
to expand existing medical centers, using resources that would 
otherwise be devoted to patient care to cover administrative costs, or 
would require the removal of certain clinical functions to create space 
for VISN staff in at least nine VISNs given the bill's proposed 
realignment of VISNs 1, 2, and 3, as well as 20 and 21.
    As a result of this legislation, Veterans may be forced to travel 
to different locations for services that were previously available at 
the new host facility, or may be unable to access new services that 
would have been available had construction resources not been required 
to modify existing facilities to accommodate VISN staff. While section 
4 of the bill states that nothing in the bill shall be construed to 
require any change in the location or type of medical care or service 
provided by a VA medical center, the logistical reality of required co-
location with medical centers would necessitate this result.
    VA also does not support section 3 of S. 3084. Section 3 would 
require VA to create up to four regional support centers to ``assess 
the effectiveness and efficiency'' of the VISNs. Section 3 identifies a 
number of functions to be organized within the four regional centers 
including:

     financial quality assurance;
     OEF/OIF/OND outreach;
     homelessness effectiveness assessments;
     women's Veterans programs assessments;
     energy assessments; and
     such other functions as the Secretary deems appropriate.

    This would present several challenges, as certain services are more 
appropriately organized as fully consolidated national functions 
instead of regional ones. The functions identified for homelessness and 
women Veterans would create capabilities that duplicate existing 
national services. The current structure (VISN accountability and 
national oversight) is directly linked with ensuring accountable 
leadership oversight that is much more proximate to health care 
services provided to Veterans in facilities. The proposed structure 
creates two national-level entities competing for oversight analysis 
relationships with facilities. Furthermore, the proposed functions may 
not be the most appropriate ones to offer for consolidation into four 
centers. VHA has created seven Consolidated Patient Account Centers to 
achieve superior levels of sustained revenue cycle management, 
established national call centers to respond to questions from Veterans 
and their families, and is assessing consolidation of claims payment 
functions to achieve greater efficiencies and accuracy. These types of 
functions are more appropriate to move off-station without damaging the 
necessary management/accountability relationship between leadership, 
line management, and staff. The rationale behind the selected functions 
does not appear to have been based on a thorough analysis of the types 
of functions best suited to consolidation.
    S. 3084 appears to propose a reduction in the FTE associated with 
regional management, but the proposed regional service centers are 
likely to increase the overall staffing requirement. We believe this 
actually will result in a diversion of resources away from critical 
patient care. The proposed legislation would result in VISN management 
staff of roughly 780 persons. If each of the four regional centers is 
just 110 FTEE, a not unrealistic assumption given the scope of 
responsibilities identified in the legislation, then the proposed model 
would result in overall growth of regional staff compared with VHA's 
current plans.
    It is not possible currently to identify costs for the proposed 
legislation but it is expected that the requirement to co-locate 
functions with medical centers would result in costlier clinical leases 
or additional construction. Additionally, the proposed VHA Central 
Office, Regional Center, and VISN structure would require increased 
staff.

           S. 3202--DIGNIFIED BURIAL OF VETERANS ACT OF 2012

    S. 3202, the ``Dignified Burial of Veterans Act of 2012,'' would 
amend section 2306 of title 38, United States Code, to authorize VA to 
furnish a casket or urn, of such quality as the Secretary considers 
appropriate for dignified burial in a national cemetery, of the remains 
of a Veteran for whom the Secretary is unable to identify next of kin, 
if there are not otherwise sufficient resources available to furnish a 
casket or urn. The bill would also require VA to submit a report to the 
Senate and House Committees on Veterans' Affairs within 180 days of 
enactment, to describe industry standards for caskets and urns, and 
assess compliance with such standards at VA national cemeteries.
    VA does not object to enactment of the main feature of S. 3202, 
provided Congress identifies appropriate cost offsets, but believes its 
reporting requirement is unnecessary. Section 2 of the bill, would 
assist in ensuring that a suitable casket or urn is provided for 
interment in a national cemetery of the remains of any Veteran without 
family and necessary resources. This legislation is consistent with 
VA's continued efforts to address the needs of homeless Veterans--many 
of whom die as unclaimed and indigent individuals. Section 3 of the 
bill, requiring a report on industry standards for caskets and urns and 
VA's compliance with such standards at national cemeteries, is 
unnecessary. Currently, NCA relies upon licensed funeral directors who 
prepare remains to comply with relevant Federal, State, and local laws 
regarding the preparation of Veterans' remains. When caskets or urns 
are presented for burial, NCA cemetery directors assess containers to 
determine any possible health or safety risks and whether the caskets 
or urns are sufficiently constructed to allow for necessary handling 
for burial. On rare occasions when caskets or urns do not meet these 
standards, NCA instructs the funeral director to return to the cemetery 
with remains in a proper container to facilitate burial. For the 
remains of Veterans with next of kin, NCA respects the wishes of 
families regarding their choice of containers so long as there are no 
public health or safety concerns.
    VA recognizes that S. 3202 complements other bills recently 
introduced in Congress that seek to address issues relating to the 
unclaimed remains of Veterans.

    S. 2244 and H.R. 2551, both titled the ``Veterans Missing in 
America Act,'' generally propose to expand VA's authority to provide an 
allowance to those who assist with the transportation and interment of 
unclaimed remains of Veterans. VA will continue to provide technical 
assistance to the Committees on these bills.
    At this time, VA is unable to estimate the extent of costs that 
would result from enactment of S. 3202 because it is difficult to 
project the number of unclaimed Veteran remains that may be affected by 
this legislation. In 2009, the National Funeral Directors Association 
projected that the average cost for a metal casket was $2,295.

    Chairman Murray, this concludes my statement. I would be happy to 
answer any questions you or the other Members of the Committee may 
have.
                                 ______
                                 
                                 
                                 
                                 ______
                                 
                               Enclosure
                                VA Views

S. 1391--IMPROVING THE DISABILITY COMPENSATION EVALUATION PROCEDURE FOR 
     VETERANS WITH POST TRAUMATIC STRESS DISORDER OR MENTAL HEALTH 
  CONDITIONS RELATED TO MILITARY SEXUAL TRAUMA, AND FOR OTHER PURPOSES

    S. 1391 would amend 38 U.S.C. Sec. 1154, Consideration to be 
accorded time, place, and circumstances of service, by adding a new 
subsection (c) that would liberalize the standard of proof for service 
connection of Post Traumatic Stress Disorder (PTSD) and a new 
subsection (d) that would lower the standard of proof for service 
connection of ``covered mental health conditions'' related to military 
sexual trauma.
    Proposed new section 1154(c) would require the Department of 
Veterans Affairs (VA) to accept as sufficient proof of service 
connection for PTSD alleged to have been incurred or aggravated by 
military service: (1) a diagnosis of PTSD by a ``mental health 
professional;'' (2) written testimony by the Veteran that the PTSD was 
incurred or aggravated during service; and (3) a written statement by 
the mental health professional relating the PTSD to the claimant's 
service, if the claimed incurrence or aggravation of PTSD is consistent 
with the circumstances, conditions, or hardships of the Veteran's 
service.
    Proposed new section 1154(d) would similarly require VA to accept 
as sufficient proof of service connection for covered mental health 
conditions-defined as PTSD, anxiety, depression, or ``other mental 
health conditions the Secretary determines to be related to military 
sexual trauma''-when the condition is claimed to result from military 
sexual trauma during active service: (1) a diagnosis of the covered 
mental health condition by a ``mental health professional;'' (2) 
written testimony by the Veteran of the alleged trauma; and (3) a 
written statement by the mental health professional relating the mental 
health condition to the claimed trauma, if the claimed trauma is 
consistent with the circumstances, conditions, or hardships of the 
Veteran's service.
    Proposed sections 1154(c) and (d) would require departure from 
current practice for adjudicating both PTSD claims and claims based on 
other covered mental health conditions. In the case of PTSD claims, 
current procedures under 38 CFR Sec. 3.304(f) require credible 
supporting evidence that an in-service stressor occurred in order to 
establish that current PTSD symptoms are related to an event in 
service. This generally means objective and verifiable documentation 
that the stressor actually occurred.
    Section 3.304(f) currently provides particularized rules for 
establishing stressors related to combat, former prisoner-of-war (POW) 
status, fear of hostile military or terrorist activity, and personal 
assault. These particularized rules are based on an acknowledgement 
that certain circumstances of service may make the claimed stressor 
more difficult to corroborate. At the same time, they require threshold 
evidentiary showings designed to ensure accuracy and fairness in 
determinations as to whether the claimed stressor occurred. Evidence of 
a Veteran's service in combat or as a prisoner of war generally provide 
an objective basis for concluding that claimed stressors related to 
such service occurred. Evidence that a Veteran served in an area of 
potential military or terrorist activity may provide a basis for 
concluding that stressors related to fears of such activity occurred. 
In such cases, VA also requires the opinion of a VA or VA-contracted 
mental health professional, which enables VA to ensure that such 
opinions are properly based on consideration of relevant facts, 
including service records, as needed. For PTSD claims based on a 
personal assault, lay evidence from sources outside the Veteran's 
service records may corroborate the Veteran's account of the inservice 
stressor, such as statements from law enforcement authorities, mental 
health counseling centers, family members or former servicemembers, as 
well as other evidence of behavioral changes following the claimed 
assault.
    S. 1391 would require VA to accept as proven the occurrence of 
military sexual trauma or a PTSD stressor without even the minimal 
threshold evidence currently required in most compensation claims to 
support a Veteran's account of events in service. The claimant would be 
required merely to state that PTSD was incurred or aggravated in 
service or that a military-sexual-trauma stressor or event occurred in 
service. As long as there was a current diagnosis of PTSD, or other 
covered mental health condition, and a mental health professional 
offered a medical opinion that the symptoms were related to military 
service, service connection would be granted. This would occur whether 
the mental health professional had access to the Veteran's service 
records or not or was otherwise able to evaluate the veracity of the 
claimant's statements regarding the occurrence of the claimed in-
service stressor or event.
    The regulatory provisions at 38 CFR Sec. Sec. 3.303 and 3.304(f) 
have established equitable standards of proof and the evidence for 
corroboration of an in-service injury, disease, or event, for purposes 
of service connection. Further, 38 U.S.C. Sec. 1154 properly requires 
consideration of the time, place, and circumstances of service when 
evaluating disability claims and provides for acceptance of lay 
statements concerning combat-related injuries, provided evidence 
establishes that the Veteran engaged in combat. S. 1391 would expand 
section 1154 to require VA to accept lay statements as sufficient proof 
of in-service events in all PTSD claims and military sexual trauma 
claims involving covered mental health conditions, based solely on the 
nature of the claim and without requiring the objective markers, such 
as combat service, that are essential to the effective operation of 
section 1154. Without the requirement of any evidentiary threshold for 
the mandatory acceptance of a lay statement as sufficient proof of an 
occurrence in service, this legislation would eliminate, for discrete 
groups of Veterans, generally applicable requirements that ensure the 
fairness and accuracy of claim adjudications.
    VA is committed to serving our Nation's Veterans by accurately 
adjudicating MST claims in a thoughtful and caring manner, while fully 
recognizing the unique evidentiary considerations involved in such an 
event. The Under Secretary for Benefits has spearheaded the efforts of 
the Veterans Benefits Administration (VBA) to ensure that these claims 
are adjudicated compassionately and fairly, with sensitivity to the 
unique circumstances presented by each individual claim.
    VA is aware that, because of the personal and sensitive nature of 
the MST stressors in these cases, it is often difficult for the victim 
to report or document the event when it occurs. To remedy this, VA 
developed regulations and procedures specific to MST claims that 
appropriately assist the claimant in developing evidence necessary to 
support the claim. As with other PTSD claims, VA initially reviews the 
Veteran's military service records for evidence of MST. VA's regulation 
also provides that evidence from sources other than a Veteran's service 
records may corroborate the Veteran's account of the stressor incident, 
such as evidence from mental health counseling centers or statements 
from family members and fellow Servicemembers. Evidence of behavior 
changes is another type of relevant evidence that may establish 
occurrence of an assault, such as a request for transfer to another 
military duty assignment. Veterans are provided notification regarding 
the types of evidence that may establish occurrence of an in-service 
personal assault and are requested to submit or identify any such 
evidence.
    VBA has also placed a primary emphasis on informing VA regional 
office personnel of the issues related to MST and providing training in 
proper claims development and adjudication. VBA developed and issued 
Training Letter 11-05, Adjudicating Posttraumatic Stress Disorder 
Claims Based on Military Sexual Trauma, in December 2011. This was 
followed by a nationwide Microsoft Live Meeting broadcast on MST claims 
adjudication. The broadcast focused on describing the range of 
potential markers that could indicate occurrence of an MST stressor and 
the importance of a thorough and open-minded approach to seeking such 
markers in the evidentiary record. In addition, the VBA Challenge 
Training Program, which all newly hired claims processors are required 
to attend, now includes a module on MST within the course on PTSD 
claims processing. VBA also provided its designated Women Veterans 
Coordinators with updated specialized training. These employees are 
located in every VA regional office and are available to assist both 
female and male Veterans with their claims resulting from MST.
    VA believes these actions ensure that MST claimants are given a 
full and fair opportunity to have their claim considered, with a 
practical and sensitive approach based on the nature of MST. VA 
believes that processes and training in place now provide MST claimants 
a full and fair opportunity to present their claim. VA has recognized 
the sensitive nature of MST-related PTSD claims and claims based on 
other covered mental health conditions, as well as the difficulty 
inherent in obtaining evidence of an in-service MST event. Current 
regulations provide multiple means to establish an occurrence, and VA 
has initiated additional training efforts and specialized handling 
procedures to ensure thorough, accurate, and timely processing of these 
claims.
    In summary, VA opposes S. 1391 because we believe it would go too 
far in relaxing standards requiring service connection for a current 
disability to be based on credible supporting evidence of an injury, 
disease, or event in service.
    Benefit costs are estimated to be $137.1 million during the first 
year, $2.0 billion for 5 years, and $7.1 billion over 10 years. Costs 
for general operating expenses are estimated to be $5.0 million during 
the first year, $24.1 million for 5 years, and $52.5 million over 10 
years. IT costs are estimated to be $196 thousand during the first 
year, $531 thousand for 5 years, and $967 thousand over 10 years.

         S. 3049--EXPANDING THE DEFINITION OF HOMELESS VETERAN

    S. 3049 would broaden the definition of ``homeless veteran'' found 
in 38 U.S.C. Sec. 2002(1) to include ``any individual or family who is 
fleeing, or is attempting to flee, domestic violence, dating violence, 
sexual assault, stalking, or other dangerous or life-threatening 
conditions in the individual's or family's current housing situation, 
including where the health and safety of children are jeopardized, and 
who have no other residence and lack the resources or support networks 
to obtain other permanent housing.'' It would do this by adding to the 
Title 38 definition a reference to an additional subsection of the 
general definition of homeless individual found in the McKinney-Vento 
Homeless Assistance Act, at 42 U.S.C. Sec. 11302.
    VA supports the intent of S. 3049. VA understands that the 
Department of Housing and Urban Development (HUD) uses the definition 
found in 38 U.S.C. Sec. 2002(1) in the application of some of its 
programs. Therefore, we suggest the Committee consult with HUD 
regarding any changes to that definition.
    VA has taken steps to address the critical issue of domestic 
violence. In recognition of the unique and emerging health challenges 
posed by victims of domestic violence, the Deputy Under Secretary for 
Health for Policy and Services recently chartered a Domestic Violence 
Task Force to ``develop a national plan/policy on domestic violence to 
address identification of domestic violence and access to services for 
Veterans, who need help planning for and achieving physical, emotional, 
and psychological safety and well being; and define the scope of 
domestic violence to be addressed.'' As evidenced by this task force, 
VA intends to study this population and VA's options for serving this 
population; however, at this time, VA lacks subject matter experts to 
implement programming directly targeted at victims of domestic 
violence. Furthermore, in the event VA would be expected to reach and 
target this population, VA needs time and resources to implement 
systems, protocol, and policies to ensure timely interventions and meet 
the needs of this vulnerable population. Domestic violence is a complex 
health issue and addressing it involves collaboration between many 
programs and external local, State and Federal agencies to address 
identification, prevention, provision of safety supports, treatment, 
and legal consequences.
    VA is not able to provide an accurate cost estimate for S. 3049 
since we currently lack information regarding the size and 
characteristics of the potential population. For example, VA's 
estimates of the homeless population do not include individuals fleeing 
domestic violence. Many VA providers have only minimal training on 
domestic violence. S. 3049 would likely require additional training for 
VA employees and providers, which may have some costs, depending upon 
the scope of the training.

S. 3206--MONTHLY ASSISTANCE ALLOWANCE TO DISABLED VETERANS TRAINING OR 
   COMPETING FOR THE PARALYMPIC TEAM AND ASSISTANCE TO UNITED STATES 
                           PARALYMPICS, INC.

    Section 1 of S. 3206 would extend the authority for appropriations 
to fund the payment of the monthly monetary allowance under 38 U.S.C. 
Sec. 322(d) (to Veterans training for or selected to compete on the 
U.S. Paralympic team) for a period of 5 years (through FY 2018). VA 
supports such an extension.
    By its own terms, the cost of enactment of this section would be $2 
million in FY 2014, with a total 5-year cost (FY 2014 through FY 2018) 
of $10 million.
    Section 2 of S. 3206 would extend (through FY 2018) VA's authority 
to award grants to United States Olympic Committee (USOC) for its U.S. 
Paralympics Integrated Adaptive Sports Program. Under current law, VA 
has provided grants totaling $7.5 million to the USOC in each FY 2010 
and FY 2011. Due to identified need, VA currently is processing an $8.0 
million USOC grant request in FY 2012. VA supports extending the 
authority for this program, which has positively impacted the lives of 
thousands of Veterans.

                      S. 3270--PENSION AMENDMENTS

    Section 1(a) of S. 3270 would amend the net worth limitations 
applicable to Veteran's pension in 38 U.S.C. Sec. 1522 to provide that 
when a Veteran (or Veteran's spouse) disposes of ``covered resources'' 
for less than fair market value (including transfers to annuities or 
trusts) on or after the beginning date of a 36-month look-back period, 
the disposal may result in a period of ineligibility for pension. In 
addition, section 1(a) would provide a method for calculating the 
period of ineligibility for pension resulting from a disposal of 
covered resources at less than fair market value. The period of 
ineligibility, expressed in months, would be determined by dividing the 
total value of all applicable covered resources disposed of by the 
Veteran (or the Veteran's spouse) by the amount of pension that would 
have been payable to the Veteran under 38 U.S.C. Sec. Sec. 1513 or 1521 
without consideration of the transferred resources.
    Section 1(b) of S. 3270 would amend 38 U.S.C. Sec. 1543 to apply to 
a surviving spouse's or surviving child's pension the same restrictions 
pertaining to disposal of covered resources at less than fair market 
value as would apply to Veterans under subsection (a).
    Section 1(c) of S. 3270 would specify the effective date and 
applicability of the amendments made by section 1(a) and (b). Section 
1(d) of S. 3270 would require VA to provide annual reports to Congress 
regarding: (1) the number of individuals who applied for pension during 
the period covered by the report; (2) the number of individuals who 
received pension during that period; and (3) the number of individuals 
whose pension payments were denied or discontinued during that period 
because covered resources were disposed of for less than fair market 
value.
    Currently, if a pension claimant (or the spouse of a Veteran 
pension claimant) disposes of assets before the date of the pension 
claim, VA does not consider those assets as part of the claimant's net 
worth, so long as the transfer was not a gift to a relative living in 
the same household as the claimant. S. 3270 would provide that such 
disposals of ``covered resources'' for less than fair market value 
during a 36-month look-back period may result in a period of 
ineligibility for pension.
    VA supports the objectives of S. 3270 to provide for consideration 
of recent asset transfers for less than fair market value in evaluating 
a pension claimant's net worth and to impose a period of ineligibility 
for pension where such transfers occur. The bill would clarify current 
law by prescribing that pension applicants cannot create a financial 
need, qualifying them for VA pension, by disposing of assets that the 
applicant could use for the applicant's own maintenance. It would also 
clarify that an applicant cannot create pension eligibility by 
restructuring assets during the 36-month period preceding a pension 
application through transfers to certain financial products or legal 
instruments, such as annuities and trusts. A recent Government 
Accountability Office study found that there is a growing industry that 
markets these products and instruments to vulnerable Veterans and 
survivors and potentially causes them harm. The amendments contemplated 
by S. 3270 would enable VA to implement necessary program integrity 
measures.
    However, VA is concerned that the provisions of S. 3270 specifying 
how the period of ineligibility will be calculated would be 
unnecessarily complex and burdensome to administer. The provisions of 
section 1(a) of S. 3270 to be codified at 38 U.S.C. 
Sec. 1522(a)(2)(E)(ii) would require VA to divide the total value of 
all applicable covered resources disposed of by the Veteran (or 
Veteran's spouse) by ``the amount of the monthly pension that would be 
payable to the veteran under section 1513 or section 1521 of this title 
without consideration of such resources under paragraph (1).'' Sections 
1(a) and 1(b) of S. 3270 would provide for similar calculations under 
38 U.S.C. Sec. Sec. 1522(b)(2)(E)(ii), 1543(a)(4)(E)(ii), and 
1543(b)(2)(E)(ii). It appears that the divisor used to calculate the 
ineligibility period under these provisions would require VA to develop 
for and adjudicate up to 3 years' worth of countable income. Such a 
complex calculation would significantly increase VA's adjudicative 
burden and, as a result, delay the payment of pension claims to 
eligible Veterans.
    VA suggests modifying this calculation method. The goals of S. 3270 
could be achieved more efficiently by revising the language describing 
the divisor to refer to ``the monthly amount a claimant would have 
received based on the maximum annual pension rate including any amount 
of increased pension payable on account of family members, but not 
including any amount of pension payable because a person is in need of 
regular aid and attendance or is permanently housebound.'' It would be 
burdensome and inefficient to require VA to develop income and expense 
information to determine up to 3 years' worth of countable income in a 
decision that would deny pension in any event. By using less claim-
specific criteria tied to the maximum annual pension rate, VA would be 
able to quickly determine the length of the penalty period and conserve 
adjudication resources for expeditious processing of claims.
    The use of such less-specific criteria is not without precedent. 
Congress used similar language in 38 U.S.C. Sec. 1503(a)(8) in 
establishing the rule for calculating the 5-percent threshold for 
medical expense deductions in VA pension, which is based on the maximum 
annual pension rate including increased pension payable on account of 
family members, but without regard to special monthly pension.
    At this time, VA has no objection to this section but is unable to 
estimate the costs or savings associated with this proposal because 
sufficient data is not available.

    S. 3238--A BILL TO DESIGNATE THE DEPARTMENT OF VETERANS AFFAIRS 
 COMMUNITY BASED OUTPATIENT CLINIC IN MANSFIELD, OHIO, AS THE DAVID F. 
   WINDER DEPARTMENT OF VETERANS AFFAIRS COMMUNITY BASED OUTPATIENT 
                     CLINIC, AND FOR OTHER PURPOSES

    S. 3238 would designate the Department of Veterans Affairs 
community based outpatient clinic located in Mansfield, Ohio, as the 
``David F. Winder Department of Veterans Affairs Community Based 
Outpatient Clinic.'' VA defers to Congress in the naming of this 
facility.

 S. 3282--A BILL TO AMEND TITLE 38, UNITED STATES CODE, TO REAUTHORIZE 
 THE VETERANS' ADVISORY COMMITTEE ON EDUCATION, AND FOR OTHER PURPOSES

    S. 3282 would amend 38 U.S.C. Sec. 3692 to extend the expiration 
date of the Veterans Advisory Committee on Education (Committee) to 
December 31, 2014. It would also change the composition of the 
Committee to include representatives of institutions and establishments 
furnishing education or vocational training to eligible Veterans or 
persons enrolled under chapter 31 of Title 38 (Training and 
Rehabilitation for Veterans with Service-Connected Disabilities) while 
removing those providing training to Veterans or persons enrolled under 
chapter 32 of that title (Post-Vietnam Era Veterans' Educational 
Assistance).
    Further, S. 3282 would require the composition of the Committee, to 
the maximum extent practicable, to include:

     Veterans who served on active duty and were deployed in 
connection with a contingency operation,
     at least one Veteran who is a student currently enrolled 
in a program of education and receiving assistance for the pursuit of 
such program of education under chapters 30, 31, 33, or 35 of Title 38,
     at least one representative from the American Council on 
Education or an affiliated organization,
     at least one representative from an organization that 
represents Veterans,
     a representative of a State Approving agency, and
     at least two school certifying officials from different 
regions of the country.

    The Committee would be required to seek feedback on the policies of 
VA relating to the administration of chapters 30, 31, 33, 35, and 36 of 
Title 38 and chapter 1606 of Title 10 from students who are currently 
training under such chapters or Veterans seeking to enroll for training 
under such chapters.
    At least twice each year, the Committee would be required to submit 
to VA and Congress a report on the administration of chapters 30, 31, 
33, 35, and 36 of Title 38 and chapter 1606 of Title 10, including 
recommendations for legislative and administrative action to improve 
educational assistance under such chapters.
    VA supports this legislation. If reauthorized, VA would be able to 
continue to receive recommendations and seek advice from the Members of 
the Committee with regard to the administration and proposals to 
enhance VA education benefit programs. VA estimates that S. 3282 would 
have insignificant costs associated with its enactment.

 S. 3308--A BILL TO AMEND TITLE 38, UNITED STATES CODE, TO IMPROVE THE 
FURNISHING OF BENEFITS FOR HOMELESS VETERANS WHO ARE WOMEN OR WHO HAVE 
                   DEPENDENTS, AND FOR OTHER PURPOSES

    Section 1(a) of S. 3308 would amend 38 U.S.C. Sec. 2012(a) to 
permit a grantee receiving per diem payments under VA's Homeless 
Providers Grant and Per Diem Program (GPD Program) to use part of those 
payments for the care of a dependent of a homeless Veteran who is 
receiving services covered by the GPD Program grant. This authority 
would be limited to the time period during which the Veteran is 
receiving services under the grant.
    Section 1(b)(1) of the bill would amend 38 U.S.C. Sec. 2061(c) to 
require the Secretary to ensure that the total amount of grants awarded 
in any year under VA's Grant Program for Homeless Veterans with Special 
Needs is not less than 15 percent of the total amount of grants awarded 
under the GPD Program under 38 U.S.C. Sec. 2011. This would ensure a 
level of minimum funding for grants targeted to assist homeless 
populations with special needs, such as women, including those with 
minor dependents, frail elderly, etc. Section 1(b)(2) would amend 38 
U.S.C. Sec. 2061 to authorize for appropriation such sums as may be 
necessary for the purposes of this program for FY 2013 and each fiscal 
year thereafter. The law currently authorizes for appropriation $5 
million to conduct the program through FY 2012.
    VA supports the intent of section 1(a) of S. 3308. We feel that 
this authority is needed to fully reach the entire homeless population. 
However, full implementation of the legislation would require 
additional funding to avoid diminished services for homeless Veterans. 
At the current level of funding VA would be unable to provide grants to 
current grant recipients as well as Veterans with dependants.
    VA does not support Section 1(b) for two reasons. First, it fails 
to take into account that entities receiving grants under 38 U.S.C. 
Sec. 2011 become eligible, subject to the availability of 
appropriations, to receive per diem payments subsequently under 38 
U.S.C. Sec. 2012. This means that VA may award per diem payments to 
current grant recipients in lieu of awarding new grants under section 
2011. Indeed, VA conducted its last capital grant Notice of Funding 
Availability in FY 2010. Since then, VA has offered a Special Needs 
grant round pursuant to 38 U.S.C. Sec. 2061 and a GPD ``Per Diem Only'' 
grant round pursuant to 38 U.S.C. Sec. 2012 (see also 38 CFR part 
61.33).
    Second, funding for Special Needs Grant Program is not a separate, 
line-item budget item. Funds designated for this program are included 
in the general allocation for the entire GPD program and come out of 
VA's Medical Services account. With competing priorities for Medical 
Service dollars, VHA currently funds the GPD Programs at the levels 
that are authorized to be appropriated to for these programs. Were the 
mandate in section 1(b) enacted, it would dramatically disrupt GPD 
Program operations and force the closure of current GPD projects. To 
illustrate, within the GPD Program's current budget of approximately 
$224 million for FY 2012, VA expects to support approximately 15,000 
operational GPD beds with per diem payments in the amount of 
approximately $164 million (80 percent bed occupancy rate), and support 
GPD Liaison positions in the amount of approximately $29 million. 
Additionally, there are approximately 1,900 capital beds in development 
from past capital grant rounds. VA estimates these capital beds could 
require an additional $21 million in per diem grant support. Were the 
requirements of section 1(b)(1) in place, VA would be required to spend 
at least $33 million on GPD Special Needs grants. This would be a 
dramatic increase in Special Needs funding--far above the current 
mandated spending level of $5 million. Such an increase would have to 
be absorbed from the GPD Program budget, and, to do that, the GPD 
Program would be forced to close existing and proven GPD projects.
    This concern is heightened by the fact that under existing law the 
total amount authorized for appropriation for the GPD program will drop 
from $250 million in FY 2013 to $150 million in FY 2014 and every 
fiscal year thereafter. For FY 2012, approximately $164 million is 
slated to cover per diem payments to approximately 15,000 Veteran beds. 
In FY 2014, the required funding for per diem payments will exceed the 
amounts authorized to be appropriated for the GPD's programs. VA will 
then be forced to close GPD projects or reduce per diem rates for all 
beds to remain within those authorization limits. In other words, 
without a corresponding provision in 38 U.S.C. Sec. 2013 to authorize 
appropriations in such sums as are needed to carry out the purposes of 
the GPD for FY 2014 and thereafter, the effect of the mandate in 
section 1(b)(2) will be meaningless.
    VA estimates the costs associated with enactment of S. 3308 to be 
$25.5 million for FY 2013, $137.3 million over 5 years, and $302.5 
million over 10 years.

           S. 3309--HOMELESS VETERANS IMPROVEMENT ACT OF 2012

    S. 3309 is a comprehensive bill to continue and improve VA's 
provision of benefits to homeless Veterans and their families. Key 
provisions of the bill are targeted at addressing specific problems 
identified in recent reports by VA's Office of Inspector General and 
the Government Accountability Office, e.g., current barriers to access 
to care and services faced by both homeless women Veterans and homeless 
Veterans with children, the need for infrastructure improvements to 
ensure the privacy and security of women Veterans receiving services 
under VA or VA-sponsored programs, etc.
    Section 2 of S. 3309 would amend current law to prohibit the 
Secretary from making a grant for a project under VA's Homeless 
Providers GPD Program unless the applicant also agrees in its grant 
application to meet the physical privacy, safety, and security needs of 
homeless Veterans receiving services through the project.
    VA supports Section 2. This new requirement would help reinforce 
the GPD Program's inspection efforts and also ensure that GPD grantees 
comply with VA's ongoing efforts to ensure the privacy, safety, and 
security needs of Veterans participating in the GPD Program. We note as 
a practical matter that current GPD grantees would be required to 
absorb the costs of making these improvements as VA lacks authority to 
offer grants to existing GPD providers to renovate or remodel existing 
GPD facilities. (38 CFR part 61.10.3) To help current grantees recover 
these unanticipated costs, VA would need authority similar to that 
specified in 38 U.S.C. Sec. 2012(c), wherein all GPD grantees were 
required to comply with the Life Safety Code. In section 2012(c), 
Congress authorized a five-year period during which VA offered grants 
to GPD grantees to assist the grantees in meeting the new requirements 
of the Life Safety Code. Regardless, future grant rounds for new 
grantees would incorporate this requirement as part of the application 
process.
    VA does not support Section 3 of S. 3309, which would amend current 
law to require the Secretary, when awarding grants under the GPD 
Program, to assist eligible entities not only in establishing, but also 
in maintaining programs to furnish services for homeless Veterans 
(i.e., outreach services; rehabilitative services; vocational 
counseling and training; and transitional housing assistance). VA does 
not support this legislative measure because it would likely result in 
substantial costs that are not contemplated in the GPD Program's budget 
or in long-term financial planning for the GPD Program. VA believes 
that most, if not all, GPD projects would request grant funding for 
repairs and/or remodeling, but for the reasons previously explained, it 
is unlikely there would be sufficient funds available to cover repairs 
and/or remodeling of grantees' facilities.
    The GPD Program was, in part, conceived to help save the Federal 
Government such costs, especially given the fact that such services can 
generally be obtained at lower cost in the community. Were VA to 
provide grants to cover the costs of maintaining grantees' 
infrastructures, the overall cost-effectiveness of the GPD Program 
would be reduced, and, more importantly, fewer funds would be available 
for the provision of direct services to homeless Veterans. As an 
administrative matter, VA would have to amend its GPD regulations 
before such maintenance grants could be awarded.
    VA estimates the cost of Section 3 of S. 3309 to be $29.0 million 
in FY 2013; $68.4 million over 5 years; and $115.5 million over 
10 years.
    Section 4 of the bill would amend 38 U.S.C. Sec. 2044(e) to require 
that, of the amounts required to be made available for conduct of VA's 
Financial Assistance Program for Supportive Services for Very Low-
Income Veteran Families in Permanent Housing (referred to below as the 
``SSVF'' Grant Program), at least 1 percent of such funding must be 
made available for the furnishing of legal services to assist Veteran 
families with issues that interfere with their ability to obtain or 
retain housing or supportive services.
    VA does not support Section 4 because it duplicates existing 
authority. Grants awarded under the SSVF Program already require 
grantees to assist participants with obtaining legal services for 
issues that interfere with their ability to obtain or retain permanent 
housing or supportive services. See 38 CFR Sec. 62.33(g), implementing 
38 U.S.C. Sec. 2044(b)(1)(D)(vii). Some grantees have identified 
creative no-cost options for providing such legal services, relying on 
area law school clinics and local bar associations' pro bono 
initiatives. Such a spending-minimum for legal services would likely 
discourage grantees from cultivating local networks of legal service 
providers who will provide participants services at no cost. Beyond 
discouraging or providing a disincentive for the development of no-cost 
options for providing legal services, VA is also concerned that this 
provision would not be an efficient use of resources inasmuch as the 
mandated level of funding could well exceed the grantee's actual costs 
of obtaining legal services for participants. Yet, even in such cases, 
grantees would still have to slate the mandated-minimum amount for this 
purpose, using funds that could otherwise be expended to furnish other 
needed supportive services to participants.
    Our non-support for section 4 is not meant to discount the central 
role that legal services play in preventing and ending homelessness 
among Veterans. Garnering adequate resources or partnerships for the 
provision of legal services to homeless Veterans and those who are at 
risk of becoming homeless is absolutely key to this effort. Veterans 
accessing services in our homeless health care programs often have 
multiple unmet legal needs ranging from criminal matters (e.g., 
unresolved warrants) to civil matters (e.g., child support arrears and 
landlord-tenant disputes). While SSVF grants can be targeted at helping 
address their participants' legal needs, those participants constitute 
only part of the homeless Veteran population in need of such services. 
We are heartened by the growing level of interest among lawyers and law 
students in serving homeless Veterans, as evidenced by an increasing 
number of Veteran-focused law school clinics and pro bono initiatives. 
Still, far more legal resources are needed to build a national practice 
community of attorneys who have the expertise and dedication needed to 
effectively serve this population. Outside of awarding grants under 
section 2044, VA's ability to help non-profits provide or coordinate 
the provision of legal services to homeless Veterans is hamstrung by 
limits on our legal authority. We are currently exploring ways to 
leverage other existing Federal resources to deliver legal services to 
both homeless and at-risk Veterans, and we would be happy to discuss 
these efforts with the Committee.
    VA estimates the cost of Section 4 of S. 3309 to be $3 million in 
FY 2013; $15 million over 5 years; and $30 million over 10 years.
    Section 5(a) of S. 3309 would amend 38 U.S.C. Sec. 2012(a) to 
permit per diem payments made by the Secretary to grantees under VA's 
GPD Program to include payments for furnishing care for a dependent of 
a homeless Veteran, but only while the Veteran is receiving services 
from the grantee under such grant.
    Section 5(a) of S. 3309 is identical to section 1(a) of S. 3308, 
discussed above. VA supports this section, but we refer you to our 
earlier comments, which identify some concerns we have with its 
enactment. VA estimates the cost of $25.5 million for FY 2013; $137.3 
million over 5 years; and $302.5 million over 10 years.
    Section 5(b)(1) of S. 3309 would require the Secretary to make 
funds available for per diem payments under VA's GPD Program to grant 
recipients or eligible entities that are considered to be ``non-
conforming.'' Non-conforming recipients or entities fall into three 
categories: (1) those that meet each of the transitional and supportive 
services criteria prescribed by the Secretary and furnish services to 
homeless individuals of which not less than 75 percent are Veterans; 
(2) those that meet at least one but not all of criteria prescribed by 
the Secretary and furnish services to homeless individuals of which not 
less than 75 percent are Veterans; and (3) those that meet at least one 
but not all of the criteria prescribed by the Secretary and furnish 
services to homeless individuals of which less than 75 percent are 
Veterans. Currently, the Secretary's authority to make per diem 
payments to these non-conforming recipients and entities is 
discretionary. Section 5(b)(2) of the bill would require the Secretary 
to prescribe such regulations as may be necessary to implement this 
change.
    VA does not support Section 5(b). The number of eligible conforming 
entities seeking to receive GPD funds already far exceeds the resources 
of the GPD Program.
    For example, from 1994 through 2010, VA received 3,252 applications 
from conforming eligible entities for grant funding under the GPD 
Program. These applications included capital grant funding, per diem 
only funding, and GPD special needs funding. Out of the 3,252 
applications from conforming eligible entities, VA could only fund 
1,115 of these applications. Similarly, from 1994 through 2010, VA 
received applications requesting almost $1.4 billion in capital grant 
funding, but VA could only fund approximately $197 million in GPD 
capital grants. It is highly unlikely that funding will ever be 
available for nonconforming entities, rendering this mandate 
ineffectual and generating false expectations on the part of non-
conforming entities who would seek such assistance. We are more 
concerned that changing the discretionary language in 38 U.S.C. 
Sec. 2012(d)(1) to mandatory language would remove needed discretion 
and produce the undesired result of non-conforming entities receiving 
grants over conforming entities solely because of this requirement.
    There are no additional costs associated with section 5 because 
costs would come from those funds already slated to be awarded under 
the GPD.
    Section 6(a) would authorize the Secretary, subject to the 
availability of appropriations, to award grants to cover the 
operational expenses of grant recipients' comprehensive service centers 
that are not otherwise covered by per diem payments made under the GPD 
Program. Section 6(b) would limit the aggregate amount of all such 
grants awarded in any Fiscal Year to $500,000. Section 6(c) would 
require the Secretary to promulgate regulations not later than one year 
after the date of the Act's enactment to carry out this new authority.
    VA does not support Section 6 of S. 3309. VA does not believe this 
measure would be an effective use of VA's resources and the GPD 
Program's budget. VA funds would likely be put to better use funding 
traditional outreach in the community or Community Resource and 
Referral Centers (CRRCs). Historically, it has been difficult for 
service centers to remain viable for several reasons. VA's statutory 
authority is limited to paying ``per diem'' to service center 
providers, and the service centers have difficulty in providing the 
federally-required information under Office of Management and Budget 
(OMB) Circulars and other Federal standards needed to accurately 
reflect the services they provide, to determine in a timely manner the 
eligibility of the individuals receiving those services, and to 
determine the amount of time actually spent with the individuals 
served. Given GPD grantees' difficulties in accounting for services 
provided in service centers, VA does not believe service centers are an 
effective outreach model for VA homeless programs and services, 
especially given VA has more effective and proven methods of reaching 
the homeless Veteran population. For instance, VA excels at traditional 
outreach in the community and is introducing CRRCs throughout the 
country. VA estimates the cost associated with enactment of section 6 
could be $500,000 per any fiscal year these operational grants are 
awarded. VA is unable, however, to estimate costs with greater 
specificity given the disparate operational needs of each GPD service 
center.
    Section 7 of S. 3309 would extend dental benefits under 38 U.S.C. 
Sec. 2062 to a Veteran enrolled in VA's health care system who is also 
receiving for a period of 60 consecutive days assistance under section 
8(o) of the United States Housing Act of 1937 (commonly referred to as 
``Section 8 vouchers.''). It would also amend current law to permit the 
Secretary to disregard breaks in the continuity of assistance or care 
for which the Veteran is not responsible. VA supports the intent of 
section 7 of S. 3309, but must condition this support on assurance of 
the additional resources that would be required were this provision 
enacted.
    VA recognizes the need for dental care and supports the improvement 
of oral health and well-being for Veterans experiencing homelessness. 
Indeed, increasing access to dental care for Department of Housing and 
Urban Development VA Supportive Housing (HUD-VASH) Veterans is an 
important step in VA's Plan to End Veteran Homelessness. Severe dental 
disease plagues the majority of Veterans experiencing homelessness, 
particularly the chronically homeless Veterans participating in HUD-
VASH. Severe dental disease seriously impacts physical health as well 
as self esteem and mental health.
    Under Directive 2007-039, homeless Veterans participating in the 
GPD Program, Domiciliary Residential Rehabilitation Program, Health 
Care for Homeless Veterans (HCHV) contract residential treatment 
program, Community Residential Care Program, and Compensated Work 
Therapy-Transitional Residence (CWT-TR) program are eligible for a one-
time course of focused dental care. (38 U.S.C. Sec. 1712(a)(1)(H); 38 
U.S.C. Sec. 2062). Section 7 would expand dental eligibility to 
Veterans participating in the HUD-VASH Program Veterans.
    While VA is committed to ensuring eligible Veterans receive 
patient-centered, cost-effective, evidence-based care, we acknowledge 
that current resources are inadequate to provide these dental benefits 
to a new cohort of Veterans and to accommodate the related increase in 
workload. An expansion of the eligible dental population without a 
corresponding expansion of resources would severely limit VA's ability 
to deliver dental care to Veterans already receiving VA dental care 
benefits.
    Finally, as a technical matter, the language proposed for section 
2062 refers in error to subsection ''(a)'' when it should instead 
reference subsection ''(b).'' That is, it should be amended in relevant 
part to read: ''(b) Eligible Veterans.'' VA further notes that while 
Section 7 of S. 3309 would amend the current structure of 38 U.S.C. 
Sec. 2062, the only substantive change would be the inclusion of HUD-
VASH Veterans.
    VA estimates that there would be significant costs in the first 
years of operation as thousands of HUD-VASH Veterans become eligible 
for dental care. However, after the first few years of operation, the 
cost of providing dental care to Veterans in HUD-VASH would drop 
dramatically because the dental needs of this population would be 
satisfied or stabilized. VA would avoid new costs because VA expects a 
10 percent turnover in HUD-VASH vouchers in each fiscal year. 
Specifically, VA estimates the total cost associated with enactment of 
section 7 for FY 2013 to be $75.9 million; $123.0 million over a five-
year period, and $182.3 million over a 10-year period. (These estimates 
are comprised of the separate amounts estimated for direct patient care 
as well as projected increases in administrative costs.) VA's cost 
estimate for this provision only focused on HUD-VASH vouchers and 
Veterans participating in the HUD-VASH program. It is possible that 
Veterans eligible for VA health care reside in Section 8 housing that 
is unaffiliated with the HUD-VASH program. As presently drafted, 
Section 7 could further increase the cost of this bill.
    Section 8 of S. 3309 includes a series of extensions to reauthorize 
VA's benefits programs for homeless Veterans. VA supports Section 8 and 
notes that, if enacted, these extensions would not result in any 
additional costs beyond those contemplated in VA's FY 2013 budget 
request. Each provision of Section 8 is discussed below in greater 
detail.
    Section 8(a) would authorize to be appropriated $250,000,000 for FY 
2013 and $150,000,000 for FY 2014 and each fiscal year thereafter for 
the conduct of VA's GPD Program.
    VA supports Section 8(a). Under current law, the amount authorized 
to be appropriated for the GPD Program for FY 2013 will be reduced from 
$250,000,000 to $150,000,000 and it remains the same for each 
subsequent fiscal year. We support section 8(a) to the extent that it 
would retain the program's current level of authorization for FY 2013. 
We have concerns, however, about the terms that would drop the 
authorization level to $150,000,000 for FY 2014 and each fiscal year 
thereafter. Such a decrease would be highly problematic. GPD 
expenditures will far exceed the amount authorized to be appropriated 
for the program for FY 2014 and in following fiscal years. VA would 
require additional funding to support the existing projects at 
anticipated per diem and occupancy rates in FY 2014 and beyond. 
Otherwise, VA would be forced to either cut per diem payments to GPD 
community providers or summarily terminate operational GPD projects 
presently serving homeless Veterans.
    Section 8(b) would authorize to be appropriated $50,000,000 for FY 
2013, for the conduct of the U.S. Department of Labor's (DOL) Homeless 
Veterans Reintegration Programs. We defer to the views of the Secretary 
of Labor on this provision.
    Section 8(c) would extend VA's general treatment and rehabilitation 
authority (codified at 38 U.S.C. Sec. 2031(a)) for seriously and 
mentally ill Veterans from December 31, 2012 to December 31, 2014. VA 
supports this legislative measure, which would reauthorize the VA's 
Health Care for Homeless Veterans Program (consisting of VA's premier 
outreach program and a program offering contract therapeutic housing).
    Section 8(d) would extend VA's operation of comprehensive service 
centers for homeless Veterans (under 38 U.S.C. Sec. 2033) from 
December 31, 2012 to December 31, 2014. VA supports section 8(d), which 
would re-authorize VA's Community Resource and Referral Centers.
    Section 8(e) would extend, through December 31, 2013, the 
Secretary's authority under 38 U.S.C. Sec. 2041 to sell, lease, or 
donate properties to nonprofit organizations that provide shelter to 
homeless Veterans. Under current law, the authority will expire on 
December 31, 2012. VA supports the extension, as it will help VA meet 
its goal of ending Veteran homelessness by 2015. We note, however, that 
the five-year extension that the Administration proposed would better 
enable VA to achieve our goal. While any extension of authority under 
38 U.S.C. Sec. 2041 would result in a reduction in property sales 
proceeds, neither a one-year, nor a five-year extension would result 
any significant loan subsidy costs.
    Section 8(f) would require VA to make available (from amounts 
approPriated for Medical Services) $300,000,000 for FY 2013 to carry 
out the Department's Financial Assistance Program (required by 38 
U.S.C. Sec. 2044). VA supports section 8(f), which would re-authorize 
appropriations for the SSVF Program, VA's premier prevention and rapid 
re-housing program. VA has already budgeted $300 million for the SSVF 
Program in FY 2014.
    Section 8(g) would extend VA's Grant Program for Homeless Veterans 
with Special Needs through 2015. VA supports this measure.
    Section 8(h) would extend VA's Advisory Committee on Homeless 
Veterans from December 31, 2012, to December 31, 2014. VA supports this 
provision.

 S. 3313--WOMEN VETERANS AND OTHER HEALTH CARE IMPROVEMENTS ACT OF 2012

    Section 2 of the bill would add a new section 7330B to Title 38, 
entitled ``Facilitation of reproduction and infertility research.'' 
This new section would require the Secretary of VA to ``facilitate 
research conducted collaboratively by the Secretary of Defense and the 
Director of the National Institutes of Health'' to improve VA's ability 
to meet the long-term reproductive health care needs of Veterans with 
service-connected genitourinary disabilities or conditions incurred or 
aggravated in line of duty that affect the Veterans' ability to 
reproduce, such as spinal cord injury. The Secretary of VA would be 
required to ensure that information produced by research facilitated 
under section 73308 that may be useful for other activities of the 
Veterans Health Administration (VHA) is disseminated throughout VHA. No 
later than three years after enactment, VA would be required to report 
to Congress on the research activities conducted under section 7330B.
    VA supports section 2 of S. 3313. Generally, VA supports 
implementing research findings for the benefit of Veterans. VA's goal 
is to restore the capabilities of Veterans with disabilities to the 
greatest extent possible. We utilize new research into various 
conditions to improve the quality of care we provide. Of note, rather 
than requiring VA to conduct research, this section would require VA to 
facilitate research that is conducted collaboratively by the Secretary 
of Defense and the Director of the National Institutes of Health. It is 
not clear how the term ``facilitate'' would be defined, which could 
raise privacy and security issues with respect to identifiable Veteran 
information. Given the ambiguity over the meaning of this term, VA is 
unable to provide a cost estimate at this time. If facilitation 
requires fairly minor involvement (coordination, distribution, etc.), 
VA expects the costs of this provision would be nominal; however, if 
facilitation is intended to mean direct funding, proposal reviews, and 
additional staff, costs would be greater.
    Section 3 of S. 3313 would include fertility counseling and 
treatment, including assisted reproductive technology, among those 
things that are considered to be ``medical services'' under chapter 17 
of title 38, U.S.C., as provided in 38 U.S.C. Sec. 1701(6).
    VA supports the intent of section 3 of S. 3313, but must condition 
this support on assurance of the additional resources that would be 
required were this provision enacted. The provision of Assisted 
Reproductive Technologies (including any existing or future 
reproductive technology that involves the handling of eggs or sperm) is 
in keeping with VA's goal to restore the capabilities of Veterans with 
disabilities to the greatest extent possible and to improve the quality 
of Veterans' lives. For many Veterans, having children is an important 
and essential aspect of life, and those who desire but are unable to 
have children of their own commonly experience feelings of depression, 
grief, inadequacy, poor adjustment, and poor quality of life.
    VA estimates the cost of providing these new benefits to all 
Veterans would be $59 million in FY 2013, $37 million in FY 2014, $232 
million over 5 years, and $529 million over 10 years. The cost estimate 
is higher in the first year than in subsequent years because VA assumes 
that existing demand would result in immediate utilization of this 
benefit, but that demand would decline after these services were 
provided.
    Section 4 would add a new section 1787 to Title 38 that would 
require VA to furnish fertility counseling and treatment, including 
assisted reproductive technology, to a spouse or surrogate of a 
severely wounded enrolled Veteran who has an infertility condition 
incurred or aggravated in line of duty, if the spouse and the Veteran 
apply jointly for such counseling and treatment through a process 
prescribed by VA. This section would authorize VA to ``coordinate 
fertility counseling and treatment'' for other spouses and surrogates 
of other Veterans. Section 4 would require VA to prescribe regulations 
to carry out section 1787 no later than 1 year after enactment.
    VA supports section 4 in part, but must condition this support on 
assurance of the additional resources that would be required were this 
provision enacted. While VA supports providing infertility services 
including Assisted Reproductive Technology (ART) to severely wounded 
Veterans described in section 4 and their spouses or partners, VA does 
not support coverage of surrogates. The additional coverage of 
surrogates is inconsistent with coverage provided by the Department of 
Defense (DOD), Medicaid, Medicare, and several private insurers and 
health systems. Current DOD policy addressing assisted reproductive 
services for severely injured Servicemembers specifically excludes 
coverage of surrogates. Moreover, the complex legal, medical and policy 
arrangements of surrogacy vary from state to state due to inconsistent 
local regulations. VA acknowledges that surrogacy may offer the only 
opportunity for Veterans and their partners to have a biological child. 
However, there may be other options to consider when exploring how best 
to compensate these Veterans for their loss and to facilitate 
procreation.
    VA recommends clarification of the phrase, ``a severely wounded 
veteran who has an infertility condition incurred or aggravated in line 
of duty in the active military, naval, or air service'' in subsection 
(a) of proposed section 1787 in section 4. The current language is 
unclear as to whether this benefit would be available to the spouses 
and surrogates of enrolled Veterans that have suffered loss or loss or 
use of creative organs, or if the eligible population would be more 
limited based on certain conditions of such Veterans (e.g. those with 
SCI, polytrauma, genitourinary injuries). VA also recommends 
clarification of the terms ``fertility counseling and treatment'' and 
``assisted reproductive technology.'' In addition, the meaning and 
scope of the coordination contemplated under proposed section 1787(b) 
(which would authorize VA to ``coordinate fertility counseling and 
treatment'' for the spouses and surrogates of other Veterans not 
described in section 1787(a)) is unclear, and could potentially account 
for spouses and surrogates of all other Veterans. VA recommends that 
this be clarified as well.
    VA recommends that this legislation be consistent with DOD's 2012, 
``Policy for Assisted Reproductive Services for the Benefit of 
Seriously or Severely Ill/Injured (Category II or Ill) Active Duty 
Servicemembers.'' As such we recommend this legislation account for 
both severe injury and illness. VA cannot separate the costs of illness 
and injury. In the context of reproductive health, the distinction 
between illness and injury often is not a clearly defined boundary.
    VA also recommends the language of the bill be modified to account 
for different types of family arrangements, so that benefits are not 
limited to only spouses of Veterans described in proposed section 1787 
(e.g. to include both spouses and partners of Veterans).
    The bill does not state whether maternity services would be covered 
for a female spouse of a Veteran once infertility treatment is provided 
and pregnancy is established. These benefits typically would be 
provided in the private sector following successful fertility 
treatment. If the Committee intends that these benefits be included, we 
recommend that be made clear in the bill language.
    VA also notes that the timeline to implement regulations for this 
program within one year of enactment is unrealistic given the 
complexity of issues involved.
    VA's cost estimates for care provided under this section do not 
account for maternity services for a female partner or spouse of a 
Veteran with infertility because the bill does not state that maternity 
services would be covered for a female partner or spouse of a Veteran 
once infertility treatment is provided and pregnancy is established. 
Potential costs for surrogates are also not reflected in this analysis 
because VA has no reliable way to predict how many surrogates would be 
utilized and cannot project the costs to cover the full range of legal 
and medical issues arising from surrogacy. This analysis accounts for 
the following infertility services, and includes the costs of providing 
in vitro fertilization to the proposed eligible population: advice/
office visits, testing, drug therapy, surgery or treatment for blocked 
tubes, tubotubal anastomosis (reversal of tubal ligation), vasovasotomy 
(reversal of vasectomy), varicocele repair (repair of varicose veins 
around scrotum), artificial insemination (AI)/intrauterine insemination 
(lUI), assisted reproductive technologies (ART), and ART with donated 
egg/sperm, ART with frozen embryo, and ART with host uterus. VA's cost 
estimates also assume there is pent-up demand for these services, so 
first year costs are expected to be significantly higher as Veterans 
and their families would immediately utilize these treatment options. 
The estimates reflect only the cost of services and do not reflect any 
potential costs associated with additional enrollment or additional 
utilization. VA's cost estimate is based on the assumption that the 
benefits under section 4 would be extended to the spouses of Veterans 
with SCI, polytrauma, or genitourinary injuries, or other creative 
organ loss. VA is unable to differentiate between creative organ loss 
that is a result of injury and that which is a result of illness. 
Therefore, this analysis includes spouses and partners of Veterans with 
creative organ loss which could be a result of illness or injury.
    VA estimates the total cost to provide care under section 4 for 
spouses and partners of severely injured Veterans (those with 
polytrauma, genitourinary injuries, and spinal cord injuries, as well 
as creative organ loss, which could result from both injury or illness) 
to be approximately $77 million in FY 2013, $36 million in FY 2014, 
$252 million over 5 years, and $590 million over 10 years. As with 
section 3, VA anticipates a greater cost in FY 2013 as existing demand 
for these services is addressed.
    Section 5 would require VA to enhance the capabilities of the VA 
Women Veterans Call Center (WVCC) in responding to requests by women 
Veterans for assistance with accessing VA health care and benefits, as 
well as in referring such Veterans to community resources to obtain 
assistance with services not furnished by VA.
    VA supports section 5 of S. 3313, and VA believes the most 
effective means of implementing this section would be to establish an 
inbound calling system specifically for women Veterans. By building on 
capabilities within the WVCC, an incoming call center would allow women 
Veterans to call the WVCC, and VA to connect them to resources, assist 
with specific concerns, and provide information on services and 
benefits. Many Veterans call VA daily requesting more details on how to 
enroll, how to find their DD-214, and what benefits they have earned. 
WVCC can directly connect women Veterans to Health Eligibility Center 
employees for enrollment information and discussion of benefits 
available to them. Calls could also be transferred to the appropriate 
medical center to assist eligible Veterans with obtaining a health care 
appointment. Once a woman Veteran is connected to VA health care 
services, the Women Veterans Program Manager could also assist her in 
finding community resources that may not be provided by VA.
    VA estimates section 5 would cost $1.2 million in FY 2013, $6.4 
million over 5 years, and $14.1 million over 10 years.
    Section 6 of S. 3313 would expand the locations and duration of the 
pilot program required by section 203 of Public Law 111-163. Section 
203 required VA to carry out a pilot program to evaluate the 
feasibility and advisability of providing reintegration and 
readjustment services in group retreat settings to women Veterans 
recently separated from service after a prolonged deployment. Section 
6(a) would increase the number of locations at which VA is required to 
carry out the pilot program from three to fourteen locations. Section 
6(b) would extend the duration of the pilot from 2 years to 4 years.
    VA supports section 6 of S. 3313. VA is currently in the final year 
of the original 2-year pilot program, authorized by section 203 of 
Public Law 111-163. These retreats under the pilot program focus on 
building trust and developing peer support for the participants in a 
therapeutic environment. In FY 2011, VA provided three retreats to 
women Veterans with three more retreats scheduled for FY 2012. VA could 
benefit from additional retreats as a greater number of women Veterans 
will be able to participate. These additional participants will also 
provide more data for VA to make a determination as the appropriateness 
of these retreats during the final reporting phase. Initial reports 
provided after the completed retreats show favorable results with 
supplying participants with tools needed to make a successful 
reintegration into civilian life.
    While VA supports section 6, we note that there may not actually be 
fourteen distinct geographic locations that offer the level of service 
the program requires. Therefore, we recommend that section 6(a) be 
amended to require VA to carry out the pilot program in up to fourteen 
locations. VA would continue to look for new locations to hold these 
retreats if section 6 were enacted, but previously used facilities may 
need to be reused due to the shortage of potentially qualifying 
locations based on the retreat requirements, specifically the need for 
specialized locations to complete outdoor team building exercises and 
other conditions.
    Because VA will have completed retreats at six locations by the end 
of FY 2012, section 6 would require VA to schedule retreats at an 
additional eight locations before entering the final reporting phase. 
VA estimates that the cost of implementing this pilot program at an 
additional eight locations for an additional 2 years of the pilot 
program would cost $335,640 in FY 2013 and $348,000 in FY 2014, for a 
total of $683,640.
    Section 7(a) would modify the duration of the pilot program 
required by section 205 of Public Law 111-163. Section 205 required VA 
to carry out a 2-year pilot program at no fewer than three VISNs to 
furnish child care services to eligible Veterans as a means of 
improving access to mental health care and other health care services. 
Section 7(a) would extend the duration of the pilot such that ''[a] 
child care center that is established as part of the pilot program may 
operate until the date that is 2 years after the date on which the 
pilot program is established in the third Veterans Integrated Service 
Network.''
    VA supports section (7)(a). Currently, VA has two operational sites 
for the pilot program required by section 205 of Public Law 111-163: 
the first site established in Buffalo in October 2011, and the second 
site established in Northport in April 2012. The third identified site, 
in American Lake, WA, began offering services in the community in 
August 2012, and is expected to open its program on its VA campus in 
late 2012. This amendment would extend the authorization to execute 
currently planned programs and consequently would result in no 
additional cost to VA.
    Section 7(b) would require VA to carry out a pilot program to 
assess the feasibility and advisability of providing assistance to 
qualified Veterans to obtain child care during the period such Veterans 
are receiving readjustment counseling and related mental health 
services at a Vet Center. The pilot program would be carried out in at 
least three Readjustment Counseling Service Regions selected by VA, for 
a 2-year period beginning when the last pilot location established 
under this section is initiated. VA would be required to report to 
Congress on the pilot program not later than 180 days after completion 
of the pilot program, which would include findings and conclusions, as 
well as recommendations for continuation or expansion of the pilot 
program. Paragraph (8) of section 7(b) would authorize the 
appropriation of $1,000,000 for each FY 2014 and FY 2015 to carry out 
the pilot program. This section would define ``Vet Center'' as ``a 
center for readjustment counseling and related mental health services 
for veterans under section 1712A of title 38, United States Code.''
    VA supports section 7(b). Some Veterans who use Vet Center 
services, especially those who have served in either Iraq or 
Afghanistan, have voiced concerns that the lack of available child care 
has impacted their ability to consistently use Vet Center services. Vet 
Center staff members are constantly searching for new initiatives that 
have the potential to increase Veteran access to services. This pilot 
program could help to identify the scope of these concerns within the 
Vet Center program and determine the effectiveness of potential 
interventions. However, we have identified some concerns about 
confidentiality under the proposed pilot program, as VA's Vet Centers 
currently maintain a separate set of records to preserve Veteran 
information. There is a possibility that Veterans participating in the 
program would need to consent to a verification process that could lead 
to a child care provider knowing that the Veteran is using Vet Center 
services. The pilot program could allow us to determine whether this 
has an impact on utilization of Readjustment Counseling Services.
    VA is not able to provide an accurate cost estimate for section 
7(b), as VA has no experience in predicting the potential use of such 
child care programs by Veterans who use Vet Center services. It is not 
viable to use cost estimates from the VA Child Care Pilot Program 
required by section 205 of Public Law 111-163, as this pilot is 
providing additional services through onsite child care and Vet Centers 
do not have space to accommodate such additional services. Further, 
usage comparisons with this pilot are not viable, as Vet Centers 
provide services during non-traditional hours, including after normal 
business hours and on weekends when requested by the Veteran. Depending 
upon how the program is executed, the $1 million that would be 
authorized to be appropriated under paragraph (8) of section 7(b) may 
not be adequate to support a pilot program offering child care services 
at three Vet Center locations.

S. 3316--A BILL TO REQUIRE THE SECRETARY OF LABOR TO CARRY OUT A PILOT 
   PROGRAM ON PROVIDING VETERANS WITH ACCESS AT ONE-STOP CENTERS TO 
  INTERNET WEB SITES TO FACILITATE ONLINE JOB SEARCHES, AND FOR OTHER 
                               PURPOSES.

    Section 1 of S. 3316 would require the Secretary of Labor to 
commence a pilot program to assess the feasibility and advisability of 
providing Veterans seeking employment with access to computing 
facilities to facilitate the access of such Veterans to Internet Web 
sites. The bill requires commencement of the pilot program not later 
than 90 days after the date of the enactment of this Act. VA defers to 
the DOL on section 1 of the bill.
    Section 2 of this bill would repeal 38 U.S.C. Sec. 7324, which 
requires the Secretary of VA to submit to Congress an annual report on 
the use of authorities to enhance retention of experienced nurses. VA 
supports this proposal. This reporting requirement has been provided 
annually to Congress since 2002. The Veterans Health Administration 
(VHA) is very interested in retaining experienced nurses, and this 
report has demonstrated for 10 years how VHA utilizes its authorities 
to enhance retention. Given that VHA intends to continue its retention 
efforts, as the report has demonstrated over the last 10 years, there 
is minimal value in resubmitting the same data, with slight variation, 
annually. There would be a cost savings associated with the bill. 
Annually, VA spends $4,082 to prepare this report. VA estimates cost 
savings of $20,400 over 5 years and $40,820 over 10 years.

  S. 3324--GRANTS TO NONPROFIT ORGANIZATIONS FOR THE CONSTRUCTION OF 
                    FACILITIES FOR TEMPORARY LODGING

    S. 3324 would authorize VA to award grants to the Fisher House 
Foundation, Inc. for the construction, furnishing, and decorating of 
Fisher Houses to be used by VA to provide temporary lodging under 38 
U.S.C. Sec. 1708(a). This bill would also authorize VA to accept, use, 
and dispose of gifts of services or property for purposes of awarding 
these grants or for operating and maintaining Fisher Houses. Finally, 
the bill would authorize the appropriation of $4,000,000 for FY 2013 
and each fiscal year thereafter.
    VA Fisher Houses improve access to care for Veterans by providing a 
supportive environment for family members and caregivers to stay during 
the course of medical treatment. Veterans are more likely to travel 
long distances to receive care if their families and caregivers can 
accompany them without bearing the burden of costs associated with 
hotel lodging. VA supports the Fisher House and other similar 
foundations. We note that the bill would set a new precedent in 
allowing funding for Fisher House construction, where previously VA 
only provided operation and maintenance funding. Further, the bill 
limits these grants to only the Fisher House Foundation. Other 
community organizations have provided funding for the construction of 
temporary lodging at VA medical centers. For example, Lilly Endowment, 
Inc., in collaboration with other community organizations, funded a 
grant to construct the ``Veterans House,'' which opened in 2011, and is 
located on the grounds of the Richard L. Roudebush VA Medical Center in 
Indianapolis, Indiana.
    VA estimates the cost of this bill to be $4.2 million in the first 
year, $20.9 million over 5 years and $41.9 million over 10 years.

S. 3336--A BILL TO AUTHORIZE THE SECRETARY OF VETERANS AFFAIRS TO CARRY 
OUT A MAJOR MEDICAL FACILITY PROJECT LEASE FOR A DEPARTMENT OF VETERANS 
  AFFAIRS OUTPATIENT CLINIC AT EWA PLAIN, OAHU, HAWAII, AND FOR OTHER 
                                PURPOSES

    S. 3336 would authorize the Secretary of VA to carry out a major 
medical facility project lease for an outpatient clinic at Ewa Plain, 
Oahu, in an amount not to exceed $16,453,300.
    VA supports the bill, but as written it does not fully describe the 
project. Because the outpatient clinic will be co-located with the 
Department of Defense, VA suggests modifying the language as set forth 
below.

        ``The Secretary of Veterans Affairs may carry out a major 
        medical facility lease for a Department of Veterans Affairs 
        outpatient health care access center, to include a co-located 
        clinic with the Department of Defense and the co-location of 
        the Veterans Benefits Administration Honolulu Regional Office 
        and the Kapolei VA Vet Center, in an amount not to exceed 
        $16,453,300.''

  S. 3340--MENTAL HEALTH ACCESS TO CONTINUED CARE AND ENHANCEMENT OF 
                      SUPPORT SERVICES ACT OF 2012

Title I
    With regard to sections 101 through 103 and sections 107 through 
113 of S. 3340, VA defers to the views of the Department of Defense 
(DOD), as these sections primarily affect DOD programs.
    Section 104 of S. 3340 would limit disclosure by DOD medical and 
mental health care providers of a mental health condition of a member 
of the Armed Forces, treatment of a member for a mental health 
condition, or a member's request for treatment of a mental health 
condition. Under this section, a DOD medical or mental health care 
provider could only make such a disclosure if:

    (1) The disclosure is to another covered entity (as defined for 
purposes of the Health Insurance Portability and Accountability Act of 
1996 (HIPAA)) and is necessary;
    (2) The member concerned requests the disclosure;
    (3) The member concerned does not meet the minimum standards for 
deployment prescribed under section 1 074f(f) of Title 10, United 
States Code, at the time of the disclosure, regardless of the 
deployment status or plans of the member; or
    (4) The disclosure is necessary in an emergency to protect the life 
or safety of the member concerned or others.

    While VA supports the goal of limiting unnecessary disclosures of 
Servicemembers' mental health records, we do not support section 104 
because its provisions would complicate and delay the delivery of 
benefits to which Veterans are entitled. Currently, the Veterans 
Benefits Administration (VBA) is authorized to request and receive 
mental health treatment records from DOD without requiring the Veteran 
to sign a medical release for such disclosure. However, because VBA is 
not a ``covered entity'' under HIPAA, section 104 would require that a 
Servicemember or Veteran specifically request that VBA obtain the 
protected records. Thus, the provisions of section 104 would add an 
additional administrative burden for VBA in adjudicating claims for 
mental disorders that would potentially operate to the detriment of 
Veterans in need of compensation benefits by delaying the adjudication 
of their claims.
    There are no mandatory or significant discretionary costs 
associated with section 104. However, the proposed provision would 
likely delay claims processing for Veterans seeking compensation for 
mental health conditions by imposing the additional requirement that VA 
obtain from every Veteran claiming compensation for a mental health 
condition a specific release of information to forward to DOD. This 
additional step could ultimately delay the delivery of benefits, or 
possibly result in a denial of benefits otherwise warranted if the 
Veteran failed to provide the necessary authorization.
    Section 105 would require DOD and VA to enter into an MOU governing 
the sharing of examination results and other records retained under 
DOD's medical tracking system for members of the Armed Forces deployed 
overseas.
    VA does not support the proposed provision. Current agreements 
between DOD and VA already permit the sharing of information contained 
within medical tracking systems for members deployed overseas. The 
current agreements enable VA to procure such records for purposes of VA 
health care and benefits claims. For example, DOD and VHA share 
information from DOD's Pre-and Post-Deployment Health Assessment 
surveys and the Post-Deployment Health Reassessments surveys by 
utilizing the Federal Health Information Exchange (FHIE) and 
Bidirectional Health Information Exchange systems. DOD sends data on 
separated Servicemembers to VA on a monthly basis, and weekly for 
individuals referred to VA for care or evaluation. Because VA and DOD 
already share this information pursuant to an MOU governing health 
information sharing, this provision is unnecessary. It is unclear 
whether this provision would require an additional MOU to replace or 
supplement the existing memorandum covering the same subject. There 
would be no costs associated with enactment of this provision.
    Section 106 would require DOD and VA to enter into an MOU providing 
for participation of members of the Armed Forces in VA peer support 
counseling programs and would require VA to provide training to 
Servicemembers who will perform peer support counseling duties under 
those programs. VA has no objection to this section of S. 3340. VA 
already is undertaking actions consistent with the objective of section 
106 without the use of a memorandum of understanding. VA currently has 
a peer support specialist position in development for which active duty 
Servicemembers would be eligible to apply. All VA peer support 
counselors receive training. In addition to the formal peer support 
training program, a volunteer position description has also been 
developed expressly to provide volunteer support to those Veterans in 
the suicide prevention program. While VA does not consider these 
volunteers to be ``peer specialists'' and would not expect or want 
these volunteers to provide counseling services, there are a variety of 
ways that they can provide support to fellow Veterans, such as 
companionship. VA encourages and supports this engagement through the 
suicide prevention volunteer program. VA estimates the cost of this 
provision would be $32.4 million for FY 2013; $167.5 million over 
5 years; and $349.8 million over 10 years.

Title II
    Section 201(a) would require that VA, no later than December 31, 
2013, develop and implement a comprehensive set of measures to assess 
mental health care services furnished by VA. These measures must 
provide an accurate and comprehensive assessment of the timeliness of 
the furnishing of VA mental health care, the satisfaction of patients 
who receive VA mental health care services, the capacity of VA to 
furnish mental health care, the availability and furnishing of 
evidence-based therapies by VA. Section 201(b) would require VA, not 
later than December 31, 2013, to develop and implement guidelines for 
the staffing of general and specialty mental health care services, 
including at community-based outpatient clinics. Such guidelines must 
include productivity standards for providers of mental health care.
    VA has no objections to Section 201(a), although it is partially 
duplicative of current processes in place by the VHA Office of Mental 
Health Operations (OMHO) and Office of Mental Health Services (OMHS). 
OMHO and OMHS have partnered to develope four separate work groups to 
address access measurement in response to the recent review by the 
Office of the Inspector General. VHA leadership has put forth both 
temporary and long-term proposals addressing access measurement. VHA is 
currently reviewing patient satisfaction using the Survey of Healthcare 
Experiences of Patients survey tool, and conducting meetings with 
Veterans at every OMHO site visit scheduled this year and on a 
recurring 3-year basis to provide feedback from Veterans on mental 
health services. VHA has also developed a specific survey to obtain 
Veteran feedback about mental health care and will be implementing the 
survey in FY 2013. Capacity to furnish mental health care is measured 
by the Comprehensive Mental Health Information System (MHIS), which 
allows VHA to review the amount of mental health services provided per 
unique Veteran at a facility and compare results across facilities. 
Likewise, VHA is able to partially monitor the availability and 
furnishing of evidence-based psychotherapies (EBP) using the 
Comprehensive MHIS, which provides an overall measure for psychotherapy 
implementation as well as specific metrics related to the provision of 
such services for Veterans with PTSD, Depression, Substance Use 
Disorders , and Serious Mental Illness (SMI). VHA anticipates the 
implementation of the templates for the EBP notes in FY 2013 will 
provide more specific information for analysis.
    VA has no objections to section 201(b), OMHO is partnering with 
OMHS to further develop the mental health staffing model. A pilot is 
currently underway in (Veterans Integrated Service Networks (VISN) 1, 
4, and 22, the results of which will help further guide implementation 
to all VISNs in FY 2013. Productivity standards for mental health 
providers have been drafted and are being reviewed internally by VHA 
before final approval. There are no additional costs involved for these 
subsections if efforts are covered by current VHA staff.
    Section 201(c) would require VA seek to enter into a contract with 
the National Academy of Sciences to create a study committee to consult 
with VA on VA's development and implementation of the measures and 
guidelines required by subsections (a) and (b); and to conduct an 
assessment and provide an analysis and recommendations on the state of 
VA's mental health services. The contract must require the study 
committee to assess certain issues, conduct surveys, and make 
recommendations to the Secretary on certain issues. Any subcommittee 
that assists the study committee must include at least one former VHA 
official and two former VHA employees who were providers of mental 
health care. The study committee would be required to submit periodic 
reports to VA and provide other consultation to VA. Not later than 30 
days after receiving a report from the Committee, VA would be required 
to submit to the Congressional Veterans' Affairs Committees a report on 
VA's plans to implement each recommendation in the report.
    Section 201(c) appears to be duplicative of processes already in 
place within OMHO. However, VA does not object to the provision because 
a contract might be beneficial for consultative purposes to augment 
current internal efforts.
    VA has no objection to this subsection.VHA has already reviewed 
barriers to mental health services using focus groups with mental 
health provider staff as well as through OMHO site visits at every 
facility this fiscal year. Comprehensive site visits have been 
conducted during which OMHO reviewed the implementation of the Uniform 
Mental Health Services Handbook at each facility. VHA could further 
modify these ongoing site visits to review implementation of early 
interventions services for hazardous drinking and relationship problems 
for Operation Enduring Freedom/Operation Iraqi Freedom/Operation New 
Dawn (OEF/OIF/OND) Veterans, as proposed in section 201(c). A survey of 
Veterans and clinical providers is also currently being finalized for 
distribution to the field and will include Veterans from OEF/OIF/OND. 
Follow-up analyses of both the surveys and the site visits will be 
submitted to upper management detailing overall concerns. Individual 
facilities are submitting action plans based on each site visit report. 
These actions plans are monitored by OMHO and a follow-up action plan 
will be developed based on the survey summary. It should be noted that 
site visit teams are also comprised of facility mental health providers 
and leaders. A compiled report can be made regularly to the Secretary 
for distribution to Congress as desired.
    Section 201(d) would require VA to make available to the public on 
a VA Internet Web site the measures and guidelines developed and 
implemented under this section and an assessment of the VA's 
performance using such measures and guidelines. VA would be required to 
update the measures, guidelines, and assessment made available to the 
public not less frequently than quarterly.
    VA has no objection to this provision. VHA could publish its 
measures and guidelines along with an assessment of VA's performance 
that is based on these metrics. This would be placed on an Internet Web 
site for public awareness. However, it should be noted that such 
assessments cannot always be updated quarterly, as some metrics may be 
updated at various points of the year.
    Section 201(e) would require VA to submit to the Congressional 
Committees on Veterans' Affairs a report on the Secretary's progress in 
developing and implementing the measures and guidelines required by 
section 201 no later than June 30, 2013, and no less frequently than 
twice each year thereafter. This subsection specifies what the report 
must include.
    VA has no objection to providing reports to the Senate Veterans' 
Affairs Committee (SVAC) and House Veterans' Affairs Committee (HVAC) 
to report on progress on the implementation of the measures and 
guidelines from above. However, to reduce the burden of report 
preparation, we recommend this provision be modified to require reports 
annually or as needed.
    Section 201(f) would require VA to submit to the Congressional 
Committees on Veterans' Affairs a report on the Secretary's planned 
implementation of such measures and guidelines not later than 30 days 
before the date on which the Secretary begins implementing the measures 
and guidelines required by this section. This subsection sets forth the 
required elements of this report.
    VA has no objection to this provision. While VHA already has 
measures in place, OMHO could submit a report to the Secretary that 
outlines descriptions of each measure and current vacancies. Prior to 
submitting an assessment of how many additional positions may be needed 
to meet demand for services, VHA would need to complete the staffing 
model pilot and incorporate revisions to the staffing model based on 
the outcome of the pilot.
    For those subsections of section 201 with costs, VA estimates the 
cost of Section 201 provisions to be $2.3 million in FY 2013; $7.7 
million over 5 years; and $9.1 million over 10 years.
    Section 202 would limit the individuals who can receive 
readjustment counseling from VA, including at Vet Centers, to the 
following:

    (1) Individuals (Veterans and members of the Armed Forces) who 
served on active duty in a theater of combat operations or an area at a 
time during which hostilities occurred in that area.
    (2) Individuals (Veterans and members of the Armed Forces) who 
provided direct emergency medical or mental health care, or mortuary 
services to the causalities of combat operations or hostilities, but 
who at the time were located outside the theater of combat operations 
or area of hostilities.
    (3) Individuals (Veterans and member of the Armed Forces) who 
engaged in combat with an enemy of the United States or against an 
opposing military force in a theater of combat operations or an area at 
a time during which hostilities occurred in that area by remotely 
controlling an unmanned aerial vehicle, notwithstanding whether the 
physical location of such Veteran or member during such combat was 
within such theater of combat operations or area.
    (4) Individuals who previously received readjustment counseling.
    (5) Individuals who are family members of a member of the Armed 
Forces who is serving on active duty in a theater of combat operations 
or in an area at a time during which hostilities are occurring in that 
area.
    (6) Individuals who are family members of a Veteran or member of 
the Armed Forces described above.

    With respect to individuals described in (1) through (4) above, VA 
would be authorized to provide counseling to assist in readjusting to 
civilian life. For individuals described in (5) and (6) who are family 
members of a member who is deployed in a theater of combat operations 
or an area at a time during which hostilities are occurring in that 
area, VA may provide counseling during such deployment to assist them 
in coping with the deployment. For individuals who are family members 
of a member or Veteran who is readjusting to civilian life, VA may 
provide counseling to them to the degree that counseling furnished to 
them is found to aid in the readjustment of the Veteran or member to 
civilian life.
    Section 202 also would permit licensed and certified mental health 
care providers to determine that mental health services are needed to 
facilitate a Veteran's successful readjustment to civilian life. 
Currently, the law only permits physicians or psychologists to do this.
    Section 202 would define the term ``Vet Center'' as a facility 
which is operated by VA for the provision of services under this 
section and which is situated apart from VA general health care 
facilities.
    Section 202 would define the term ``family member'' to mean an 
individual who is a member of the family of the Veteran or member of 
the Armed Forces, including a parent, a spouse, a child, a step-family 
member, or an extended family member; or an individual who lives with 
the Veteran or member of the Armed Forces, but is not a member of the 
family of the Veteran or member of the Armed Forces.
    Finally, section 202 would authorize VA to provide for and 
facilitate the participation of VA employees who provide services under 
this section in recreational programs that are designed to encourage 
the readjustment of Veterans eligible for counseling under this 
section; and operated by organizations named in or approved by VA to 
prepare, present, and prosecute claims for Veterans' benefits.
    VA supports this section, which would expand readjustment 
counseling services to two new cohorts: (1) Medical, Mental Health, and 
Mortuary Professionals who deal with the casualties of war; and (2) 
Servicemembers and Veterans who served in positions within unmanned 
aerial vehicle crews. Both of these groups represent individuals that 
may not have necessarily deployed to combat theaters or areas of 
hostilities though still experience firsthand the reality of war and 
have their own unique readjustment to civilian life.
    There would be no cost associated with this section. These two 
cohorts represent a relatively small number of Veterans and 
Servicemembers. Furthermore, VA will be augmenting Vet Center staff 
around Active Duty military bases, where many of these individuals are 
stationed, as a part of the implementation of Section 401, Public Law 
111-163 which expands Vet Center eligibility to active duty 
Servicemembers who served in OEF/OIF/OND.
    Section 203 would authorize VA, subject to the availability of 
appropriations, to furnish mental health care to immediate family 
members of members of the Armed Forces who are deployed in connection 
with a contingency operation through VA medical facilities, !elemental 
health modalities, and such community, nonprofit, private, and other 
third parties as the Secretary considers appropriate. Family members 
would not be eligible for VA payments for beneficiary travel as part of 
this care.
    VA does not support this provision. These services are currently 
provided to family members of deployed Servicemembers by TRICARE or at 
a DOD medical facility. It is unclear what additional services would be 
offered by VA that are not already provided by TRICARE or DOD.
    VA estimates the cost of the provision to be $1.1 billion in FY 
2013; $7.6 billion over 5 years; and $19 billion over 10 years.
    Section 204 would amend Subchapter 1 of Chapter 73 of title 38 of 
the United States Code, to add a new section 7309, which would 
restructure the Readjustment Counseling Service (RCS) as a distinct 
organization within VHA, and add a new position of Chief Officer with 
direct authority over RCS staff and assets, including Vet Centers, who 
would report directly to the Under Secretary for Health. It would 
establish qualifications standards for Chief Officer, including, in 
part, combat Veteran status, psychological doctorates and internships 
approved by the American Psychological Association (APA), and minimum 
amount of required experience in administering and providing direct 
counseling or outreach services. This new section would fund the 
activities of RCS, including Vet Centers, through VHA's Medical Care 
appropriations, but prohibit allocation of the funds through the 
Veterans Equitable Resource Allocation system. Section 7309 also would 
require an annual report to Congress on the activities of RCS, 
including each Vet Center's workload, additional treatment capacity, 
and ratio between FTE employees and individuals served, and detailed 
analysis of demand and unmet need for readjustment counseling services 
and the plan for meeting such need.
    VA does not support this section, which would reorganize RCS within 
VHA. RCS is an independent organizational unit within VHA that provides 
unique services in a safe and confidential environment not provided at 
VA medical center facilities. Its current organizational placement 
under the Deputy Under Secretary for Policy and Services allows RCS to 
interact with all other clinical programs at the national level, while 
maintaining independence at the operational level. This alignment 
provides a conduit for coordination and collaboration where services 
are similar (e.g. policy development for mental health services that 
are common to both RCS and other facilities); it also supports the 
alignment of patient needs when primary care or specialty services are 
identified.
    Section 204 would also establish the statutory qualifications in 
the new section 7309 for the Chief Officer position. These include 
combat Veteran status, psychological doctorates and internships 
approved by the APA, and minimum years of experience in administrating 
or providing direct counseling and outreach services. Qualification 
requirements for VA's organizational Chief Officers are generally not 
set forth in statute. For example, Title 38 does not recognize specific 
professional associations for other health care professionals. In 
addition, the APA would have the sole authority to determine 
satisfactory doctorates and internships. This would conflict with the 
Secretary's authority under 38 U.S.C. Sec. 7402(b)(8) to determine, by 
policy, whether a particular psychological doctorate or internship is 
``satisfactory,'' and would require a statutory amendment before VA 
could accept doctorates or internships from other psychological 
professional associations. Finally, new section 7309 would establish 
the minimum amount of experience required to qualify for the Chief 
Officer position. There is no evidence to support that any set time 
makes a person more or less qualified to apply for the position. These 
provisions could limit VA's ability to recruit and appoint qualified 
candidates and result in an unintentional limitation on the sources of 
qualified individuals.
    There are no costs associated with this section.
    Section 205 would require the Secretary to establish a national 
program of outreach to societies, community organizations and 
government entities in order to recruit qualified mental health 
providers on a part-time, without compensation basis under 38 U.S.C. 
Sec. 7405. Section 205 would enable VA to partner with or assist in 
developing a community entity, including through use of a sharing 
agreement under 38 U.S.C. Sec. 8153 that provides strategic 
coordination to the societies, community organizations, and government 
entities in order to maximize the availability and effective delivery 
of their mental health services to Veterans. In carrying out the 
national outreach program, VA would train mental health professionals 
on military and service specific culture, combat experience, and other 
factors unique to Veterans who served in OEF/OIF/OND.
    This section would require VA to participate in outreach to recruit 
Without Compensation (WOC) Mental Health providers to provide mental 
health services on VA's behalf. VA currently has provisions for woe 
Employees that require mandatory credentialing and privileging 
procedures to assure competency and safety. VHA wants to ensure it has 
the ability to set recruitment targets and approve only those 
individuals who are qualified to provide mental health services. This 
summer VHA will release an accredited Military Culture Training program 
that will be available to all community providers, including those who 
provide care in the community for Veterans and Servicemembers.
    We do not believe that this legislation is needed and we do not 
support the widespread recruitment of WOC mental health providers who 
are not credentialed and privileged to provide services under our 
guidelines. However, VA supports the goal of conducting outreach to 
mental health providers who are appropriately qualified to treat our 
Nation's Veterans. VA is well positioned to set the appropriate 
recruitment and training guidelines that will maintain the integrity 
and safety of VA mental health care.
    VA estimates costs of $32.4 million for FY 2013; $167.5 million 
over 5 years; and $349.8 million over 10 years. Other costs may be 
needed, e.g., to run EES training programs for such WOC employees, but 
those cannot be estimated at this time.
    Section 206 would amend 38 U.S.C. Sec. 7411 to authorize 
reimbursement to full-time board-certified physicians and dentists for 
certification, recertification, or continuing professional education 
(CME) expenses up to $1,000 per year or, in the case of full-time 
psychiatrists, up to $4,000 per year.
    VA does not support this section, which would create an inequity 
among other professionals subject to similar continuing education and 
certification obligations.
    VA estimates costs for the provision at $24.6 million in FY 2013; 
$132 million over 5 years; and $292 million over 10 years.
    Section 207 of S. 3340 would require (as opposed to merely 
authorize) the Secretary to establish and carry out the peer support 
counseling program as provided for in 38 U.S.C. Sec. 1720F(j). Section 
207 would also require that the training provided to peer counselors 
include the training carried out under a contract with a national not-
for-profit mental health organization for Veterans of OEF and OIF to 
provide peer outreach and peer support services. This program would 
need to commence at each VA medical center no later than 270 days after 
enactment of the Act.
    VA does not support this provision. Currently, peer services are 
being provided at VA medical centers. In addition, the President 
recently signed an Executive Order to improve access to mental health 
services for Veterans, Servicemembers and military families. The Order 
requires VA to hire and train 800 peer-to-peer counselors to empower 
Veterans to support other Veterans and help to meet mental health care 
needs by December 31, 2013. Toward this end, new peers will be hired 
this fiscal year and throughout the coming fiscal year to enable VHA to 
provide these services at all VA medical centers and very large 
community-based outpatient clinics (CBOC). VA has developed the 
national training program and is currently soliciting bids for 
implementation. It is expected that an award will be made this summer 
and training will begin this fall.
    VA estimates that this provision will cost $27.8 million in FY 
2013; $249.4 million over 5 years; and $567.3 million over 10 years.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Patty Murray to 
Madhulika Agarwal, M.D., M.P.H., Deputy Under Secretary for Health for 
        Policy and Services, U.S. Department of Veterans Affairs

    Question 1. Last Congress, we created a pilot program to provide 
child care at several VA medical centers for veterans who were coming 
in for health care services. I understand that the first site opened in 
October 2011, but that the third site is not open for business yet. 
Please provide any preliminary assessment of the program, or lessons 
learned from the implementation to date.
    Response. In October 2011, the Department of Veterans Affairs (VA) 
began carrying out a 2-year pilot program to provide child care 
services to eligible Veterans at the Buffalo VA Medical Center (VAMC), 
and expanded this program to the Northport VAMC in April 2012. The 
third selected site, at American Lake, WA, a Division of the VA Puget 
Sound Health Care System, is scheduled to open in early fiscal YEAR 
(FY) 13. Preliminary information from this program reveals that 
Veterans are overwhelmingly supportive of the program and report that 
it has made health care more accessible for them. In FY 2012, VA 
projects it will spend a little more than $1 million to support the 
program. Data from the Buffalo program covers 10 months (October 2011-
July 2012), and Veteran utilization has steadily increased. Buffalo 
cared for 108 children in the month of July. The overall monthly 
average for the number of children cared for is 61. The program 
operates 5 days a week at both the Buffalo and Northport VAMCs. The 
Northport VAMC has 3 full months of data available (May 2012-
July 2012), and has experienced high utilization since opening, 
providing care to 130 children in the month of July. The overall 
monthly average for the number of children cared for is 92.
    We have identified contracting and construction issues as 
challenges to timely implementation. For example, the Buffalo VAMC 
operated under a monthly purchase order until VA awarded a contract on 
June 22, 2012. Other delays with construction and contracting have 
pushed back the opening of the American Lake site until early FY 2013.
    VA officials have learned several valuable lessons from this pilot. 
Perhaps most important is that an implementation team comprised of 
individuals from General Counsel, Contracting, Public Affairs, and 
other offices is essential to timely implementation. The requirement 
for an integrated implementation team will be added as experience has 
indicated significant delays occurred as each office dealt with issues 
such as outreach and contracting sequentially rather than concurrently.
    We also receive valuable feedback from Veterans concerning hours of 
operation, logistics, implementation, and other elements of the program 
via our approved satisfaction survey. Suggestions for improvement are 
carefully considered and implemented as appropriate. As the pilot 
progresses, we anticipate other lessons learned will be more readily 
identified, and we will include this information in our report to 
Congress after the completion of the pilot program.
    VA has determined that its authority to execute the pilot program 
will expire on October 2, 2013, 2 years after the first pilot site 
opened in Buffalo. Because not all facilities began providing these 
services at the same time, under the current authority, Northport and 
American Lake will not be able to operate for a full 2 years. Section 
7(a) of S. 3313, the Women Veterans and Other Health Care Improvements 
Act of 2012 which currently resides in the Committee, would provide a 
technical amendment authorizing the program to run for a period of 2 
years beginning on the date the third site is activated. If such an 
amendment were made, VA would expand the pilot to additional locations 
in FY 2013 to obtain more, valuable information on the costs and 
benefits. These sites would be selected based upon interest by facility 
leadership, availability of resources, need for child care services 
among the Veteran population, and other relevant factors. These 
additional locations would provide VA with more data, thereby allowing 
VA to provide a better recommendation to Congress on whether the pilot 
should be continued or expanded.

    Question 2. The Mental Health ACCESS Act of 2012 would make a range 
of improvements to mental health services for our servicemembers and 
veterans. Among its other provisions, this bill would expand the 
availability of mental health services for family members of veterans 
and deployed servicemembers. Please discuss the importance of veterans 
having good, stable family support when they return home from 
deployments, and the extent to which VA can help accomplish this goal.
    Response. Family members of Veterans with emotional symptoms and 
problems that arise during their military service or post-deployment 
face many challenges as they strive to be a significant source of 
strength and support for their Servicemember or Veteran family member. 
A recent study found that 86 percent of Veterans with Post Traumatic 
Stress Disorder (PTSD) view their symptoms as a source of family stress 
(Batten et al., 2009). In the case of PTSD, symptoms of emotional 
numbing, including difficulties experiencing and expressing positive 
and negative feelings, can hinder the ability of the Veteran with PTSD 
to feel close or connected to family members (Riggs et al, 1998). Also, 
symptoms such as irritability, being easily startled, and having 
trouble concentrating or sleeping can contribute to conflict within the 
family (Taft et al., 2007). Other issues that can contribute to 
relationship and family issues include difficulty with trusting others, 
lowering of self-esteem, and problems with power and control.
    Family members are an extremely important source of support for 
Veterans as they heal. The ability to reconnect and reestablish strong 
bonds with loved ones is a critical part of the post-deployment 
adjustment and the recovery process. The ultimate goal of family 
support is creating and sustaining mutually-satisfying relationships 
that bolster the Veteran's successful community adjustment. Research 
shows that more than three-fourths of Veterans with PTSD are interested 
in more family involvement in treatment (Batten et al., 2009). 
Furthermore, the success of treatment for PTSD can be increased if 
family members provide the Veteran with social and emotional support.
    VA has the ability to provide a number of services, including 
several couple- and family-based programs to help families develop the 
skills and attitudes to support recovery. VA offers a telephone 
hotline, Coaching into Care, for family members to learn effective 
strategies to encourage the Veteran to begin or reinitiate VA Services. 
Many VA facilities sponsor ``The Support and Family Education (SAFE) 
Program,'' which is an 18-session educational workshop for families of 
Veterans living with PTSD or serious mental illness. Families may 
attend as many sessions as needed. SAFE topics include Communication 
Tips for Family Members, Problem-Solving Skills for Families, and 
Skills for Managing Stress Effectively as a Family Member. VA also 
offers Veteran-Centered Brief Family Consultation (VCBFC), in which the 
family meets with a mental health professional as needed to resolve 
specific issues related to the Veteran's treatment and recovery. This 
intervention is designed to be brief; it usually consists of between 
one and five sessions for each consultation. Finally, VA offers more 
intensive couples counseling to help Veterans and their loved ones have 
more satisfying relationships.
    Recently, VA was authorized through section 304 of Public Law 111-
163 to provide services to family members up to 3 years after 
deployment to receive readjustment counseling and mental health 
services to assist the family member in readjusting after deployment. 
These services are available through Vet Centers, as well as at an 
increasing number of VA medical centers as new peer support specialists 
are hired. Mental health services for family members can be arranged 
with community organizations as needed.

References

Batten, S. V., Drapalski, A. L., Decker, M. L., DeViva, J. C., Morris, 
            L. J., Mann, M. A., & Dixon, L. B. (2009). Veteran interest 
            in family involvement in PTSD treatment. Psychological 
            Services, 6(3), 184-189.
Riggs, D. S., Byrne, C. A., Weathers, F. W., & Litz, B. T. (1998). The 
            quality of the intimate relationships of male Vietnam 
            veterans: problems associated with Post Traumatic Stress 
            Disorder. Journal of Traumatic Stress, 11(1), 87-101. doi: 
            10.1023/A:1024409200155.
Taft, C. T., Street, A. E., Marshall, A. D., Dowdall, D. J., & Riggs, 
            D. S. (2007). Posttraumatic stress disorder, anger, and 
            partner abuse among Vietnam combat veterans. [Research 
            Support, U.S. Gov't, Non-P.H.S.]. J Fam Psychol, 21(2), 
            270-277. doi: 10.1037/0893-3200.21.2.270

    Question 3. A veteran is lost to suicide every 80 minutes, and so 
far this year, one servicemember commits suicide per day. One of the 
keys to effective suicide prevention is ensuring there is timely access 
to care. Often veterans only seek care when they are on the verge of 
crisis. If VA turns them away because they are too busy, we have lost 
the opportunity to help that individual. Concerns remain whether there 
are enough providers in the system.
    How can VA use authorities like those provided in the Mental Health 
ACCESS Act, along with existing hiring and retention authorities, to 
recruit and retain top mental health providers?
    Response. In direct support of the Mental Health Hiring Initiative 
(MHHI), the Veterans Health Administration (VHA) Workforce Management 
and Consulting (WMC) Office, in partnership with the VHA Human 
Resources (HR) and Office of Mental Health (OMH), has developed and 
implemented a systematic process to recruit, hire, and retain top 
mental health providers.
    WMC created multiple task forces that target the recruitment and 
staffing efforts to bring these new employees into VA as effectively 
and efficiently as possible. The Recruitment and Marketing Task Force 
provides oversight of the national recruitment and marketing strategies 
for MHHI.

Recruitment & Marketing Task Force
    Key processes include use of a skilled national team of 
professional health recruiters, targeted advertising and outreach, 
aggressive recruitment from a pipeline of qualified candidates to 
leverage against mission critical mental health vacancies, and 
provision of consultative services to Veterans Integrated Service 
Networks (VISN) and VA stakeholders.
    The National Recruitment Program (NRP) provides VHA with an in-
house team of highly skilled professional recruiters employing private 
sector best practices to fill VA's most mission critical clinical 
occupations. As of July 16, 2012, the NRP has provided dedicated 
recruitment support to 251 mental health positions at the specific 
request of VISN/VAMC leadership (primarily psychiatry and psychology). 
This team of recruiters has helped hiring managers identify and select 
over 100 psychiatrists. One example of their efforts was recruitment at 
the American Psychiatric Association (APA) event held May 5-8, 2012, in 
Philadelphia, PA, which resulted in identifying 7 psychiatrists who 
have received offers, and all are projected to be on board by 
September 30, 2012.
    The Marketing and Advertising task group has implemented an 
aggressive, multi-faceted, sustained national marketing and outreach 
campaign to include maximum visibility to rural and highly rural 
markets. Completed milestones include:

     Spotlight advertisement renewed on USAJobs Web site as of 
June 18, 2012. An earlier run resulted in over 8,000 ``click-throughs'' 
to www.VAcareers.va.gov.
     Online banner advertisement currently being run on seven 
professional mental health association homepages.
     Eleven Web banners currently running through the Joining 
Forces partnership and its APA-affiliated networks.

    VA has taken these efforts over the past several months and in 
previous years to partner with professional associations, societies, 
and other health care organizations for the purpose of recruiting 
additional mental health providers.

Hiring and Tracking Task Force
    The Hiring and Tracking Task Force provides oversight for MHHI. 
This team moves the hiring process forward expeditiously in a focused 
manner and addresses any issues or concerns immediately while resolving 
road blocks to fill each position promptly. This task force provides 
daily oversight on the tracking status of each position and 
consultative services to VISN Human Resource officers (HRO), OMH, and 
VHA recruiters, as needed. This task force tracks the daily progress of 
the 1,900 new hires as well as the 2,815 existing vacancies. The task 
force conducts daily conference calls with the field H.R. community to 
ensure engagement and accountability. Hiring Task Force members 
collaborate with VISN HROs to ensure efficiency and flexibility by 
implementing specific workflows to enhance timelines:

Recruitment and Retention Incentives
    VHA promotes maximized flexibility with, and availability of, 
recruitment and retention incentives (relocation, home buy-out, signing 
bonuses, student loan repayment programs, etc.) to better attract the 
best qualified candidates. VHA collaborates with the Office of Human 
Resource Management to reassess current salary tables for psychiatrists 
to make these positions more competitive with private industry and DOD.
    Provider retention remains a top strategic priority for VHA in its 
commitment to maintaining quality services to Veterans. These 
incentives permit the staffing and retention of difficult-to-fill 
positions with high quality candidates who possess unique skills and 
competencies. VA clinical education programs are a crucial resource for 
VA's employment pipeline. With over 100,000 trainees rotating through 
VA facilities annually, we have a vigorous developmental cohort from 
which to recruit new staff in 40 or more disciplines. We know, for 
example, that roughly 70 percent of current VA optometrists, 
physicians, and psychologists participated in VA training programs 
prior to their employment in VA. VA is still reviewing the provisions 
of the Mental Health ACCESS Act to determine how those provisions might 
complement these efforts.

    Question 4. I understand the Department has reviewed each VISN 
office and is proposing to reduce the number of staff.
    a. How are you posing to change which functions will be performed 
by the network offices?
    Response. VA recognizes the need to improve the consistent and 
efficient use of staffing resources in each VISN office and to ensure 
that staffing is aligned with mission and function. To this end, a 
workgroup comprised of a small group of VISN directors was chartered in 
the fall of 2011 to conduct a review of each VISN office to establish 
definitions of core and non-core staff functions, identify targeted 
staffing levels, develop an implementation timeline and plan to align 
VISN staffing levels, and develop a monitoring mechanism to assure 
achievement of target staffing levels. As part of the VISN staffing 
alignment process, each VISN was asked to review its organizational 
chart and staffing reports, and identify which functions are performed 
by whom, which functions are core to the mission of the VISN office, 
and describe the basis for consolidating certain functions. The input 
provided by the VISNs was evaluated by the workgroup. The workgroup 
identified a core set of staff for all VISNs and that plan has now been 
approved by the Under Secretary of Health. VHA staff briefed staffs on 
the House and Senate Committees on Veterans' Affairs on July 17, 2012.

    b. What do you believe is an appropriate number of medical centers 
for a network office to oversee?
    Response. VISN boundaries were developed originally based on 
patient-referral patterns, including aggregations of patients and 
facilities that would be needed to support a continuum of primary, 
secondary, and tertiary care, and to a lesser extent, to be consistent 
with jurisdictional boundaries such as state lines. Every VISN 
composition is unique, and the complexity levels of the VA medical 
centers, size of patient populations, geographies and regional aspects 
vary widely. There is no prescribed number of appropriate medical 
centers for a Network Office to oversee. However, currently the maximum 
number of health care systems in any one VISN is 11, and that number 
does represent the upper limit that would be advisable.

    c. When was the last time the Department reviewed the network 
boundaries to see if they are still the most appropriate way to 
organize the health care system?
    Response. The current VISN boundaries were first drawn in 1995 as 
part of VHA's ``Vision for Change'' plan for reorganizing the Veterans 
Health Administration, which called for the dissolution of the 
hierarchical central office, regional office and network structure, in 
favor of 22 VISNs with 5-11 medical centers and various other VA 
assets. One of the sub-objectives of the VISN boundaries of 1995 was to 
achieve a basic budgetary and planning unit for delivery of Veterans 
health care, and a means of pooling resources. The last time VA 
reviewed the number of VISNs was in 2002, and merged VISNs 13 and 14 to 
form VISN 23. When the VISNs were originally formed, there were no 
medical foster homes, no ambulatory surgery centers, and hundreds fewer 
community-based outpatient clinics, community living centers (nursing 
homes), and domiciliaries. VA has subsequently gathered more data on 
long-term care and mental health services, as well as for some 
inpatient services, because sufficient information was not available at 
the time regarding demand for these services and other factors.

    Question 5. VA currently has discretionary authority to pay 
beneficiary travel for some individual who are not otherwise covered 
specifically by law. Given how difficult it can be for veterans who are 
blind or have the serious injuries outlined in S. 1755, it would seem 
these veterans could use this assistance. How many of these veterans 
received beneficiary travel benefits from VA under the existing 
authority?
    Response. VA does not track beneficiary travel payments by patient 
diagnosis. However, historical data indicates that approximately 33 
percent of VHA users collect travel benefits. Assuming the same benefit 
use rate for the three groups identified in S. 1755, VA estimates the 
following beneficiary travel usage based upon workload for FY 2011.


------------------------------------------------------------------------
                                                            Beneficiary
                 Condition                    VHA Users     Travel Users
------------------------------------------------------------------------
Spinal Cord Injury (SCI)..................     20,724          6,839
Amputee...................................      7,088          2,339
Blind.....................................     39,956         13,185
                                           -----------------------------
  Total...................................     67,768         22,363
------------------------------------------------------------------------


    Question 6. The Department recently set a goal to increase access 
to mental health care services through telehealth consultations, and is 
working to improve veterans' access to services in rural areas. As you 
know, bandwidth capacity in rural areas can be severely limited. Some 
medical centers have to prioritize clinical services when networks are 
slow in order to protect critical hospital functions. One particularly 
vulnerable service is these remote mental health care services are 
interrupted. What is VA's plan to ensure each medical center and clinic 
involved in the clinic-based telehealth program is properly equipped 
and will have enough bandwidth to conduct video consultations?
    Response. In anticipation of using telehealth to expand Veterans 
access to mental health services (telemental health) and other 
specialty care services, VA ensured the necessary support structures 
are in place as part of its FY 2011-2012 Expansion Initiative. The 
Telehealth Expansion Initiative began in June 2011, and resulted in the 
completion of major purchases in all VISNs of clinical 
videoconferencing equipment and associated telehealth peripherals and 
equipment; and the hiring of Telehealth Program Managers in each VISN 
and Telehealth Coordinators at every VAMC. In FY 2012, funding support 
continued for these positions and VISNs were provided additional 
funding to recruit 1,144 Telehealth Clinical Technicians (TCTs) to 
assist clinicians with delivery of telehealth based care, where the 
patient and the provider are separated geographically.
    As of 3rd quarter FY 2012, this VA initiative has:

     Provided more than 3,200 clinical videoconferencing units 
for telehealth to all VAMCs and their associated sites of care.
     Ensured these sites of care have the necessary 
telecommunications capability (``bandwidth''), namely being able to 
provide two concurrent clinical video telehealth (CVT) consultations at 
384 kilobits/second, in place by September 2012.
     Recruited and trained a 1,012 telehealth clinical 
technicians (TCT) to assist clinicians in VA medical centers and 
community-based outpatient clinics to provide care via telehealth, and 
to offer the first line of support in the event of technical problems 
with equipment as of June 2012.
     Established a national telehealth help desk that provides 
immediate access to technical assistance for clinicians and TCTs at all 
VA sites of care with expertise to resolve technical problems that TCTs 
cannot address on-site.

    As a result of this preparatory work VA has the technology 
infrastructure and technical support to meet its goals for increased 
access to mental health care services through telehealth consultations.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Scott Brown to 
Madhulika Agarwal, M.D., M.P.H., Deputy Under Secretary for Health for 
        Policy and Services, U.S. Veterans Health Administration

    Question 1. Please describe the relationship that currently exists 
between VA and the Fisher House Foundation.
    Response. Fisher Houses are housing facilities located at, or in 
proximity to, a VA medical facility; are available for residential use 
on a temporary basis by patients of that facility and their family 
members; and are constructed by and donated to the Secretary by the 
Zachary and Elizabeth M. Fisher Armed Services Foundation.
    VA has 21 operational Fisher Houses with planned expansion to 38 VA 
Fisher Houses over the next several years. In 2011, over 11,797 
families and caregivers utilized VA Fisher Houses in order to be close 
to a Veteran or Active Duty Servicemember during the course of medical 
treatment.
    VA Fisher Houses improve access to care for Veterans and Active 
Duty Servicemembers by providing a supportive environment for family 
members and caregivers to stay during their course of medical 
treatment. Veterans and Active Duty Servicemembers are more likely to 
travel long distances to receive care if their families and caregivers 
can accompany them without bearing the burden of costs associated with 
hotel lodging. Once donated to VA, it is the expectation of the Fisher 
House Foundation that VA Fisher Houses are maintained in pristine 
condition, and funding is available to support the costs of 
refurbishing, redecorating, and replacing major appliances in VA Fisher 
Houses. The corresponding VA medical center is also responsible for 
funding all Fisher House operations.

    Question 2. In the opinion of VA leadership, how many VA medical 
centers or campuses require a Fisher House, and which sites are the 
most critical?
    Response. VA has a formal process to identify and prioritize VA 
medical centers for Fisher House construction. First, VA initiates a 
formal call for Fisher House applications.
    Applications are evaluated and prioritized based upon the following 
criteria:

     The availability of services in specialty areas such as 
Polytrauma, Spinal Cord Injury, Blind Rehabilitation, Transplant, 
Inpatient Palliative Care and Hospice Programs, and Oncology Programs;
     VA medical centers serving a large post-9/11 Active Duty 
population;
     VA medical centers serving large rural catchment areas; 
and
     The availability of land to construct a VA Fisher House on 
or within close proximity to a VA medical center.

    The following are locations with an identified need for a Fisher 
House:

     Michael E. DeBakey VA Medical Center, (second house)--
Houston, Texas
     North Florida /South Georgia Veterans Healthcare System--
Gainesville, Florida
     Tennessee Valley Healthcare System Murfreesboro Campus--
Murfreesboro, Tennessee
     Clement J. Zablocki Veterans Affairs Medical Center--
Milwaukee, Wisconsin
     Louis Stokes VA Medical Center--Cleveland, Ohio
     VA Long Beach Healthcare System--Long Beach, California
     VA Connecticut Healthcare System--West Haven, Connecticut
     VA Eastern Colorado Healthcare System--Denver, Colorado 
(new medical center)
     Orlando VA Medical Center--Orlando, Florida
     Omaha-VA Nebraska/Western Iowa Healthcare System--Omaha, 
Nebraska
     VA Maine Healthcare System--Togus, Maine
     VA Caribbean Healthcare System--San Juan, Puerto Rico
     New Mexico VA Healthcare System--Albuquerque, New Mexico
     Portland VA Medical Center--Portland, Oregon
     Southern Arizona VA Healthcare System--Tucson, Arizona

    VA continues to assess on a regular basis the need for additional 
Fisher Houses, and many VA medical centers have expressed interest in 
future Fisher House construction.

    Question 3. For those existing VA medical centers and campuses 
without a Fisher house, what is the VA currently doing to provide 
families with comparable lodging?
    Response. VA medical centers provide alternative resources to 
accommodate families requiring temporary lodging assistance. These 
resources may include providing lodging at a temporary lodging facility 
located at a VA health care facility (generally referred to as a 
``Hoptel''), or a temporary, non-VA lodging facility, such as a hotel 
or motel, funded by a VA health care facility. VA medical centers also 
have relationships with community Hospital Hospitality organizations, 
such as Ronald McDonald House, to assist with temporary lodging 
accommodations for family members as needed.

    Question 4. In the absence of legislation, what can VA do within 
existing authorities to fund the Fisher House construction on the 
grounds of medical centers and campuses?
    Response. The construction of VA Fisher Houses is a joint venture 
between the Department of Veterans Affairs and the Fisher House 
Foundation. Existing statutory authority (38 U.S.C. Sec. 1708) defines 
the term ``Fisher House'' as a housing facility that is located at, or 
in proximity to, a Department medical facility; is available for 
residential use on a temporary basis by patients of that facility and 
others described in 38 U.S.C. Sec. 1708(b)(2); and is constructed by, 
and donated to the Secretary by, the Zachary and Elizabeth M. Fisher 
Armed Services Foundation. Current statutory authority does not 
authorize VA to fund Fisher House construction.

    Question 5. In 2011 GAO released a report entitled, Homeless Women 
Veterans: Actions Needed to Ensure Safe and Appropriate Housing. In 
that report, GAO found that VA and HUD lacked information regarding the 
characteristic and needs of homeless women veterans at the national, 
state, and local levels. What is the VA currently doing to get a handle 
on this problem, especially as it relates to understanding the unique 
needs of homeless women veterans with children?
    Response. Established in 2009 by Department of Veteran Affairs 
Secretary, the National Center on Homelessness among Veterans (the 
Center), is a multi-site initiative within VISN 4 and 8, with 
leadership offices located at the Philadelphia VAMC. As a key component 
of VA's National Homeless Programs Office, the Center and its academic 
affiliates play a critical role in piloting new innovations and 
developing the empirical knowledge needed to improve the care and 
quality of life for Veterans who are homeless or at-risk for 
homelessness. The Center's goal is to improve services to homeless 
Veterans by developing, promoting, and enhancing policy, clinical care 
research, and education. The Center is also designed to be a national 
resource for both VA and community partners, improving the quality and 
timeliness of services delivered to homeless Veterans and their 
families. The Center is developing a comprehensive Homeless Registry, a 
data warehouse that tracks and monitors homeless program expansion, 
operation, and treatment outcomes. The Homeless Registry allows ``real-
time'' access to data by VA providers, program administrators, VAMC 
staff, as well as VISN and VHA Central Office leadership to facilitate 
performance monitoring and decisionmaking.
    The registry enhances VHA's capacity to utilize longitudinal 
programmatic and Veteran-specific data to better evaluate how programs 
function and how the system as a whole is progressing to end Veteran 
homelessness. The registry has the capacity to provide individualized 
reports on Veteran characteristics by geographic regions. This new 
capacity facilitates VHA's ability to target resources (program funding 
and grant funding) to where the need is greatest. Examples include 
gender specific, age, and service era data that inform decisions 
related to Supportive Services for Veteran Families (SSVF) and 
Department of Housing and Urban Development-Department of Veterans 
Affairs Supportive Housing (HUD-VASH) programs as well as Grant and Per 
Diem (GPD).
    VHA has also realigned its data collection about homeless programs 
to be more consistent with those in HUD's Homeless Management 
Information System (HMIS) standards. VA bed capacity is now entered 
into the HMIS bed inventory section to achieve coordinated and complete 
data collection of VA resources in HMIS. VA and HUD have collaborated 
on a single reporting mechanism of Veteran homelessness in the Veterans 
Annual Homelessness Assessment Report (Vet AHAR). These modifications 
promote greater consistency in reporting prevalence of Veteran 
homelessness both inside and outside of VA.
    In June 2012, the Homeless Data Cube became available through the 
VHA Support Service Center (VSSC). The Homeless Data Cube provides data 
on VA Homeless Services, data analysis, and reporting. The data in the 
cube goes back to 2006 through the present and utilizes a variety of 
data sources. The Homeless Data Cube contains descriptive and 
demographic data on homeless Veterans, including gender, Operation 
Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/
OIF/OND) status, etc. The Homeless Data Cube also contains utilization 
and outcome data on homeless and at-risk Veterans served within VA. 
Finally, the data can be analyzed by program, location (including 
national, facility, VISN and state), and fiscal year.
    Since 1993, VA has collaborated with local communities across the 
United States in Project Community Homelessness Assessment, Local 
Education, and Networking Groups (CHALENG) for Veterans. The mission of 
CHALENG is to bring together Veterans, representatives from VAMCs and 
Veterans Benefits Administration regional offices, community providers 
and advocates, local officials, and other concerned citizens to 
identify the needs of homeless Veterans and then work to meet those 
needs through planning and cooperative action. In 2011, the CHALENG 
Veterans survey provided gender specific information, and in 2012, the 
community partner survey will include gender specific questions to 
increase awareness of women and their families' unique needs.
    VA is working with the US Interagency Council on Homelessness, 
national Veterans Service Organizations, and Federal, state, local and 
community partners that serve homeless and formerly homeless women 
Veterans and children to capture the needs of homeless women Veterans.

    Chairman Murray. Thank you very much. We really appreciate 
the VA's testimony today. I just have a couple of questions I 
am going to ask and then I will submit the rest for the record 
because we want to make sure we have time to get to the second 
panel today, and I know there are a number of Committee Members 
here who want to ask you questions as well.
    Let me just begin. The witnesses on the next panel are 
going to talk about VA's fertility treatment options for 
seriously injured veterans. Their testimony, when taken 
collectively, is resoundingly clear. VA's fertility treatment 
options fall short for our veterans with very severe injuries.
    Unlike the Department of Defense, the VA is prohibited by 
regulation from offering IVF. I wanted to ask you today, is the 
VA considering lifting the ban?
    Dr. Agarwal.
    Dr. Agarwal. Thank you for the question, Madam Chairman.
    Consistent with VA's goals to improve health and quality-
of-life for veterans, we do offer certain infertility 
treatments and diagnostic tests including genetic counseling.
    However, regulation in 1999 did exclude IVF services from 
VA's defined medical benefits package. DOD in April this year 
has defined and clarified implementation guidance on provision 
of IVF services for certain categories of servicemembers, and 
the VA is reviewing its regulatory options and your Women's 
Health Bill, which was introduced on June 19, and we will work 
with you and your staff to bring about what needs to happen.
    Chairman Murray. Well, the VA cannot offer much in the way 
of care for spouses. What does that mean for couples who need 
extra assistance conceiving a child because of the war injury?
    Dr. Agarwal. Thank you again for this question, Madam. 
Congress has generally restricted eligibility of health care 
services in VA to spouses. There are some rare exceptions such 
as in CHAMPVA.
    S. 3313 is aimed at expanding that authority to include 
infertility management for spouses under some circumstances 
when the veterans injury has precluded their ability to 
procreate naturally. We do not have our position on this yet 
but are reviewing it and again look forward to working with you 
and the Committee.
    Chairman Murray. I appreciate it. On our second panel we 
are going to have some compelling testimony. I hope that the 
Members of our Committee are able to hear what I have been 
hearing as well on this.
    I also wanted to just mention the Mental Health ACCESS Act 
of 2012, which I have introduced. I want to stress we need 
comments back from the VA very urgently on this. This is going 
to expand the availability of mental health services for family 
members of veterans and deployed servicemembers.
    As we talked about, the VA currently has very limited 
authority to provide service to family members. So, I would 
appreciate your comments back on that as soon as you can as 
well.
    With that, let me turn it over to Senator Burr for any 
questions he has.
    Senator Burr. I thank the Chairman.
    Mr. Secretary Schoenhard, VA's written testimony states 
that the VHA has, and I quote, already reviewed each VISN 
headquarters, is in the process of working with each to 
streamline operations, create efficiencies internal to each 
VISN and to realign resources.
    Has General Shinseki been briefed on what that realignment 
is going to look like?
    Mr. Schoenhard. Ranking Member Burr, yes, he had been 
briefed, and we are still in the process of discussion and 
evaluation.
    Senator Burr. When does the Secretary plan to approve those 
recommendations?
    Mr. Schoenhard. Sir, we should be having this accomplished 
here in the coming weeks. We look forward to briefing you and 
your staff.
    Senator Burr. Will we be briefed before the Secretary signs 
off on it or after the Secretary signs off on it?
    Mr. Schoenhard. Sir, I think we would brief you after the 
Secretary signs off.
    Senator Burr. Does the Committee play any part in this 
process?
    Mr. Schoenhard. Sir, we would very much appreciate the 
opportunity to brief you and the members of your staff and any 
Members of the Committee regarding our work.
    Senator Burr. Before or after the Secretary signs off?
    Mr. Schoenhard. Sir, I think we would like to further 
evaluate and review our work and then sit with you, Sir.
    Senator Burr. In the 17 years since Dr. Kaiser created the 
VISNs, there has been a significant growth in the number of 
VISN headquarters staff. The original plan called for 220 full-
time workers, full-time employees. Yet, the current staff is at 
1,340.
    Do you anticipate the staff level in VISN reorganization to 
be cut?
    Mr. Schoenhard. Sir, we do. Let me just, if I can, just 
back up and say we have done a systemic review of the function 
of the VISN, and I think that you will be seeing reductions in 
our staff as a result of this effort.
    Senator Burr. Well, I just was taken a little bit aback by 
the Under Secretary's comments that my legislation was too 
prescriptive. I am not sure how you can set up an 
administrative structure without it being prescriptive.
    Mr. Schoenhard. Yes, sir.
    Senator Burr. You have got to design what it is over, what 
its mission is, and hopefully what the staffing is; and that 
is, in fact, what I put in my legislation.
    Is that what your review is going to do?
    Mr. Schoenhard. Yes. We have looked at the core function of 
a VISN, the core staff required to accomplish that mission, and 
I think that our focus has been with the end in mind what is it 
that a VISN should do as the main operating vehicle for 
accountability and leadership to address all of the concerns we 
have heard this morning regarding care to rural veterans, care 
and mental health and the rest, to do that in a way that is 
population health based, is based on the veterans in that 
location with sufficient span of control to accomplish that 
mission and to serve veterans.
    Senator Burr. I look forward to the opportunity for you and 
I to get together.
    Mr. Schoenhard. Yes, sir.
    Senator Burr. Sooner rather than later.
    Mr. Schoenhard. Yes, sir.
    Senator Burr. Mr. Murphy, you addressed the Second 
Amendment issue. If individuals, let me ask you this. How many 
veterans' names have been turned over to NICS? How many are 
currently on that list?
    Mr. Murphy. I do not have the details on the number of 
names that are currently on their list. I can tell you the 
details around the number of requests for relief or removal 
from the list.
    Senator Burr. How many names have been requested to be 
relieved?
    Mr. Murphy. 185, Senator.
    Senator Burr. How many have been granted?
    Mr. Murphy. A total of 19.
    Senator Burr. That is out of 127,000 names that have been 
turned over on the NICS list?
    Mr. Murphy. Correct. I am assuming your numbers are 
correct. I do not have those in front of me.
    Senator Burr. Trust me, they are.
    Mr. Murphy. OK.
    Senator Burr. If individuals seek relief from the NICS 
reporting requirements, does the VA assist them in coming up 
with the evidence needed to show whether they are dangerous?
    Mr. Murphy. Yes, Senator, we do.
    Senator Burr. What do you do?
    Mr. Murphy. The Duty to Assist Act requires us to fully 
develop the case. This is not a light matter in the Veterans 
Administration. This is a fully adjudicated, fully developed 
claim with a full decision letter, with an explanation of how 
the decision was arrived at with all supporting evidence and 
documentation provided to them.
    Senator Burr. Are there any veterans that are determined 
incapable to handle their own personal finances whose name is 
not put on the NICS list?
    Mr. Murphy. Let me make sure I understand the question. Are 
there veterans who----
    Senator Burr. You have somebody that has determined that a 
veteran cannot write a check. So, they cannot handle their 
finances. They have now assigned to a spouse to be in charge of 
the finances.
    Is there anybody that that has happened to that that 
veteran was not then listed on the NICS list?
    Mr. Murphy. I can say that they are not supposed to be. I 
am not saying that through administrative process for errors 
that it had not occurred.
    Senator Burr. My understanding, and I will get you to go 
back and clarify this if I am wrong, every veteran who is 
relieved of their financial or deemed that they cannot handle 
their own finances is automatically put on the list.
    Mr. Murphy. They are placed on the list by the Veterans 
Administration. Yes.
    Senator Burr. So, what are the qualifications of the VA 
employees who make the decisions about whether veterans and 
their families should be stripped of their Second Amendment? 
What training do these people go through?
    Mr. Murphy. I do not believe we have an option in this, 
Senator. We are directed----
    Senator Burr. You have VA employees that are making a 
decision on whether somebody is capable of doing their own 
personal finances. That determination that they are not capable 
of doing that strips them of their Second Amendment right. It 
is very simple.
    What training does that VA employee go through to be 
qualified to make a determination that would strip somebody of 
their constitutional rights?
    Mr. Murphy. Our employees, our adjudicators are trained in 
determining whether or not that veteran is capable of making 
the financial determinations they have with the funds that the 
Veterans' Administration provides to that individual.
    As a result of that decision, they are placed on the NICS 
list. It is not a determination whether the individual is 
capable of handling firearms or not. It is, can they manage 
their personal finances or not.
    Senator Burr. I know. But when they go on the NICS list, 
they are now deprived of firearm ownership.
    Mr. Murphy. That is correct.
    Senator Burr. OK. So, a determination that they cannot 
handle their personal finances strips them of their Second 
Amendment right and also, the way that it is written, it 
forbids any firearm to be handled by anybody in the household.
    So, you, in essence, strip the spouse of the Second 
Amendment right. You strip children of the Second Amendment 
right because you have determined that a veteran cannot handle 
their own personal finances.
    Are we in agreement?
    Mr. Murphy. We are.
    Senator Burr. OK. I do not want to make this too 
simplistic. But if a veteran cannot sign their name to a check 
and the VA determines that their spouse should be assigned the 
financial responsibilities because you are transferring money 
into an account, do we agree that that would trigger their 
listing on the NICS list and they would lose their Second 
Amendment right as well as everybody else in the household?
    Mr. Murphy. That is one I need to ask Mr. Hipolit to verify 
for me because I am unaware of the requirement for other 
members of the household's restriction to own firearms.
    Mr. Hipolit. Yes, that is correct as well. I was also 
personally not aware of the household restriction. I know that 
if VA determines that the person is incapable of handling their 
financial affairs, that does get them on the NICS list.
    Senator Burr. But you would agree, Mr. Hipolit, that a 
determination that they cannot handle their finances has a wide 
definition to it?
    Mr. Hipolit. I would say that if VA determines that they 
are unable to handle their finances, that does qualify them to 
get on the NICS list and their names are referred for the list.
    Senator Burr. That is not necessarily a mental 
determination. It could be a physical determination, correct? 
If they are not capable of handling their finances.
    Mr. Hipolit. If they had a physical disability that 
impaired their ability to handle their financial affairs.
    Senator Burr. So, they are automatically classified as 
dangerous?
    Mr. Hipolit. Our determination is just whether they can 
handle their financial affairs and then that automatically 
triggers the requirements to refer their names.
    Senator Burr. So, would you agree that the purpose of the 
NICS list which is to take guns away from dangerous people and 
the threshold that VA currently uses to determine who goes on 
the NICS list are potentially two very different things?
    Mr. Hipolit. I think that the law enforcement agencies 
determined who should be put on the NICS list, and they 
determined that person is found to be----
    Senator Burr. But they do not in the case of veterans. In 
the case of veterans, the only person that determines whether 
they go on the NICS list is the VA, and it is determined based 
upon are they capable of handling their own personal finances.
    Mr. Hipolit. Well, the law that requires us to make the 
referral is a regulation from the----
    Senator Burr. And you are the only agency in the Federal 
Government that across-the-board sends every person that is not 
qualified to handle their personal finances to the NICS list?
    Are you aware of that?
    Mr. Hipolit. That is not my understanding. It is my 
understanding that other agencies refer people as well.
    Senator Burr. Other agencies refer people but they have a 
different threshold for the ones that they refer. I think they 
might use the definition of dangerous, and what I have heard 
you say is dangerous does not come into play. Mental capacity 
does not come into play. Capability of handling your own 
personal finances is the only threshold, and when they hit 
that, they are automatically put on the NICS list.
    Mr. Hipolit. From the VA standpoint, if they are determined 
not to be able to handle their financial affairs, we have to 
refer them for the NICS list.
    Senator Burr. I hate to dig in on this. I just want to 
point out to you that the threshold is very, very different at 
VA. There are many veterans, spouses, and family members who 
are deprived of their Second Amendment rights to own firearms 
based upon an arbitrary decision by somebody at VA that they 
cannot handle their own personal finances.
    These people are all of a sudden labeled as dangerous when, 
in fact, the decisions may have been a physical disability that 
did not permit them to handle their own finances. I hope this 
is something the Committee will look at. I am actually shocked 
that the Veterans' Affairs Committee is not outraged at the way 
this is being implemented. 127,000 of our country's veterans 
are stripped of a constitutional right. Some probably should. 
Many of those 127,000 should have never had their right taken 
away.
    I thank the Chair.
    Chairman Murray. Senator Boozman.
    Senator Boozman. Just really quickly to follow up. So, the 
process is that they are deemed where they need help in 
handling their finances.
    How do they become aware that they are on the list? Do you 
send him a letter, explaining again that all the guns in the 
house need to go out and all that?
    I guess what I am saying is do the people who are actually 
on the list know that they are on the list----
    Mr. Murphy. It is actually more extensive than that, 
Senator.
    Senator Boozman [continuing]. And the ramifications of what 
has happened to them.
    Mr. Murphy. There is a decision made and with the 
appointing of a fiduciary comes a VA employee actually visiting 
the veteran's home, talking with the veteran, explaining to the 
veteran, and ensuring that they are in a safe environment for 
that veteran to be living.
    Mr. Hipolit. Under the NICS Improvements Act, there was a 
notification requirement put in. Before VA declares somebody 
incompetent, we have to make them aware that that would affect 
their ability to possess and buy a firearm. So, there is a 
notification requirement.
    Senator Boozman. Of the 18 that were reversed, how long did 
it take to go through the process?
    Mr. Murphy. The number of days to complete is 187.
    Senator Boozman. 187 days?
    Mr. Murphy. Yes, sir.
    In that, there are some requirements to allow veterans time 
notices with time to respond, multiple 60-day periods. So, in 
order to provide due process to the veteran to fully develop 
their rights under this in the appeals process 187 days.
    Senator Boozman. Did you say 18 had been reversed?
    Mr. Murphy. It is 19, Senator.
    Senator Boozman. 19.
    Mr. Murphy. Yes, sir.
    Senator Boozman. So, the average of those was 187 days?
    Mr. Murphy. Correct, to get reversed.
    Senator Boozman. What was the longest?
    Mr. Murphy. I do not have the details on the spread. If you 
would like, I would be more than happy to provide those for 
you.
    Senator Boozman. What would you guess?
    Mr. Murphy. The 187 days average includes some of the 
veterans for us just starting this process. So, what I would 
say that that number would be higher than what the average if I 
just looked over the last few cases that went through.
    So, the first few veterans that went through going through 
a new process took a little bit longer time and pushed it 
beyond that 187 days. But I believe that the next time I appear 
before you, if you asked me this question, it is going to be 
some number below that 187.
    Senator Boozman. Thank you, Madam Chair.
    Chairman Murray. Thank you. Senator Burr, do you have a 
question?
    Senator Burr. Madam Chairman, just one follow-up question 
to Mr. Murphy because you said that you were under duty to 
assist.
    Mr. Murphy. That is correct, Senator.
    Senator Burr. I have got this memo from the Department of 
Veterans Affairs, dated November 22, 2010, and it says that the 
duty to assist as demonstrated in an order and examinations for 
securing private medical records do not apply in this program.
    Mr. Murphy. Well, Senator, then I was in error.
    Senator Burr. OK. I just wanted to make sure we were on the 
same sheet. Thank you.
    Mr. Murphy. I did bring three documents today. I understand 
how important this is to you, so what it is is our Fast Letter, 
the specific instructions to the field for the relief process. 
In addition to that, I have two redacted decision letters: one 
that was granting the relief; and one that was denying the 
relief. If you would like to see those, Senator, I would make 
those available to you.
    Senator Burr. Let me just ask the Chair if she would make 
them available for the record?
    Chairman Murray. I will do that.
    [The letters referred to follows:]

    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    

    Senator Boozman. Madam Chair, can I just ask one other 
thing quickly?
    Chairman Murray. Yes, Senator Boozman.
    Senator Boozman. In regard to Senator Ayotte, you know, 
with her bill and the cemetery issue in the Philippines, can 
you all comment about that?
    I guess, you know, one of the things that we are so proud 
of when you go overseas and you see the--we are the only Nation 
in the world that really does that, you know, that takes such 
good care of our veterans. That really distinguishes us instead 
of the mass graves and this and that. We have done such a 
tremendous job. Tell me about, you know, rectifying that or if 
you feel like we need to rectify it, specifically what the 
problem is, how we got into this situation.
    Mr. Murphy. That is a bill, well, the picture is shown 
there and VA's understanding of exactly the condition of that 
specific cemetery, that is a bill that falls clearly under the 
American Battle Monuments Commission, and we have to defer to 
their input on that bill.
    Mr. Hipolit. I would add that the National Cemetery 
Administration maintains cemeteries within the United States 
and the Commonwealth of Puerto Rico. We do not have overseas 
cemeteries. The American Battle Monuments Commission 
traditionally maintain the overseas cemeteries.
    Senator Boozman. So, is this particular cemetery in a 
Catch-22 situation where it does not have anybody who has 
claimed it because I suspect if it fell under their--if they 
felt like it fell under their jurisdiction, they would be 
taking care of it.
    Mr. Hipolit. I cannot speak for them, but I think as of 
this time no Federal agency has responsibility for that 
cemetery.
    Senator Boozman. Can we say that you all are committed to 
helping to work that out where there is a claiming of the 
cemetery so we can do the appropriate thing?
    Mr. Hipolit. Our position is that we need to defer to the 
American Battle Monuments Commission because that would be more 
within their jurisdiction then within VA's. I can see that 
those pictures were quite moving of the current condition of 
the cemetery, and I can fully understand the concern over it.
    Senator Boozman. Good. Thank you very much.
    Chairman Murray. Thank you very much.
    With that, I would like to thank this panel. I do have 
additional questions I will submit for the record because I 
want to leave time for our second panel today. So, thank you 
again very much.
    Dr. Agarwal. Thank you.
    Chairman Murray. With that, I like to call up our second 
panel; and as we are changing out positions here, I am going to 
introduce them.
    We are going to be joined today by Tracy Keil. She is the 
wife of a paralyzed veteran, as well as Dr. Mark Thomas Edney, 
who is an Operation Iraqi Freedom veteran and a urologist who 
is representing the American Urological Association.
    Speaking on behalf of VetsFirst today is Vice President of 
Veterans Policy, Heather Ansley. Rounding out this panel is Joy 
Ilem. She is the Deputy National Legislative Director of the 
Disabled American Veterans.
    Before I turn to the testimony from this panel, I also want 
to take a moment to thank retired Staff Sergeant Andrew 
Robinson for joining us today. He is in the audience.
    Andrew was injured in 2006 when a roadside bomb threw him 
from the truck that he was in. Like Tracy, who we will be 
hearing from in just a moment and her husband Matt, Andrew and 
his wife Sarah also went through some very challenging times 
and had to use in-vitro fertilization to conceive there now 6-
month-old twins I understand.
    Andrew, I want to thank you for your service to the 
country, and thank you for driving down to be here with us 
today for this important legislative hearing.
    All of your statements will be entered into the record, and 
I really do appreciate all of your testimony today.
    Ms. Keil, I am going to start with you and thank you so 
much for your courage in coming speaking to our Committee 
today. So we will begin with you.

            STATEMENT OF TRACY KEIL, CAREGIVER AND 
                    SPOUSE OF AN OIF VETERAN

    Ms. Keil. Good afternoon, Chairman Murray, Ranking Member 
Burr, Members of the Committee. Thank you for inviting me to 
share my family's experiences with you today.
    My husband, Staff Sergeant Matthew Keil, was shot in the 
neck while on patrol in Ramadi, Iraq, February 24, 2007, just 6 
weeks after we were married.
    The bullet went through the right side of his neck, hit his 
vertebral artery, went to his spinal cord, and exited his left 
shoulder blade. Matt instantly became a quadriplegic.
    When I first saw him 3 days after he was injured, I was in 
shock. They explained to me that he had a Christopher Reeves-
type injury. He was on a ventilator for the rest of his life, 
and he would never move his arms or legs.
    Matt and I looked at each other in the hospital room at 
Walter Reed, and he asked me if I still loved him. I told him, 
baby, you are stuck with me. At that moment, we knew that we 
would be OK if we stayed in it together.
    I knew that we just needed to work really hard to get Matt 
off his ventilator and increase his life expectancy so that we 
could live out our dreams.
    Ultimately, we moved to Craig Hospital in Denver to be 
closer to our families. Four weeks to the day of arriving at 
Craig Hospital, Matt was officially off his ventilator, and we 
could truly concentrate on him doing physical rehabilitation.
    Matt was able to regain 10 percent function of his left arm 
but not his hand. He was feeling good and getting used to his 
new normal of being a wheelchair and asking for help for 
everything. It was while we were at Craig Hospital that we 
started talking about having a family.
    The Craig doctors talked to us about in-vitro 
fertilization, letting us know that that would be most likely 
the only way we could conceive. We started to get really 
excited that even though so much had been taken away from Matt 
physically that we could still have the future that we always 
dreamed up.
    We had our whole lives ahead of us. Matt was just 24 when 
he was injured, and I was 28. We were very fortunate that he 
survived his injuries that day, and we made a promise to each 
other on our wedding day, for better or for worse, in sickness 
and in health; and we meant every word and we still do today.
    It is a challenge for my husband and I every day, but we 
knew we still wanted a family. I remember back when he was in 
rehab at Craig and all we could talk about was when we were 
going to be adjusted to our new normal and when we will be 
ready to have children. We always knew since the day we met 
that we wanted to have kids.
    In 2008, we moved into a fully accessible home built for us 
by Homes For Our Troops, and we started filling like things 
were falling back into place in our lives. We felt like we were 
getting back on track to where we were before he was injured.
    However, his injury ultimately, unfortunately, prevents him 
from having children naturally. In mid-2008, I started asking 
the VA what services they could offer my husband and I to 
assist us with fertility. I remember hitting roadblocks at 
every turn, and I decided to take things into my own hands.
    At one point, I was leading 12 women whose husbands were 
injured, writing letters, and making phone calls, and trying to 
get anyone to listen to us that we really needed help.
    Fertility treatments are very expensive; and since I had 
left my full-time job, we were still trying to adjust living on 
one income. I felt helpless and hopeless that our dreams of 
having a family may never come true.
    The VA did finally say that they would cover the sperm 
withdrawal from my husband and that costs around $1,000 and 
that they would store it for us at no charge. However, they 
could not offer me anything.
    It is very difficult to put into words the emotions that I 
felt when I found out there was no help available for us from 
the VA or TRICARE. I felt very defeated, sad, disappointed and, 
in some ways, I felt helpless.
    I researched everything I could about how to get TRICARE to 
cover some of the costs, but they could not because it was a 
direct result of my husband's injuries and that fell under the 
VA. The VA said they had no programs in place for this sort of 
thing. I even started asking nonprofits to assist with the cost 
and they could not help due to the other immediate needs of 
injured servicemembers.
    In January 2010, my husband and I decided that we needed to 
move forward with our plans to start a family and we began our 
journey of fertility treatments. We selected a doctor in the 
private sector that has been a leader in IVF. We were fortunate 
that the best fertility doctor in the world is right in our 
town.
    Having a doctor located near our home was helpful because I 
had to go every other day and then daily near the time of the 
transfer. This made it very easy for my husband to be there 
with me every step of the way.
    I was on several medications that I took every day along 
with injections into my stomach three times a day. I would go 
to the doctor every other day for blood draws to check my 
hormone levels and make sure everything was progressing 
normally.
    Each time I would be at the fertility clinic I was charged 
anywhere from $250 to $650. TRICARE did not cover any of these 
costs of anything related to the fertility treatments because I 
did not have any fertility issues myself. Everything was a 
direct result of my husband's injuries.
    We are fortunate that Matt and I got pregnant on our first 
try with IVF. We welcomed our twins Matthew and Faith November 
9, 2010. As you can see from the attached photographs, they are 
happy, healthy, and they love riding around with their dad.
    As a couple who had already sacrificed so much for our 
country, I do not believe we should also have to give up on our 
dream of having a family. Fertility treatments are not a 
guarantee of having children, but it does give us hope.
    It gives us hope that we can have a normal life just like 
everyone else. Part of living the American dream for us was 
having a home to raise our children and, of course, having the 
children to fill our home.
    Now we have both, and while it is incredibly difficult to 
raise children while your husband is in a wheelchair, it is 
possible. We are living proof that anything is possible.
    This is exactly the way our family is supposed to be. I 
strongly believe that my husband is supposed to be in a 
wheelchair. I cannot tell you why but this is the life that we 
are supposed to be living, and it is what it is supposed to 
look like. We are happy. We are healthy, and we are living out 
our dreams.
    Now that my husband is retired, we are able to raise our 
children together as stay-at-home parents. We are a team and my 
only wish is that other families could find this happiness. One 
of the things I love the most about having children now is that 
their dad is just their dad. They do not see the wheelchair. 
They make him feel like the man he was before he was injured, 
and they complete our life together and the kids have helped 
fulfill our dreams that we had when we got married and started 
our life together.
    I would like to emphasize this statement. Wartime changes a 
family. It should not take away the ability to have one.
    I hope that hearing our story today has helped you 
understand the importance of offering fertility treatments to 
injured veterans who have lost the ability to reproduce 
naturally.
    I have always wanted more than anything for my husband to 
feel whole again. There is no magical cure for spinal cord 
injury. There is nothing out there that will help him walk 
again or move his arms.
    However, Congress, the VA, and the American people have 
said countless times that they want to do everything they can 
to support him and other wounded warriors. This is your chance 
to honor his sacrifice and others like him. Having a family is 
exactly what he needed to feel whole again.
    Please help us make these changes so that other families 
can share in this experience, and I also ask that you turn to 
the last page of my written statement and look at the photos I 
have provided. This is the face of a truly recovered injured 
veteran.
    Thank you for your time and I look forward to your 
questions.
    [The prepared statement of Ms. Keil follows:]

 Prepared Statement of Tracy Keil, Caregiver and Spouse of OIF Veteran

    Good Afternoon. Chairman Murray, Ranking Member Burr, Members of 
the Committee, thank you for inviting me to share my family's 
experience with you today.
    My husband, Matt, was shot in the neck while on patrol in Ramadi, 
Iraq, on February 24, 2007, just 6 weeks after we were married. The 
bullet went through the right side of his neck, hit his vertebral 
artery, went through his spinal cord and exited through his left 
shoulder blade. Matt instantly became a quadriplegic. When I first saw 
him 3 days after he was injured I was in shock, they explained to me 
that he had a ``Christopher Reeve type injury.'' He would be on a 
ventilator for the rest of his life, and would never move his arms or 
legs.
    Matt and I looked at each other in his hospital room at Walter Reed 
and he asked me if I still loved him? I said ``baby you're stuck with 
me!'' at that moment we knew that we would be OK if we stayed in this 
together. I knew that we just needed to work really hard to get Matt 
off his ventilator to increase his life expectancy. Ultimately we moved 
to Craig Hospital in Denver to be closer to family support.
    Four weeks to the day of arriving at Craig Hospital in Denver, Matt 
was officially off of his ventilator and we could truly concentrate on 
him doing physical rehabilitation. Matt had regained about 10% function 
of his left arm but not his hand. He was feeling good and getting used 
to his new normal of being in a wheelchair and asking for help for 
everything.
    It was while we were at Craig hospital that we started talking 
about having a family. Craig doctors talked to us about invitro 
fertilization and recommended some doctors for us to speak to when we 
were ready to start a family. We started to get really excited that 
even though so much had been taken away from Matt physically that we 
could still have the future we always dreamed of.
    My husband is the most amazing man I have ever met. He is strong, 
honest and loyal, and he wanted us to both have everything we always 
wanted before his injury and we agreed that this injury wasn't the end, 
it was the beginning of a new life, and we were in this together.
    We had our whole lives ahead of us. Matt was just 24 when he was 
injured and I was 28. We are very fortunate that he survived his 
injuries that day and we made a promise to each other on our wedding 
day ``For better or worse, in sickness and in health.'' I meant every 
word and still do today. It is a challenge for my husband and me every 
day, but we knew we still wanted to start a family. I remember back 
when he was in rehabilitation at Craig Hospital it's all we could talk 
about was when we were going to be adjusted to our new normal and when 
would we be ready to have children. We always knew we had wanted 
children.
    In 2008 we moved into a fully handicap accessible home built for us 
by Homes For Our Troops. We were starting to feel like things were 
falling into place in our lives. We felt like we were starting to get 
back on track to where we were before Matt was injured.
    His injury unfortunately prevents him from having children 
naturally. In mid 2008 I started asking the VA what services they could 
offer my husband and I to assist us with fertility. I can remember 
hitting road blocks at every turn. I decided to take things into my own 
hands and write letters and make phone calls to try and get anyone to 
listen to us that we needed help. Fertility treatments are very 
expensive and since I had left my full time job we were still adjusting 
to living on one income.
    I felt helpless and hopeless and thought that our dreams of having 
a family may never come true. The VA finally said that they would cover 
the sperm withdrawal from my husband * * * that costs $1,000 and that 
they would store the sperm for us at no charge.
    It was very difficult when I found out there was no help available 
for us from the VA or TRICARE. I felt very defeated, sad, disappointed 
and in some ways I felt helpless. I researched everything I could about 
how to get TRICARE to cover some of the costs but they couldn't because 
it was a direct result of my husbands' injury and that fell under the 
VA. The VA said that they had no programs in place for this sort of 
thing. I even started asking non profits to assist with the cost and 
they couldn't help due to the other immediate needs of injured 
servicemembers.
    I am very pleased that this issue is being addressed because it is 
necessary for the success of the families. We shouldn't have to 
struggle with how we are going to pay for costly fertility treatments 
when they are a direct result of a combat injury. We already have so 
many adjustments to make to all of our hopes and dreams and plans. We 
should never have to contemplate whether or not to even have children 
because of how expensive fertility treatments can be. I have always 
wanted more than anything for my husband to feel whole again. There is 
no magical cure for a spinal cord injury, there is nothing out there 
that will help him walk again or move his arms. What we do have though 
is a strong voice. We can help other families just like ours so they 
don't have to go through what we went through.
    In January 2010 my husband and I decided that we needed to move 
forward with our plans to start a family and we began our journey of 
fertility treatments. We selected a doctor in the private sector that 
has been a leader in IVF. Having a doctor located near our home was 
very important for us because I had to go to the doctor every other day 
and then daily near the time of the transfer. This made it very easy 
for my husband to be there with me every step of the way. I was on 
several medications that I took 3 times a day along with giving myself 
hormone injections into my stomach three times a day for several weeks. 
I would go back to the doctor every other day for blood draws to check 
my hormone levels to make sure everything was progressing normally. 
TRICARE did not cover any of the costs of anything related to the 
fertility treatments because I did not have any fertility issues, 
everything was a direct result of my husbands' injury.
    Matt and I were very fortunate that we got pregnant on our first 
try with IVF. We welcomed our twins Matthew and Faith on November 9, 
2010.
    Fertility treatments are not a guarantee of having children, but it 
gives us hope. It gives us hope that we can have a normal life just 
like everyone else. Part of living the American Dream for us was having 
a home to raise our children * * * and of course having the children to 
fill our home. Now we have both and while it is incredibly difficult to 
raise children while your husband is in a wheelchair it is possible. We 
are living proof of anything is possible.
    To be honest, not walking is the easy part. The hard part is that 
it affected every single aspect of our lives. Matt requires assistance 
with almost everything. As his caregiver, I feed him, bathe him, dress 
him, get him in and out of bed, I am the sole driver in our household, 
I even assist him with changing the channel on the TV. He has lost 
almost all independence. The day we had our children something changed 
in both of us. This is exactly what we had always wanted, our dreams 
had arrived. While it may be challenging to care for my husband and my 
children, this is exactly what our family is supposed to be. I strongly 
believe that my husband is supposed to be in a wheelchair, I can't tell 
you why, but this is what our life is supposed to look like. We are 
happy, we are healthy and we are living out our dreams. Now that my 
husband is medically retired we have the ability to raise our children 
together as stay home parents. We are a team and my only wish is that 
other families could find this happiness.
    Since having our children I see my husband light up again, I see 
him happy, fulfilled. He is truly living the American Dream. I cannot 
imagine where we would be if we didn't save money knowing we would need 
to do IVF in the future.
    One of the things I love the most about having children now is that 
their dad is just their dad. They don't see the wheelchair. They will 
be kind to people with disabilities and more understanding. All of the 
injured veterans who have children are helping share with others that 
people with disabilities are just like everyone else, they just do 
things a little differently. My husband is a shining example of a 
wonderful father who loves his children and we would have done anything 
possible to have them.
    They make him feel like the man he was before he was injured, they 
complete our life together and the kids have helped fulfill our 
American dream. The VA, Congress and the American People have said 
countless times that they want to do everything they can to support my 
husband or make him feel whole again and this is your chance. Having a 
family is exactly what we needed to feel whole again. Please help us 
make these changes so that other families can share in this experience.
    If the VA does decide to begin offering fertility treatments I 
think it's important to note that this is a very personal issue. 
Selecting a doctor to perform these treatments was very personal for my 
family and we didn't want to use ``just anybody.'' We wanted to go to 
the best. I think it would be wonderful to let the private sector help 
these men and women start their families and do their part to help 
injured servicemembers. This way if the families choose, they can go to 
a private sector doctor to have these services performed. I know that 
it is a challenge for my family to drive to the VA on a daily basis for 
treatments. Sometimes families can find something closer to their homes 
to make things easier. We have to remember that we are talking about 
the most severely injured veterans that encounter fertility issues due 
to their injuries, so doing whatever is easiest for the family is 
extremely important.
    Fertility is an area where we need experts in the field with 
extensive experience. Those doctors are already set up in private 
practices across the country. I think it would be very beneficial to 
the families to fee base the fertility specialist of their choice. 
There is also the option of capping the benefit at a certain amount of 
money or a certain amount of rounds of fertility treatments. As family 
of a severely injured veteran, I do not expect taxpayers to pay for 
every single thing we could ever wish for, so putting a limit on the 
fertility amounts is certainly understandable and expected.
    There are about 600 men and women who have returned home with 
damage to their reproductive ability. Today I ask you to please support 
these brave servicemembers in their dream to have families. I am here 
today to say that this injury took away so much of my husband 
physically that he cannot get back, but we could not let this injury 
take away our dream of a family. Having children meant that we were 
back to where we were before he was injured. It brought a sense of 
accomplishment and fulfilled our dreams of a family. In some ways it 
made my husband feel whole again.
    I hope that hearing our story today has helped you understand the 
importance of offering fertility treatments to injured veterans who 
have lost the ability to reproduce naturally. What happened to them is 
by no fault of their own. Wartime changes a family, it shouldn't take 
away the ability to have one.

    Thank you for your time.

    Chairman Murray. Ms. Keil, thank you so very much for your 
courage in speaking out for so many others. I have been looking 
at the pictures. They are actually in front of me. I am sorry 
the audience cannot see them. They are absolutely adorable.
    And you are right. That is truly compelling. So, thank you 
very much for being here today.
    Dr. Edney, we will turn to you.

  STATEMENT OF MARK THOMAS EDNEY, M.D., OIF VETERAN, MEMBER, 
   LEGISLATIVE AFFAIRS COMMITTEE OF THE AMERICAN UROLOGICAL 
                          ASSOCIATION

    Dr. Edney. Chairman Murray, Ranking Member Burr, Members of 
the Committee, honored guests, fellow servicemembers, I thank 
the Committee on Veterans' Affairs for inviting me to testify.
    My name is Mark Edney. I am a Urologist, a physician who 
treats genitourinary disease and injury. I am also an Army 
Reservist.
    It is an honor and privilege to be able to testify before 
the Senate Committee on Veterans' Affairs in support of Senate 
3313. My testimony has the support of many organizations 
dedicated to this issue, including the American Urological 
Association, The Men's Reproductive Health Alliance, the 
American Fertility Association, and the Men's Health Network, 
and others, many of whom are represented in the room today.
    I am a husband and the father of three children, ages 10, 
7, and 5 years. In my 10 years of reserve service, I have been 
called back to duty three times: first to Walter Reed Army 
Medical Center in 2004, next a combat tour with the 399th 
Combat Support Hospital in Mosul, Iraq in 2006, and finally a 
tour at Tripler Army Medical Center in Hawaii in 2009.
    I have seen and treated genitourinary injury in the theater 
of operations, and I have also participated in its chronic 
management in our largest military medical centers.
    It is important to understand the breadth of the types of 
injuries that can occur that threaten fertility. The most 
common mechanism of injury to the genitourinary organs in 
theater right now is blast effect from improvised explosive 
devices and also from gunshot wounds.
    The most common types of male genitourinary injuries are 
testicular rupture, penile shaft, urethral and bladder injury. 
Blast injuries to the phallus often result in erectile 
dysfunction or render it otherwise incapable of intercourse.
    Urethral injuries often result in scar tissue, preventing 
the release of semen. Shrapnel often penetrates the perineum, 
the area that includes the sexual organs and the rectum.
    Even with proper current protective gear, the perineum is 
exposed. In these instances, the external sexual organs may be 
preserved, but injury can occur to the pelvic portion of the 
tissue cylinders responsible for normal function.
    Damage can also occur to the nerve and vascular supply 
responsible for normal function. Damage anywhere in the sperm 
delivery system may result in the absence of sperm in the 
semen.
    There are a range of female injuries that can result from 
fertility problems. Blast injury can occur to the perineum and 
the vaginal vault which precludes intercourse. Shrapnel or 
bullet penetration of the pelvis can injure the ovaries, 
inhibiting egg development and delivery. Damage to the 
fallopian tubes easily results in a lack of ability to transmit 
the egg to the uterus.
    Overall genitourinary injuries comprise five to 10 percent 
of wounds suffered in battle, but they can be some of the most 
psychologically debilitating.
    Spinal cord and Traumatic Brain Injury are two major 
classes of non-neurologic injury that can also impede utility 
through sexual dysfunction in men.
    There are also non-ballistic threats to women's 
reproductive health in theater. A recent survey of female 
soldiers revealed that there can be a lack of confidence of the 
unit level health care providers with respect to competence in 
women's health issues and concerns around confidentiality 
leading to avoidance of care seeking.
    There are underappreciated psycho-social issues with female 
family separation that can have both psychological and 
physiological effects that lead to sexual dysfunction and 
fertility issues.
    The issue of military sexual trauma which can have a 
profound impact on sexual function and fertility continues to 
be addressed military-wide through the sexual harassment, 
assault response and prevention program.
    To support these issues, S. 3313 has critical provisions 
that improve female--the female veterans call center and expand 
the counseling of women upon separation from the military.
    Given the many ways that injured soldiers can return to 
their home units, their civilian life, and their families with 
fertility-threatened injuries, the question becomes how are we 
willing to help them.
    Though genitourinary is not publicly visible, it is no less 
physically or psychologically debilitating than loss of limb or 
other overtly disfiguring injury. Professionals who specialize 
in fertility will attest to the intense psychological pain and 
suffering endured by infertile couples who will go to great 
financial and emotional extremes in order to conceive a child.
    S. 3313 contains powerful provisions that provide access to 
advanced reproductive technologies for fertility impaired 
soldiers, their spouses, and surrogates.
    Intrauterine insemination or IUI and in-vitro fertilization 
or IVF are the advanced reproductive techniques that S. 3313 
makes available.
    IUI is the deposition to process sperm into the uterine 
canal to then finish the normal cycle of fertilization. It is 
used when female anatomy is intact at and above the cervix but 
when any number of the injuries I have mentioned preclude 
delivery of sperm to the uterine cavity.
    IVF is employed when the injury or combination of injuries 
precludes the normal meeting of sperm and egg. Fertilization is 
achieved in the laboratory. Then the fertilized eggs is then 
replanted back into the uterus for normal gestation.
    If the uterus has been rendered incapable of sustaining a 
pregnancy, a surrogate can be engaged for the pregnancy of the 
natural parents fertilized egg.
    It is noteworthy that the substantial cost of an IVF cycle 
in the private sector where battle injury infertile VA couples 
now must turn is on the order of $20-30,000 per cycle with 
success rates of 20 to 40 percent per cycle. Multiple cycles 
are often necessary.
    The expertise and technology exists within the VA and the 
DOD for a fraction of the cost. We just need S. 3313 to unlock 
it for these most deserving Americans.
    There is a desperate need to establish a research database 
of soldiers with genitourinary injury to better study the 
continuum of care from prevention to initial management to 
reconstruction and to fertility treatment and outcomes.
    Senator Murray's bill takes a critical step in calling for 
the Department of Defense and the NIH to conduct collaborative 
research to address the long-term reproductive health care 
needs of veterans with service-connected reproductive injuries.
    Also to this end, I want to bring to the Committee's 
attention H.R. 1612, which has been reintroduced this session 
with the sponsorship of Congressman Brett Guthrie and 25 
cosponsors in the House.
    The bill, promulgated by the American Urological 
Association, sets up a national commission on uro-trauma. The 
16-member commission, which is a collaboration of the 
Departments of Defense, Veterans Affairs, and Health and Human 
Services, will be a sunset commission with defined objectives.
    They are in summary, one, to study the current state of 
knowledge from prevention to initial management to chronic 
therapy. Two, to identify public and private resources that can 
be brought to bear for fertility-impaired soldiers. Three, to 
identify care enhancing programs of potential benefit to the 
genitourinary injured soldier.
    The bill is described in more detail in my written 
testimony, and I would be happy to discuss it further with any 
Members of the Committee who might be interested in supporting 
it.
    We as a Nation have done better recently at addressing the 
physical disability that results from war injury. 
Appropriately, hundreds of millions of dollars have been 
dedicated to the research and development of prosthetics to 
return soldiers with loss of limb to a higher degree of 
physical ability. We are getting better at detecting and 
addressing the psychological wounds of war from PTSD and 
dramatic brain injury.
    There is an important group who have been left behind. 
Those suffering the publicly invisible but intensely 
emotionally painful loss of fertility as the result of 
genitourinary injury.
    Let us together show these finest Americans that we are 
willing to go beyond our current efforts of physical and 
emotional support. Let us use the expertise and tools that we 
have in place today to restore their fertility so that they may 
1 day look into the eyes of their own children and see the 
family history, the pride, and hope for the future that so many 
of the rest of us have been blessed to know.
    We owe these brave Americans no less for the sacrifices 
they have made for our great Nation.
    I thank the Committee again for the privilege and honor of 
being asked to testify.
    [The prepared statement of Dr. Edney follows:]

 Prepared Statement of Mark T. Edney, M.D., F.A.C.S., Army Reservist, 
    Operation Iraqi Freedom Veteran and Member, Legislative Affairs 
               Committee, American Urological Association

    Chairman Murray, Ranking Member Burr, Members of the Committee, 
honored guests, fellow servicemembers, I thank the Committee on 
Veterans' Affairs for inviting me to testify.
    It's an honor and privilege to testify before the Senate Committee 
on Veterans Affairs in support of Senate Bill 3313. This Bill provides 
critically needed support for soldiers within the Department of 
Veterans Affairs who have suffered fertility-impairing trauma in 
battle. My comments have the support of many organizations that have 
tangibly dedicated themselves to the care, rehabilitation, and 
restoration of fertility to soldiers who have suffered urogenital and 
other forms of trauma that threaten fertility. These organizations 
include the American Urological Association, The Men's Reproductive 
Health Alliance, the American Fertility Association, and the Men's 
Health Network. This is by no means an exhaustive list of the 
professional organizations and patient advocacy groups with a vested 
interest in this subject, many of whom are represented in the room 
today.
    I am a Urologist, a specialist who treats genitourinary disease and 
injury, in private practice in Salisbury, MD. I am a husband and the 
father of three children 10, 7, and 5 years old. I am also an Army 
Reservist of 10 years. I have been called to active duty 3 times: first 
to Walter Reed Army Medical Center in 2004, one tour with the 399th 
Combat Support Hospital in Mosul, Iraq in the winter of 2006, and 
finally a tour at Tripler Army Medical Center in 2009. I have seen and 
treated genitourinary trauma in the theater of operations and have 
participated in its chronic management at our largest military medical 
centers stateside.
    To begin, a brief review of the mechanics of natural human 
fertilization may be helpful. The testicle produces two elements 
essential to fertility: sperm and testosterone. After going through the 
stages of maturation, sperm leave the testicle through a series of 
tubes (the epididymis and vas deferens) and wait temporarily in the 
section of vas deferens that enters the prostate gland (ejaculatory 
duct). When ejaculation occurs, the supporting fluid (semen), is 
released from the seminal vesicles, sperm is released from the 
ejaculatory ducts (emission), and the mixture is propelled forward to 
be deposited in the vagina. Sperm then begin their journey across the 
cervix, into the body of the uterus. Eventually a very small percentage 
of the original populations make it to the fallopian tube to meet the 
egg which upon penetration of a single spermatozoon, is then 
fertilized. The fertilized egg (zygote) then implants in the wall of 
the uterus for the remainder of gestation.
    Normal female physiology is as follows: Eggs mature in the ovaries 
and once per cycle, an egg (oocyte) is released into the fallopian tube 
and begins its migration toward the body of the uterus. If it 
encounters a sperm on the way and becomes fertilized, the resulting 
zygote (fertilized egg) implants into the wall of the uterus and 
gestation ensues. If not, the oocyte is expelled and the process 
repeats on a monthly basis.
    It's important to understand the breadth of types of injuries that 
result in threats to fertility. The most common mechanism of injury to 
the genitourinary organs in Operation Iraqi Freedom and Operation 
Enduring Freedom is blast effect from improvised explosive devices 
(IEDs), followed by gunshot wounds. The most common types of male 
genitourinary injuries, sometimes seen in isolation, but commonly in 
combination are: testicular rupture (unilateral or bilateral), penile 
shaft/pendulous urethral injury, posterior urethral injury, and bladder 
injury. Spinal cord injury and Traumatic Brain Injury are two major 
classes of non-urological injury that can impede fertility through 
ejaculatory dysfunction. If testicular rupture injuries present within 
a few hours as most do with current evacuation systems, salvage is 
possible with rates of up to 74% reported recently. Bilateral 
testicular loss is a devastating injury that obviously precludes future 
fertility.
    Blast injuries to the phallus often result in either erectile 
dysfunction or otherwise render it mechanically incapable of 
intercourse to achieve a natural pregnancy. Urethral injuries of either 
the pendulous or posterior aspect often result in stricture (scar 
tissue) formation that renders ejaculation either impaired or 
impossible. Schrapnel often penetrates the perineum, the area that 
includes the sexual organs and rectum. The perineum, even with proper 
use of the current protective gear, is unprotected. In these instances, 
the external sexual organs may be preserved but injury can occur to the 
portion of the erectile bodies (the tissue cylinders in the penis 
responsible for erection) that attach to the pubic bones or to the 
nerve and vascular supply responsible for erectile function. Even if 
the testicles are uninvolved or salvaged after a schrapnel injury, 
damage to the ductal system anywhere from epididymis to ejaculatory 
duct may result in lack of sperm delivery to the ejaculate.
    There is a groin-protective garment that is issued to soldiers as 
they are deployed. It is a triangular shaped shield that attaches to 
the front of the Improved Outer Tactical Vest (IOTV). Its design and 
location, however, are felt by many soldiers to be cumbersome and to 
inhibit mobility and so it is not worn by many. There is a critical 
need to invest in the research and development of protective gear for 
the genital organs that is effective and practical for the tactical 
environment.
    Blast or gunshot wounds to the female pelvis can also result in a 
variety of fertility-impairing injuries. Trauma to the perineum and 
vagina can easily result in an altered vaginal vault that renders 
intercourse impossible. Additionally, penetrating schrapnel injury to 
the female pelvis can disrupt the ovaries, fallopian tubes, body of the 
uterus or the vaginal vault. Fallopian tube injuries can preclude the 
normal passage of the egg and therefore prevent fertilization. Uterine 
injury can result in a uterus incapable of sustaining a pregnancy which 
then opens the issue of surrogacy.
    Women also experience non-ballistic risks to maintenance of 
reproductive health while in theater. A recent white paper developed by 
the Army's Women's Health Assessment Team identified several barriers 
to optimal genitourinary health for female soldiers in theater. These 
included lack of secure facilities for women to attend to personal 
hygiene. There is in some instances a lack of confidence in unit-level 
health care provides with respect to competence in women's health 
issues and concerns around confidentiality leading to avoidance of 
care-seeking. There are underappreciated psycho-social issues with 
female family separation that can have both psychological and 
physiological effects that lead to sexual dysfunction and fertility 
issues. The issues of military sexual trauma, which can have profound 
impact on sexual function and fertility, continue to be addressed 
military-wide through the Sexual Harassment/Assault Response and 
Prevention (SHARP) program. S. 3313 seeks to meet these needs in two 
critical ways. First, by increasing the number of retreat-style 
counseling opportunities for returning female soldiers, and second, by 
improving the functionality of the female veterans' call center.
    Given the many ways that injured soldiers can return to their home 
units or civilian life and their families with fertility-threatening 
injuries, the question becomes how are we willing to help them? Though 
genitourinary trauma is not publicly visible it is no less physically 
or psychologically debilitating than loss of limb or other overtly 
disfiguring injury. Procreation is one of the most fundamental of human 
instincts.
    The range of male and female injuries described above can all 
result in the inability for couples to achieve a pregnancy in standard 
fashion. That's where advanced reproductive technology is brought to 
bear and where S. 3313 will have an immediate and profound impact for 
fertility-impaired soldiers, and their spouses. The advanced techniques 
are specifically intrauterine insemination (IUI) and in-vitro 
fertilization (IVF). IUI involves processing sperm that have been 
obtained either from the ejaculate or harvested from the testicle or 
epididymis, and implanting them directly into the uterus to complete 
the remainder of the natural fertilization process. In-vitro 
fertilization (IVF) is the process by which sperm and egg are united in 
a controlled laboratory environment and post-fertilization the zygote 
is placed in the uterus for implantation. IUI is employed when female 
anatomy is intact and functional from the cervix up, but either a male 
or female injury precludes depositing a requisite number of sperm into 
the vagina. As IUI is less technology and labor intensive, it is also 
less expensive per cycle. IVF is employed when a male and or female 
injury precludes the natural union of sperm and egg in the fallopian 
tube for any number of the reasons mentioned above. In cases where the 
uterus has been rendered incapable of sustaining a pregnancy, a 
surrogate can be engaged to carry the fertilized egg for the natural 
parents. More labor intensive than IUI, IVF also costs more but it is 
important to note that the cost per cycle of IVF in government 
facilities is tens of thousands of dollars less than in the private 
world, where VA couples are now forced to seek care at $20-30,000 
dollars per cycle. The per-cycle success rate depends on a variety of 
factors including age. Pregnancy rates range between 20 and 45% per 
cycle and live birth rates range between 10% and 30% per cycle.
    An important provision of S. 3313 provides treatment to the spouse 
of the injured soldier. It's important to understand the concept of 
sub-fertility. It is possible that a soldier with a fertility impairing 
injury, given a normally functioning partner, could still conceive 
naturally. Should the partner, however, have a condition resulting in 
sub-fertility (low sperm count, low sperm volume for men or hormonal 
cycle variables or minor anatomic variation for women), the partner 
under S. 3313 would be eligible for treatment.
    Currently the Department of Defense as of April 2012 (DOD 
instruction 1300.24) provides for advanced fertility treatment for 
soldiers who have suffered genitourinary injury. This DOD policy is a 
start but as currently written only covers those soldiers with the most 
severe general injury status who may be infertile. There are soldiers 
in the DOD who may have suffered isolated genitourinary injury and 
despite their infertility may remain functional in their MOS and this 
class of soldiers is not covered for infertility care under current 
policy. It's important that the Department of Veterans Affairs create 
policy based on ``infertility injury'' and not a more general injury 
scale so as to capture every soldier who has been rendered infertile 
from battle injury. Every soldier with battle injury infertility 
deserves access to advanced reproductive technology.
    There is a desperate need, not only within the Department of 
Veterans Affairs but including the Departments of Defense and Health 
and Human Services to fund a longitudinal, prospective database of 
soldiers with genitourinary injury to better study the continuum of 
care from prevention, to initial management in theater, to 
reconstruction at higher levels of care to fertility treatment and 
outcomes. S. 3313 takes a critical step in calling for the Dept of 
Defense and NIH to conduct collaborative research to address long-term 
reproductive health care needs of veterans with service-connected GU/
reproductive injuries. Also to this end, I want to bring to the 
Committee's attention H.R. 1612 which has been re-introduced this 
session with the sponsorship of Congressman Brett Guthrie along with 25 
co-sponsors in the House. The Bill, promulgated by the American 
Urological Association, seeks to establish a National Commission on 
Urotrauma. The 16 member Commission, a collaboration of the Departments 
of Defense, Veterans Affairs, and Health and Human Services, will be a 
sunset Commission with defined objectives as follows: 1) To conduct a 
comprehensive study of the present state of knowledge of the incidence, 
duration, and morbidity of, and mortality rates resulting from 
urotrauma and of the social and economic impact of such conditions; 2) 
To evaluate the public and private facilities and resources (including 
trained personnel and research activities) for the prevention, 
diagnosis, and treatment of, and research in such conditions; and 3) To 
identify programs (including biological, behavioral, environmental, and 
social programs) in which, and the means by which, improvement in the 
management of urotrauma can be accomplished. The Bill has been scored 
at a nominal cost and the offset has been identified. I would be happy 
to discuss the Bill further with any Members of the Committee who would 
like to learn more and perhaps support it.
    There is a wealth of expertise and the infrastructure is in place 
within the Department of Veterans Affairs and Department of Defense to 
provide soldiers with fertility-impairing injuries comprehensive 
management so that they may have their own children. S. 3313 unlocks 
that capability for soldier in the VA system to protect them from the 
$20-30,000 per cycle fees in the private sector where they now by 
necessity seek treatment. This is a wrong that S. 3313 rights. We as a 
nation have done better recently at addressing the physical disability 
that results from war injury. Appropriately, hundreds of millions of 
dollars have been dedicated to the research and development of 
prosthetics to return soldiers with loss of limb to a higher degree of 
physical ability. We are getting better at detecting and addressing the 
psychological wounds of war from PTSD and Traumatic Brain Injury. 
There's an important group who have been left behind: those suffering 
the publicly-invisible but intensely emotionally painful loss of 
fertility as a result of genitourinary injury. Let's together show 
these finest of Americans that we are willing to go beyond our current 
efforts of physical and emotional support. Let us use the expertise and 
tools that we have in place today to restore their fertility so that 
they may one day look into the eyes of their own children and see the 
family history, pride, and hope for the future that so many of the rest 
of us have been blessed to know. We owe these brave Americans no less 
for the sacrifices they have made for our great Nation.

    Chairman Murray. Thank you very much, Dr. Edney.
    With that, let us now turn to Ms. Ansley please.

STATEMENT OF HEATHER ANSLEY, M.S.W., VICE PRESIDENT OF VETERANS 
                       POLICY, VETSFIRST

    Ms. Ansley. Thank you. Chairman Murray, Ranking Member 
Burr, and distinguished Members of the Committee, thank you for 
inviting VetsFirst to share our views and recommendations 
regarding the legislation that is the subject of this morning's 
hearing.
    My oral testimony will focus on our support for the Mental 
Health ACCESS Act of 2012. First, however, I would like to take 
a moment to highlight our support for some of the other bills 
included in today's hearing that are of particular interest to 
our members.
    Specifically, we support S. 3313, which has been discussed 
already today. S. 1838, regarding service dog training, and 
S. 1755 concerning coverage for rehabilitation services for 
certain veterans.
    Each of these bills is critically important to allowing 
disabled veterans to live in their communities full, healthy 
lives. Our comments on these and other bills before the 
Committee are included in our written testimony.
    The chair of the VetsFirst Committee who was on the Hill 
with me yesterday spent 16 months at the Bronx VA in the late 
1960s after acquiring a spinal cord injury and he recently told 
me that during those 16 months he had one visit with a 
psychologist.
    The visit ended rather abruptly when he told the 
psychologist that he was thinking about returning to grad 
school. The psychologist shut the folder and wished him well. 
Thirty-six years later, after becoming a quadriplegic, he 
finally sought the mental health counseling that he needed to 
deal with the emotional and mental consequences that any type 
of serious injury brings.
    Although the services of the Bronx VA have greatly improved 
since that time, we want to make sure that another generation 
of veterans do not have problems accessing VA mental health 
care.
    Through VetsFirst work with the Consortium for Citizens 
with Disabilities, CCD, which is a coalition of over 100 
national consumer, service-provider, and professional 
organizations that advocate on behalf of people with 
disabilities, we are working to expand our efforts and working 
with members of the disability community, the veterans 
community, and mental health communities to engage in efforts 
to address these concerns.
    To expand our efforts, we are working with the Mental 
Health Liaison Group, MHLG, which is a coalition comprised of 
national behavioral health organization's that represents 
consumers, family members, advocates, professionals, and 
providers and advocates on behalf of people with until health 
or substance use issues.
    We highlighted our concerns about wait times for 
appointments and asserted our belief that clinicians might need 
to be given the time and resources to provide patients with 
evidence-based therapy in a letter that we sent to VA earlier 
this year.
    We have also expressed that VA should leverage the full 
range of certified mental health professionals that are 
available. We are pleased that VA has reached out toward us 
regarding our concerns, and we welcome the opportunity to 
continue working with VA and appreciate the outreach to both 
CCD and MHLG including the Vietnam Veterans of America, the 
American Foundation for Suicide Prevention, Mental Health 
America, and VetsFirst, who are the members of the coalitions 
that are leading this outreach effort with VA.
    The remainder of my comments on the Mental Health ACCESS 
Act of 2012 reflect the views of VetsFirst and my comments 
addressed only Title II which directly concerns VA.
    Access to quality mental health care is critical in 
ensuring that veterans are able to successfully reintegrate 
into their communities. We appreciate the requirement in this 
legislation for a VA to develop a measure of access to health 
care that will evaluate the timeliness, satisfaction, capacity, 
and availability of furnishing evidence-based therapies.
    We also support the requirement that VA develop a 
comprehensive staffing model that will include productivity 
standards. Requiring the VA to work with the National Academy 
of Sciences to create a study committee to advise in the 
development of these guidelines and measures will provide a 
heightened level of expertise. The mandates for transparency 
that require posting this information online will increase 
accountability.
    To increase access, we also support expanding eligibility 
for Vet Centers services which is a positive step for 
servicemembers, families, and veterans.
    As we all know, Vet Centers are vital links to care for 
many who might not otherwise seek services. The role that Vet 
Centers plays an important role in the delivery of this care. 
We support this legislation expansion of eligibility as long as 
Vet Centers are properly resourced to meet the needs that they 
are designed to address.
    Although VA must have sufficient resources to meet the 
mental health needs of our Nation's veterans, we also believe 
that the scope of the need requires VA to link with community 
resources.
    We support the requirement for VA to carry out a national 
program of outreach to connect with community mental health 
resources which represents a good opportunity to mobilize 
qualified providers in a concerted effort to organize 
clinicians who meets VA requirements and that will help to 
expand service capacity.
    In addition to community resources, peer support counselors 
are also an important component of the mental health delivery 
system. The counselors serve as a useful vector for helping 
individuals to seek more formal types of care and that 
establishing one of these programs at each VA medical center 
will ensure the availability of these services to as many 
veterans as possible.
    Again, thank you for the opportunity to share VetsFirst's 
views on this legislation. This concludes my testimony and I 
will be pleased to answer any questions that you may have.
    [The prepared statement of Ms. Ansley follows:]

 Prepared Statement of Heather L. Ansley, Esq., M.S.W., Vice President 
 of Veterans Policy, VetsFirst, a program of United Spinal Association

    Chairman Murray, Ranking Member Burr, and other Distinguished 
Members of the Committee, Thank you for the opportunity to testify 
regarding VetsFirst's views on the bills under consideration today.
    VetsFirst represents the culmination of 60 years of service to 
veterans and their families. United Spinal Association, through its 
veterans service program, VetsFirst, provides representation for 
veterans, their dependents and survivors in their pursuit of Department 
of Veterans Affairs (VA) benefits and health care before VA and in the 
Federal courts. Today, United Spinal Association is not only a VA-
recognized national veterans service organization, but is also a leader 
in advocacy for all people with disabilities.
women veterans and other health care improvements act of 2012 (s. 3313)
    After a decade of war, many severely disabled veterans who have 
experienced trauma related to improvised explosive devices and other 
conditions of warfare may experience infertility. For many veterans, 
the ability to start or grow their families represents an important 
part of moving forward with their lives. Unfortunately, the current 
services available from VA in many cases do not reflect the needs of 
these veterans and their families.
    Presently, VA provides male veterans who have spinal cord injuries 
with fertility services for retrieving, storing, and preparing sperm 
for use for assisted reproductive technology. These services are 
available to male veterans who are service-connected and also for those 
who have access to VA health care but whose disabilities are not 
related to their military service. Although VA provides these services 
for male veterans who have spinal cord injuries, there is no provision 
to provide the assisted reproductive technologies needed for 
fertilization.
    The Women Veterans and Other Health Care Improvements Act takes 
important steps toward assisting veterans, their spouses, and 
surrogates in holistically addressing infertility. VetsFirst supports 
the addition of fertility counseling and treatment, including treatment 
using assisted reproductive technology to the definition of medical 
services. We are also pleased that this legislation not only expands 
the definition of medical services to include these treatments, but 
also provides them to veterans' spouses or surrogates. We are 
disappointed, however, that these services are not required for 
veterans who are not service-connected.
    We appreciate the requirement for the promulgation of regulations 
to implement these new statutory requirements. To provide a level of 
certainty to veterans and their spouses, it will be important for VA to 
develop a non-inclusive list of the types of technologies that will be 
provided (at a minimum) by VA. It must also be clear to veterans and 
their spouses or surrogates whether VA will provide services related to 
subsequent costs of pregnancy and post-partum care.
    This legislation also requires VA to facilitate collaborative 
research with the Department of Defense (DOD) and the National 
Institutes of Health which will help VA to address the long-term 
reproductive health needs of veterans. This research will be critical 
in addressing the unique infertility issues of veterans with combat-
related injuries. We are also pleased that the legislation requires 
that the research be disseminated within the Veterans Health 
Administration to guide treatment practices.
    VetsFirst also supports efforts in the legislation to improve 
access to VA services for women veterans. Women make up an increasing 
percentage of the veteran population. Consequently, VA must improve 
efforts to address the unique needs and concerns of women veterans. 
Otherwise, women may be hesitant to take advantage of their benefits.

   MENTAL HEALTH ACCESS TO CONTINUED CARE AND ENHANCEMENT OF SUPPORT 
                     SERVICES (ACCESS) ACT OF 2012

    The need to access high quality VA mental health services when 
needed is critically important for our Nation's veterans and their 
families. After a decade of war, the number of veterans who need mental 
health services due to Post Traumatic Stress Disorder and other wounds 
related to their service has greatly increased. Veterans from previous 
wars also continue to need mental health care services which allow them 
to be vital contributors to their communities and families.
    The difficulty of some veterans in accessing VA mental health care 
services in a timely manner has been detailed in numerous hearings 
before this Committee over the last year. The report from VA's Office 
of Inspector General regarding access to mental health care that was 
released on April 23, 2012, highlighted concerns about appointment 
times and the lack of accurate performance data. Aside from the 
statistics, we are acutely aware of the sheer human toll of war as 
reflected by the number of servicemembers and veterans who are 
committing suicide on a daily basis.
    As an organization that is both a veterans service organization and 
a disability organization, we are very concerned about the ability of 
veterans to have timely access to evidence-based therapies. Through our 
work with the Consortium for Citizens with Disabilities (CCD), 
VetsFirst is working with members of the disability, veterans, and 
mental health communities to engage in efforts to address these 
concerns. Specifically, representatives of the CCD Veterans and 
Military Families Task Force and the Mental Health Liaison Group (MHLG) 
have been meeting regularly to better determine how we might work with 
VA to improve access to mental health services for our Nation's 
veterans.
    CCD is a coalition of over 100 national consumer, service provider, 
and professional organizations which advocates on behalf of people with 
disabilities and chronic conditions and their families.
    The MHLG is a coalition comprised of national behavioral health 
organizations representing consumers, family members, advocates, 
professionals, and providers which advocates on behalf of individuals 
with, or at risk of, a mental health or substance use condition, 
including servicemembers, veterans, and their families.
    On April 5, the CCD Veterans and Military Families Task Force and 
MHLG sent a letter signed by 41 member organizations to VA expressing 
our concerns about the delay in veterans receiving VA mental health 
services. In this letter, which is included with our testimony, member 
organizations highlighted our concerns about wait times for 
appointments. We also asserted our belief that clinicians must be given 
the time and resources to provide veterans with evidence-based 
therapies that represent the best practices for addressing veterans' 
specific needs. Last, we asserted that VA should leverage the full 
range of certified mental health professionals, including psychiatric 
social workers and licensed professional counselors, to increase access 
to these best practice therapies.
    We are pleased to report that VA reached out to us regarding our 
concerns, and we look forward to growing our partnership to ensure that 
our Nation's veterans have access to needed mental health services. We 
welcome the opportunity to continue working with VA and appreciate the 
outreach to CCD and MHLG, including Vietnam Veterans of America, the 
American Foundation for Suicide Prevention, Mental Health America, and 
VetsFirst who are the member organizations leading the outreach effort.
    The remainder of VetsFirst's comments on the Mental Health ACCESS 
Act of 2012 reflect our individual views. For purposes of our 
testimony, we are limiting our comments to Title II--Department of 
Veterans Affair Matters.
    Access to quality mental health care is critical in ensuring that 
veterans are able to successfully reintegrate into their communities. 
To ensure that access standards are being met, VA must develop 
comprehensive measures that accurately determine whether proper access 
to services is being provided. We appreciate the requirement in this 
legislation for VA to develop a measure of access to health care that 
will evaluate timeliness, satisfaction, capacity, and availability and 
furnishing of evidence-based therapies by VA. We also support the 
requirement that VA develop a comprehensive staffing model that will 
include productivity standards.
    The development of access measures and staffing guidelines for 
mental health care is crucial to meeting the mental health care needs 
of veterans. Requiring VA to contract with the National Academy of 
Sciences to create a study committee to advise in the development of 
these guidelines and measures will provide a heightened level of 
expertise. We also support the requirement for the study committee to 
assess the mental health needs of our newest veterans. The mandates for 
transparency through reporting and posting the measures and guidelines 
online will help to facilitate accountability.
    Expanding access to Vet Centers is a positive step in efforts to 
address the mental health care for veterans, servicemembers, and their 
families. Vet Centers are a critical link to care for many veterans who 
might not otherwise seek services. The role that Vet Centers play in 
the delivery of this care is crucial. Thus, the services and supports 
provided by Vet Centers must be available when needed by these 
individuals. We support this legislation's expansion of eligibility for 
services as long as Vet Centers are properly resourced because of the 
great need for readjustment services by servicemembers and their 
families.
    We also support the proposed organization of VA's Readjustment 
Counseling Service. We appreciate the inclusion of language stating 
that, ``The Readjustment Counseling Service is a distinct 
organizational element within Veterans Health Administration.'' We are 
also pleased that the Chief Officer of the Service will have direct 
authority over staff and assets and that its budget request will be 
listed separately. The autonomy of the Service contributes to its 
successful outcomes and outreach to veterans.
    Although VA must have sufficient resources to meet the mental 
health needs of our Nation's veterans, the scope of the need requires 
VA to fully utilize any available resources that will properly meet 
these needs. Requiring VA to carry out a national program of outreach 
to connect with community mental health resources represents a good 
opportunity to mobilize qualified providers. A concerted effort to 
organize clinicians who meet VA requirements will expand the capacity 
of VA services. We are also pleased that the legislation requires 
training in military culture to ensure that these providers are able to 
better meet the needs of veterans.
    In addition to community resources, peer support counselors are 
also an important component of the mental health delivery system. These 
counselors serve as useful vectors for helping individuals to seek more 
formal types of mental health care. Requiring that peer support 
counseling programs be established at each medical center will ensure 
the availability of these services to as many veterans as possible.
    We believe that the steps taken in Title II of this legislation 
will strengthen VA's ability to serve veterans, servicemembers, and 
their families.
To require VA to consider the resources of individuals applying for 
        pension that were recently disposed of by the individuals for 
        less than fair market value when determining the eligibility of 
        such individuals for such pension (S. 3270)
    VA's pension program provides benefits for veterans who are low-
income and are either permanently and totally disabled, or age 65 and 
older, if they served during a period of war. These benefits are 
critical for veterans who have few other resources available to them.
    Because these benefits are very important to low-income disabled 
veterans, we believe that these benefits must be protected to ensure 
that they are fully available when needed. As a result, we do not 
condone fraudulent efforts to benefit from the VA's pension program. We 
also believe, however, that people should not have to impoverish 
themselves just to receive the services that they need whether in VA's 
program or any other government benefits program.
    The look-back proposed in this legislation seeks to preempt efforts 
to transfer assets to make veterans eligible for pension benefits. 
Without commenting further on the specific merits of this proposal, we 
are concerned that the legislation does not exempt transfer of assets 
to special needs trusts. Special needs trusts are designed to 
supplement the services and supports received by people with 
disabilities through Social Security and Medicaid. The funds in a 
special needs trust may be used for expenses such as modifying a home 
for accessibility, paying for recreational activities, or purchasing 
tickets to visit family. If the funds were made directly available to 
the individual, then he or she may lose eligibility for Supplemental 
Security Income (SSI) benefits and Medicaid services and supports, 
which are income dependent. By placing the funds in a special needs 
trust, parents can ensure, for instance, that their disabled children 
retain eligibility for these crucial benefits and services.
    A good example illustrating the importance of special needs trusts 
is found in the current quandary with the DOD survivor benefit plan 
(SBP). An SBP annuity allows for retiring servicemembers to make a 
portion of their retired pay available to their survivors. However, 
Federal law requires that these benefits must be paid to a ``natural 
person.'' Thus, if a child with a disability is in receipt of income 
dependent services and supports, then the child may lose these benefits 
and services because SBP funds cannot be paid to a special needs trust. 
Unfortunately, the amount received from the annuity may not be 
sufficient to pay for the services lost. Thus, the child not only loses 
eligibility for the services but then is unable to pay for them 
privately.
    In the November 2011 edition of Exceptional Parent Magazine, Kelly 
A. Thompson, an attorney, relayed how this dilemma played out for one 
adult child with a disability.

        ``A recent example concerns a 52 year-old man with an 
        intellectual disability who had lived in a group home for 18 
        years and attended a day program for individuals with 
        disabilities. His only income was SSI of $674 per month. His 
        SSI benefits and Medicaid paid for his programs and services. 
        However, when his father, a retired Navy officer, died, his 
        adult son began to receive military SBP in the amount of $2,030 
        per month. This SBP payment made him ineligible for Medicaid 
        waiver services. The private pay cost of the programs and 
        services he was receiving prior to his father's death is $8,600 
        per month, more than four times his SBP payment. He lost his 
        group home placement, as well as his day program, and was 
        transferred to a state ``training center''--a large 
        institutional setting isolated from the community.'' \1\
---------------------------------------------------------------------------
    \1\ Kelly A. Thompson, ``The Dilemma for Military Parents of 
Children with Disabilities.'' EP Magazine. November 2011.

    People with disabilities greatly benefit from access to special 
needs trusts. In the Omnibus Budget Reconciliation Act of 1993, 
Congress exempted the transfer of assets for the benefit of a person 
with a disability under the age of 65 from the look-back provisions of 
the Medicaid program. Thus, not only is a person with a disability able 
to benefit greatly from a special needs trust but the transfer of 
assets to the trust for the benefit of another does not count against 
the transferor in the event that he or she subsequently needs Medicaid 
assistance. In light of the importance of special needs trust, it is 
clear that these benefits should be available for the disabled children 
of veterans, without disadvantaging the veteran in receiving VA pension 
benefits if needed.
    It should also be noted that a person with a disability who is 
under the age of 65 may have his or her own assets transferred into a 
special needs trust that directly benefits him or her. These types of 
trusts may only be established by a parent, grandparent, legal 
guardian, or a court and allow the individual to remain eligible for 
Medicaid services and supports. Any remaining funds available at death 
must be used to pay-back the Medicaid program for services provided.
    Any efforts to penalize transfer of assets under the VA's pension 
program must provide for appropriate exemptions for transfers to 
special needs trusts similar to those available through other Federal 
programs also based on financial need.
To require VA to carry out a pilot program on service dog training 
        therapy (S. 1838)
    Service animals provide multi-faceted assistance to people with 
disabilities. Specifically, service animals promote community 
integration. In addition to performing specific tasks such as pulling a 
wheelchair or opening a door, these same service animals can also help 
to break down barriers between people with disabilities and society. In 
addition to increased social interaction, many people with disabilities 
also report experiencing a greater sense of independence.
    We support efforts to ensure that properly trained service animals 
are available to veterans who can benefit from their assistance. This 
legislation provides a unique opportunity to benefit not only veterans 
seeking the assistance of a service dog but also provides veterans with 
post-deployment mental health concerns or Post Traumatic Stress 
Disorder the opportunity to benefit from training these dogs. The dual 
nature of this approach has the potential to assist a wide range of 
veterans.
To provide coverage under the VA's beneficiary travel program for the 
        travel of certain disabled veterans for certain special 
        disabilities rehabilitation (S. 1755)
    Veterans who have spinal cord injuries or disorders, vision 
impairments, or double or multiple amputations require access to 
rehabilitation services that allow them to live as independently as 
possible with their disabilities. For those veterans who need these 
services but who are not eligible for travel benefits, the ability to 
pay for travel to these rehabilitation programs is very difficult. In 
addition, few of these services are available locally, particularly in 
rural areas.
    We strongly support providing travel benefits for catastrophically 
disabled non-service-connected veterans who need to travel to receive 
in-patient care at special disabilities rehabilitation programs. Every 
effort must be made to reduce barriers that limit access to these 
services. The long-term savings of ensuring that these veterans are 
able to maintain their health and function significantly outweighs the 
short-term costs associated with this legislation.
Veteran Voting Support Act of 2011 (S. 1264)
    Exercising the right to vote is a fundamental aspect of American 
citizenship. For servicemembers and veterans who have served as the 
defenders of our Nation's freedoms, the opportunity to register to vote 
and exercise that right is particularly meaningful.
    The Veteran Voting Support Act seeks to increase access to voter 
registration opportunities by requiring VA to provide voter 
registration applications and assistance to veterans during specified 
interactions with VA. Although we support the efforts of this 
legislation to ensure that veterans have increased opportunities to 
register to vote, we are concerned by the lack of a meaningful 
enforcement mechanism and protections for registrants that are 
available through the National Voter Registration Act (NVRA).
    The NVRA provides mechanisms, including state designation of 
Federal agencies as voter registration agencies, to ensure that 
citizens, including veterans, have more opportunities to register to 
vote or update a previous registration. Since 2008, at least seven 
states have requested that VA agree to designation as a voter 
registration agency.
    If VA were to be designated as a voter registration agency under 
the NVRA, in the event of a violation, either the Department of Justice 
(DOJ) or a third party may bring an action requesting enforcement. 
Under the Veteran Voting Support Act, however, the only initial remedy 
is for the veteran to provide written notice to the facility director 
or the Secretary of Veterans Affairs. If the violation is not remedied 
within 90 days, the individual may file a written notice of complaint 
with DOJ and the Election Assistance Commission. But, there is no 
opportunity for third party litigation, which has proven critical in 
ensuring that the NVRA is enforced by individual states.
    Although the Veteran Voting Support Act parallels the NVRA, other 
important aspects of the NVRA would not be available under this 
legislation. For example, if a veteran registers to vote through VA 
under the mechanism of the Veteran Voting Support Act, then the 
veteran's registration will not be official until submitted by VA. 
Under the NVRA, the registration would be considered officially 
submitted once provided to VA.
    Last, we are concerned that the Veteran Voting Support Act does not 
require VA to report the number of voter registration applications 
submitted to VA. Thus, it will be difficult to determine whether VA is 
fully implementing the legislation as required. Ultimately, we believe 
that the NVRA provides a better system of voting rights that is more 
enforceable than those envisioned under the Veteran Voting Support Act.
    Unfortunately, VA has expressed concern that agreeing to state 
designation as a voter registration agency would be too costly and 
would expand VA's mission at a time when resources are critically 
needed to assist veterans of the wars in Iraq and Afghanistan, as well 
as meet the needs of veterans of all eras. We believe, however, that 
serving as a voter registration agency enhances VA's fulfillment of its 
mission to help veterans reintegrate into their communities.
    Thus, we would support legislation that is at least modeled on the 
requirements of the NVRA.

    Thank you for the opportunity to testify concerning VetsFirst's 
views on these important pieces of legislation. We remain committed to 
working in partnership to ensure that all veterans are able to 
reintegrate in to their communities and remain valued, contributing 
members of society.

    Chairman Murray. Thank you very much.
    Ms. Ilem.

STATEMENT OF JOY J. ILEM, DEPUTY NATIONAL LEGISLATIVE DIRECTOR, 
                   DISABLED AMERICAN VETERANS

    Ms. Ilem. Chairman Murray and the Members of the Committee, 
thank you for inviting DAV to present our views on the bills 
under consideration today. I will limit my remarks to five 
bills that are of particular interest to DAV and our members.
    In accordance with the long-standing resolutions, DAV is 
pleased to support S. 1391, a bill that would change the 
standard of proof required to establish service connection for 
veterans with Post Traumatic Stress Disorder resulting from 
military service and mental health conditions related including 
PTSD due to military sexual trauma.
    We believe the enactment of this bill would provide a 
commonsense standard of proof or veterans who have experienced 
serious mental and physical trauma but that is often difficult 
to verify because of a lack of documentation.
    S. 2259 would provide cost-of-living adjustment or COLA in 
the rates of compensation for veterans with service-connected 
disabilities and the rates of DIC. DAV supports this 
legislation. However, consistent with DAV resolution 172, we 
oppose rounding down adjusted rates to the lower whole dollar.
    We thank the Chairman for her continued efforts on 
improving VA services for women veterans and are pleased to 
support S. 3313. This bill is focused on improving the 
Department's ability to meet the long-term reproductive health 
care needs of veterans who have a service-connected condition 
that affects the veteran's ability to reproduce.
    While DAV has no specific resolution from our membership 
related to reproductive and infertility research and 
infertility counseling and treatment because it focuses on 
service-connected injuries and would be beneficial to many DAV 
members and veterans, we have no objection to the passage of 
these provisions.
    Regarding the remaining sections of the bill, DAV has heard 
positive feedback related to counseling services in retreat 
settings and the childcare pilot programs established in Public 
Law 111-163. We supported the original provisions for these 
pilots in according to DVA resolution 185 and are pleased to 
support the proposal to expand them in this measure to include 
veterans seeking readjustment counseling services at Vet 
Centers.
    The Mental Health ACCESS Act of 2012 focuses on improving 
and enhancing the programs and activities of DOD and VA related 
to suicide prevention, resilience, and behavioral health 
disorders of members of the Armed Forces, veterans, and their 
families.
    We appreciate the bill's provisions related to implementing 
a comprehensive set of measures to assess timeliness, 
satisfaction, and barriers to mental health care, improving 
access to services, productivity standards for the providers, 
and establishing an IOM study committee with the inclusion of 
members that have VA clinical mental health experience.
    Of particular interest to DAV is section 204 of the 
measure. As intended by Congress in establishing its original 
mandate in 1979, the RCS was to be an independent, non-medical, 
non-psychiatric model of care for veterans who were in need of 
combat related readjustment services but did not necessarily 
want to go to traditional mental health clinics in VA.
    Today's new combat veterans have made it clear to DAV and 
others that date too desire a similar non-stigmatizing 
readjustment program to aid them and to have found Vet Centers 
to be a welcoming, non-judgmental places to receive that help.
    DAV is pleased to support this comprehensive measure in 
accordance with DAV resolution 189 and 200 and we appreciate 
the Chairman's continued efforts on improving mental health 
programs for veterans, members of the Armed Forces, and their 
families.
    The final bill we would like to comment on is S. 3084, the 
VISN Reorganization Act of 2012. This measure would require the 
Secretary of the VA to restructure and realign VHAs 21 current 
Veterans Integrated Service Networks or VISNs and to set 
personnel limits for the VISNs.
    DVA has no specific resolution concerning the 
organizational alignment of the VISNs and no formal position on 
this bill. However, we have urged Congress to examine VISN 
staffing and functions by conducting an independent study of 
the VISN structure.
    In this regard, we appreciate Senator Burr's intention to 
address this critical issue in his measure. It appears from 
VA's testimony in the previous panel that it is working toward 
a VISN reorganization plan; and like this Committee, we look 
forward to hearing more about that plan and are hopeful that 
the best VISN model to serve our veteran population will be 
established.
    Madam Chair, that concludes my statement and I am happy to 
answer any questions you or Committee Members may have. Thank 
you.
    [The prepared statement of Ms. Ilem follows:]

              Prepared Statement of Joy J. Ilem, Deputy, 
       National Legislative Director, Disabled American Veterans

    Chairman Murray, Ranking Member Burr and Members of the Committee: 
On behalf of the Disabled American Veterans (DAV) and our 1.2 million 
members, all of whom are wartime disabled veterans, I am pleased to 
present our views on the 23 legislative bills and two draft measures 
under consideration today.

              S. 1264, VETERAN VOTING SUPPORT ACT OF 2011

    The Veteran Voting Support Act of 2011 would require the Secretary 
of Veterans Affairs to permit facilities of the Department to be 
designated as voter registration agencies and expand assistance to 
veterans in registering to vote and voting. Section 3 of the bill 
directs the Department of Veterans Affairs (VA) to provide mail voter 
registration application forms to each veteran who seeks to enroll in 
the VA health care system; and is already enrolled in such system when 
there is a change in the veteran's enrollment status or when there is a 
change in the veteran's address.
    It also requires the Secretary to accept completed voter 
application forms and transmit them to appropriate state election 
officials and requires forms accepted at VA medical centers, community 
living centers, community-based outpatient centers, and domiciliaries 
be transmitted within ten days of acceptance, unless a completed form 
is accepted within five days before the last day for registration to 
vote in an election, in which case it must be transmitted within five 
days of acceptance.
    Section 4 requires each director of a VA community living center, 
domiciliary, or medical center to provide assistance in voting by 
absentee ballot to resident veterans, and requires such assistance to 
include: 1) providing information relating to the opportunity to 
request an absentee ballot; 2) making available absentee ballot 
applications upon request, as well as assisting in completing such 
applications and ballots; and 3) working with local election 
administration officials to ensure the proper transmission of the 
applications and ballots.
    Section 5 requires the Secretary to permit nonpartisan 
organizations to provide voter registration information and assistance 
at facilities of the VA health care system.
    Section 6 prohibits the Secretary from banning any election 
administration official, whether state or local, party-affiliated or 
non-party affiliated, or elected or appointed, from providing voting 
information to veterans at any VA facility. It also directs the 
Secretary to provide reasonable access to facilities of the VA health 
care system to state and local election officials for the purpose of 
providing nonpartisan voter registration services to individuals.
    Although DAV has a long-standing resolution encouraging disabled 
veterans to register to vote and to vote--and initially provided our 
support for S. 1556, the Veteran Voting Support Act of 2009--at this 
time we have reconsidered our position on the bill due to concerns 
about the overall negative impact this bill would have on the Veterans 
Health Administration (VHA) and the fact that VA is currently providing 
voter registration to veterans when requested. Currently, VHA Directive 
2008-053 defines VA's policy for assisting patients who seek 
information on voter registration and voting. Based on the policy, VA 
does not solicit voter registration but provides assistance to veterans 
who are inpatients under VA's care; residents of VA community living 
centers and domiciliaries who want to get registered to vote or vote in 
an election. Additionally, state and local election officials, as well 
as non-partisan groups are invited into VA health care facilities and 
those visits are coordinated to ensure there are no disruptions in 
patient care services. Finally, flyers and information on the voting 
assistance program are posted throughout facilities and volunteers have 
been specifically recruited in the past to help with these efforts. 
Based on this policy, it appears that much of the bill would be 
duplicative of VA's current efforts and therefore unnecessary. 
Likewise, we are confident that the policy and existing Federal 
Regulations under title 38, subsection 17.33, ensure veteran patients 
the opportunity to exercise their voting privilege.

                                S. 1391

    S. 1391 would change the standard of proof required to establish 
service connection for veterans with Post Traumatic Stress Disorder 
(PTSD) resulting from military service, and for veterans suffering from 
certain mental health conditions, including PTSD, resulting from 
military sexual trauma that occurred in service.
    Essentially, S. 1391 would eliminate the requirement of an in-
service, verifiable stressor in conjunction with claims for PTSD. Under 
this change, VA would now be able to award entitlement to service 
connection for PTSD even when there is no official record of such 
incurrence or aggravation in service, provided there is a confirmed 
diagnosis of PTSD coupled with the veteran's written testimony that the 
PTSD is the result of an incident that occurred during military 
service, and a medical opinion supporting a nexus between the two.
    In November 2010, VA modified its prior standard of proof for PTSD 
related to combat veterans by relaxing the evidentiary standards for 
establishing in-service stressors if it was related to a veteran's 
``fear of hostile military or terroristic activity.'' S. 1391 would 
buildupon that same concept and expands it to cover all environments in 
which a veteran experiences a stressor that can reasonably result in 
PTSD, regardless of whether it occurred in a combat zone, as long as it 
occurred when the veteran had been on active duty or active duty for 
training. The legislation would also remove the current requirement 
that the diagnosis and nexus opinion come only from VA or VA-contracted 
mental health professionals, but would instead allow any qualified 
mental health professional.
    S. 1391 would also allow VA to award entitlement to service 
connection for certain mental health conditions, including PTSD, 
anxiety and depression, which a veteran claims was incurred or 
aggravated by military sexual trauma experienced in service, even in 
the absence of any official record of the claimed trauma. Similar to 
the evidentiary standard above for PTSD, the veteran must have a 
diagnosis of the covered mental health condition together with a 
written testimony by the veteran that the claimed trauma was incurred 
during military service. Further, the veteran must have a medical 
opinion from a mental health professional indicating that the claimed 
mental health condition is reasonably related to military sexual 
trauma, which would include a physical assault of a sexual nature, 
battery of a sexual nature, or sexual harassment while the veteran was 
serving on active duty or active duty for training.
    DAV supports S. 1391, which is consistent with DAV Resolutions 59 
and171. DAV Resolution 171 states that, ``establishing a causal 
relationship between injury and later disability can be daunting due to 
lack of records or certain human factors that obscure or prevent 
documentation of even basic investigation of such incidents after they 
occur * * *'' and that, ``* * * an absence of documentation of military 
sexual trauma in the personnel or military unit records of injured 
individuals prevents or obstructs adjudication of claims for 
disabilities for this deserving group of veterans injured during their 
service, and may prevent their care by VA once they become veterans * * 
*.'' Further, DAV Resolution 59 states that, ``* * * proof of a causal 
relationship may often be difficult or impossible * * *'' and that, ``* 
* * current law equitably alleviates the onerous burden of establishing 
performance of duty or other causal connection as a prerequisite for 
service connection * * *.'' Enactment of S. 1391 would provide a 
commonsense standard of proof for veterans who have experienced serious 
mental and physical traumas in environments that make it difficult to 
establish exact causal connections.

                                S. 1631

    S. 1631 would authorize the Secretary of Veterans Affairs to 
establish a center for technical assistance for non-Department health 
care providers who furnish care to veterans in rural areas. This bill 
makes the head of such center the Director of the Rural Veterans Health 
Care Technical Assistance Center. It also requires the Secretary, in 
selecting the center's location, to give preference to a location that, 
among other things, has a high number of veterans in rural and highly 
rural areas, and is near one or more entities carrying out programs and 
activities relating to health care for rural populations.
    The purpose of the center would be to develop and disseminate 
information, educational materials, training programs, technical 
assistance and materials and other tools to improve access to health 
care for veterans living in rural areas. It would also help to 
establish and maintain Internet-based information such as best practice 
models, research results and other appropriate information.
    VHA's Office of Rural Health's (ORH) mission is to improve access 
and quality of care for enrolled rural and highly rural veterans by 
developing evidence-based policies and innovative practices to support 
their unique needs. ORH includes information on its Web site about the 
three Veterans Rural Health Resource Centers (VRHRC) that have been 
established. The Western Region center in Salt Lake City focuses on 
outreach, access issues and the special needs of Native Americans 
(American Indian, Alaska Native, Native Hawaiian, Pacific Islander) and 
aging veterans. The Central Region center in Iowa City, Iowa focuses on 
evaluating rural health programs and piloting new strategies to help 
veterans overcome barriers to access and quality. The Eastern Region 
center located in Gainesville, Florida focuses on developing models to 
deliver specialty care services to rural areas, training VA and non-VA 
service providers caring for rural veterans and bringing specialty care 
to community-based clinics via tele-health technology.
    DAV Resolution No. 203 supports the mission of the VA's Office of 
Rural Health and improvements to VA coordinated health care services 
for veterans living in rural areas. DAV originally supported S. 1631 
when it was introduced in September 2011. It is unclear from the 
information we have available to us if any of the VRHRCs are in fact 
devoting resources toward the intent of this bill, which is to aid non-
VA providers who furnish care to veterans in rural areas with technical 
assistance. We urge the Committee to ask VA to provide specific details 
in this regard. In the event that VA is not working toward this goal, 
we continue to support this bill and taking other actions to help 
medical providers better deliver much-needed health care to veterans in 
rural areas.

                                S. 1705

    Introduced by Chairman Murray, this bill would designate the VA 
Medical Center in Spokane, Washington, as the ``Mann-Grandstaff 
Department of Veterans Affairs Medical Center.'' DAV has no resolution 
on this issue and has no national position on this bill.

           S. 1707, VETERANS SECOND AMENDMENT PROTECTION ACT

    Introduced by Senator Burr, this bill would amend title 38, United 
States Code, to clarify the conditions under which certain persons may 
be treated as adjudicated mentally incompetent for certain purposes. 
DAV has no resolution on this issue and has no position on this bill.

                                S. 1755

    S. 1755 would provide for coverage under VA's beneficiary travel 
program disabled veterans with vision impairment, a spinal cord injury, 
or multiple amputations for travel related to in-patient care in a 
special disabilities rehabilitation program. Currently, VA is 
authorized to pay the actual necessary expense of travel (including 
lodging and subsistence), or in lieu thereof an allowance based upon 
mileage, to eligible veterans traveling to and from a VA medical 
facility for examination, treatment, or care. According to title 38, 
United States Code, Section 111(b)(1), eligible veterans include those 
with a service-connected rating of 30 percent or more; receiving 
treatment for a service-connected condition; in receipt of VA pension; 
whose income does not exceed the maximum annual VA pension rate, or; 
traveling for a scheduled compensation or pension examination.
    Notably, the VA Secretary has the discretionary authority under 
section 111(b)(2), to make payments for beneficiary travel to or for 
any person not currently eligible for travel by such person for 
examination, treatment, or care.
    DAV has no resolution on this issue and has no position on this 
bill. However, we would note that while the intended recipients of this 
expanded eligibility criteria would certainly benefit, we would urge 
the Committee to consider a more equitable approach rather than one 
based on the specific impairments of a disabled veteran. Further, we 
ask that if the Committee does favorably consider this measure, it also 
take appropriate actions to ensure that sufficient additional funding 
be provided to VA to cover the cost of the expanded program.

 S. 1799, ACCESS TO APPROPRIATE IMMUNIZATIONS FOR VETERANS ACT OF 2011

    This measure would require the Secretary of Veterans Affairs to 
make available periodic immunizations against certain infectious 
diseases as adjudged necessary by the Secretary of Health and Human 
Services through the recommended adult immunization schedule 
established by the Advisory Committee on Immunization Practices. The 
bill would include such immunizations within the authorized 
preventative health services available for VA-enrolled veterans. The 
bill would establish publicly reported performance and quality measures 
consistent with the required program of immunizations authorized by the 
bill. The bill would require annual reports to Congress by the 
Secretary confirming the existence, compliance and performance of the 
immunization program authorized by the bill.
    Although DAV has no adopted resolution from our membership dealing 
specifically with this matter of immunizations for infectious diseases, 
DAV Resolution No. 193 calls on VA to maintain a comprehensive, high 
quality, and fully funded health care system for the Nation's sick and 
disabled veterans, specifically including preventative health services. 
Preventative health services are an important component of the 
maintenance of general health, especially in elderly and disabled 
populations with compromised immune systems. If carried out 
sufficiently, the intent of this bill could also contribute to 
significant cost avoidance in health care by reducing the spread of 
infectious diseases and obviating the need for health interventions in 
acute illnesses of those without such immunizations. For these reasons, 
DAV supports this bill and urges its enactment.

                                S. 1806

    S. 1806 would amend the Internal Revenue Code of 1986 to allow 
taxpayers to designate overpayments of tax as contributions to the 
homeless veterans assistance fund. DAV has no resolution on this issue 
and has no position on this bill.

                                S. 1838

    S. 1838 would require the Secretary of Veterans Affairs to carry 
out a pilot program on service dog training therapy. If enacted, this 
measure would require the Department to conduct a pilot program to 
assess the feasibility and advisability of using service dog training 
activities as part of an integrated post-deployment mental health 
program. The purpose of the pilot program is for VA to produce 
specially trained service dogs for veterans; to determine how 
effectively the program would assist veterans with Post Traumatic 
Stress Disorder (PTSD) and the feasibility of extending or expanding 
the pilot program.
    DAV has no resolution on this issue and has no position on this 
bill. However, we are looking forward to the receipt of findings from 
VA's ongoing research project to determine the efficacy of service dog 
usage by veterans challenged by mental illness and post-deployment 
mental health conditions related to combat, including PTSD. We 
recognize that trained service animals can play an important role in 
maintaining functionality and promoting maximum independence and 
improved quality of life for persons with disabilities--and that pilot 
programs such as the one proposed could be of benefit to certain 
veterans. However, we do have a concern about VA's experience with 
advanced training methods for the many varieties of highly specialized 
service dogs.

          S. 1849, RURAL VETERANS HEALTH CARE IMPROVEMENT ACT

    S. 1849, the Rural Veterans Health Care Improvement Act, would 
require VA to develop a five-year strategic plan for ORH for improving 
access to, and the quality of, health care services for veterans in 
rural areas.
    DAV supports the intention of S. 1849 in accordance with DAV 
Resolution No. 203. However, we note that the VA's ORH has made 
available its ``Strategic Plan Refresh'' for Fiscal Years 2012-2014 
with six specific goals and a number of initiatives to achieve those 
goals. The VA's Strategic Plan on rural health care is comprehensive 
and seems to cover many of the provisions listed in S. 1849; however, 
we would like to see additional information on the use of mobile 
clinics and coordination of care for women veterans living in rural 
areas. We ask VA to provide an update on the use of mobile clinics in 
rural areas and the provisions in the bill that would require a survey 
of each VA facility that serves rural and highly rural areas concerning 
the provision for and coordination of care for women veterans--
including options for fee-basis care and specialty care. DAV is 
interested in hearing VA's testimony on these topics, and in the event 
that their current two-year plan does not address those specific 
provisions outlined in S. 1849, we would support passage of an amended 
version of this bill related to those specific provisions or any others 
that are missing from VA's plan.

                                S. 2045

    S. 2045 would require judges of the United States Court of Appeals 
for Veterans Claims to reside within 50 miles of the District of 
Columbia. DAV has no resolution on this issue and has no position on 
this bill.

            S. 2244, VETERANS MISSING IN AMERICA ACT OF 2012

    This bill would direct the Secretary of Veterans Affairs to 
cooperate with veterans service organizations and other groups in 
assisting the identification of unclaimed and abandoned human remains. 
The VA would also be required to determine if any such remains are 
eligible for burial in a national cemetery. The VA would cover the 
burial cost if the remains are determined to be that of an eligible 
veteran who does not have a next of kin or other person claiming the 
remains, and there are no available resources to cover burial and 
funeral expenses. In addition, the bill calls on the VA to establish a 
public database of the veterans identified in this project. DAV has no 
resolution on this issue and has no position on this bill.

 S. 2259, VETERANS' COMPENSATION COST-OF-LIVING ADJUSTMENT ACT OF 2012

    S. 2259 would provide for a cost-of-living adjustment (COLA), 
effective December 1, 2012, in the rates of compensation for veterans 
with service-connected disabilities and the rates of dependency and 
indemnity compensation for the survivors of certain disabled veterans 
based on the Social Security COLA. DAV generally supports this 
legislation; however, consistent with DAV Resolution 172, we oppose 
rounding down the adjusted rates to the next lower whole dollar.

 S. 2320, REMEMBERING AMERICA'S FORGOTTEN VETERANS CEMETERY ACT OF 2012

    S. 2320 would direct the American Battle Monuments Commission to 
provide for the ongoing maintenance of Clark Veterans Cemetery in the 
Republic of the Philippines, and for other purposes. DAV has no 
resolution on this issue and has no position on this bill.

                                S. 3049

    S. 3049 would expand the definition of homeless veteran for 
purposes of benefits under the laws administered by the Secretary of 
Veterans Affairs. DAV has no resolution on this issue and has no 
position on this bill.

                                S. 3052

    S. 3052 would require the Secretary of Veterans Affairs to notify 
veterans who electronically file claims for benefits that they may be 
able to receive assistance from veterans service organizations (VSOs), 
and to provide contact information for such VSOs. DAV Resolution 001 
states that, ``* * * our first duty as an organization is to assist the 
service-connected disabled, their surviving spouses and dependents * * 
*,'' and the inclusion of information explaining the availability of 
VSO assistance and VSO contact information on electronic claims 
applications would likely increase our ability to do exactly that. In 
fact, DAV has made this exact request to the Veterans Benefits 
Administration as they have been developing a new electronic paperless 
claims system, and it is our understanding that just as VSO contact 
information is provided to veterans who file paper claims, it will 
similarly be provided to those who file electronic claims. As such, 
while enactment of statutory language may not be necessary, we are not 
opposed to the favorable consideration of this bill.

                S. 3084, VISN REORGANIZATION ACT OF 2012

    S. 3084, the VISN Reorganization Act of 2012, would require the 
Secretary of Veterans Affairs to restructure and realign VHA's 21 
current Veterans Integrated Service Networks (VISNs) as well as set 
personnel limits for VISNs.
    Section 2 of the bill would place a limitation on the number of 
VISN management units at 12, down from the current 21, and would lay 
out the missions, policies, budgets, procedures and other 
responsibilities of these integrated regional VISNs, including 
alliances with other agencies, health care organizations and 
governments in conducting their work. It would also specify that each 
network's VISN headquarters be restricted to not exceed employment of 
more than 65 full-time employee equivalents, including contractors, and 
would require VA to submit reports to Congress annually on VISN 
employment; budget and other benchmarks. This section would also 
prescribe a consolidation of the existing 21 VISNs in a specified 
pattern and direct the Secretary to choose one of the existing VISN 
offices consolidated as sites of the new combined VISN headquarters, 
including dealing with leased space in commercial buildings, relocation 
of employees and reemployment assistance for those displaced.
    Section 3 of the bill would establish four VISN regional support 
centers whose main purpose would be to evaluate the effectiveness and 
efficiency of the new VISNs, across a number of parameters, with a 
preference that these support centers be established in existing VA 
medical center locations.
    Section 4 of the bill would clarify that this reorganization of 
VISNs would not require any change to existing direct care at VA sites, 
including medical centers, CBOCs, or Vet Centers.
    DAV has no resolution concerning the organizational alignment of 
the VHA, or of the VISNs; thus, DAV has no position on this bill. 
However, last year, DAV, along with other national VSOs, put forward a 
set of nine recommendations to eliminate waste, duplication and 
inefficiency within VA, one of which dealt with the size of VISN 
bureaucracy versus its original mandate as outlined in VA's ``Vision 
for Change'' report that led to the creation of the current VISN 
structure.
    We would also note that the VA Office of Inspector General recently 
completed two reports on VHA's VISNs, with a particular concern about 
the size of their staffing. Results of these reviews were inconclusive, 
but strongly suggested that VISNs have expanded their permanent 
staffing allocations significantly compared to the levels in 1995, 
rather than relying on using ``temporary'' task forces and working 
groups pulled from medical centers and other facilities as envisioned 
in the original plan. In addition, a number of coordinator positions 
covering a variety of subjects (OEF/OIF; suicide; quality; 
credentialing of professionals; and FRC, etc.) have been imposed by 
Congress or VA Central Office over the years, further adding to their 
staffing totals. Also, pressures on acquisition, human resources and 
financial management have dictated establishment of consolidated 
functions for the activities at the VISN level leading to additional 
personnel.
    In our recommendations, DAV and the other VSOs urged Congress to 
examine VISN staffing and functions by contracting with the National 
Academy of Sciences, Institution of Medicine (IOM), to conduct an 
independent study of the VISNs, including their staffing levels, and to 
submit recommendations to Congress about whether and how these 
functions should be reorganized. We believe such a study is necessary 
before setting specific limitation on either the number of VISNs (12) 
or FTEE per VISN (65). Therefore, we recommend that the Committee ask 
IOM to conduct such a study, with appropriate protections for the many 
benefits the structure has brought to VA health care, before taking any 
legislative action to restructure or reorganize VHA's VISN system.

           S. 3202, DIGNIFIED BURIAL OF VETERANS ACT OF 2012

    S. 3202, the Dignified Burial of Veterans Act of 2012, would 
authorize VA to furnish a casket or urn to a deceased veteran when VA 
is unable to identify the veteran's next-of-kin and determines that 
sufficient resources are not otherwise available to furnish a casket or 
urn for burial in a national cemetery. The bill would further require 
that VA report back to Congress on the industry standard for urns and 
caskets and whether burials at VA's national cemeteries are meeting 
that standard. Under current law, VA is not authorized to purchase a 
casket or urn for veterans who do not have a next-of-kin to provide 
one, or the resources to be buried in an appropriate manner. DAV has no 
resolution on this issue and has no position on this bill. However, if 
it is to be favorably considered by the Committee, we urge additional 
resources be provided to VA to ensure that implementation of this 
discretionary authority does not result in a reduction of funding for 
other authorized programs.

                                S. 3206

    S. 3206 would extend from 2013 to 2018 the authorization of 
appropriations under title 38, United States Code, section 322, 
allowing VA pay a monthly assistance allowance to disabled veterans 
training or competing for the Paralympic Team. It would similarly 
extend the authorization of appropriation under section 521A for VA to 
provide assistance to United States Paralympics, Inc.
    The DAV has testified previously on sections 521A and 322 before 
and after enactment of Public Law 110-389.\1\,\2\ Specifically, while 
the intent of Public Law 110-389 is laudable, our concern was and 
remains the impact it may have on the National Disabled Veterans Winter 
Sports Clinic, which is a rehabilitation event and not a training 
ground for future Olympians.\3\
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    \1\ Meeting the Needs of Injured Veterans in the Military 
Paralympic Program: Hearing before the House Committee on Veterans' 
Affairs, 111th Congress. 17 (2009) (testimony of Adrian Atizado)
    \2\ Legislative Hearing on H.R. 4255, H.R. 6221, H.R. 6224, H.R. 
6225, and H.R. 6272: Hearing before the Subcommittee on Economic 
Opportunity of the House Committee on Veterans' Affairs, 111th 
Congress. 19 (2008) (testimony of Kerry Baker)
    \3\ Section 521A, paragraph (d) of the bill states, amongst other 
things, that a program under that section includes a program that 
``promotes * * * competition.'' The activities described in that same 
section are, among others, instruction, participation, and 
``competition in paralympic sports.''
---------------------------------------------------------------------------
    In addition, the same paragraph allows for individuals with 
disabilities who are not veterans or members of the Armed Forces to 
participate in sports programs that receive funds originating from VA 
grants. As an organization devoted to improving the lives of our 
Nation's wartime disabled veterans, we are concerned about any shift of 
VA's mission, personnel, and resources away from disabled veterans, 
their families and survivors.
    Unfortunately, our concern was appropriate based on issues 
surrounding the implementation, oversight and accountability for the 
first year of the grant program authorized under section 521A. As you 
may be aware, VA and U.S. Paralympics, a division of the United States 
Olympic Committee (USOC), signed its Memorandum of Understanding at the 
beginning of fiscal year 2010, announced the Olympic Opportunity Fund 
and subsequently sought proposals. It was in this first year that it 
became apparent to DAV there was a lack of VA oversight and 
accountability on the implementation of the grant program and grant 
recipients, as well as a lack of accountability to ensure adherence by 
certain grant recipients to the intent of the law.
    We note, however, that a number of improvements have been and 
continue to be made since the consolidation of VA's Office of National 
Programs and Special Events, which managed VA's National Rehabilitation 
Special Events, with the Office of National Veterans Sports Programs 
and Special Events, and additional staff and resources were provided to 
this office. Furthermore, we look forward to the actions VA will take 
to address the findings and recommendations of the Government 
Accountability Office's investigation of this grant program.
    In an effort to ensure limited VA resources are wisely spent 
directly, rather than incidentally, on disabled veterans and disabled 
members of the Armed Forces to participate in recreation and sport 
activities, we urge this Committee, if this measure is favorably 
considered, to include a future mandatory review of this grant program 
by the Government Accountability Office (GAO). We also urge this 
Committee to conduct oversight of this grant program subsequent to the 
release of GAO's upcoming and future reports.

                                S. 3238

    S. 3238 would designate the VA community-based outpatient clinic in 
Mansfield, Ohio, as the David F. Winder Department of Veterans Affairs 
Community Based Outpatient Clinic. DAV has no resolution on this issue 
and has no national position on this bill.

                                S. 3270

    S. 3270 would require the Secretary of Veterans Affairs to consider 
the resources of individuals applying for pension that were recently 
disposed of by the individuals for less than fair market value when 
determining the eligibility of such individuals for such pension. DAV 
has no resolution on this issue and has no position on this bill.

     S. 3309, HOMELESS VETERANS ASSISTANCE IMPROVEMENT ACT OF 2012

    S. 3309, the Homeless Veterans Assistance Improvement Act of 2012, 
is a comprehensive bill that focuses on improving services for homeless 
veterans.
    Sections 2, 3 and 4 of the bill require that recipients of VA 
grants for comprehensive service programs for homeless veterans meet 
physical privacy, safety, and security needs of such veterans; modify 
the authority of the Department to provide capital improvement grants 
for comprehensive service programs that assist homeless veterans by not 
only establishing but maintaining such programs; and provide funding 
for furnishing legal services to very low-income veteran families in 
permanent housing.
    Section 5 modifies the requirements relating to per diem payments 
for services furnished to homeless veterans allowing such payments to 
include furnishing care for a dependent of a homeless veteran who is 
under the care of that veteran while he or she receives services from 
the grant recipient (or entity).
    Section 6 authorizes grants by VA to centers that provide services 
to homeless veterans to be used for operational expenses. The aggregate 
amount of all grants awarded in any fiscal year may not exceed 
$500,000.
    Section 7 expands the authority of VA to provide dental care to 
eligible homeless veterans who are enrolled for care for a period of 60 
consecutive days, and who are receiving assistance under section 8(o) 
of the United States Housing Act of 1937 (42 U.S.C. 17 1437f(o)); or 
receiving care (directly or by contract) in any of the following 
settings; a domiciliary; therapeutic residence; community residential 
care coordinated by the Secretary; or a setting for which the Secretary 
provides funds for a grant and per diem provider.
    Section 8 of this measure extends the dates, authorities and 
resources affecting homeless veterans for the following programs in 
title 38, United States Code:

     Comprehensive programs
     Homeless veterans reintegration programs
     Outreach, care, treatment, rehabilitation and therapeutic 
transitional housing for veterans suffering from serious mental illness
     Program to expand and improve provision of benefits and 
services by VA to homeless veterans
     Housing assistance for homeless veterans
     Financial assistance for supportive services for very low-
income veteran families in permanent housing
     Grant program for homeless veterans with special needs; 
and
     The Advisory Committee on Homeless Veterans

    DAV is pleased to support S. 3309, the Homeless Veterans Assistance 
Improvement Act of 2012, as it is in line with DAV Resolution No. 205, 
which calls for us to support sustained and sufficient funding to 
improve services for homeless veterans. This resolution approved by our 
membership also urges Congress to strengthen the capacity of VA's 
programs to end homelessness among veterans and to provide health care 
and other specialized services for mental health, including dental 
care.

 S. 3313, WOMEN VETERANS AND OTHER HEALTH CARE IMPROVEMENTS ACT OF 2012

    S. 3313, the Women Veterans and Other Health Care Improvements Act 
of 2012, contains a number of important enhancements to women veterans 
health care programs.
    Section 2 of the bill instructs the Secretary of Veterans Affairs 
to facilitate reproductive and infertility research conducted 
collaboratively by the Secretary of Defense and the Director of the 
National Institutes of Health to find ways to meet the long-term 
reproductive health care needs of veterans who have a service-connected 
genitourinary disability or a condition that was incurred or aggravated 
while serving on active duty, such as spinal cord injury, that affects 
their ability to reproduce.
    The Secretary of Veterans Affairs would ensure that any information 
produced by the research deemed useful for other activities of the VHA 
be disseminated throughout the VHA. Within three years after the date 
of enactment, the Secretary will report to Congress on the research 
activities conducted.
    Section 3 of the measure clarifies that fertility counseling and 
treatments, including treatment using assisted reproductive technology, 
are medical services the Secretary may furnish to veterans.
    Section 4 of this bill requires the Secretary to furnish 
reproductive treatment and care for spouses and surrogates of veterans 
by allowing the Secretary to furnish fertility counseling and 
treatment, including the use of assisted reproductive technology, to a 
spouse or surrogate of a severely wounded veteran who has an 
infertility condition incurred or aggravated while on active duty and 
who is enrolled in the health care system established under section 
1705(a) 25 of title 38, United States Code, if the spouse and the 
veteran apply jointly for such counseling and treatment through a 
process prescribed by the Secretary.
    In the case of a spouse or surrogate of a veteran not described who 
is seeking fertility counseling and treatment, the Secretary may refer 
such spouse or surrogate to a qualified clinician and would be required 
to prescribe regulations to carry this out no later than one year after 
enactment.
    While DAV has no specific resolution from our membership related to 
reproductive and infertility research and fertility counseling and 
treatment, this section of the bill is focused on improving the 
Departments' ability to meet the long-term reproductive health care 
needs of veterans who have a service-connected condition that affects 
the veteran's ability to reproduce. For these reasons DAV has no 
objection to the passage of these sections of the bill, with the 
exception of subsection (b) of section 4 of the measure: DAV has no 
position on that particular subsection.
    Section 5 of this bill requires that the Secretary of Veterans 
Affairs enhance the capabilities of the VA women veterans call center 
by responding to requests by women veterans for assistance with 
accessing health care and benefits and by referring such veterans to 
community resources to obtain assistance with services not furnished by 
VA.
    Sections 6 and 7 of the bill seek to modify the pilot program of 
counseling women veterans newly separated from active duty in retreat 
settings by increasing the number of locations from three to fourteen 
and by extending the time of the pilot program from two years to four 
years; and to modify the duration of the established child care pilot 
programs for certain veterans receiving VA health care under Public Law 
111-163 to note that the pilot program may operate until the date that 
is two years after the date on which the pilot program is established 
in the third VISN.
    Section 7 of the measure would also require a child care pilot 
program in at least three Readjustment Counseling Service Regions for 
certain veterans receiving readjustment counseling and related mental 
health services. It requests the Secretary of Veterans Affairs to carry 
out a pilot program to assess the feasibility and advisability of 
providing assistance to qualified veterans to obtain child care so that 
such veterans can receive readjustment counseling and related mental 
health services.
    Child care assistance under this subsection may include: stipends 
for the payment of child care offered by licensed child care centers 
either directly or through a voucher program; payments to private child 
care agencies; collaboration with facilities or programs of other 
Federal departments or agencies; or other forms of assistance as the 
Secretary considers appropriate. When the child care assistance under 
this subsection is provided as a stipend, it must cover the full cost 
of such child care.
    No later than 180 days after the completion of the pilot program, 
the Secretary shall submit to Congress a report on the pilot program. 
The report shall include the findings and conclusions of the Secretary 
as a result of the pilot program, and shall include such 
recommendations for the continuation or expansion of the pilot program 
as the Secretary considers appropriate. There is authorized to be 
appropriated to the Secretary of Veterans Affairs to carry out the 
pilot program $1,000,000 for each of fiscal years 2014 and 2015.
    We thank the Chairman for her continued efforts on improving VA's 
women veterans heath programs and services and are pleased to support 
this draft measure. DAV has heard positive feedback related to the 
pilot program of counseling women veterans newly separated from active 
duty in retreat settings and the childcare pilots established in Public 
Law 111-163. We supported the original provisions for these program 
pilots and are pleased to support the proposal to expand them. 
Likewise, we are supportive of the provisions in section 5 of the bill 
that require VA to enhance the capabilities of the Department's women 
veterans call center related to assistance with accessing health care 
and benefits and referrals to community resources to obtain assistance 
with services not furnished by VA.

      DRAFT BILL TO ESTABLISH AND NAME OUTPATIENT CLINIC IN HAWAII

    Introduced by Senator Inouye, this bill would authorize the 
Secretary of Veterans Affairs to carry out a major medical facility 
project lease for a VA outpatient clinic at Ewa Plain, Oahu, Hawaii and 
designate such clinic as the Daniel Kahikina Akaka Department of 
Veterans Affairs Clinic. DAV has no resolution on this issue and has no 
national position on this bill.

             DRAFT BILL ON MENTAL HEALTH ACCESS ACT OF 2012

    This draft measure, the Mental Health Access to Continued Care and 
Enhancement of Support Services Act of 2012, or the Mental Health 
ACCESS Act of 2012, is a comprehensive bill focused on improving and 
enhancing the programs and activities of the Department of Defense 
(DOD) and VA related to suicide prevention and resilience and 
behavioral health disorders of members of the Armed Forces and 
veterans.
    All of the sections in Title I of this bill are related to DOD 
matters with the exception of sections 105, 106 and 109. These 
provisions require collaboration between the two agencies with respect 
to improving sharing of patient records and information under the 
medical tracking system/electronic health record shared between DOD and 
VA; participation of members of the Armed Forces in peer support 
counseling programs of VA; and compliance of DOD with requirements for 
use of VA's Schedule for Rating Disabilities in determinations of 
disability of members of the Armed Forces. DAV recognizes the need for 
the both Departments to collaborate on certain mental health matters 
and we are supportive of these specific sections in accordance with DAV 
Resolution No. 200, approved by our membership. This resolution 
supports program improvements and enhanced resources to support 
readjustment services for the post-deployment mental health needs of 
war veterans. Further, DAV Resolution No. 177 calls for improved 
collaboration between VA and DOD in making disability determinations. 
As for the remaining sections in Title I of the measure, however, DAV 
takes no formal position on the issues that fall exclusively under the 
jurisdiction of DOD.
    Sections in Title II of the measure deal with VA mental health 
matters. Section 201would instruct the Secretary of Veterans Affairs to 
develop and implement a comprehensive set of measures to assess mental 
health care services VA is providing. The provisions would require VA 
to specifically assess the timeliness of the furnishing of mental 
health care; the satisfaction of patients who receive it; VA's current 
capacity to furnish mental health care; and the availability and 
furnishing of evidence-based therapies.
    The section also would require that the Secretary develop and 
implement guidelines and productivity standards for providers of mental 
health care for the staffing of general and specialty mental health 
care services, including those resident in community-based outpatient 
clinics. The bill would require the Secretary to enter into a contract 
with the National Academy of Sciences Institute of Medicine (IOM) to 
create a study committee to assess and provide an analysis and 
recommendations on the state of VA's mental health services. The study 
committee would also be responsible for assessing barriers to accessing 
mental health care by Operation Enduring Freedom, Operation Iraqi 
Freedom, or Operation New Dawn (OEF/OIF/OND) veterans as well as the 
quality of mental health care they are receiving.
    We are especially pleased that the bill would require VA to provide 
detailed recommendations for overcoming observed barriers, and to 
improve access to timely, effective mental health care at VA health 
care facilities and that the Secretary and IOM would be required to 
include at least one former VHA official and at least two former VA 
employees who were providers of mental health care as members of the 
study committee. Likewise, we are pleased the bill includes provisions 
to ensure transparency in the process--specifically that the measures 
and guidelines developed and implemented as well as an assessment of 
the performance of VA using such measures and guidelines are to be made 
available to the public on a VA Web site and must be updated quarterly 
at a minimum.
    Given the previous hearings held by this Committee on mental health 
matters and the findings from various informal surveys and official 
reports on timeliness of VA mental health care and ongoing staffing 
shortages, DAV fully supports the aforementioned provisions. These 
requirements are in line with a mandate from our membership contained 
in DAV Resolution No. 200.
    Section 202 would expand the Vet Center mandate established in 
Public Law 111-163 to include Readjustment Counseling Service (RCS) 
furnishing counseling to certain members of the Armed Forces and their 
family members. This language would authorize limited eligibility for 
family members to receive counseling separately from a given 
servicemember when those family members are dealing with combat-related 
deployment problems. Under this section, counseling furnished could 
include a comprehensive assessment of the veteran's or family member's 
psychological, social, and other characteristics to ascertain whether 
they are experiencing difficulties associated with coping with the 
deployment of a member, or readjustment of the family to civilian life 
of a veteran or servicemember following a deployment.
    The RCS provides an optimal model of psychological counseling for a 
veteran's family to assist with recovery and post-deployment mental 
health challenges. Therefore, we believe this provision is fully 
consistent with the RCS's mission and goals to help combat veterans 
recover from that unique experience. Public Law 111-163 provided VA a 
new authority for active duty personnel to receive Vet Center services 
outside their military chains of command, as well as a number of other, 
novel authorities enabling family caregivers of severely injured 
veterans to receive direct VA services. Historically, Vet Centers have 
been counseling family members in certain circumstances when such 
counseling is helpful to keep families intact, to deal with survivors' 
grieving of a lost servicemember or veteran, to deal with separation 
anxieties and depression, and to aid family members in coping with a 
number of deployment-related stresses. Therefore, we see these new 
provisions as consistent with the RCS mission to continue as a non-
medical source of healing and recovery for this young population. We 
believe this is an important, but incremental improvement in the RCS 
mandate. Therefore, DAV fully endorses this provision in accordance 
with DAV Resolution No. 189 that supports a comprehensive Vet Center 
Program for combat veterans of all eras.
    Section 203 establishes authority for the Secretary of Veterans 
Affairs to furnish mental health care through facilities other than Vet 
Centers to immediate family members of Armed Forces personnel deployed 
in connection with a contingency operation; this authority would be 
subject to the availability of appropriations for this purpose. We 
support this provision, also on the strength of Resolution No. 189.
    Section 204 stipulates the organization of the RCS in the VA and 
notes that it is a distinct organizational element within the VHA that 
provides counseling and other important health and psychological 
services. This measure would require the Chief Officer of the 
Readjustment Counseling Service to report directly to the Under 
Secretary for Health with no intervening supervisory layers between 
them. The provision would also specify qualifications of an individual 
for holding this sensitive post.
    For the past 35 years, the RCS has served as a quasi-independent 
source of psychological counseling for combat veterans and family 
members. In fact, the Committee may recall that the original charter 
for the RCS was modeled on a novel readjustment counseling service 
initiated independently by DAV following the Vietnam War when it became 
apparent to our predecessors that VA was not addressing the urgent 
counseling and readjustment needs of a number of Vietnam veterans. As 
intended by Congress in establishing its original mandate in 1979, the 
RCS was to be an independent, non-medical, non-psychiatric source of 
care for certain veterans who did not want to be labeled ``mentally 
ill'' by VA, but who were in need of services to aid them in 
readjusting from the sacrifices they endured in military combat 
environments. The RCS succeeded all expectations in playing that role. 
Today's combat veterans have made it clear to DAV and others that they 
desire a similar, non-stigmatizing service to aid them, and have found 
the Vet Centers to be welcoming, non-judgmental places to receive that 
help.
    Without notice to this community and without any consultation 
beforehand, the VHA journalized the RCS under its medical professional 
arm. The RCS office now reports through, and is thus restrained by, a 
gauntlet of bureaucracies led by VA physicians and those working for VA 
physicians in VA Central Office. Reporting to physicians is wholly 
inconsistent with the non-medical, psychological and pastoral mission 
of RCS, and detracts from its historic role as planner, budgeter, 
staffer and operator of all RCS programs in 300 Vet Centers in every 
State and most major cities. No other VA medical professional service 
in the current VHA configuration possesses this level of combined 
responsibility or accountability as does the RCS. We cannot see any 
advantage having been accrued to VHA as a consequence of this 
realignment (except perhaps to promote medical and psychiatric 
traditionalism), but many disadvantages have become apparent.
    With these views in mind, we strongly endorse this section that 
would return RCS to its traditional state of independence from medical 
and psychiatric supervision in a VA bureaucracy.
    The section also would require funding for the activities of the 
Readjustment Counseling Service, including the operations of Vet 
Centers, to be derived from amounts appropriated for the VHA for 
medical services and not through the Veterans Equitable Resource 
Allocation system that funds most other VA clinical care. The section 
would also require the budget request for the RCS to be segregated from 
other funding needs for VHA. We fully support these provisions on the 
same basis that we support RCS being maintained as a separate entity in 
VHA's organization, reporting only to the Under Secretary for Health. 
If funding for RCS is routed through VERA, it is subject to the overall 
needs of each VISN. This would give each VISN office the opportunity to 
parse RCS funding to other needs deemed more urgent or higher priority. 
We do not support this concept. RCS funding should be maintained and 
justified by RCS only, exclusive of interference by outside interests.
    The section also requires that, not later than March 15 of each 
year, the Secretary shall submit a report to the Committee on Veterans' 
Affairs of the Senate and the House of Representatives on the 
activities of the RCS during the preceding calendar year. Each report 
would include for each period covered: 1) a summary of the activities 
of the RCS, including its Vet Centers; 2) a description of the workload 
and additional treatment capacity of the Vet Centers, including, for 
each Vet Center, the ratio of the number of full-time equivalent 
employees and the number of individuals who received services or 
assistance; 3) a detailed analysis of demand for and unmet need for 
readjustment counseling services; and 4) the Secretary's plan for 
meeting any such unmet needs. We support this provision.
    Section 205 would instruct the Secretary of Veterans Affairs to 
carry out a national program of outreach to societies, community 
organizations, and government entities in order to recruit mental 
health providers, who meet the quality standards and requirements of 
the VA to provide mental health services for the Department on a part-
time, without-compensation basis. In carrying out this program the 
Secretary could partner with a community entity or assist in the 
development of a community entity, including by entering into an 
agreement that would provide strategic coordination of the societies, 
community organizations, and government entities in order to maximize 
the availability and efficient delivery of mental health services to 
veterans. The Secretary would be required to provide training to mental 
health providers to ensure that clinicians who provided mental health 
services under this authority gain sufficient understanding of military 
and service specific culture, combat experience, and other factors that 
are unique to the experience of OEF/OIF/OND veterans.
    DAV is pleased to support this comprehensive draft measure and we 
appreciate the Chairman's continued efforts on improving mental health 
programs and services for our Nation's servicemembers, veterans and 
their families. We are especially appreciative of your recognition of 
the importance of the RCS's role in restoring new veterans to society 
and family life following their strenuous deployments to Afghanistan 
and Iraq, over this decade-long war. We particularly appreciate those 
provisions in this bill.
    DAV would again like to thank the Committee for the opportunity to 
submit our views on the numerous legislative measures under 
consideration at this hearing. Much of the proposed legislation would 
significantly improve VA benefits and services for our Nation's 
servicemembers, veterans and their families.

    This concludes my testimony. I am happy to answer any questions 
Committee Members may have related to my statement.

    Chairman Murray. Thank you.
    Thank you very much to all of our folks who have come today 
to testify. We really appreciate it. I just am going to do a 
couple of questions and then submit some for the record as our 
time is running out rapidly.
    But I did want to go back to Ms. Keil. The Department of 
Defense, as I mentioned earlier, provides access to advanced 
reproductive treatments and recently issued some guidance on 
offering these services at no cost to severely injured 
servicemembers and their spouses.
    The VA, on the other hand, cannot provide these services, 
and it is pretty clear they do not meet the reproductive health 
needs of veterans who have experienced severe trauma as you 
outlined to us in your testimony a few moments ago.
    When you and your husband, Matt, were trying to conceive, 
you faced some very substantial roadblocks from both the 
Department of Defense and VA; and since that time, DOD has 
changed their policy. They now do offer fertility services for 
severely injured veterans.
    I believe that veterans like Matt have earned DOD and VA 
coverage and there should be no difference. I assume you agree 
with that.
    Ms. Keil. I absolutely agree. My understanding is that you 
would need to travel to a military treatment facility in order 
to receive those services that the DOD is offering, whether 
that be Fort Bragg or Walter Reed. That is not an option for 
families of the most severely injured such as my husband.
    There is no way that I could travel to one of those 
treatment facilities and to care for my husband, and I want him 
there every step of the way.
    So, that for us would not be an option. I feel that he, 
with his service and sacrifice, I feel that he now falls under 
the VA guidelines of care. He is a medically retired 
servicemember, and he ultimately is the VA's responsibility.
    So, I feel that we fall under their responsibility.
    Chairman Murray. Thank you very much. I really appreciate 
that.
    Ms. Ilem, I just wanted to ask you. One of the issues I 
hear a lot about especially for women veterans is the lack of 
childcare. It is a substantial barrier to families accessing 
health care, and Congress has begun to address that issue.
    The last Congress, as you know, we created a pilot program 
to provide childcare at several of our VA medical centers. This 
year the legislation I have introduced expands upon that 
success to include childcare at several Vet Centers.
    This is important because Vet Centers, as you know, provide 
mental health care and readjustment counseling services in a 
comfortable, non-clinical setting that some veterans prefer.
    So, I wanted to ask you. I was really pleased to hear your 
testimony today about the positive experiences that a number of 
your members have had.
    How do you think expanding access to child care services 
would improve the accessibility to care for our veterans?
    Ms. Ilem. And we definitely appreciate your leadership on 
that issue. It was a long time coming. It certainly has been 
identified as a barrier over the years in numerous studies and 
I think we heard from the recent event that you hosted with a 
number of women veterans who need psychological counseling that 
are using the Vet Center and even VA's that child care, having 
access to child care was a big issue because for the children 
it is just not an appropriate place for them to bring their 
children, discussing some very private matters during those 
sessions.
    So, I think it absolutely opens the door one more step for 
those that Vet Centers should be included and we welcome those 
provisions.
    Chairman Murray. OK. Thank you very much and again we are 
out of time but I do want to thank all of our witnesses today, 
and I will just let everyone know that I am going to be working 
with all the Members of this Committee as we develop 
legislation based on today's hearing on all of these bills as 
well as our last legislative hearing for our markup which is 
going to be held in July.
    I am optimistic that by the time of the next markup, the 
President is going to be signing into law the Honoring America 
Veterans and Caring for Camp Lejeune Families Act of 2012, 
which includes legislation from our last markup.
    Veterans legislation continues to be bipartisan and that is 
as it should be. So, I want to thank all the members of our 
Committee. The Senators who are working on legislation I look 
forward to working with all of you in the coming weeks on this 
critical legislation affecting our Nation's heroes.
    Thank you very much.
    With that, this Committee hearing is adjourned.
    [Whereupon, at 11:59a.m., the Committee was adjourned.]


                            A P P E N D I X

                              ----------                              


Prepared Statement of Max Cleland, Secretary, American Battle Monuments 
                               Commission

    Mr. Chairman and Members of the Committee: Thank you for this 
opportunity to offer testimony on several bills before the Committee. 
As only one, S. 2320, the Remembering America's Forgotten Veterans 
Cemetery Act of 2012, pertains to responsibilities of the American 
Battle Monuments Commission, I will limit my testimony to it.
    S. 2320 would direct the American Battle Monuments Commission to 
provide for the ongoing maintenance of the former Clark Air Base 
Cemetery in the Republic of the Philippines.
    We agree that Clark cemetery is a problem that warrants resolution. 
When the Air Force vacated Clark Air Base and the base rights agreement 
with the Philippines expired, the cemetery became the responsibility of 
the Philippine Government. Over time, this had the effect of leaving 
its care in the hands of a few dedicated VFW volunteers. They have done 
a wonderful job with limited resources, particularly considering that 
burials of U.S. veterans have continued since the Air Force departure, 
but the volunteers cannot be expected to continue that effort 
indefinitely.
    We do not know how many of the 8,000 dead at Clark cemetery are 
U.S. veterans--the Clark Veterans Cemetery Restoration Association Web 
site cites several thousand as confirmed veterans and others as 
presumed veterans.
    We are on record as stating that Clark cemetery does not fall 
within our Commission's core commemorative mission. That remains true. 
However, given the Air Force's history with the cemetery and the fact 
that veterans' burials have continued, we initiated a meeting in ABMC's 
Virginia Headquarters last December with representatives of the Air 
Force and the Department of Veterans Affairs National Cemetery 
Administration to explore possible solutions to this issue. A consensus 
could not be reached on what should or could be done.
    ABMC has serious concerns with S. 2320 as drafted. While this 
bill's intention is laudable, we do not believe the bill addresses 
adequately issues that must be resolved before any corrective action is 
taken.
    If the Congress should decide to move legislation forward, the 
Administration believes such legislation should address three critical 
elements: access, authority, and funding.

    1. Access--To our knowledge, the United States has no legal 
standing to undertake any work at Clark cemetery. The Department of 
State would have to enter negotiations with the Philippine Government 
to provide long-term U.S. access to the cemetery. This would have to be 
accomplished before any agency of the Federal Government could maintain 
the cemetery.
    2. Authority--ABMC has no authority to spend its appropriations to 
maintain a cemetery controlled by a foreign government and the 
Administration does not support any change in this position.
    3. Funding--The requirement that the Commission restore, operate 
and maintain Clark cemetery ``subject to the availability of 
appropriations for the restoration, operation, and maintenance of 
cemeteries by the American Battle Monuments Commission'' is not 
supportable. We cannot successfully complete a project of this scale 
with existing appropriations without significant negative consequences 
on the rest of ABMC's program. There is presently no government 
estimate of the cost to restore and maintain Clark cemetery. The Clark 
Veterans Cemetery Restoration Association estimated the restoration 
cost at $2.0 million and annual maintenance costs at $250,000. There 
are more than 8,000 graves to maintain at Clark cemetery-more than we 
maintain at 19 of our 24 overseas cemeteries. Most of the headstones at 
Clark are partially buried in volcanic ash. We believe the 
association's estimates do not come close to the amount required given 
the magnitude of the restoration work required.

    ABMC's Fiscal Year 2013 budget request for Salaries and Expenses is 
$2.7 million, or five percent, below our Fiscal Year 2012 
appropriation. Most of that reduction will be taken in maintenance and 
infrastructure programs. We cannot sustain such reductions indefinitely 
while maintaining the standards our war dead deserve and that our 
Nation demands.
    We recognize that the Budget Control Act limits all agencies, 
including ABMC, to a budgeted level in the out years, and that any 
increase to our budget would have to be offset from another agency's 
out year allowances. Nonetheless, if the Congress directs our agency to 
take on a large-scale new program requirement such as the restoration 
and maintenance of Clark cemetery, even the association's under-
estimated cost would reduce our Fiscal Year 2013 funding request by an 
additional four percent--for a total reduction of $5.0 million. Taken 
further, this would result in a 14 percent cut in program funding for 
engineering and maintenance, horticulture, logistics and 
interpretation.
    This is not sustainable for an agency of our size and budget. An 
unfunded new mission of the scope of Clark cemetery cannot help but 
have a significant impact on our ability to execute our core mission.
    Before closing, I must comment on Finding 8 of the bill, which 
references the Commission's fund raising authority. We caution the 
Committee from going down this road. Requiring private funding of new 
memorial projects authorized by the Congress has become common 
practice, but fund-raising results have not been universally 
successful. It is not common practice to require private funding of our 
Nation's overseas cemeteries. S. 2320 implies that the care of ABMC 
cemeteries could become dependent on the uncertainties of public fund 
raising. This carries with it the implication that the Congress is 
prepared to back away from the commitment to provide perpetual care to 
the war dead buried within them.
    S. 2320 has serious issues that prevent us from supporting this 
legislation.
                                 ______
                                 
  Prepared Statement of the American Society for Reproductive Medicine

    The American Society for Reproductive Medicine appreciates the 
opportunity to provide comment on S 3313, the ``Women Veterans and 
Other Health Care Improvements Act of 2012,'' and is pleased that the 
Senate Veterans' Affairs Committee has considered this bill for a 
public hearing.
    ASRM is a multidisciplinary organization of nearly 8,000 medical 
professionals dedicated to the advancement of the art, science, and 
practice of reproductive medicine. ASRM members include obstetrician/
gynecologists, urologists, reproductive endocrinologists, nurses, 
embryologists, mental health professionals and others. As the medical 
specialists who present treatment options for patients and perform 
procedures during what is often an emotional time for them, we 
recognize how important a means to addressing their medical condition 
can be for those hoping to build their families.
    The ``Women Veterans and Other Health Care Improvements Act of 
2012'' would direct the Secretary of Veterans Affairs to collaborate 
with the Secretary of the Department of Defense and the Director of the 
National Institutes of Health to facilitate research to improve the 
long term reproductive health care needs of veterans who have a 
service-connected genitourinary disability or a condition that was 
incurred or aggravated in the line of duty that affects the veteran's 
ability to reproduce. ASRM is very pleased that this bill recognizes 
the need for greater attention, dedication and investment of Federal 
resources to the disease of infertility. The National Institutes of 
Health and the Centers of Disease Control are two public agencies that 
devote resources to this disease, but due to the myriad of causes of 
infertility, and the numerous implications of the disease, it is 
vitally important that other Federal agencies work to make combating 
infertility a priority. The attention to infertility by the agencies 
governing our military service personnel and our separated from 
military service personnel is long overdue and welcomed.
    The bill allows that the Department of Veterans Affairs may furnish 
fertility counseling and treatment, included assisted reproductive 
technologies, to veterans and requires the Department of Veterans 
Affairs to furnish fertility counseling and treatment, including 
assisted reproductive technologies, to a spouse or surrogate of a 
severely wounded veteran who has an infertility condition incurred or 
aggravated in the line of duty as long as the spouse and veteran apply 
jointly for such counseling and treatment.
    ASRM solidly supports the provision of fertility services to 
severely wounded veterans. It is nothing but unjust to send our 
military personnel into harm's way and to not provide health care 
services to address health care needs that arise due to their service 
and dedication to our country.
    Of course, because infertility is a disease and one that affects 1 
in 8 couples, we advocate for the provision of health benefits to 
address the disease for all those affected, no matter the cause. 
Insurance coverage of infertility is rare. And while we can debate as 
to what is essential and what is not essential when it comes to 
coverage of health care, there is a huge gap when it comes to the 
ability of individuals diagnosed with infertility to treat their 
disease. In fact, the Federal Employee Health Benefits Program, the 
largest employer-sponsored private health plan in the Nation, and a 
model for the health reform law in several key areas, does not provide 
coverage for most infertility services, and specifically for assisted 
reproductive technology. ASRM would recommend that the Federal 
Government can demonstrate its commitment to the importance of 
addressing infertility by requiring its own health program to provide 
coverage for infertility services for its own workforce.
    We would like to raise a couple of additional shortcomings in the 
bill.
    First, the bill is written is such a way to give the Department of 
Veterans Affairs the option (i.e. ``may'' furnish) to provide fertility 
counseling and treatment for veterans generally, but ``shall'' provide 
fertility counseling and treatment for spouses or surrogates when a 
severe injury occurs to the veteran during the line of duty. As 
written, the bill seems to leave out the required treatment of the 
veteran himself or herself when injured during the line of duty. 
Obviously this is not the intent of your bill, but the language should 
be clarified to require coverage of the injured veteran himself or 
herself. The source of the infertility can be male factor, female 
factor or both.
    The bill could go further to specifically include furnishing of 
services to those affected by infertility caused by exposure to toxins 
during their deployment as these exposures can also compromise one's 
ability to reproduce. So too, fertility preservation is a common 
concern for military personnel with orders to deploy, and coverage by 
TRICARE for those who opt to attempt to preserve their fertility via 
sperm banking should be allowed.
    The bill limits required fertility counseling and treatments to a 
spouse or surrogate of the injured veteran. Until such time that every 
state legally recognizes the marriage of same sex partners, the effect 
of this bill will be that only those veterans whose marriage is deemed 
legal will be furnished those services outlined in the bill. This 
effectively denies coverage to injured veterans who are single or who 
are in same sex partnerships. It is no longer a stigma to reproduce 
outside of the context of marriage, or a male/female marriage, and ASRM 
would recommend that holding veterans to a standard that is not the 
norm any longer in today's society is discriminatory.
    ASRM would also recommend that you clarify the term ``surrogate'' 
in the bill as this word can have different meanings. It would be 
appropriate to precede the word ``surrogate'' with the word 
``gestational'' in the bill language. ASRM would further recommend that 
the use of donor gamates be a covered treatment option.

    Thank you for the opportunity to comment on this bill and for your 
attention to this important public health issue.
                                 ______
                                 
             LETTER FROM NATHANIEL BEELER OF AVON, INDIANA

    Chairman Murray, Members of the Senate Veterans' Affairs Committee, 
My name is Nathaniel Beeler and I am 10 years old, almost 11. I live in 
Avon, Indiana. I am working to alert Senators about an important 
veteran's issue that is addressed in Senate Bill S. 2320. Clark 
Veteran's Cemetery in the Philippines urgently needs your support. Many 
of our soldiers who sacrificed their lives for our country lie in 
disgraceful conditions at the Clark Veteran's Cemetery in the 
Philippines. I care deeply for the veterans who sacrificed their lives 
for my very freedom and I think they should have respectful conditions 
for the price they paid.
    I first read about the cemetery last summer and I wanted to do 
something to support our fallen heroes. I made a power point 
presentation and presented this issue to my class in April and we wrote 
letters to Senator Coats, Senator Lugar, and Congressman Todd Rokita. 
Since then, I have expanded my efforts to include six petition drives. 
I have collected a total of 764 signatures, ranging from kindergartners 
to a WWII Pearl Harbor survivor. After I got out of school in May, I 
decided to increase my efforts ten-fold.
    I know it must grieve you also to know that our veterans are lying 
in disgrace, buried in ash and weeds. Some have 8-12 inches of ash 
covering their headstones so that you cannot read their information. 
This is not how the United States treats their veterans. These brave 
men and women, who sacrificed for my freedom, kept our freedom for many 
generations to come. Now they lay in disgrace and dishonor and that 
violates their sacrifice and ruins the vision of how the United States 
treats their fallen comrades.
    I know that I am only 10 years old, but I want to do something for 
the veterans because of how much they have done for me. I live in 
freedom and luxury in the greatest nation in the world, thanks to them. 
I get to go to school without being blown up on the way, good food is 
in our kitchen and available abundantly at the store even though we are 
at war, and I sleep in a warm, comfortable bed without fear of being 
attacked and killed in the night, all because of the sacrifice and 
efforts of our veterans.
    Here is the issue: When the Air Force left the Philippines due to 
volcanic eruption, they left in a hurry, and failed to place the 
cemetery under the proper agency to manage our cemeteries on foreign 
soil. S. 2320 would place Clark under the ABMC. All of it is explained 
in my PowerPoint presentation, which I will attach. [A paper version is 
held in Committee files.] We have veterans buried there who died in the 
Spanish American war all the way to an Iraqi veteran. I just read a 
great book called The Great Raid of Cabanatuan and I learned about how 
many Filipino people sacrificed and suffered and died alongside our 
troops. They were brave young men and women who helped turn the tide in 
WWII. Many suffered through or died on the Bataan Death March and were 
POWs. A lot of them were freed and then went into the jungles and 
mountains to lead or participate in the underground gorilla effort 
against the Japanese. We could never have rescued our POW's without 
their help. This has made me even more dedicated and motivated to 
doubling up on my efforts to restore Clark Veteran's Cemetery.
    Since you are all Members of the Senate Committee on Veterans 
Affairs, you are very important and Clark needs your support! All of my 
hope and trust is in you because only the U.S. Government can restore 
this forgotten cemetery which contains our brave war dead. If the US 
doesn't do something now, it will be like they have been abandoned 
twice. I read a good book called Behind the Enemy Lines. It is about 
brave men and women that fought for our country from the Revolutionary 
War all the way to Iraq. The stories are so amazing, especially the 
soldiers bravery! The stories reminded me of the men and women who are 
buried at Clark. I am very devoted and motivated to bring them the 
honor and dignity they have earned and deserve. By supporting this 
bill, you could influence other Senators to support S. 2320, and have 
the domino effect.
    When I grow up, I hope to be a pilot in the Marines. I have read 
that the Marines main statement is: ``Leave no man behind.'' But at 
Clark, many Marines have been left behind, buried in ash and dishonor. 
I will never stop fighting for them and their honor, because they never 
stopped fighting for me and for you and for our Nation.
    I am only 10 years old but I have been taught that the United 
States is the most powerful and just nation in the world and we have 
this title because of the many veterans who fought under our flag 
because they believed that freedom was worth dying for. Even if they 
were fighting for other people's freedom, they believed the ideas the 
United States stands for are worth dying for. So now they lay in 
disgrace when they are really heroes. We can't allow this to go on! We 
have to act now.
    I can only go out and get signatures of support and every one I 
talked to agreed that we should be able to read the headstones of our 
war dead. But you can make a law and fix this predicament.
    A gold star mother signed my petition on Saturday, June 16th. I 
have thought many times about all the mothers of those who are buried 
at Clark, and how sad and exasperating it must be to have your child 
buried in disgrace and dishonor when they sacrificed and gave of 
themselves in order that we are a free country.
    I hope you will support S. 2320! I have another petition drive 
scheduled for July 4, 2012. It will be my biggest event yet--15,000 
people attended in the past. I think I will gain many signatures and 
much progress for the effort to restore Clark Veteran's Cemetery!
    I am attaching my power point and my petitions to be admitted into 
public testimony, along with my statement. I hope this is read and 
admitted because I really want to help Clark Veteran's Cemetery to be 
restored!
            Sincerely,
                                          Nathaniel Beeler.
                                 ______
                                 
 Prepared Statement of Thomas Zampieri, Ph.D., Director of Government 
                Relations, Blinded Veterans Association

                              INTRODUCTION

    The Blinded Veterans Association (BVA) is the only congressionally 
chartered Veterans Service Organization exclusively dedicated to 
serving the needs of our Nation's blinded veterans and their families. 
The organization has served blinded veterans for 67 years. On behalf of 
BVA, thank you for this opportunity to present statement for the record 
on the issue of the current Department of Veterans Affairs (VA) 
Beneficiary Travel Program. Chairwoman Patty Murray, Ranking Member 
Burr, and members of the Senate VA Committee, thank you for the changes 
you already have made to Beneficiary Travel in recent years, and today 
we appreciate the introduction of S. 1755 to improve the access for 
disabled blind and spinal cord injured veterans who require services at 
the VA specialized Blind Rehabilitation Centers (BRCs) and Spinal Cord 
Injury Centers (SCIs).

            BENEFICIARY TRAVEL FOR BLINDED VETERANS: S. 1755

    BVA thanks Senator Tester for introducing S. 1755. We also express 
appreciation to Congressman Michaud for H.R. 3687, the companion House 
bill legislation for disabled SCI and blinded veterans who are 
currently ineligible for travel benefits. This bill would assist low-
income and disabled veterans by removing the travel financial burdens 
to access vital care that improve independence and quality of life. 
Veterans who must currently shoulder this hardship, which often 
involves airfare, can be discouraged by these costs to travel to a BRC 
or SCI site. The average age of veterans attending a BRC is 67 because 
of the high prevalence of degenerative eye diseases in this age group.
    It makes little sense to have developed, over the past decade, 
outstanding blind rehabilitation programs with 13 Blind Centers and 
with high quality inpatient specialized services, only to tell low 
income, disabled blinded veterans that they must pay their own travel 
expenses to access the training they need. To put this dilemma in 
perspective, a large number of our constituents are living at or below 
the poverty line while the VA Means threshold for travel assistance 
sets $14,340 as the income mark for eligibility to receive the benefit. 
VA utilization data revealed that one in three veterans enrolled in VA 
health care was defined as either a rural resident or a highly rural 
resident. The data also indicate that blinded veterans in rural regions 
have significant financial barriers to traveling without utilization of 
public transportation.
    To elaborate on the challenges of travel without financial 
assistance, the data found that for most health characteristics 
examined, enrolled rural and highly rural veterans were similar to the 
general population of enrolled veterans. The analysis also confirmed 
that rural veterans are a slightly older and a more economically 
disadvantaged population than their urban counterparts. Twenty-seven 
percent of rural and highly rural veterans were between 55 and 64. 
Similarly, approximately 25 percent of all enrolled veterans fell into 
this age group.\1\ In FY 2007, rural veterans had a median household 
income of $19,632, 4 percent lower than the household income of urban 
veterans ($20,400).\2\ The median income of highly rural veterans 
showed a larger gap at $18,528, adding significant barriers to paying 
for air travel or other public transportation to enter a BRC or SCI 
rehabilitation program. More than 70 percent of highly rural veterans 
must drive more than four hours to receive tertiary care from VA. 
Additionally, states and private agencies do not operate blind services 
in rural regions. In fact, almost all private blind outpatient agency 
services are located in large urban cities. With the current economic 
problems with state budgets clearly in view, we expect further cuts to 
these social services that will bring even more challenges to the 
disabled in rural regions.
---------------------------------------------------------------------------
    \1\ Department of Veterans Affairs, Office of Rural Health, 
Demographic Characteristics of Rural Veterans Issue Brief (Summer 
2009).
    \2\ VSO IB 2013 Beneficiary Travel pg 119-120, 124-125.
---------------------------------------------------------------------------
    Consider the following facts:

     In a study of new applications for recent vision loss 
rehabilitation services, 7 percent had current major depression and 
26.9 percent met the criteria for subthreshold depression.\3\
---------------------------------------------------------------------------
    \3\ Horowitz et al., 2005, Major and Subthreshold Depression Among 
Older Adults Seeking Vision Rehabilitation Services The Silver Book 
2012, Volume II pg 9 www.silverbook@ agingresearch.org.
---------------------------------------------------------------------------
     Vision loss is a leading cause of falls in the elderly. 
One study found that visual field loss was associated with a sixfold 
risk of falls.\4\
---------------------------------------------------------------------------
    \4\ Ramratten, et al., 2001 Arch Ophthalmology 119(12) 1788-94. 
Prevalence and Causes of Visual Field Loss in the Elderly, 
www.Silverbook.org/visionloss Silver Book, Volume II 2012 pg 9.
---------------------------------------------------------------------------
     While only 4.3 percent of the 65 and older population 
lives in nursing homes, that number rises to 6 percent of those who are 
visually impaired, and 40 percent of those who are blind.\5\
---------------------------------------------------------------------------
    \5\ Rein, David B. et al., 2006 The Economic Burden of Major Adult 
Visual Disorders in the U.S. www.Silverbook.org/visionloss Silver Book, 
Volume II 2012 pg 9.
---------------------------------------------------------------------------
     Individuals who are visually impaired are less likely to 
be employed-44 percent are employed compared to 85 percent of adults 
with normal vision in working population age 19-64.\6\
---------------------------------------------------------------------------
    \6\ Rein, et al. The Economic Burden of Major Adult Vision 
Disorders in the U.S. 2006 www.Silverbook.org/visionloss Volume II 
pg 10.

    If blinded veterans are not able to obtain the blind center 
training to learn to function at home independently because of travel 
cost barriers, the alternative--institutional care in nursing homes--
may be far more expensive. The average private room charge for nursing 
home care was $212 daily ($77,380 annually), and for a semi-private 
room it was $191 ($69,715 annually), according to a MetLife 2008 
Survey. Even assisted living center charges of $3,031 per month 
($36,372) rose another 2 percent in 2008. BVA would point to these more 
costly alternatives in describing the advantages of VA Beneficiary Care 
so that veterans can remain in their homes, functioning safely and 
independently, and with the rehabilitation training needed to re-enter 
the workforce.
    We caution that private agencies for the blind are almost always 
outpatient centers and located in large urban cities. Many rural states 
have no vision rehabilitation centers and they do not have the full 
specialized nursing, physical therapy, audiology, pharmacy, radiology 
or laboratory support services that are necessary for the clinical care 
that BRCs and SCIs provide. The lack of electronic health care records 
in private centers is also a problem when veterans return to VA for 
their other medical follow-up care. BVA requests that all private 
agencies be required to demonstrate peer reviewed quality outcome 
measurements that are a standard part of VHA Blind Rehabilitative 
Service. They must also be accredited by either the National 
Accreditation Council for Agencies Serving the Blind and Visually 
Handicapped (NAC) or the Commission on Accreditation of Rehabilitation 
Facilities (CARF). Blind Instructors should be certified by the Academy 
for Certification of Vision Rehabilitation and Education Professionals 
(ACVREP).

                               CONCLUSION

    Chairwoman Murray and Ranking member Burr, BVA again expresses its 
thanks for the changes that the VA committee has made to these 
Beneficiary Travel programs in the past couple of years. BVA requests 
support for S. 1755, which will ensure that VHA cover travel costs by 
changing Title 38, Section 111 of the U.S. Code Eligibility. Veterans 
who would not otherwise be able to attend special rehabilitation 
programs to improve their quality of life will now have that 
opportunity. The end result will also be a previously unavailable means 
for blind or spinal cord injured veterans to live independently in 
their own homes. BVA appreciates the opportunity to provide this 
statement for the record today.
                                 ______
                                 
       Prepared Statement of Hon. Bruce E. Kasold, Chief Judge, 
               U.S. Court of Appeals for Veterans Claims

    Chairman Murray, Ranking Member Burr, and Distinguished Members of 
the Committee: Thank you for the opportunity to present written 
testimony on a number of legislative proposals, in particular S. 2045, 
which would establish in statute a duty station for the judges of the 
United States Court of Appeals for Veterans Claims, consistent with 
other Federal courts, as well as a requirement for active service 
judges to reside within fifty miles of the District of Columbia. This 
past March, I provided testimony to the House of Representatives 
Committee on Veterans' Affairs, Subcommittee on Disability Assistance 
and Memorial Affairs, on a mirror proposal in the House--H.R. 4213--and 
my testimony today essentially is unchanged.
    In the haste of creating the Court of Appeals for Veterans Claims--
the youngest Federal appellate court--the application of several policy 
issues written in statute and applicable to Federal judges in general 
appears to have been overlooked with regard to the judges of the Court 
of Appeals for Veterans Claims. A defined duty station is one example. 
The duty station for Federal judges generally is prescribed by statute, 
see 28 U.S.C. Sec. 456, but until your proposal and that of H.R. 4213, 
no similar legislation has applied to the Court of Appeals for Veterans 
Claims. In the absence of legislation, the Court's Board of Judges has 
determined that the duty station for all Court personnel, including 
active judges other than recall-eligible retired judges, is the Court's 
principal office. This mirrors your proposed bill.
    With regard to a residence requirement, we note that congressional 
mandate is mixed with regard to establishing such a requirement for an 
appellate court with national jurisdiction. Although the judges of the 
Court of Appeals for the Federal Circuit are required to reside within 
50 miles of the District of Columbia, see 28 U.S.C. Sec. 456, the 
judges of the Court of Appeals for the Armed Forces have no residency 
requirement.
    To the extent the perceived need for a residency requirement arises 
from concerns over the efficient operation of the Court, we note that 
working from a remote area is becoming more practical. Our cases are 
now electronically filed and stored and are accessible anywhere a judge 
can locate a computer. Decisions are circulated for review 
electronically, and this is the preferred method to distribute cases 
for review even for those present and working at the Court (as opposed 
to working remotely). Conversations can and do take place by e-mail, 
phone, and video (although video is not widely available at the Court 
yet, but likely not far off). Indeed, recently, one of our judges was 
on travel and worked a case electronically with his iPad while his wife 
was driving the car. Moreover, the advent of e-filing and enhanced 
electronic communication capability, as well as recent changes in the 
administrative processing of appeals after they have been briefed--as 
discussed in my testimony before this Committee last month--have 
resulted in the Court's most productive years.
    Should Congress proceed with a residency requirement for the Court, 
we suggest that it be tied to the Washington, DC, greater metropolitan 
area, and not just the confines of the District of Columbia, to be 
consistent with the statutorily required location of the Court's 
principal office, which can be anywhere in the Washington, DC, greater 
metropolitan area. See 38 U.S.C. Sec. 7255.
    With regard to the other legislative proposals before the 
Committee, I note that they concern operations unrelated to the Court 
or matters within the specific purview of the Department of Veterans 
Affairs. Accordingly, I have no special insight to offer the Committee.

    Thank you again for the opportunity to provide a written statement 
on the proposed legislation.
                                 ______
                                 
      Letter from Dennis L. Wright, Captain, U.S. Navy (Retired), 
       Chairman, Clark Veterans Cemetery Restoration Association








    [Attachments listed were not submitted to the Committee.]
                                 ______
                                 
        letter from the national coalition for homeless veterans
    Chairman Patty Murray, Ranking Member Richard Burr, and 
Distinguished Members of the Senate Committee on Veterans' Affairs: The 
National Coalition for Homeless Veterans (NCHV) is honored to submit 
this written testimony for the hearing on health and benefits 
legislation on June 27, 2012. NCHV represents more than 2,100 
community- and faith-based organizations nationwide that serve veterans 
and their families in crisis. These organizations help our Nation's 
most vulnerable heroes by providing health services, emergency and 
supportive housing, job training and placement assistance, legal aid, 
case management and other critical supports.
    A few of the bills addressed at today's hearing would significantly 
impact the ability of service providers to deliver the needed care to 
help homeless and at-risk veterans achieve or maintain independent 
living:

     S. 1806, Sen. Barbara Boxer's bill to amend the Internal 
Revenue Code of 1986 to allow taxpayers to designate overpayments of 
tax contributions to the homeless veterans assistance fund
     S. 3049, Sen. Mark Begich's bill to expand the definition 
of homeless veteran for purposes of benefits under the laws 
administered by the Secretary of Veterans Affairs
     S. 3309, Sen. Patty Murray's ``Homeless Veterans 
Assistance Improvement Act of 2012''

    NCHV supports each of these measures. We offer a few targeted 
recommendations to improve upon S. 3309, however.

  S. 1806, A BILL TO AMEND THE INTERNAL REVENUE CODE OF 1986 TO ALLOW 
    TAXPAYERS TO DESIGNATE OVERPAYMENTS OF TAX CONTRIBUTIONS TO THE 
                   HOMELESS VETERANS ASSISTANCE FUND

    Limited Federal funds for homeless veteran assistance are often 
concentrated in heavily populated areas. A significant number of 
community- and faith-based service providers lie outside of major 
metropolitan areas, which makes it is more difficult to compete for 
Federal grants. However, the homeless and at-risk veterans served by 
these organizations require the same help to reintegrate into society 
as those in larger urban areas.
    This bill would establish the Homeless Veterans Assistance Fund, 
which would supplement proven Federal programs and could be authorized 
to target nontraditional, or ``nonconforming entities,'' and support 
high-demand activities such as:

     Child care assistance for single veterans in employment 
assistance programs
     Transportation assistance to medical and employment 
services
     Security deposits and utility hook-up fees for housing 
placements
     Clothing, uniforms and tools for employment

    The U.S. General Accounting Office has reported that American 
taxpayers may have overpaid as much as $945 million, based on data from 
tax year 1998. This amounts to an average overpayment of $438 per 
taxpayer (``Tax Deductions,'' March 2002). Tax overpayments may be 
inevitable, but they do not need to be meaningless. The simple act of 
checking a box, as authorized by this bill, would enable taxpayers to 
contribute all or part of their overpayments to help prevent and end 
homelessness for those who have served this country in a way 
increasingly few Americans ever will.

 S. 3049, A BILL TO AMEND TITLE 39, UNITED STATES CODE, TO EXPAND THE 
DEFINITION OF HOMELESS VETERAN FOR PURPOSES OF BENEFITS UNDER THE LAWS 
           ADMINISTERED BY THE SECRETARY OF VETERANS AFFAIRS

    The Department of Veterans Affairs (VA) currently defines 
``homeless veteran'' based on an incomplete citation of the McKinney-
Vento Homeless Assistance Act (42 U.S.C. 11302 (a)). The full 
definition of ``homeless'' under this act includes the following:

        ``Any individual or family who is fleeing, or is attempting to 
        flee, domestic violence, dating violence, sexual assault, 
        stalking, or other dangerous or life-threatening conditions in 
        the individual's or family's current housing situation, 
        including where the health and safety of children are 
        jeopardized, and who have no other residence and lack the 
        resources or support networks to obtain other permanent 
        housing.''

    Sen. Begich's bill serves a single purpose: to include this 
provision in VA's definition of ``homeless veteran.'' Although some of 
these veterans may already qualify for VA homeless assistance due to 
the nature of their circumstances, we must make certain that we do not 
deny these vulnerable families the help that they need.

   S. 3309, ``HOMELESS VETERANS ASSISTANCE IMPROVEMENT ACT OF 2012''

Sec. 2. Requirement that recipients of grants from Department of 
        Veterans Affairs for comprehensive service programs for 
        homeless veterans meet physical privacy, safety, and security 
        needs of such veterans.
    Earlier this year, the VA Office of Inspector General reported 
``serious female veteran safety, security, and privacy issues'' at 
certain Grant and Per Diem (GPD) Program sites (``Audit of the Homeless 
Providers Grant and Per Diem Program,'' March 2012). Sec. 2 of this 
bill would help to remove any ambiguity over the need for grantees to 
fully address these issues in the grant application process.
Sec. 3. Modification of authority of Department of Veteran Affairs to 
        provide capital improvement grants for comprehensive service 
        programs that assist homeless veterans.
    Successful GPD providers who have previously received Capital 
Grants to establish their programs should have the opportunity to 
compete for funding to maintain those program facilities, including 
making the necessary renovations to serve homeless women veterans. Sec. 
3 of this bill would give the VA Secretary the discretion to make these 
grants.
Sec. 4. Funding for furnishing legal services to very low-income 
        veteran families in permanent housing.
    Outstanding warrants can present a barrier to independent housing 
for veterans and their families. Dozens of communities around the 
country have responded to this issue by adopting veteran-specific court 
programs. One such example is the Homeless Court Program (HCP)--a 
collaboration between veteran service providers and local court systems 
in which a veteran's participation in a rehabilitative program can be 
considered ``payment'' for various misdemeanor offenses.
    Sec. 4 of this bill would set aside at least 1.0 percent of SSVF 
Program funding for providers that will provide ``legal services to 
assist the veteran family with issues that interfere with the family's 
ability to obtain or retain housing or supportive services.'' NCHV 
recommends that this funding be targeted to communities that have 
demonstrated both a commitment and an ability to resolve veterans' 
legal issues. This could be accomplished by restricting these funds to 
communities with established Veterans Court programs.
Sec. 5. Modifications to requirements relating to per diem payments for 
        services furnished to homeless veterans.
    The Grant and Per Diem Program currently lacks authority to 
directly serve veterans' dependent children. Under the current 
authorization, veteran families are either forced to split up or be 
denied entry into the program.
    With the introduction and rapid expansion of the SSVF Program, VA 
has recognized that homelessness cannot be effectively ended and 
prevented without caring for the veteran family as a whole. This same 
philosophy should apply to the GPD Program.
    Sec. 5 of this bill would allow veterans' dependents to directly 
receive services through the program. Additionally, under this section 
the VA Secretary would be required to make per diem payments to 
``nonconforming entities,'' such as those discussed earlier in this 
testimony (regarding S. 1806). The Secretary is already authorized to 
make these payments. A mandate would potentially benefit underserved 
communities, but it should not be applied if it will compromise the 
integrity of the highly competitive GPD Program.
Sec. 6. Authorization of grants by Department of Veterans Affairs to 
        centers that provide services to homeless veterans for 
        operational expenses.
    Drop-in service centers are an important element of the GPD 
Program. They provide essential services and referrals to homeless and 
at-risk veterans who may not yet be ready or willing to enter into a 
residential therapy program, or are unable to because of capacity 
limitations. Yet with a reimbursement rate of no more than $4.86 per 
hour per veteran accessing the service center, few grantees can afford 
to maintain full-time staff for this purpose.
    The operational grants allowed by Sec. 6 of this bill would help 
support established service centers. NCHV recommends this provision 
clearly identify staffing expense as an allowable operational cost.
Sec. 7. Expansion of Department of Veterans Affairs authority to 
        provide dental care to homeless veterans.
    VA dental care for homeless veterans is a limited resource and does 
not reach enough of the homeless veteran community. For many of these 
men and women veterans, their job prospects and self-esteem suffer 
until they are able to address such issues as severe oral pain and 
missing teeth. The department's dental program helps them alleviate 
these barriers.
    Veterans who live in housing units supported by HUD-VASH vouchers, 
meanwhile, have an enormous advantage over the homeless veteran 
population at large: stable housing with regular case management and 
counseling supports. Given these considerations, NCHV does not endorse 
Sec. 7 of this bill, which would expand eligibility for VA's homeless 
veteran dental care to a non-homeless population: HUD-VASH voucher 
holders.
Sec. 8. Extensions of authorities and programs affecting homeless 
        veterans.
    This section would impact nearly every major homeless veteran 
program in the Federal Government. Among the critical FY 2013 
reauthorizations included in this section are:

     $250 million for the Grant and Per Diem Program
     $300 million for the Supportive Services for Veteran 
Families Program
     $50 million for the Homeless Veterans Reintegration 
Program (HVRP), the Nation's only employment program wholly dedicated 
to serving homeless veterans

    The GPD Program represents one of six pillars in the VA Secretary's 
Five-Year Plan to End Veteran Homelessness: community partnerships. Its 
role in ending veteran homelessness should not be diminished. 
Therefore, NCHV is concerned that Sec. 8 of this bill would scale back 
the program's authorization to $150 million well before the maturity of 
the Five-Year Plan in 2015. We recommend that the program's 
authorization be sustained at the $250 million level.
    Additionally, while this section would reauthorize the Special 
Needs Grant Program through 2015, NCHV maintains that the current 
authorization level of $5 million is insufficient to meet the needs of 
the program's target populations--particularly veterans with dependent 
children. We recommend that the program's authorization should be at 
least 15 percent of the total authorization for section 2011, title 38, 
U.S. Code. This would help to ensure that the necessary capital funding 
is available to provide safe, private and secure facilities for 
homeless women veterans and single homeless veterans with dependent 
children.

                              IN SUMMATION

    NCHV has been at the center of the campaign to end veteran 
homelessness since 1990, and knows better than most the role that the 
Senate Committee on Veterans' Affairs has played in bringing our Nation 
to within reach of the goal of ending veteran homelessness. With 
passage of this legislation, this Committee will buildupon its rich 
bipartisan legacy of leadership in providing assistance that is 
responsive to the needs of an evolving veteran population.
    We greatly appreciate the opportunity to submit this written 
testimony on behalf of our Nation's homeless veteran service providers, 
and look forward to working with this Committee to help advance 
S. 1806, S. 3049, and S. 3309--with the above recommendations--to the 
full Senate.
            Respectfully,

    John Driscoll,
    President and CEO.
Matt Gornick,
Policy Assistant Director.
      
                                 ______
                                 
          Prepared Statement of Paralyzed Veterans of America

    Chairman Murray, Ranking Member Burr, and Members of the Committee, 
Paralyzed Veterans of America (PVA) would like to thank you for the 
opportunity to present our views on the broad array of legislation 
impacting the Department of Veterans Affairs (VA) pending before the 
Committee. These important bills will help ensure that veterans receive 
the best health care and benefits services available to them.

S. 3313, THE ``WOMEN VETERANS AND OTHER HEALTH CARE IMPROVEMENTS ACT OF 
                                 2012''

    PVA strongly supports the ``Women Veterans and Other Health Care 
Improvements Act of 2012.'' If enacted, this bill would improve health 
care services for women veterans within the VA.
    PVA is particularly pleased to see the provisions related to 
reproductive services for catastrophically disabled service-connected 
veterans. One of the most devastating results of spinal cord injury or 
dysfunction for many individuals is the loss of the ability to have 
children and raise a family. PVA has long sought inclusion of 
reproductive services in the spectrum of health care benefits provided 
by the VA. Sections 2, 3 and 4, of the proposed legislation are 
significant steps in securing these much needed and long overdue 
treatment modalities that are critical components of catastrophically 
disabled veterans' maximization of independence and quality of life.
    Advancements in medical treatments have for some time made it 
possible to overcome infertility and reproductive disabilities. For 
some paralyzed veterans procreative services have been secured in the 
private sector at great cost to the veteran and family. In April 2010, 
a Memorandum promulgated by the Office of the Assistant Secretary of 
Defense (Health Affairs) extended reproductive services, including in-
vitro fertilization, to servicemembers and retired servicemembers who 
had a loss of reproductive ability due to serious injury while on 
Active Duty. The Memorandum notes ``Although many medical and other 
benefits are available to these members and their families, members 
with spinal and other injuries that make it impossible to conceive a 
child naturally are not provided TRICARE coverage, which can assist 
them in becoming a parent.''
    An implementing guidance memorandum described available 
reproductive services as sperm retrieval, oocyte retrieval, in-vitro 
fertilization, artificial insemination, and blastocyst implantation. 
Similar to the Department of Defense's recognition that reproductive 
services are crucial elements in affording catastrophically disabled 
individuals and their spouses with life-affirming ability to have 
children and raise a family, so too will passage of the provisions of 
this bill that authorize the VA to offer similar services to veterans 
disabled in service to the Nation.
    This bill also proposes to improve access to VA care by making both 
health care and benefits information available through the VA Women 
Veterans Call Center, as well as referrals for community resources to 
obtain assistance with services not furnished by the VA. While we 
support improvements to the call center, PVA believes that VA must 
continue working toward developing a comprehensive model of care that 
provides woman veterans with a broader variety of quality services that 
they need. The FY 2013 Independent Budget reported that 51 percent of 
women veterans who utilize VA health care services also use non-VA 
providers. Given this high percentage of woman seeking health care 
services in the VA and with other providers, the VA must not only work 
to improve the variety of services available to meet women's health 
care needs, but it must also work to ensure that there is adequate care 
coordination with the non-VA providers serving women veterans. Care 
coordination is the only way to monitor the quality of care provided to 
women veterans outside the VA health care system.
    PVA also supports the proposed extensions of the pilot program for 
counseling in retreat settings for women veterans newly separated from 
service, and the pilot programs on assistance for child care for 
certain veterans. Providing veterans with child care assistance 
eliminates a barrier to care that prevents many veterans from receiving 
appropriate health services. Women veterans are one of the fastest 
growing populations within the VA health care system and we must make 
certain that they have access to, and receive, quality health care 
services through the VA.

                                S. 3238

    PVA's National office has no position on naming the VA community-
based outpatient clinic in Mansfield, Ohio, as the David F. Winder VA 
Community-Based Outpatient Clinic. PVA believes naming issues should be 
considered by the local community with input from veterans 
organizations within that community. With that in mind, we would defer 
to the views of PVA's Buckeye Chapter.

                                S. 3206

    PVA supports S. 3206, a bill that would extend the authorization 
for the VA to pay a monthly assistance allowance to disabled veterans 
training or competing for the Paralympic team. PVA continues to support 
the partnership between the Paralympics and the VA to expand sports and 
recreation opportunities to disabled veterans and injured 
servicemembers. We believe that this has certainly been a worthwhile 
program as the need for expansion of these activities is necessary. We 
appreciate the role that the Paralympics have played in this expansion.

       S. 3202, THE ``DIGNIFIED BURIAL OF VETERANS ACT OF 2012''

    PVA fully supports the provisions of S. 3202, the ``Dignified 
Burial of Veterans Act of 2012.'' Under current law, VA is not 
authorized to purchase a casket or urn for veterans who have no 
designated next-of-kin or who lack the resources to provide and 
appropriate, dignified burial to properly memorialize the deceased 
veteran. The proposed legislation would ensure that VA furnishes a 
casket or urn to a deceased veteran when VA is unable to identify the 
veteran's next-of-kin and determines that sufficient resources are not 
otherwise available to furnish a casket or urn for burial in a national 
cemetery. This provision is consistent with the requirements that would 
be placed on the VA if the provisions of S. 2244, the ``Veterans 
Missing in America Act,'' were enacted. Additionally, this bill would 
require VA to issue a report to Congress on the industry standard for 
urns and caskets and whether burials at VA's national cemeteries are 
meeting that standard.

            S. 3084, THE ``VISN REORGANIZATION ACT OF 2012''

    PVA opposes S. 3084, a bill that would establish a new 
organizational structure for the alignment of the Veterans Integrated 
Service Networks (VISN) around the country. PVA has serious concerns 
about the precedent that this legislation would set. The VA currently 
uses the VISN structure as a management tool for the entire VA health 
care system. It makes no sense for the Congress to legislate how the VA 
should manage its system. Furthermore, this sets a dangerous precedent 
whereby any member could decide that the VA's VISN alignment is not 
satisfactory (in their opinion), and that it should be redrawn in such 
a way to support his or her own state or district.
    However, we believe that the current network alignment could be 
reassessed and possibly realigned. There is certainly nothing that 
suggests that 21 service networks is the optimal structure. But where 
does the VA draw the line when establishing its health care system 
structure? With the current 21 VISN's, the VA seems to do a good job of 
managing a massive health care system. This is not to suggest that the 
administration of these networks is not bloated, but the alignment 
itself seems satisfactory.
    Meanwhile, it is our understanding that the Veterans Health 
Administration is already considering a realignment of its VISN 
structure. If this is in fact the case, then we believe the VA should 
provide more information on this plan.

                                S. 3052

    PVA supports the provisions of S. 3052. This legislation affirms 
the important role that veterans' service organizations (VSO) play in 
assisting veterans with their claims for benefits. It would ensure that 
veterans who choose to file a claim for benefits electronically are 
informed about their options for representation from a VSO national 
service program. We would offer one suggestion about the proposed 
language of the bill. We believe that the qualifier--``to the degree 
practical''--at the beginning of the new Section 5103B should be 
removed from the bill. We see no reason why it would not be practical 
to inform veterans of their representation options. However, this 
language gives the VA an excuse should it choose not to provide this 
information.

                                S. 3049

    PVA supports S. 3049, a bill that expands the legal definition of 
``homeless veterans'' to align with the commonly accepted legal 
standard for homelessness that exists in this country. Due to an 
oversight in the law, the legal definition of ``homeless veterans'' 
differs significantly from the existing definition of homelessness. 
Specifically title 38 U.S.C. does not recognize as being homeless an 
``individual or family who is fleeing, or is attempting to flee, 
domestic violence, dating violence, sexual assault, stalking, or other 
dangerous or life-threatening conditions in the individual's or 
family's current housing situation'' (42 U.S.C. Sec. 11302b). The 
wording change proposed by S. 3049 would allow veterans who experience 
a domestic violence situation, and choose to leave that situation, to 
access the same benefits available to all other homeless veterans. 
Currently, in order to qualify for benefits offered to homeless 
veterans through the VA, an individual must only meet the definition of 
homeless in outlined by 42 U.S.C. Sec. 11302a. It only makes sense that 
the VA's definition for homelessness align with the larger Federal 
standard.
    S. 2320, the ``Remembering America's Forgotten Veterans Cemetery 
Act of 2012''
    Since 1991, the veterans' cemetery at Clark Air Force Base in the 
Philippines has remained unattended and seriously deteriorated. 
Volunteers have over the years tried to do some minor maintenance, but 
those efforts have proven futile at best. No Federal assistance has 
been provided to upkeep the Clark Veterans Cemetery. Meanwhile, the 
remains of more than 8,300 servicemembers and their dependents remain 
interred there.
    The fact that the final resting place for those who have served and 
sacrificed is in such a state of decay is wholly unacceptable. The 
American public would not stand for any national cemetery in this 
county to be maintained in this manner, and similar hallowed grounds 
outside of the United States should not be treated in this way as well. 
PVA supports S. 2320 which would give the American Battle Monuments 
Commission (ABMC) authority to care for Clark Veterans Cemetery. The 
ABMC is the best suited to assume this authority with their experience 
in care for cemeteries and monuments in foreign lands. We must however 
emphasize that adequate additional resources must be provided to the 
ABMC to ensure that the proper care is given to the cemetery.
    S. 2259, the ``Veterans' Compensation Cost-of-Living Adjustment Act 
of 2012''
    PVA supports S. 2259, the ``Veterans' Compensation Cost-of-Living 
(COLA) Adjustment Act of 2012,'' that would increase, effective as of 
December 1, 2012, the rates of compensation for veterans with service-
connected disabilities and the rates of dependency and indemnity 
compensation (DIC) for the survivors of certain disabled veterans. This 
would include increases in wartime disability compensation, additional 
compensation for dependents, clothing allowance, and dependency and 
indemnity compensation for children. PVA continues to oppose the 
provision of this legislation that would round down any benefit to the 
next lower whole dollar amount.
    Last year marked the first time in three years that veterans (and 
Social Security recipients) received a COLA increase. While our economy 
continues to struggle, veterans' personal finances have been affected 
by rising costs of essential necessities to live from day to day and 
maintain a certain standard of living.

                                S. 2045

    PVA does not support the proposed legislation. We believe that 
imposing the locality residence requirement would lead to the negative 
impression across the country that the Court of Appeals for Veterans 
Claims is an ``inside the beltway club,'' a common concern often raised 
by people on many issues outside of the Washington metropolitan region. 
Perhaps more importantly, we are concerned that imposing this locality 
restriction could eliminate some of the most qualified judges from 
consideration for the Court. In fact, we understand that one of the 
currently sitting judges works remotely from his home in another state 
and continues to be one of the most productive judges on the Court.

        S. 2244, THE ``VETERANS MISSING IN AMERICA ACT OF 2012''

    The purpose of the Missing in America (MIA) Project is to locate, 
identify and inter the unclaimed cremated remains of American veterans 
through the joint efforts of private, state and Federal organizations. 
The non-profit organization seeks to ``provide honor and respect to 
those who have served this country by securing a final resting place 
for these forgotten heroes.'' The proposed legislation would require 
the VA to assist entities in possession of unclaimed or abandoned human 
remains in determining if any such remains are the remains of veterans 
or other individuals eligible for burial in a national cemetery. 
Additionally, the legislation would require the VA to cover the cost of 
funeral expenses and burial in the event that no next-of-kin can be 
identified. PVA fully supports this legislation. We would only 
emphasize that Congress must provide any additional resources necessary 
to allow VA to provide burial services.

      S. 1849, THE ``RURAL VETERANS HEALTH CARE IMPROVEMENT ACT''

    PVA supports S. 1849, a bill that requires a five year strategic 
plan for the VA Office of Rural Health (ORH) to improve access and the 
quality of health care services for veterans in rural areas. 
Approximately 40 percent of veterans who utilize VA health care 
services live in rural areas, with a significant proportion of this 
population residing in ``highly rural'' areas. If enacted, S. 1849 
would require the VA to create a strategic plan for the ORH that 
includes identifying goals and objectives for recruitment and retention 
as well as for improving timeliness of care provided to veterans living 
in rural areas.
    PVA believes that attracting and retaining adequate staff within 
the Veterans Health Administration (VHA) is one of the most critical 
elements to providing quality health care in a timely manner. However, 
recruiting and retaining medical professionals in rural settings 
continues to be a challenge as the population of veterans residing in 
rural areas continues to grow. PVA believes that the requirements of 
S. 1849 to provide specific goals and objectives to improve rural 
health care for veterans has the potential to further develop and 
expand upon the improvements that VA has already made in the area of 
rural health care. Particularly, PVA is pleased that this bill requires 
VA leadership to define specific goals and objectives in the areas of 
recruitment and retention, and enhance the use of current programs 
using technology to increase veterans' access to VA health care 
services.
    While PVA supports S. 1849, it must be noted, that this bill 
requires the VA ORH to develop a strategic plan that includes goals and 
objectives for ensuring timeliness and improving the quality of health 
care services provided through contract and fee-basis providers. PVA 
believes that non-VA providers serve a purpose in meeting the health 
care needs of veterans residing in rural areas and are an essential 
component of the VA providing timely care in remote settings. However, 
such options should not be used as a method or course to eliminate VA 
facilities. PVA believes that the greatest need is still for qualified 
VA health care providers to be located in rural settings. We believe 
that the VA is the best health care provider for veterans. Providing 
primary care and specialized health services is an integral component 
of VA's core mission and responsibility to veterans. Over the years, VA 
has earned a reputation as a leader in the medical field for its 
quality of care and innovation in providing ``veteran-specific'' health 
care.
    Providing quality health care in rural settings is a continuous 
challenge for the VA, however, Congress, the VA, and stakeholders such 
as veteran service organizations must continue to develop innovative 
strategies to meet the health care needs of rural veterans. PVA 
believes that the strategic plan proposed in S. 1849 is a step in the 
right direction.

                                S. 1838

    While PVA has no specific position on this proposed legislation, we 
believe that it could be beneficial therapy for veterans dealing with 
Post-Traumatic Stress Disorder (PTSD) and other mental health issues. A 
model program for this service was created in 2008 at the Palo Alto VA 
Medical Center in conjunction with the Assistance Dog Program. This 
program, maintained by the Recreational Therapy Service at the Palo 
Alto VAMC, is designed to create a therapeutic environment for veterans 
with post-deployment mental health issues and symptoms of PTSD to 
address their mental health needs. Veterans participating in this 
program train service dogs for later placement with veterans with 
hearing and physical disabilities. As we understand it, in 2006, Walter 
Reed Army Medical Center conducted a similar, privately-funded, pilot 
program where service dogs were used in therapeutic settings.
    In these programs, training service dogs for fellow veterans is 
believed to be helping to address symptoms associated with post-
deployment mental health issues and PTSD in a number of ways. 
Specifically, veterans participating in the programs demonstrated 
improved emotional regulation, sleep patterns, and sense of personal 
safety. They also experienced reduced levels of anxiety and social 
isolation. Further, veterans' participation in these programs has 
enabled them to actively instill or re-establish a sense of purpose and 
meaning while providing an opportunity to help fellow veterans 
reintegrate back into the community. Given the apparent benefit to 
veterans who have participated in similar programs as the one proposed 
by S. 1838, we see no reason to oppose this legislation.
    S. 1799, the ``Access to Appropriate Immunizations for Veterans Act 
of 2011''
    PVA supports S. 1799, which proposes to amend title 38, United 
States Code to provide for requirements related to the immunization of 
veterans. It is accepted fact that proper and timely administration of 
immunizations can prevent the onset of more significant medical issues. 
By requiring the Secretary to ensure these immunizations are 
administered in compliance with the recommended adult immunization 
schedule, and requiring quality measures to ensure this is done, it can 
be expected that veterans using the VA will be healthier and less 
likely to suffer potential medical ailments. The Department of Defense 
(DOD) follows these procedures to ensure a more ready military force. 
It only makes medical and economic sense that the health gains achieved 
by the DOD program for individuals prior to leaving service should be 
continued to maintain and benefit the health of veterans. Proper and 
timely immunizations are a guarantee of better medical health in the VA 
patient population.

                                S. 1755

    PVA strongly supports S. 1755, a bill to amend title 38, United 
States Code, to provide certain disabled veterans coverage under the 
beneficiary travel program of the VA when seeking services for special 
disabilities rehabilitation. Currently, the Department of Veterans 
Affairs (VA) does not provide travel reimbursement for catastrophically 
disabled non-service-connected veterans who are seeking inpatient 
medical care. PVA believes that expanding VA's beneficiary travel 
benefit to this population of severely disabled veterans will lead to 
an increasing number of catastrophically disabled veterans receiving 
quality comprehensive care, and result in long-term cost savings for 
the VA.
    Under S. 1755, Section 111 of title 38 U.S. Code would be amended 
to extend travel reimbursements benefits for inpatient care to 
catastrophically disabled non-service-connected veterans who have 
incurred a spinal cord injury or disorder, visual impairment, or 
multiple amputations. For this particular population of veterans, their 
routine annual examinations often require inpatient stays, and as a 
result, significant travel costs are incurred by these veterans. 
Eliminating the burden of transportation costs as a barrier to 
receiving health care, will improve veterans' overall health and well 
being, as well as decrease, if not prevent, future costs associated 
with both primary and long-term chronic, acute care.
    Too often, catastrophically disabled veterans choose not to travel 
to VA medical centers for care due to significant costs associated with 
their travel. When these veterans do not receive the necessary care, 
the result is often the development of far worse health conditions and 
higher medical costs for the VA. For veterans who have sustained a 
catastrophic injury like a spinal cord injury or disorder, timely and 
appropriate medical care is vital to their overall health and well-
being.

       S. 1707, THE ``VETERANS SECOND AMENDMENT PROTECTION ACT''

    Regarding S. 1707, the ``Veterans Second Amendment Protection 
Act,'' PVA has no formal position on this legislation.

                                S. 1705

    PVA's National office has no position on naming the VA medical 
center in Spokane, Washington, as the ``Mann-Grandstaff Department of 
Veterans Affairs Medical Center. PVA believes naming issues should be 
considered by the local community with input from veterans 
organizations within that community. With that in mind, we would defer 
to the views of PVA's Northwest Chapter.

                                S. 1631

    PVA generally supports the intent of S. 1631, legislation that 
authorizes the VA to establish a center for technical assistance for 
non-VA health care providers who furnish care to veterans in rural 
areas. As previously stated, we believe that the VA is the best health 
care provider for veterans. However, when veterans reside in rural 
areas and do not have timely access to VA health care services, it is 
important that the care provided outside of the VA meet the proper 
standards of quality and can be properly coordinated with VA medical 
professionals. S. 1631 proposes to improve collaboration on veterans' 
health care matters between VA and non-VA providers serving veterans in 
rural areas by encouraging exchange of health care information between 
providers, creating shared internet-based information databases to 
collect information on mechanisms to improve health care for veterans 
in rural areas, and creating systems to monitor fee expenditures of the 
VA relating to non-VA provider services.
    PVA recognizes that veterans frequently seek health care services 
from non-VA providers independently and through VA purchased care and 
contract care programs. Therefore the VA must continue its efforts to 
increase care coordination, as this bill proposes, with private 
providers to ensure that veterans receive the best possible health care 
services available. With this in mind, PVA is concerned that the 
creation of the Rural Veterans Health Care Technical Assistance Center 
will contribute to growing VA administrative costs and perhaps will 
result in a duplication of efforts, as it appears that the purpose of 
the center is in direct alignment with VA's Office of Rural Health. It 
is unclear in the bill exactly where the supervisory authority of the 
center will come from; therefore, PVA recommends that the center be 
housed within the ORH to most efficiently utilize VA resources.

                                S. 1391

    PVA supports S. 1391. According to reports, sexual assault in the 
military continues to be a serious problem, despite several actions by 
the Department of Defense (DOD) to combat the issue, including required 
soldier and leader training. As the military works to reduce the threat 
and incident of military sexual trauma (MST), it is important that 
victims of MST, both women and men, have the ability to receive care 
from the VA and receive timely, fair consideration of their claims for 
benefits. This is particularly important given the number of MST 
occurrences that go unreported. While current policies allowing 
restricted reporting of sexual assaults should reduce the number of 
incidents which have ``no official record,'' it can still be 
anticipated that there are those who will not report the incident out 
of shame, fear of reprisals or stigma, or actual threats from their 
attacker. To then place a high burden of proof on the veteran who has 
experienced MST to prove service-connection, particularly in the 
absence of an official record, would add further trauma to an already 
tragic event.
    One particular recommendation that PVA would like to make about the 
proposed language is a clarification on what constitutes a ``mental 
health professional.'' We would hope that the intent of this 
legislation is not to limit ``mental health professionals'' to only VA 
health care professionals.

          S. 1264, THE ``VETERAN VOTING SUPPORT ACT OF 2011''

    PVA supports S. 1264, the ``Veteran Voting Support Act of 2011.'' 
PVA advocates for the rights of veterans, persons with disabilities, 
and all Americans, which enable them to participate in the election 
process. Making the voting process accessible and available for 
paralyzed veterans has been a priority for our organization.
    PVA supports the requirement of the VA to provide information 
relating to requesting an absentee ballot and making absentee ballots 
available upon request. PVA also supports the provision of the bill 
that would permit nonpartisan organizations to provide voter 
registration information at facilities of the VA.

      THE ``HOMELESS VETERANS ASSISTANCE IMPROVEMENT ACT OF 2012''

    PVA generally supports the provisions of the draft legislation, the 
``Homeless Veterans Assistance Improvement Act.'' Many of the grant 
programs outlined in the legislation will help veterans who are 
homeless or are facing the prospect of homelessness to overcome the 
hurdles that they may face. PVA is disappointed to see that the annual 
amount authorized the Secretary of Veterans Affairs to carry out 
homeless veterans programs is being decreased from $200 million to $150 
million. This step reflects a concern that we raised in the past that 
changing authorization levels for funding homeless programs would 
likely be an empty gesture.
    PVA is particularly pleased to see the extension of the Homeless 
Veterans Reintegration Program (HVRP). However, we are concerned that 
this extension only provides for one additional year. The HVRP program 
is perhaps one of the most cost-effective and cost-efficient programs 
in the Federal Government. Despite being authorized $50 million per 
year, it generally is appropriated less than half of that authorized 
level every year. And yet, it continues to serve a large number of 
veterans who are taking the necessary steps to overcome homelessness.
    Ultimately, in order to ensure that the myriad of homeless programs 
are successful, fully sufficient resources must be provided to these 
programs. Otherwise, overcoming homelessness becomes a policy without 
the possibility of true success.

                THE ``MENTAL HEALTH ACCESS ACT OF 2012''

    PVA supports the proposed legislation, the ``Mental Health ACCESS 
Act of 2012.'' The proposed bill would improve and enhance the programs 
and activities of the VA regarding suicide prevention and resilience, 
and behavioral health disorders for veterans and servicemembers. While 
the VA has made tremendous strides in the quality of care and variety 
of services provided to veterans in the area of mental health, PVA 
believes that issues involving access to mental health care continue to 
exist and more must be done to make certain that all veterans receive 
timely and effective services. It is for this reason that we thank the 
Committee for reviewing this important piece of legislation.
    Under the proposed bill, the VA is required to conduct a 
comprehensive assessment of VA mental health care services with 
particular attention to the areas of timeliness of care, mental health 
staffing, and the availability and furnishing of evidence-based 
therapies. The bill goes a step further and requires the VA to 
establish a ``Study Committee'' to assist in developing and 
implementing the aforementioned improvements in mental health care 
delivery. PVA believes that a comprehensive assessment of VA mental 
health services is much needed, and we also support the requirement to 
have the VA develop and implement guidelines for the staffing of 
general and specialty mental health care services, including community-
based outpatient clinics. Such staffing guidance is especially 
important in light of VA's recent announcement to hire additional 
mental health professionals.
    One of the most significant provisions of the bill is the proposal 
to amend title 38, United States Code, Section 1712A to expand 
eligibility for readjustment counseling and related mental health 
services. If enacted, this bill will enable VA to provide certain 
members of the Armed Forces, and their family members, with counseling 
services through VA Vet Centers. PVA strongly supports these amendments 
as we understand that servicemember deployments and veteran 
readjustment to civilian life not only affects the individuals who 
served their country, but also their family members, loved ones, and 
others that serve as close support networks. Nonetheless, with such a 
significant expansion of services now becoming available to this new 
population, PVA is concerned that the cost increases associated with 
this change have the potential to limit the quality and availability of 
services for the intended groups. PVA recommends that the VA and 
Congress conduct an assessment that evaluates the ability of Vet 
Centers to provide the services needed by veterans, servicemembers, and 
their family members to best determine if and when these services can 
be provided.
    Additionally, the draft legislation gives the VA Secretary the 
authority to furnish mental health care through facilities other than 
Vet Centers to immediate family members of servicemembers deployed in 
connection with a contingency operation. Again, PVA supports and 
understands the intended purpose of this provision, however, should the 
VA provide the prescribed services, both VA and Congress must work to 
ensure that adequate resources are made available to meet the new 
demand.
    PVA would once again like to thank the Committee for the 
opportunity to submit our views on the legislation considered today. 
Enactment of much of the proposed legislation will significantly 
enhance the health care and benefits services available to veterans, 
servicemembers, and their families. We look forward to working with the 
Committee to ensure quick enactment and implementation of these 
important changes.

    This concludes PVA's statement. We would be happy to receive any 
questions that you may have.
                                 ______
                                 
            Letter from Barbara Collura, President, Resolve
                      The National Infertility Association,
                                         McLean, VA, June 26, 2012.
Hon. Patty Murray,
Chairman,
Committee on Veterans' Affairs
U.S. Senate, Washington, DC.
                  RE: Testimony for hearing on S. 3313
    Dear Chairman Murray: On behalf of the 7.3 million Americans who 
are diagnosed with infertility, I commend you for introducing S. 3313, 
the ``Women Veterans and Other Health Care Improvements Act of 2012.'' 
Infertility is a devastating diagnosis to receive and it is further 
complicated by lack of insurance coverage for most Americans. As you 
know, TRICARE, and other medical benefits for active duty military and 
veterans, does not include coverage for infertility treatments 
including assisted reproductive technologies, such as in vitro 
fertilization (IVF). This places an added hardship on our servicemen 
and women and veterans with infertility that is unnecessary.
    RESOLVE: The National Infertility Association applauds your efforts 
to provide fertility counseling and medical treatment to veterans 
wounded in the line of duty. These veterans have many necessary medical 
services available to them upon returning home, yet if their military 
service has rendered them infertile, they have no access to medical 
treatment to have a child. This is an injustice that your bill seeks to 
correct. By providing this coverage, veterans have a chance at the 
family they always dreamed of. For many wounded veterans, assisted 
reproductive technologies such as IVF may be their only hope of ever 
having a biological child with their spouse. IVF has been practiced for 
over 30 years and is a safe and effective treatment for many types of 
infertility that cannot be treated with medication or surgical 
procedures. In recent years, professional guidelines have made IVF even 
safer and more effective through reducing the incidence of multiple 
births, improving egg and embryo freezing technologies, and improving 
pregnancy rates through embryo quality.
    RESOLVE would like to suggest that infertility coverage be expanded 
to include all veterans and active duty military so that all those with 
infertility in our Armed Forces have access to the care they need. 
Infertility affects men and women equally, and some infertility is 
unexplained. It is important that men and women receive access to care 
at the same level. Many couples find that they need to utilize third 
party reproduction to have a child, such as using donated sperm, eggs 
(oocytes), or embryos. Others can have a biological child but need a 
gestational carrier surrogate to carry the pregnancy. The cost for 
these medical services should be included in this legislation.
    Our wounded veterans deserve access to the best medical care that 
is available for their medical condition, and this bill will do just 
that. So much has been taken away from our wounded veterans; don't take 
away their dream of having a child, especially when medical treatment 
exists to help them. RESOLVE stands ready to assist the Department of 
Veterans Affairs in providing the necessary support and information to 
our veterans who pursue care for their infertility.
    Thank you again for introducing this bill.
            Sincerely yours,
                                           Barbara Collura,
                                                         President.
                                 ______
                                 
               Letter from Ron Sims, Seattle, Washington



Enclosures
       Enclosures from Ron Sims regarding Clark Veterans Cemetery







                                 ______
                                 
 Prepared Statement of Morris Klein, Esq., Attorney at Law, Bethesda, 
 Maryland, and Lois Zerrer, Zerrer Elder Law Office, LLC, Springfield, 
           Missouri, on Behalf of the Special Needs Alliance

    Chairwoman Murray, Senator Burr and Members of the Committee, Thank 
you for inviting the Special Needs Alliance (SNA) to submit testimony 
this morning.
    The SNA is a national, not-for-profit organization of attorneys 
dedicated to the practice of disability and public benefits law. Our 
mission is to maintain a professional organization of attorneys skilled 
in the complex areas of public entitlements, estate, trust and tax 
planning, and legal issues involving individuals with physical and 
cognitive disabilities, including veterans with disabilities. SNA 
membership is based on a combination of relevant legal experience in 
the disability and elder law fields, direct family experience with 
disability, active participation with national, state and local 
disability advocacy organizations, and professional reputation.
    It is our privilege to provide comments on S. 3270, legislation 
that will impose a ``look-back'' period for veterans and their spouses 
who transferred countable assets and then seek a Non-Service-Connected 
Disability Pension for assistance to pay for their care needs.

                   NEED TO SPECIFY RESOURCE STANDARD

    We respectfully request that the bill ultimately include a 
provision requiring the VA to specify the maximum amount of resources 
an applicant may retain to be eligible for benefits.
    The VA does not have a clear, fixed standard as to what amount of 
resources an applicant may possess to be eligible for benefits. Other 
means-tested programs that consider resources, particularly SSI and 
Medicaid, have specified maximum amounts of resources (the amount for 
SSI is $2,000 and the amount for Medicaid is determined by the state, 
usually between $2,000 and $4,000). Administrators at the VA apparently 
have discretion in determining whether a particular applicant has 
sufficient resources to qualify for the program. This can result in 
unequal treatment between applicants. A veteran can only ``guess'' 
whether the resources he or she has is low enough to be eligible for 
benefits. Moreover, a veteran in one region may qualify for benefits 
while a veteran in another region would not be eligible. This lack of 
consistency makes it difficult for a veteran to determine whether or 
not to apply for benefits. The lack of consistency is particularly 
disquieting now that an applicant may face a ``penalty'' for 
transferring resources. Ironically, the smaller the benefit the veteran 
receives, the greater the penalty (up to the 36 month maximum).

                 CONSIDERATION OF SPECIAL NEEDS TRUSTS

    We respectfully request that the bill ultimately include a 
provision exempting special needs trusts from consideration as a 
countable resource.
    The GAO suggested an eligibility scheme that is similar to other 
means-tested programs. Other means-tested programs, such as SSI and 
Medicaid, do carve out an exception for special needs trusts. A special 
needs trust is different than the purchase of annuities that the GAO 
has criticized in a recent report, and is not the type of trust 
contemplated or discussed as abusive. Only a person who has suffered a 
disability can become a beneficiary of a special needs trust. 
Specifically, a special needs trust allows a person who has a physical 
or mental disability to have assets held in trust to help pay for care 
needs that would not be covered by public benefits. Special needs 
trusts had been used for many years. In 1993, Congress explicitly 
authorized the use of special needs trusts for the benefit of 
individuals who are under the age of 65 and disabled as defined by the 
Social Security Administration. The assets of an individual with a 
disability that are placed in a properly drafted special needs trust 
are not considered available for purposes of qualification for SSI and 
Medicaid. Such trusts are irrevocable and require funds to be used only 
for the sole benefit of the beneficiary, and any funds remaining in the 
trust after the beneficiary dies must be ``paid back'' to the state 
Medicaid agency to the extent the agency paid for the beneficiary's 
care. See 42 U.S.C. Section 1396d4(A).
    Congress has heretofore not taken a position on special needs 
trusts as they apply to VA benefits. A VA General Counsel opinion 
(VAOPGCPREC 33-97, VA General Counsel Opinion dated August 2, 1997) 
concluded that funds in a special needs trust are counted as resources. 
Thus, unlike applicants for other government needs-based benefits, 
veterans who are applicants for the improved pension and Aid and 
Attendance benefits who are also beneficiaries of special needs trusts 
will have the funds in the trust counted as an available resource. This 
in effect discriminates against the veteran who is treated differently 
than non-veterans in their ability to set aside such funds.
    We believe that there is no meaningful distinction between the 
treatment of special needs benefits for other public benefit programs 
and the VA program, and we respectfully urge the Committee to extend 
the current treatment of special needs trusts to VA benefits.

                TRANSFERS TO CHILDREN WITH DISABILITIES

    The legislation should ultimately carve out an exemption for 
transfers to blind and disabled children.
    Continuing with the GAO suggestion that the VA eligibility 
standards follow other public benefit programs, this legislation should 
also exempt transfers to the children of veterans who are blind or 
disabled. Federal law for Medicaid and SSI eligibility have exempted 
such transfers to blind and disabled children. See 42 U.S.C. Section 
1396p(a)(2)(B) and 1396p(c)(2)(A) and (B).

            ELIGIBILITY DATE AS APPLIED TO REDETERMINATIONS

    The law should only apply to transfers made after the law goes into 
effect.
    It appears clear from the language of the legislation that the 
imposition of a look-back period is to be applied prospectively, as the 
changes go into effect one year after the bill is signed into law. 
However, the law applies to annual redeterminations as well, and since 
there is a three-year look back, a beneficiary may lose benefits 
resulting from transfers made two years before the effective date of 
the law. We therefore suggest that the law be clarified to state that 
transfers made prior to the effective date of the law shall not be 
subject to the look-back period.

    Thank you again for the opportunity to share these thoughts on 
S. 3270. The Special Needs Alliance looks forward to working with the 
Committee to address these technical issues in the legislation. Please 
let us know if we can be of further assistance.
                                 ______
                                 
        Prepared Statement of Anu Bhagwati, Executive Director, 
                     Service Women's Action Network

    Chairman Murray and Members of the Committee: Thank you for the 
opportunity to present the views of the Service Women's Action Network 
(SWAN) concerning three bills included in this legislative hearing: 
S. 1391, S. 3049 and S. 3313.
    SWAN is a nonprofit service organization founded to improve the 
welfare of current U.S. servicewomen and to assist all women veterans. 
SWAN offers personal support and guidance to fellow women veterans, 
provides legal and counseling services from military law experts and 
caseworkers, recommends sound policy reform to government officials, 
and educates the public about servicewomen's issues through various 
media outlets. Conceived as a support network by and for women 
veterans, SWAN serves all military women, regardless of era, 
experience, or time in service.
    SWAN has been working on improving benefits for women veterans, 
both within the VHA and VBA as an ongoing policy priority for many 
years and is extremely encouraged by the engagement and leadership 
shown by the Committee over the years on key issues that are critical 
to ensuring that women veterans receive the very best in care and 
benefits. It is with that goal in mind that SWAN provides hearing 
testimony on the following bills:

    S. 1391--TO AMEND TITLE 38, UNITED STATES CODE, TO IMPROVE THE 
   DISABILITY COMPENSATION EVALUATION PROCEDURE OF THE SECRETARY OF 
 VETERANS AFFAIRS FOR VETERANS WITH POST TRAUMATIC STRESS DISORDER OR 
  MENTAL HEALTH CONDITIONS RELATED TO MILITARY SEXUAL TRAUMA, AND FOR 
                            OTHER PURPOSES.

    SWAN fully supports S. 1391. In 2010, the VA adopted a new 
evidenciary standard for combat-related Post Traumatic Stress Disorder 
(PTSD) claims. Prior to this change, veterans filing a claim for 
combat-related PTSD had to demonstrate they were traumatized by a 
specific event by supplying incident reports, witness statements or 
other evidence. Since the policy change, the evidence required has been 
reduced to having the veteran's trauma claim related to fear of hostile 
military or terrorist activity and that it is consistent with the 
veteran's service record. The intent behind this change was to expedite 
and increase access to much needed disability benefits for 
servicemembers suffering from the invisible wounds of war.\1\
---------------------------------------------------------------------------
    \1\ http://www1.va.gov/opa/pressrel/pressrelease.cfm?id=1922
---------------------------------------------------------------------------
    However, when making these changes. The VA did not include PTSD 
caused by Military Sexual Trauma (MST), even if that trauma was a 
result of sexual assault or sexual harassment in a combat zone. By 
excluding MST-based PTSD claims in this procedural reform, the VA has 
created a double-standard and an unfair burden on women veterans who 
must submit additional evidence to support a service connection. This 
has a particularly disparate impact on women since MST is the leading 
cause of PTSD among women veterans, while combat trauma is the leading 
cause of PTSD among men.\2\ SWAN has recently worked with a woman who 
had both an MST-based PTSD claim and a combat PTSD claim pending. She 
abandoned her MST PTSD claim and only pursued her combat PTSD claim 
after her MST claim was repeatedly rejected even after she provided the 
additional evidence requested by the VA.
---------------------------------------------------------------------------
    \2\ Street et al. 2008. ``Sexual harassment and assault experienced 
by reservists during military service: Prevalence and health 
correlates.'' Journal of Rehabilitation Research and Development 45: 
409-420; Kang et al. 2005. ``The role of sexual assault on the risk of 
PTSD among Gulf War veterans.'' Annals of Epidemiology 15(3):191-195.
---------------------------------------------------------------------------
    Additionally, SWAN has discovered through data obtained from the VA 
through a Freedom of Information Act (FOIA) request that there is a 
disparity in the approval rates of MST-based PTSD claims as compared to 
all other PTSD Claims, to include combat PTSD claims. Between 2008 and 
2010, only 32% of MST PTSD claims were approved whereas 53% of all 
other PTSD claims were approved, and nearly 50% of PTSD claims from 
Iraq and Afghanistan veterans were approved.\3\
---------------------------------------------------------------------------
    \3\ In conjunction with the ACLU, SWAN filed a Freedom of 
Information Act (FOIA) request to obtain data concerning gender 
differences in approval for MST-related PTSD claims. Based on data 
analyzed for fiscal years 2008-2010 SWAN discovered that only 32% of 
all PTSD claims related to sexual trauma are accepted. Conversely, 53% 
of PTSD claims overall are accepted. About half of PTSD claims filed by 
Iraq and Afghanistan veterans are accepted.
---------------------------------------------------------------------------
    The end state of the current policy is this: For 2 out of 3 
veterans who are survivors of in-service sexual assault they receive no 
disability benefits related to their PTSD. This lack of benefit care 
results in tremendous hardship for MST survivors, leading to untold 
mental and physical suffering, destroyed families, homelessness and 
suicide. This is not conjecture, it is supported by the facts: 40% of 
homeless women veterans report they were victims of military sexual 
assault,\4\ and the VA reports that the increase risk for sexual 
assault in the military is a factor in increased suicide among 
veterans.\5\
---------------------------------------------------------------------------
    \4\ Williamson, Vanessa and Erin Mulhall. 2009. ``Invisible Wounds: 
Psychological and Neurological Injuries Confront a New Generation of 
Veterans.'' New York: IAVA. ; Mulhall, Erin. 2009. ``Women Warriors: 
Supporting She `Who Has Borne the Battle.''' New York: IAVA.
    \5\ http://www.charleston.va.gov/features/
Female_Veterans_at_Higher_Risk_for_Suicide.asp
---------------------------------------------------------------------------
    In 2011 SWAN began working with Under Secretary for Benefits, 
Allison Hickey to correct this disparity and create a fair policy. 
Initially, General Hickey was amenable to changing the policy due to 
the clear difference in language found in 38 CFR Sec. 3.304(f)(3). She 
soon moved away from that position and instead issued a letter to the 
Regional Offices which did absolutely nothing to help. The RO letter 
simply reiterated the current policy with an added emphasis on giving 
the veteran's application the benefit of the doubt. She also issued 
instructions to increase training for claims officers but in practice, 
this has done nothing to improve the process. The claims officer is 
free to disregard the new instructions and still be justified in 
rejecting a MST-based PTSD claim based on the policy.
    What is not understood by the VA is in many cases, it is 
exceedingly difficult for a veteran suffering from MST-related PTSD to 
produce evidence to satisfy the subjective standards of the reviewing 
officer. This is due in part to the nature of sexual trauma--it often 
takes years after the initial assault for survivors to begin to seek 
out help many months or years after that to begin the arduous claims 
process. This extended amount of time between the event and the claim 
is a leading cause of rejections.
    Additionally, there a lack of official paperwork generated in most 
MST investigations, and although new policy changes have been made, 
there has existed for years and years, poor DOD-wide document retention 
policies for those forms that are produced. A new claim has the 
advantage of the new document retention policies, but any claim prior 
to 2011 does not. Finally, according to the DOD, in 2011 only 15 
percent of sexual assaults are reported, which means in 85% of sexual 
assault cases no official paperwork even exists to support a claim. In 
spite of current VBA rules which allow for non-DOD evidence to aid in 
the determination of a service-connected disability, the VBA still 
routinely denies MST-related claims, even in cases where non-DOD 
evidence is in abundance.
    Due to these systemic shortcomings that lead to ever increasing 
issues for veterans, in lieu of requirements for victims of in-service 
sexual assault to submit the corroborating evidence under the current 
policy, Committee support of S. 1391 is critical. The VA must extend to 
these claimants the same evidentiary relief it has recently afforded to 
veterans who experienced trauma due to operational deployment-related 
stressors.
     s. 3049--to amend title 38, united states code, to expand the 
definition of homeless veteran for purposes of benefits under the laws 
           administered by the secretary of veterans affairs.
    The U.S. Department of Housing and Urban Development recently 
changed their definition of ``homeless'' to include persons who flee 
their home due to domestic violence or sexual violence. S. 3049 would 
align the VA's definition of ``homeless'' with HUD's definition, 
pursuant to the Homeless Emergency Assistance and Rapid Transition to 
Housing (HEARTH) Act.\6\
---------------------------------------------------------------------------
    \6\ http://www.hudhre.info/hearth/
---------------------------------------------------------------------------
    SWAN supports S. 3049 and feels that aligning these definitions 
among Federal agencies is critical for two reasons: 1) There are 
established partnerships between the VA and HUD at the state level, and 
having parity in the definition would ensure an increased efficiency 
when operating together; 2) More specifically, the way in which the VA 
defines a ``homeless person'' can preclude them from getting emergency 
shelter or other services if they are a victim of domestic violence.
    Domestic violence is a leading cause of homelessness, particularly 
among women and families. According to a 2008 report by the US 
Conference of Mayors, 28% of families were homeless due to domestic 
violence and 39% of cities cited domestic violence as the primary cause 
of family homelessness.\7\ In spite of a decrease in overall veteran 
homelessness, women veterans are accounting for an increasing number of 
homeless. According to the GAO, the number of homeless women veterans 
has doubled from 3.89% in 2006 to 6.32% in 2010.\8\ It is critical that 
the Committee support S. 3049 in order to ensure that all veterans, 
including those who flee unsafe and abusive situations have adequate 
access to emergency and transitional housing.
---------------------------------------------------------------------------
    \7\ http://www.nationalhomeless.org/factsheets/domestic.html
    \8\ GAO, Homeless Women Veterans: Actions Needed to Ensure Safe and 
Appropriate Housing, GAO-12-182 (Washington, DC: Dec 2011).
---------------------------------------------------------------------------
 S. 3313--WOMEN VETERANS AND OTHER HEALTH CARE IMPROVEMENTS ACT OF 2012

    SWAN fully supports S. 3313, the Women Veterans and Other Health 
Care Improvement Act. The provisions in this bill that would establish 
VA reproductive and infertility research and treatments, improve the 
VA's women call center, increase the number of women's counseling 
retreat locations from three to 14 and extend the pilot programs for 
assistance for child care all address extremely important issues facing 
women veterans, and would markedly improve the veteran's ability to 
receive and sustain much needed medical assistance and care. SWAN would 
like to comment further on the infertility provisions found in the 
bill.
    Two weeks prior to the introduction of this bill, SWAN received a 
letter from a supporter named Heidi who lives in Illinois. Heidi 
described in detail her difficult, painful and ultimately disfiguring 
journey through the VA system in an effort to correct a fertility 
issue. She eventually sought help out-of-pocket at a non-VA hospital. 
There, her doctors struggled to correct the damage that had already 
been done. ``I'm sure he did all he could,'' Heidi wrote, ``but I was 
too damaged. I decided that I am not going to be able to have kids so I 
need to forget about it.''
    There is a critical need in the VA for proper research and 
treatment for infertility, particularly in light of the high rates of 
genitourinary issues including urinary tract infections (UTIs) 
experienced by military women. According to a study conducted in 2008 
by the Defense Advisory Committee on Women in the Services (DACOWITS), 
for deployed female servicemembers the most common health risk is 
urinary tract infection.\9\ This has the long-term effect of increasing 
infertility specifically among military women due to the operational 
nature of the military. The National Institute of Health has found a 
vast amount of evidence linking the presence of genitourinary infection 
with infertility.\10\ It is therefore incumbent upon the VA to provide 
proper research and treatment for infertility for these women, and 
critical for the Committee to support S. 3313.
---------------------------------------------------------------------------
    \9\ http://www.defense.gov/news/newsarticle.aspx?id=48827
    \10\ http://www.ncbi.nlm.nih.gov/pubmed/360560

    I thank the Chair and the Committee for their time and attention in 
reading this testimony. I am available to answer any further questions 
if needed.
                                 ______
                                 
 Prepared Statement of Charles Huebner, United States Olympic Committee

S. 3206--TO EXTEND THE AUTHORIZATION OF THE U.S. PARALYMPIC INTEGRATED 
 ADAPTIVE SPORTS PROGRAM AND TO PROVIDE A MONTHLY ASSISTANCE ALLOWANCE 
   TO DISABLED VETERANS TRAINING OR COMPETING FOR THE PARALYMPIC TEAM

    Chairman Murray and Ranking Member Burr, and Members of the 
Committee, my name is Charlie Huebner and I am the Chief of Paralympics 
for the United States Olympic Committee (``USOC''). Thank you for the 
opportunity to submit a statement in support of S. 3206, which extends 
the authorization for the highly successful partnership between the 
USOC and the Department of Veteran Affairs to provide Paralympic sports 
activities for disabled veterans in their communities. Paralympic 
programs are sports for physically disabled athletes. These adaptive 
sports activities have become an integral part of their recovery to a 
full and healthy life after completing their service to our country.
    In 2008 Congress passed the Veterans Benefits Improvement Act, 
which authorized the Department of Veterans Affairs to award grants to 
the United States Paralympics to ``plan, develop, manage, and implement 
an integrated adaptive sports program for disabled veterans and 
disabled members of the Armed Forces.'' The program did not commence 
until Fiscal Year 2010 and the authorization expires at the end of 
Fiscal Year 2013. It is imperative that Congress act this year to 
extend the authorization for this program to ensure there is no 
interruption in the services being provided to our disabled Veterans.
    The USOC, which itself was created by Congress, is one of only four 
National Olympic Committees that mange both Olympic and Paralympic 
sport. We are one of only a handful of National Olympic Committees that 
are 100% privately funded, with our major competitors outspending us 
often as much as 5-to-1.
    Beginning in 2003, the USOC, at the request of Congressional 
leaders, and the Military and Veteran community began providing 
technical assistance, training and leadership in providing programs to 
injured servicemembers and Veterans, with a focus on developing 
sustainable programming at the community and installation level.
    The USOC has a strong history and expertise in more than 47 sports 
(including non-Paralympic sports). We have expertise in serving persons 
with a variety of physical disabilities. The USOC has inspiring Olympic 
and Paralympic ambassadors that compel partners and competing 
organizations to collaborate for a common cause. With more than 50 
member organizations like the National Recreation and Parks Association 
and USA Hockey, we have a membership infrastructure of community sport 
organizations that touch thousands of U.S. communities, and allow for 
financial and programmatic efficiencies and significant private sector 
investment.
    Because of the extraordinary increase in need, in 2008 the USOC 
began accepting Federal funding for these programs, while continuing to 
expend considerable private resources in support of these efforts. The 
majority of these funds are distributed via grants to community sport 
organizations to implement and develop local program.
    The Paralympic Movement began shortly after World War II utilizing 
sports as a form of rehabilitation for injured military personnel 
returning from combat. Injured military personnel and Veterans are the 
soul of the Paralympic movement. When discussing the Paralympic 
movement, we are not just talking about a small number of elite 
athletes that will make future Paralympic teams. Rather, we are 
referring to the thousands of disabled active duty military personnel 
and Veterans that have participated in the growing number of physical 
activity programs created throughout the United States under the 
leadership of the USOC and our community partners--like Paralyzed 
Veterans of America, Disabled Sports USA, USA Shooting, and Metro 
Tacoma Parks and Recreation--that allow Veterans with physical 
disabilities an opportunity to re-engage in life by simply skiing with 
their buddies or playing in the backyard with their kids. As 
programming expands daily, we see a population that has lower secondary 
medical conditions, higher self-esteem, lower stress levels and higher 
achievement levels in education and employment. Increasingly, empirical 
research specific to this population is beginning to bear this out. 
More importantly, we see a population that inspires all Americans to 
pursue excellence, in sports and in life.
    We cannot emphasize enough the importance of our more than 200 
partner organizations located in more than 170 communities and 47 
states, and the District of Columbia. The Federal funding that the 
Veterans Integrated Adaptive Sports program has provided has enabled 
these organizations to leverage many millions of dollars more to 
provide the full range of Paralympic sports programming to our 
Veterans. We are proud to have the support and partnership of groups 
including the American Legion, The Fisher House Foundation, the Blinded 
Veterans Association, and the USO in endorsing S. 3206.
    We are also proud that our leadership, and our partners, accepted 
the responsibility to serve those who have served us. Because of your 
leadership in developing and providing funding for this USOC and VA 
partnership, we are able today to report on the several accomplishments 
that have been reached since the launch of the program in June 2010. 
Our primary emphasis in the first two years was to meet the immediate 
need to develop programming for the thousands of disabled Veterans 
returning to their communities and hometowns. Since June 2010, the VA, 
USOC and our more than 200 partners have:

     Distributed more than 300 grants to community sport 
organizations to develop sustainable activity programs for disabled 
Veterans returning to their hometowns.
     These community programs are investing millions of dollars 
in private resources, combined with grants from the VA-USOC grant pool, 
to reach thousands of veterans with a focus on sustainable and 
consistent physical activity at the local level.
     The VA and USOC have emphasized and led an effort to 
promote collaboration between the DOD, VA, and community sport 
organizations to recognize and enhance programmatic and financial 
efficiencies. To date, grant recipients have collaborated and partnered 
with over 70 VA and DOD medical facilities across the country.
     Created the Paralympic Resource Network, an online 
database of Paralympic programs nationally which is designed to link 
individuals with physical and visual disabilities to sports programs in 
their communities.
     Launched successful regional Pilot programs to test 
approaches for veteran recruitment and programming strategies that can 
be replicated in other areas in five locations including: Chicago-land 
area; New England; Northern California; Georgia/ Southeast region; and 
Texas/Gulf State area.
     Inaugurated the VA Rehabilitative Adaptive Sports 
Conference that provided VAMC personnel and leadership with the tools, 
resources, and training necessary to successfully develop and implement 
adaptive sport and recreation programs for disabled veterans at VA 
facilities by collaborating with external community partners.
     Distributed training stipends to over 90 Veteran athletes; 
40 of these athletes have met the national team standard in their 
respective sports.

    Again, we felt it was imperative in the first two years to focus 
the majority of our efforts on development and expansion of sustainable 
programs at the community due to the significant volume of Veterans 
returning home. Based on our experience in collaborating with the VA 
and feedback from the congressional committees of jurisdiction and our 
community partners, we recognized that program development should shift 
to a more regional focus and enhanced oversight and monitoring needed 
to be put in place with respect to program resources, generally, and 
the growing number of sub-recipients. While sustainable and consistent 
program development is a continued focus, we have already proactively 
made adjustments in collaboration with the VA to accomplish the 
following:

     Increase resources devoted to program oversight and 
monitoring in light of the expanded number of grant participants. This 
includes increasing our oversight beyond a self-reporting system, with 
desktop and personal site visits to grantees. With pro-bono services 
provided by a leading consultant firm, the USOC and VA have developed 
and instituted a new grant monitoring process, initiated internal 
audits of grant sub-award recipients, and re-deployed three USOC staff 
members to focus 100% on monitoring and oversight. In year one and two, 
staff that was also focused on developing programming, were also 
responsible for monitoring and oversight. We have determined that with 
more than 200 program partners and an estimated 150 grant recipients, 
it was not feasible for the program staff to also be responsible for 
monitoring and oversight. Please find attached the updated monitoring 
plan that the re-deployed staff are aggressively implementing and will 
meet.
     In 2011 and 2012, the USOC declined to accept the 
federally-allowed administrative fee of five percent (5%), allowing an 
estimated $700,000 to be re-invested into programming and grants.
     Enhance awareness and educational materials of the impact 
and importance of consistent physical activity for Veterans at the 
national, regional and local level. For example, in a recent public and 
privately-funded initiative around the USOC-hosted Warrior Games, the 
USOC and VA reached more than 67.0M Americans with educational 
programming about the importance of sport in the rehabilitation 
process.
     Recommend additional resources to support VA--USOC 
regional coordinators that can enhance collaboration and impact of 
programs in targeted regions throughout the United States. The emphasis 
on developing and sustaining collaboration among competing entities is 
a critical and time-consuming aspect to this cost efficient strategy. 
We believe a neutral entity must lead this effort.
     Continue to increase the number of community partners that 
are providing much-needed sport and recreation programs, primarily at 
their cost, at the local level for the disabled Veteran population.

    In closing, I would like to highlight one program that embodies all 
of our strategies, collaboration, training, technical assistance, 
awareness and financial support, along with an emphasis on hiring 
Veterans. Joe Brown is originally from Arizona. His family has a strong 
military history. His grandfather died as a POW during the Korean War. 
His father was an Air Force fighter pilot. Joe played football at the 
Ohio State University and three years in the NFL. But the Army Rangers 
were continually calling, so he joined the Army, the Rangers, and 
deployed to Iraq in 2004 and again in 2007.
    During his 2007 tour he was calling in air strikes atop a three-
story building, trying to help a unit in trouble. As his unit was 
leaving the building, Brown fell down a 30-foot shaft, suffering a 
severe brain injury. Brown knew the importance of physical activity and 
sport in the rehabilitation process. He attended the USOC VA Paralympic 
Leadership Conference to gain valuable training and connect with other 
organizations and agencies in his region. He pursued a position in the 
parks and recreation industry near a military facility so he could 
serve injured servicemembers and Veterans. He was hired by Harker 
Heights Parks and Recreation outside of Ft. Hood, Texas. Harker Heights 
was awarded a $23,000 VA-USOC grant in 2010. Joe leveraged that initial 
grant and has built a sustainable, on-going program that serves more 
than 80 veterans who can now participate in an array of physical 
activity programs under Joe's leadership.
    I would like to thank the Committee, the VA leadership, 
particularly Secretary Eric Shinseki; Mike Galloucis, Executive 
Director of the Department of Veterans Affairs' Office of Public and 
Intergovernmental Affairs; Chris Nowak, the Director of the VA's 
National Veterans Sports Programs and Special Events; our 
organizational partners in carrying out this program; of course, 
Senators Boozman and Begich, who introduced S. 3206, and other Members 
of the Committee who have joined them in cosponsoring this legislation 
that extends a program that is so critical to supporting our Nation's 
finest.
                                 ______
                                 
 Letter from Heather L. Ansley, Esq., MSW, Vice President of Veterans 
                           Policy, VetsFirst

         VetsFirst, a program of United Spinal Association,
                                      Washington, DC, July 5, 2012.
Hon. Barbara Boxer
112 Hart Senate Office Building
U.S. Senate, Washington, DC.
    Dear Senator Boxer: VetsFirst, a program of United Spinal 
Association, wishes to express our support for S. 1806, which would 
allow individuals to designate tax overpayments as contributions to a 
fund for homeless veterans. This legislation would supplement the 
efforts of the Department of Veterans Affairs (VA) and other agencies 
that assist homeless veterans and their families.
    Homelessness among veterans and their families is a critical 
problem that requires the attention of all Americans. Homeless veterans 
represent all eras of military service, including those who served in 
Iraq and Afghanistan. Our nation must provide the services and supports 
needed by homeless veterans to ensure that current and future 
generations of veterans will no longer endure homelessness.
    VetsFirst believes that this legislation will allow Americans the 
opportunity to personally invest in our nation's homeless veterans. The 
creation of the Homeless Veterans Assistance Fund will provide a new 
source of revenue to help our homeless veterans and their families, not 
supplant current efforts by VA and other agencies. Ending homelessness 
among our nation's veterans will require access to housing, health 
care, and employment. The additional funds provided through this 
legislation will give an important boost to already occurring 
assistance.
    We appreciate your leadership on this issue and urge swift passage 
of this critical legislation that will help to eliminate and prevent 
homelessness for our nation's veterans and their families. If you have 
any questions, please contact Heather Ansley, Vice President of 
Veterans Policy, at (202) 556-2076, ext. 7702 or by e-mail at 
[email protected].
            Sincerely,
                              Heather L. Ansley, Esq., MSW,
                                 Vice President of Veterans Policy.
                                 ______
                                 
      Letter from Dennis L. Wright, Captain, U.S. Navy (Retired), 
       Chairman, Clark Veterans Cemetery Restoration Association








    [Attachments listed were not submitted to the Committee.]
                                 ______
                                 
             Prepared Statement of Wounded Warrior Project

    Chairman Murray, Ranking Member Burr and Members of the Committee: 
Wounded Warrior Project (WWP) welcomes your consideration today of the 
Mental Health Access to Continued Care and Enhancement of Support 
Services (ACCESS) Act of 2012, and is very pleased to offer our views 
on its important provisions to improve and enhance VA behavioral health 
programs.
    This Committee's painstaking and patient conduct of a series of 
hearings regarding the performance of VA's mental health care system 
has made clear that--despite the dedicated efforts of its mental health 
clinicians--the Department of Veterans Affairs (VA) is not meeting its 
fundamental obligation of providing timely, effective mental health 
care to veterans of Operations Enduring Freedom, Iraqi Freedom and New 
Dawn (OEF/OIF/OND) who are struggling with combat-related mental health 
conditions.
    We applaud the Committee's oversight work and welcome VA's recent 
plan to increase its mental health staffing. While an important 
initiative, it is only a partial, and still-untested step, in the 
context of addressing wide-spread challenges.
    For years, VA has reported to Congress on the health care 
utilization of OEF/OIF/OND veterans. These data indicate that a 
relatively high percentage of these veterans have accessed VA medical 
facilities, and a significant percentage have been ``seen'' and 
diagnosed (or provisionally diagnosed) with a mental disorder. But 
these often updated and somewhat misleading reports are silent as to 
whether, for example, veterans have continued in treatment or reported 
improved. In that regard, one of the leading researchers on the mental 
health toll of the conflicts in Iraq and Afghanistan, Dr. Charles W. 
Hoge, has provided a more disturbing snapshot, underscoring real gaps 
in the VA mental health system:

        ``* * * veterans remain reluctant to seek VA care, with half of 
        those in need not utilizing mental health services. Among 
        veterans who begin PTSD treatment with psychotherapy or 
        medication, a high percentage drop out * * * With only 50 
        percent of veterans seeking care and a 40 percent recovery 
        rate, current strategies will effectively reach no more than 20 
        percent of all veterans needing PTSD treatment.'' \1\
---------------------------------------------------------------------------
    \1\ Charles W. Hoge, M.D., ``interventions for War-Related 
Postraumatic Stress Disorder: Meeting Veterans Where They Are,'' JAMA, 
306(5): (August 3, 2011) 548.

    The Committee's oversight has most effectively identified, 
documented, and sparked VA action on some of the most glaring problems 
of timeliness and access. But VA's responses--initially denying 
staffing problems, and subsequently hurriedly reversing course--create 
the impression of reactionary work with little substantive strategic 
planning. VA does not provide confidence that effective systems are in 
place or will be put in place to assure that wider gaps in the system 
will be closed or even that warriors will not re-experience in a year 
or two the kind of timeliness and access problems the Committee 
identified over the course of three hearings. We concur, therefore, 
that strong legislation is needed, and welcome the Committee's 
consideration of Title II the bill which offers promise of markedly 
improving veterans' access to needed treatment. WWP strongly supports 
those provisions.
    This legislation addresses important issues, while also implicitly 
recognizing the need for further and perhaps deeper analysis. Given the 
complexity of VA's mental health system, the variability of veterans' 
experience from facility to facility, the unreliability or absence of 
key data (as discussed in your most recent hearing on VA mental 
health), it is critical that VA seek a comprehensive independent, 
expert assessment to help assure that warriors will have reliable 
access to timely, effective mental health care across the system. We, 
therefore, applaud the inclusion in this measure of a requirement that 
VA contract with the National Academy of Sciences (NAS) to conduct a 
comprehensive assessment of VA mental health care (to include assessing 
barriers to care for OEF/OIF/OND veterans, the quality of care, and the 
range of services provided) and to provide VA specific detailed 
recommendations. NAS has served VA well in the past. We believe it can 
provide very helpful recommendations on overcoming barriers and 
improving access to timely, effective mental health care as well as on 
improving the effectiveness and efficiency of VA mental health 
services. Recommendations from a prestigious body (which under the bill 
would rely on a panel including members with VA expertise and 
experience) should provide a strong foundation for closing critical 
gaps that result in warriors never seeking needed treatment, dropping 
out of treatment prematurely, or simply not thriving despite getting 
some care. We also see real benefit in the bill's requiring VA to 
consult with NAS in developing and implementing staffing guidelines and 
other measures to assess timeliness, patient-satisfaction, capacity and 
provision of evidence-based therapies.
    Importantly, warriors consistently express high satisfaction with 
the experience of getting help from Vet Centers. They cite relatively 
unique aspects of that experience, including the opportunity to work 
with clinicians who are themselves are often combat veterans and 
understand the warrior-experience; Vet Centers' outreach-focused 
approach; and access to family services. As such, we appreciate the 
bill's focus on Vet Center services and the organizational status, 
funding and planning for the Readjustment Counseling Service. We also 
applaud the bill's clarifying that Vet Center staff can play an 
important outreach role and foster warriors' readjustment by 
participating in recreational, rehabilitative programs such as WWP's 
Project Odyssey.
    This bill is also important in recognizing that communities can 
play an important role in providing veterans access to needed mental 
health services and fostering their reintegration, and that VA can be 
an invaluable partner in such community efforts. We welcome the 
encouragement the bill provides VA to partner with community groups in 
support of those efforts, as well as the important direction that VA 
provide training in military culture and combat experience to 
clinicians who would be providing mental health services through such 
community initiatives.
    Finally, we applaud the bill's requirement that every VA medical 
center provide for peer outreach and peer support services. With too 
many veterans either still reluctant to seek mental health care or 
dropping out of care, the importance of peer-outreach and peer-support 
cannot be overemphasized.
    We look forward to working with the Committee to advance these 
important provisions in furtherance of ensuring that warriors are able 
to get timely, effective mental health care.
                                 ______
                                 

       Testimony Submitted by Senator Barbara Boxer of California

     Letter from AMVETS Department of California Service Foundation





                                 ______
                                 
 Prepared Statement of Brian A. Hampton, Maj. USAR (Ret.), President, 
              Center for American Homeless Veterans, Inc.



                                 ______
                                 
   Letter from the California Association of Veteran Service Agencies



                                 ______
                                 
        Letter from the National Coalition for Homeless Veterans



                                 ______
                                 
 Letter from Michael Blecker, Executive Director, Swords to Plowshares



                                 ______
                                 
               Letter from Raymond C. Kelley, Director, 
                   National Legislative Service, VFW



                                 ______
                                 

          Testimony Submitted by Senator Dean Heller of Nevada

   Letter from Fang A. Wong, National Commander, The American Legion



                                 ______
                                 
         Letter from Matt Gornick, Policy Assistant Director, 
                National Coalition for Homeless Veterans



      

                                  
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