[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]















  LEGISLATIVE HEARING ON DRAFT LEGISLATION, `THE VETERANS INTEGRATED 
  MENTAL HEALTH CARE ACT OF 2013;' DRAFT LEGISLATION, `THE DEMANDING 
ACCOUNTABILITY FOR VETERANS ACT OF 2013;' H.R. 241; H.R. 288; H.R. 984; 
                             AND H.R. 1284

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

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                               __________

                         TUESDAY, MAY 21, 2013

                               __________

                           Serial No. 113-19

                               __________

       Printed for the use of the Committee on Veterans' Affairs




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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               MICHAEL H. MICHAUD, Maine, Ranking 
GUS M. BILIRAKIS, Florida            Minority Member
DAVID P. ROE, Tennessee              CORRINE BROWN, Florida
BILL FLORES, Texas                   MARK TAKANO, California
JEFF DENHAM, California              JULIA BROWNLEY, California
JON RUNYAN, New Jersey               DINA TITUS, Nevada
DAN BENISHEK, Michigan               ANN KIRKPATRICK, Arizona
TIM HUELSKAMP, Kansas                RAUL RUIZ, California
MARK E. AMODEI, Nevada               GLORIA NEGRETE MCLEOD, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
PAUL COOK, California                TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana

            Helen W. Tolar, Staff Director and Chief Counsel

                                 ______

                         SUBCOMMITTEE ON HEALTH

                    DAN BENISHEK, Michigan, Chairman

DAVE P. ROE, Tennessee               JULIA BROWNLEY, California, 
JEFF DENHAM, California              Ranking Minority Member
TIM HUELSKAMP, Kansas                CORRINE BROWN, Florida
JACKIE WALORSKI, Indiana             RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio               GLORIA NEGRETE MCLEOD, California
VACANCY                              ANN M. KUSTER, New Hampshire

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.






















                            C O N T E N T S

                               __________

                              May 21, 2013

                                                                   Page

Legislative Hearing On Draft Legislation, `The Veterans 
  Integrated Mental Health Care Act Of 2013;' Draft Legislation, 
  `The Demanding Accountability For Veterans Act Of 2013;' H.R. 
  241; H.R. 288; H.R. 984; and H.R. 1284.........................     1

                           OPENING STATEMENTS

Hon. Dan Benishek, Chairman, Subcommittee on Health..............     1
    Prepared Statement of Hon. Benishek..........................    34
Hon. Julia Brownley, Ranking Minority Member, Subcommittee on 
  Health.........................................................     3
    Prepared Statement of Hon. Brownley..........................    35
Hon. Jeff Miller, Chairman, Full Committee on Veterans' Affairs..     4
    Prepared Statement of Chairman Miller........................    35

                               WITNESSES

Hon. Dennis Ross, U.S. House of Representatives, (FL-15).........     6
    Prepared Statement of Hon. Ross..............................    37
Hon. Brett Guthrie, U.S. House of Representatives, (KY-02).......     7
    Prepared Statement of Hon. Guthrie...........................    38
Mark Edney, MD, FACS, Member, Legislative Affairs Committee and 
  Urotrauma Task Force, American Urological Association..........    15
    Prepared Statement of Mr. Edney..............................    39
Michael O'Rourke, Assistant Director of Government Relations, 
  Blinded Veterans Association...................................    17
    Prepared Statement of Mr. O'Rourke...........................    41
Adrian Atizado, Assistant National Legislative Director, Disabled 
  American Veterans..............................................    18
    Prepared Statement of Mr. Atizado............................    46
Alex Nicholson, Legislative Director, Iraq and Afghanistan 
  Veterans of America............................................    20
    Prepared Statement of Mr. Nicholson..........................    49
Alethea Predeoux, Associate Director, Health Analysis, Paralyzed 
  Veterans of America............................................    22
    Prepared Statement of Ms. Predeoux...........................    51
Robert L. Jesse, M.D., Ph.D., Principal Deputy Under Secretary 
  for Health, Veterans Health Administration, U.S. Department of 
  Veterans Affairs...............................................    27
    Prepared Statement of Dr. Jesse..............................    53
    Accompanied by:

      Susan Blauert, Deputy Assistant General Counsel, U.S. 
          Department of Veterans Affairs

                       STATEMENTS FOR THE RECORD

The American Legion..............................................    54
Department of Veterans Affairs, Office of the Inspector General..    56
Military Officers Association of America.........................    58
Veterans of Foreign Wars.........................................    60
VetsFirst/United Spinal Association..............................    62
Wounded Warrior Project..........................................    63

                        QUESTIONS FOR THE RECORD

Letter To: Hon. Dan Benishek, Chairman, Subcommittee on Health, 
  From: Paralyzed Veterans of America (PVA)......................    67
Questions From: Hon. Dan Benishek, Chairman, Subcommittee on 
  Health.........................................................    67
Inquiry From: Hon. Julia Brownley, Ranking Minority Member, 
  Subcommittee on Health.........................................    69

 
  LEGISLATIVE HEARING ON DRAFT LEGISLATION, `THE VETERANS INTEGRATED 
  MENTAL HEALTH CARE ACT OF 2013;' DRAFT LEGISLATION, `THE DEMANDING 
ACCOUNTABILITY FOR VETERANS ACT OF 2013;' H.R. 241; H.R. 288; H.R. 984; 
                             AND H.R. 1284

                         Tuesday, May 21, 2013

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 10:03 a.m., in 
Room 334, Cannon House Office Building, Hon. Dan Benishek 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Benishek, Huelskamp, Wenstrup, 
Brownley, Ruiz, Negrete McLeod, Kuster.
    Also Present: Representative Miller.

           OPENING STATEMENT OF CHAIRMAN DAN BENISHEK

    Mr. Benishek. Good morning. The Subcommittee will come to 
order.
    Thank you all for joining us today as we begin to discuss 
six legislative proposals aimed at strengthening the health 
care and services we provide to our honored veterans through 
the Department of Veterans Affairs.
    The six bills on our agenda this morning are draft 
legislation, The Veterans Integrated Mental Health Care Act of 
2013; draft legislation, The Demanding Accountability for 
Veterans Act of 2013; H.R. 241, The Veterans Timely Access to 
Health Care Act; H.R. 288, The CHAMPVA Children's Protection 
Act of 2013; H.R. 984, to direct the Department of Defense to 
establish a task force on urotrauma; and H.R. 1284, to provide 
for coverage under VA's Beneficiary Travel Program for certain 
disabled veterans for travel for certain special disabilities 
rehab.
    These bills seek to address a number of important issues 
facing our veterans. I expect today's hearing to encompass a 
highly detailed and thorough discussion of the potential 
merits, challenges, and implications of each proposal before 
us.
    I look forward to working with the Ranking Member, the bill 
sponsors, and my Subcommittee colleagues to fully evaluate 
these proposals and ensure that we advance meaningful and 
appropriate legislation to fulfill the promise we made to our 
veterans.
    My bill, the Demanding Accountability for Veterans Act, is 
intended to address the pervasive lack of action taken by VA 
based on their own agreed upon timelines for remediation of 
issues and recommendations included in VA inspector general 
reports.
    Currently, the IG tracks open recommendations on their Web 
site and in their semi-annual report to Congress, the latest of 
which show that there were 177 total open reports and 1,140 
total open recommendations. Of those, 33 reports and 93 
recommendations had remained open for more than one year.
    My bill would require the IG to make a determination on 
whether VA is making significant progress on implementing VA's 
own agreed upon action plan and timeline to implement the 
recommendations made by the IG in a report concerning public 
health or patient safety.
    Under the bill, if the IG determines that significant 
progress has not been made, the IG would be required to notify 
the committees and the secretary of the department's failure to 
respond appropriately.
    Following notification, the secretary will be given 15 days 
to submit the names of each VA manager responsible for taking 
action to the IG. In turn, the secretary would be required to 
properly notify each responsible manager of the issue requiring 
action, direct that manager to resolve the issue, and provide 
him or her with appropriate counseling and a mitigation plan.
    The secretary would also be required to include in the 
responsible manager's performance review an evaluation of 
actions in response to a relevant IG report and prohibit the 
individual from receiving a bonus or other performance award 
for failure to take action.
    The goal of this legislation is simple; to create a culture 
within VA where problems that go unresolved are unacceptable.
    Far too often, I have seen serious issues that the IG has 
identified go unaddressed by the department. Such inaction is 
intolerable where the care and services provided to our 
veterans is concerned. And it is well past time for those at VA 
who are responsible for implementing needed changes to be held 
accountable for their work.
    I am hopeful that The Demanding Accountability for Veterans 
Act is the first step in ensuring that they are.
    I would be happy to answer questions my colleagues may have 
on the bill and listen to the views of all of our witnesses.
    To that end, I would like to thank all the sponsors for 
taking the time to speak with us about their proposals today. I 
am grateful for each for their leadership and advocacy efforts 
on behalf of our veterans and their families.
    I would also like to thank our veteran service organization 
partners and other stakeholders, both those who will testify 
here this morning and those who submitted statements for the 
record for their valuable input.
    I am also grateful to the VA for being here to provide the 
department's views on these important proposals.
    With that, I now yield to Ranking Member Brownley for any 
opening statement she may have.

    [The prepared statement of Hon. Benishek appears in the 
Appendix]

            OPENING STATEMENT OF HON. JULIA BROWNLEY

    Ms. Brownley. Thank you, Mr. Chairman, and thank you for 
providing the full schedule today that includes six bills 
before us that address some of the unique needs of our Nation's 
honored veterans' population.
    The bills pertain to a variety of areas that affect the 
lives of veterans every day and this Subcommittee has conducted 
many oversight hearings to understand the problems and then fix 
them.
    The first two bills on today's agenda including one of your 
proposals, Mr. Chairman, are pieces of draft legislation to 
address mental health concerns and increasing accountability at 
the VA.
    The next bill, H.R. 241, The Veterans Timely Access to 
Health Care Act, was introduced by Mr. Ross of Florida and 
pertains to timely, organized, and scheduled visits to VA 
medical facilities.
    H.R. 288, The CHAMPVA Children's Protection Act of 2013, 
sponsored by Mr. Michaud, Ranking Member of the Full Committee, 
would amend the maximum age for children to obtain medical care 
under CHAMPVA from 23 to 26 and effectively reflect The Patient 
Protection and Affordable Care Act enacted in 2010.
    I will speak further on this bill during the first panel.
    Next, H.R. 984 introduced by Mr. Guthrie of Kentucky would 
direct the Secretary of Defense to establish a national task 
force on urotrauma.
    And, finally, my bill, H.R. 1284, The Veterans Medical 
Access Act, would provide better access for blind and severely 
disabled veterans who need to travel long distances to obtain 
care at a special rehabilitation center.
    Oftentimes, blind and catastrophically-disabled veterans 
choose not to travel to VA medical centers for care because 
they cannot afford the cost associated with that travel.
    Currently, the VA is required to cover the cost of 
transportation for veterans requiring medical care for service-
connected injuries.
    H.R. 1284 would extend those travel benefits to a veteran 
with vision impairment, a veteran with spinal cord injury or 
disorder, or a veteran with double or multiple amputations 
whose travel is in connection with care provided through a 
special disabilities rehabilitation program of the VA.
    Our disabled veterans have already made the greatest of 
sacrifices and I firmly believe, as I am sure everyone here in 
this Committee hearing today believes, that no veteran should 
be denied needed medical care.
    I thank all of the Members for their thoughtful legislation 
and I want to thank you, Mr. Chairman, for including my bill 
here today.
    Thank you, and I yield back my time.

    [The prepared statement of Hon. Brownley appears in the 
Appendix]

    Mr. Benishek. Thank you, Ms. Brownley.
    I would now like to welcome our first panel to the witness 
table. At the dais we have our Chairman, a well-respected and 
well-established leader for our veterans, to discuss his draft 
legislation, The Veterans Integrated Mental Health Care Act of 
2013.
    We also have my friends and colleagues, Dennis Ross, 
Representative of Florida's 15th congressional district; and 
Brett Guthrie, Representative of Kentucky's 2nd congressional 
district. Brett is also a West Point grad and a veteran of the 
army's 101st airborne division. I would like to thank him for 
his service in uniform.
    Thank you all for being here this morning. It is a pleasure 
having you and I will yield this time for the Chairman for his 
testimony.

                 STATEMENT OF HON. JEFF MILLER

    Mr. Miller. Thank you very much, Mr. Chairman.
    It is great to be here today, with you the Members of the 
Subcommittee on Health, Representatives from the VSOs that have 
joined us and other interested stakeholders and audience 
members. I appreciate the opportunity to discuss my draft bill, 
The Veterans Integrated Mental Health Care Act of 2013.
    Two weeks ago yesterday, I spent the day in Atlanta with 
many members of the Georgia delegation to discuss inpatient and 
contract mental health program mismanagement issues at the 
Atlanta Department of Veterans Affairs Medical Center.
    This visit occurred after the VA inspector general issued 
two reports which found that failures in management, 
leadership, oversight, and care coordination at the Atlanta 
VAMC contributed to the suicide deaths of two veteran patients 
and the overdose deaths of two others.
    Now, alarmingly, the IG found that approximately four to 
five thousand veteran patients fell through the cracks and were 
lost in the system after the Atlanta VAMC failed to adequately 
coordinate or monitor the care they received under VA's 
contracts with community mental health providers.
    I wish that I could say that the issues in Atlanta are an 
isolated aberration. Unfortunately, that would be far from the 
truth. Rather, the Atlanta story is just the latest in a tragic 
series of incidents highlighting serious and systematic 
deficiencies plaguing the provision of mental health care to 
at-risk veterans through the VA health care system.
    Since 2007, VA's mental health care programs, budget, and 
staff have increased significantly, yet the numbers of veterans 
taking their own lives has remained stagnant for the past 12 
years, with 18 to 22 veteran suicide deaths per day since 1999 
according to VA's own records.
    I could go on, but the bottom line of this is that the one 
size fits all path to mental health care that the department is 
on is failing the veterans most in need of its services. And 
the time to act is now.
    I have been and will certainly continue to be a strong and 
supportive advocate of VA taking action to hire staff and 
address the continued failures of mental health care provided 
within its own walls.
    However, it has become abundantly clear through the data 
that I have discussed this morning, through committee oversight 
in this room, through numerous IG and Government Accountability 
Office reports, and through the personal accounts of the 
veteran constituents that call my office and the offices of my 
colleagues on a daily basis, to ask for help that VA cannot 
cope with the magnitude of mental health needs our veterans 
experience in a bureaucratic vacuum with the normal VA business 
as usual approach.
    In order to truly maximize mental health care access for 
today's veterans, VA has got to embrace an approach to care 
delivery that treats veterans where and how they want to be 
treated, not just where and how VA wants to do the treatment.
    Some have said this could undermine VA health care as we 
know it, but nothing could be further from the truth. This is 
not about supplanting the VA health care system. It is about 
supporting that very system.
    To truly address and resolve the breakdown in the provision 
of mental health care services to veteran patients, VA has got 
to adopt an integrated, coordinated care delivery model for 
mental health care.
    Most importantly, VA has got to adopt a mental health care 
delivery model that is truly veteran-centric, one that meets 
and cares for veteran patients where they are, treats the 
entirety of their concerns with supportive and timely wrap-
around services, and recognizes and respects their unique 
circumstances, goals, and health care needs throughout their 
lives as a veteran.
    That is why I have proposed the draft Veterans Integrated 
Mental Health Care bill that is before us this morning. It 
would take the first important step to help veterans in need, 
whether those services are provided in or outside of VA 
facilities.
    Specifically, the draft would require VA to provide mental 
health care to an eligible veteran who elects to receive such 
care at a non-VA facility through a care coordination contract 
and with a qualified entity and require such entity to meet 
specific performance metrics regarding the quality and 
timeliness of care and exchange relevant clinical information 
with the VA.
    It would ensure that existing mental health care resources, 
both those found within the VA facilities and those provided to 
veterans through fee-basis care, are managed effectively.
    It would also ensure that the care provided to veteran 
patients in need of mental health services is timely and that 
it is convenient and coordinated from the initial point of 
contact throughout the recovery process.
    I understand that some veteran service organizations have 
expressed concern about waiting until VA rolls out its own new 
contract care initiatives. And while I appreciate and I 
understand and respect those views, I look forward to working 
closely with them to address those concerns, but the time for 
waiting is over.
    Last year, the IG found that more than half of the veterans 
who go to VA seeking mental health care services wait 50 days 
on average to receive an initial evaluation.
    This year, the IG found that thousands of Georgia veterans 
had fallen through giant cracks in the system and may or may 
not have received the care that they so desperately needed. We 
cannot wait to see what next year brings.
    When a veteran is in need of mental health care services, 
the difference of a day or a week or a month can be the 
difference between life or death, contentment or continued 
struggle. The time to act is now.
    I look forward to working hand in hand with Committee 
Members, our VSO partners, and other stakeholders to strengthen 
the language in this draft bill and address any issues that may 
be raised during the Subcommittee's discussion this morning.
    I appreciate you holding this hearing, Mr. Chairman, and 
for your hard work and steadfast leadership of the Subcommittee 
on Health. I yield back.

    [The prepared statement of Hon. Jeff Miller appears in the 
Appendix]

    Mr. Benishek. Thank you, Mr. Chairman.
    I look forward to hearing from the VSOs about your 
legislation and it certainly is timely.
    With that, I will yield to Mr. Ross, my colleague. Thank 
you.

 STATEMENTS OF HON. DENNIS ROSS, A REPRESENTATIVE IN CONGRESS 
FROM THE STATE OF FLORIDA; HON. BRETT GUTHRIE, A REPRESENTATIVE 
             IN CONGRESS FROM THE STATE OF KENTUCKY

                 STATEMENT OF HON. DENNIS ROSS

    Mr. Ross. Thank you, Mr. Chairman, and thank you, Ranking 
Member Brownley and the Committee, for allowing me to testify 
on behalf of legislation I have introduced entitled The 
Veterans Timely Access to Health Care Act.
    America's veterans are the backbone of the freedom and 
prosperity that this country has enjoyed for over 200 years. We 
owe them a debt that we can never truly repay.
    Unfortunately, across the country and across Florida's 15th 
congressional district, veterans continue to encounter 
unacceptable problems and delays receiving appointments from 
the Veterans Administration for essential medical and specialty 
health care needs.
    For instance, the VA has set a goal to provide an initial 
medical health examination within 14 days from the time a 
veteran contacts a VA medical provider to schedule a 
consultation. They claim, the VA claims to have met this goal 
with a 95 percent success rate.
    However, an inspector general report in 2012 published, 
greatly contradicts these claims. In fact, the IG report 
determined that the VA met its goal only 49 percent of its 
time.
    As Chairman Miller pointed out, for example, more than 
184,000 veterans waited approximately 50 days to receive 
critical mental health evaluations, not treatment, just the 
formal evaluation. This is a disgrace to our veterans and 
something that should not be tolerated.
    Additionally, Chairman Mike Coffman of the Subcommittee on 
Oversight and Investigations held a hearing on March 14th, 2013 
to examine patient wait times at VA medical facilities. Sadly, 
the Chairman revealed that according to VA documents, at least 
two veterans died last year from diseases while waiting for a 
medical consultation at the VA.
    That is why I am proud to have introduced H.R. 241, The 
Veterans Timely Access to Health Care Act. This legislation 
supported by the Military Officers Association of America and 
the Retired Enlisted Association will ensure that veterans 
seeking primary and specialty care from a VA medical facility 
receive an appointment within 30 days period.
    This legislation also contains a number of detailed 
reporting requirements so that Congress may better track the 
VA's progress. And if the VA discovers they are not meeting 
their goals and the mandated 30-day access to care, it is my 
hope that they will reach out to Congress before the reports 
are filed so that we can work together to meet the needs of our 
Nation's brave and courageous veterans.
    We are all on the same team here with the same goal of 
providing timely, high-quality health care to our veterans. 
However, this legislation will go a long way in ensuring 
veterans' critical needs like those needs of the more 184,000 
veterans who waited over 50 days for initial mental health 
screening. We want to make sure they no longer slip through the 
cracks.
    It will also prevent the unnecessary loss of life of those 
veterans in need of medical care and consultation.
    Moving forward, I would like to work with this Subcommittee 
to strengthen this legislation potentially including additional 
access to care standards. Today, this legislation is a first 
step to hold the VA accountable.
    Thank you, Mr. Chairman, and I yield back the balance of my 
time.

    [The prepared statement of Hon. Ross appears in the 
Appendix]

    Mr. Benishek. Thank you Representative Ross. I appreciate 
your words.
    Brett, why don't you just go ahead with your testimony as 
well?

                STATEMENT OF HON. BRETT GUTHRIE

    Mr. Guthrie. Thank you, Mr. Chairman.
    And good morning, Ranking Member Brownley and colleagues.
    I come before you today as both a Member of Congress and a 
former army officer to thank you for your past support of this 
issue and continued work that we need to move forward.
    As you may know, genitourinary trauma or simply urotrauma 
is a class of wounds that literally hits below the belt. 
Urotrauma accounts for wounds to the kidneys, reproductive 
organs, and urinary tract organs. These injuries are some of 
the most common and debilitating suffered by our veterans from 
IED detonations and have long-lasting physical and 
psychological impacts.
    Urotrauma is one of the signature wounds of the IED and now 
accounts for one-eighth of all injuries suffered by our troops 
in Afghanistan. Unfortunately, the most recent data available 
suggests that this figure is still rising even after nearly 
doubling in incidence between 2009 and 2010.
    I know we are in the veterans committee today, but by way 
of background, let me paraphrase Department of Defense report 
to Congress titled Genital Urinary Trauma In The Military and 
the army's surgeon general's report entitled Dismounted Complex 
Blast Injury.
    According to these papers, urotrauma on today's battlefield 
exceeds incident rates of all prior conflicts by at least 350 
percent and, yet, the DoD under secretary for Personnel and 
Readiness concedes that urotrauma injury is not part of the 
standards of pre-deployment training for U.S. military surgeons 
and nurses and that existing infrastructure for tracking these 
casualties is not sufficient to assess the long-term prognosis 
of GU trauma injuries.
    This lack of adequate infrastructure is exacerbated by the 
inherent complications of transitional care from DoD to VA 
where most victims will receive treatment for the remainder of 
their lives.
    Let me say that this is not my view that the VA or DoD are 
ignoring urotrauma. To the contrary. I believe that many 
skilled professionals are hard at work on the issue, but, as is 
often the case in government, their efforts are divided, un-
integrated, and because of this less effective.
    By my tally, there are six government agencies currently 
working on urotrauma and while I am heartened that this 
research is occurring, I am discouraged that there seems to be 
little dialogue or centralization of information.
    Put simply, we are not learning from experience and if we 
are, we are learning too slowly. And that is why I introduced 
H.R. 984, a bill that I have authored with the help of 
practicing urologists who have cared for wounded warriors in 
Iraq and Afghanistan.
    This bill would unite public and private resources to 
address the growing problem that is urotrauma. I would like to 
highlight two specific opportunities for improved care that are 
within the Committee's jurisdiction.
    First, the existing infrastructure to track urotrauma 
patients is not sufficient. We need the research infrastructure 
to facilitate urotrauma outcomes research and corresponding 
follow-up with DoD and most critically after transition to the 
VA.
    Unfortunately, one thing I have heard time and again is 
that the joint theater trauma registry, which tracks 
approximately 16,000 trauma victims, lacks the specificity of 
detail needed to accomplish this end. VA, DoD, and health care 
providers need a better platform to coordinate care across a 
lifetime for our wounded warriors.
    Related to this is a second issue I would like to focus on, 
transition of care. Rather than mincing words, I will quote the 
American Urologists Association Urotrauma Task Force directly.
    It is clear to those urologists in DoD who care for our 
soldiers with complex urotrauma that the transition to the VA 
is currently fraught with barriers. These barriers include 
deficits of communication of the detailed medical and surgical 
history of injured servicemembers from DoD physicians to VA 
physicians.
    Another problem continues to be GU injured soldiers within 
the VA system being cared for in locations where access to 
expertise in GU trauma is lacking.
    One solution to this problem would be designated care 
coordinators to urotrauma victims. These coordinators would 
need access to DoD and VA health information and guide our 
wounded warriors toward existing centers of excellence and 
polytrauma care.
    However, as a Member of Congress, I am not wedded to a 
single solution to this or any other improvement to urotrauma 
care. That is why 984 allows for a big tent solution. As DoD 
has said in writing, we need inter-service and interagency 
relationships to facilitate aggressive, innovative, and 
relevant translational and outcomes-based clinical research.
    And that is what this does. It brings together VA, DoD, 
HHS, surgeon generals of all of our Armed Services and civilian 
expertise to create a plan to care for our wounded warriors 
from the point of injury to their final resting place decades 
from now.
    I urge this Committee to continue the work it has already 
done to further our care for these wounded warriors in 
suffering these effects, and I yield back my time.

    [The prepared statement of Hon. Guthrie appears in the 
Appendix]

    Mr. Benishek. Thank you very much, Representative Guthrie.
    I will now yield again to the Ranking Member, Ms. Brownley, 
to speak on H.R. 288.
    Ms. Brownley. Thank you, Mr. Chairman.
    H.R. 288, The CHAMPVA Children's Protection Act of 2013, 
was introduced by Mr. Michaud, Ranking Member of the Full 
Committee. Thank you for including it in today's agenda.
    Dating back to 1973, the CHAMPVA program was established to 
provide health care services to dependents and survivors of 
certain veterans. It is designed to provide care in a manner 
similar to that of DoD's TRICARE program in that it is a fee-
for-service program that provides reimbursement for medical 
care provided by the private sector.
    Individuals who are eligible for CHAMPVA are the dependents 
of certain living and deceased veterans who were rated 
permanently and totally disabled for a service-connected 
disability, died from a service-connected disability, or died 
while on active duty which was not due to personal misconduct.
    As we are all aware, The Patient Protection and Affordable 
Care Act requires health plans and health insurance issuers 
that offer dependent coverage to extend this coverage until the 
adult child turns 26 years of age.
    The fiscal year 2011 National Defense Authorization Act 
provided DoD with the authority to extend TRICARE coverage to 
age 26 as well. However, this provision has yet to apply to 
CHAMPVA.
    H.R. 288 would extend that same coverage to CHAMPVA 
beneficiaries. It is a simple fix that would ensure that our 
veterans' families are able to receive health care commensurate 
with the rest of the Nation.
    And I thank you, Mr. Chair, and I yield back the balance of 
my time.
    Mr. Benishek. Thank you, Ms. Brownley.
    I am going to yield myself five minutes for a few questions 
concerning the legislation and maybe you all can answer a 
couple of points that I have.
    Mr. Ross, thanks for your interest in ensuring that our 
veterans have timely access to care. As you know, care delayed 
is care denied.
    Some concerns have been raised about H.R. 241 that would 
establish in law a single measure of timeliness. I am looking 
forward to the opportunity to work with you on this legislation 
to achieve your goal, which I think is to ensure that veterans 
have a clear expectation that they will receive timely care and 
that the VA will be held accountable.
    But there is some concern I have about one standard. There 
are different types of issues that come up. For example, the 
mental health timeliness issue may be different than a routine 
appointment.
    Can you respond to these questions that I came up with----
    Mr. Ross. Yes, sir.
    Mr. Benishek. --when I read your legislation?
    Mr. Ross. Thank you, Chairman.
    And I agree with you. I think, you know, we are trying to 
impose one standard of 30 days. When the VA says that they now 
do it within 14 days, we know they do not meet that standard.
    What we are trying to do is assess the situation. We know 
we have a problem. We are trying to get to the solution by 
putting in initially a 30-day maximum period of time by which 
the appointment must be given and then having the assessment 
thereafter of a report from the secretary that is due to 
Congress that would show how many appointments were really made 
within 30 days, how many in excess of 30, how many in excess of 
six months.
    From that data, we should be able to then decide what is 
the appropriate standard for appointments. But I use this 
legislation as a step, the first step in trying to recognize 
that we have a problem in providing adequate and necessary 
health care in an expeditious fashion.
    And so while I am not seeking that 30 days should be the 
standard, it is a starting point to assess where the problems 
are and then hopefully take corrective action based on the 
information we get back from the secretary.
    Mr. Benishek. All right. Okay. Is there any enforcement 
mechanism about this or is this the beginning?
    Mr. Ross. Mr. Chairman, sadly there is not any enforcement. 
I say sadly because in most of these regulatory issues we have 
little enforcement ability with the agencies that we deal with. 
And I think that one of the things, I would really enjoy 
working with this Committee, is trying to find an enforcement 
mechanism.
    I think once we identify what the solution should be in 
terms of the appropriate access to care standard depending on 
the diagnosis or for that matter just the initial evaluation, 
then I think we can look at what the enforcement should be for 
their failure to do so.
    I mean, for something that would be, you know, like a 
physical soft tissue injury, there may not be as great of 
enforcement penalties, if it was something more of a severe 
mental health condition or something that requires exigent 
medical care and treatment at the time.
    Mr. Benishek. Thank you.
    Mr. Ross. Thank you.
    Mr. Benishek. Mr. Guthrie, you know, I am excited that you 
brought this up here because I am a trauma surgeon myself and I 
got to meet with some of the great urologists that provide 
urotrauma care. And I just want to commend your efforts to get 
this thing going here.
    I know that this bill would unite public and private 
resources to address the growing problem in urotrauma.
    What is being done in that area to currently make the 
private and public sector work together?
    Mr. Guthrie. Well, one of the great examples of that is 
that one of the people that brought this to my attention is a 
physician, who you are going to hear from in the second panel, 
who is in private practice, but was deployed forward with the 
national guard, so experienced it firsthand and sees it back 
now, back home in country.
    And so what we are hoping to do there, what I am not seeing 
is the DoD and VA are dealing with this. As I mentioned in my 
testimony, they are dealing with it through several different 
categories. And what we are trying to do is unite it. So we do 
have private research with public research.
    I think one example that sort of fits, I mean, in Boston in 
the marathon blast, I think the trauma surgeons there had been 
trained with some Israeli surgeons and it just happened that 
they had that special training at that time and undoubtedly 
saved lives.
    And so what can happen through the military and bringing 
private sources together can be replicated to help people, not 
just military folks, but that is what the focus is, try to 
bring everybody together from both sides, whether you are DoD 
employed or you are in private practice or private research.
    Mr. Benishek. Well, I know that it is going to be a 
challenge for our veterans who want to go home and, yet, in 
their hometown or their local VA may not have an expert 
urologist trained in urotrauma and that a task force to address 
that issue, I think, is a great idea and coordinating care 
nationally to get the best taking care of this.
    Mr. Guthrie. The biggest thing I think can come out of this 
is actually that because our guys have gotten really good 
unfortunately at training because they see it in Landstuhl and 
here.
    But when our soldiers go home to live out the rest of their 
lives, I think that is what is so important for this Committee 
to focus on. They are not going to be in Walter Reed or in 
Landstuhl for the rest of their lives. They are going to be 
home and that is what we need to focus on.
    Mr. Benishek. Thank you.
    Mr. Guthrie. Thanks for that comment.
    Mr. Benishek. I will yield now to the Ranking Member, Ms. 
Brownley, if she has any questions.
    Ms. Brownley. I do not have any questions at this time. 
Thank you.
    Mr. Benishek. Mr. Wenstrup.
    Mr. Wenstrup. No questions.
    Mr. Benishek. Ms. Kuster.
    Ms. Kuster. Thank you, Mr. Chairman, and thank you for 
convening this hearing.
    I think these are critical issues for us to be dealing 
with. And I commend you and Ms. Brownley for your leadership on 
this.
    And thank you to our colleagues.
    Both of these issues, I think, are critical and I just want 
to lend my support. I do not have any particular questions. You 
have been very informative and the testimony is very helpful.
    But I just want to say that we appreciate you coming 
forward. Thank you for service. And please know that on both 
sides of the aisle here on the Veterans Committee, these are 
bipartisan, nonpartisan issues that we want to work with you on 
and work with the VA and the VSOs and make sure that our troops 
get the care that they need.
    And I am particularly reading the testimony. The confluence 
of the mental health issues with the complex trauma issues, I 
think, is the lesson, sadly, that we will all learn from the 
last 12 years is that from what I hear back in my district in 
New Hampshire, the impact, the cumulative impact on the family 
structure.
    And I think about the urotrauma issues and I think about 
more women getting into the military and seeing combat and what 
the long-term implication is for that for our society.
    So I just commend you and I would like to work with you and 
work with the chair and the Ranking Member on this Committee 
and just say that I think it is really significant work that we 
are doing.
    Thank you. I yield back the balance of my time.
    Mr. Benishek. Thank you, Ms. Kuster.
    Mr. Huelskamp, do you have any questions for the panel?
    Mr. Huelskamp. Thank you, Mr. Chairman. I appreciate my 
colleagues for bringing these proposed bills before the 
Committee.
    I had a couple questions and wanted to see what your 
thoughts were, particularly first for Congressman Ross.
    Recently, the Committee reviewed a report from the OIG 
about, I think it was entitled Reported Outpatient Wait Times, 
and what was disturbing to me was some evidence that certain 
facilities either had an unusual definition of what the wait 
time was or actually potentially falsified the data.
    And I found that very concerning, especially when we talk 
about the need, and I agree with you, to set a standard by 
which they will reach. But when we found cases or the OIG found 
cases where they went in on the day they actually had their 
appointment, went in, says, okay, that was the wait time, the 
day they came in rather than the time they applied.
    Any thoughts on that and response from, you think, from the 
Department of Veterans Affairs when we have these kind of 
things occurring?
    Mr. Ross. Thank you, Mr. Huelskamp.
    You know, every specialty, medical specialty has practice 
protocols by which there is a recommended course of treatment 
and rehabilitation depending on the diagnosis.
    And while not having a single standard is going to work in 
terms of getting in to see the health care provider that they 
see, I think what is important is that we make sure that we 
collect the data appropriately as to when the first request is 
made until their first evaluation and then subsequent follow-
ups can be offered.
    But I think that what we are trying to do is recognize that 
we have a problem here and I think that a lot of it has been 
covered up and the issue is a lot worse than what we know it to 
be.
    So, again, I would ask to work with this Committee so that 
we can have some enforcement mechanisms in there to not only 
hold the Veterans Administration accountable, but also to make 
sure that those that are collecting the data are doing it 
appropriately and accurately.
    Mr. Huelskamp. I appreciate that. I think that is 
absolutely essential and to create legislation or ways to hold 
the VA accountable, particularly for those that it aims to 
serve.
    And, Brett, comment for you or question. I serve a very 
rural district. I am sure you understand that. I was actually 
visiting with a veteran who was in Syracuse, Kansas and this 
was about a year ago. And he had noted where he was instructed 
by the VA to make, I think it was a 260-mile, 261-mile one-way 
trip.
    And he made the round trip three times in ten days and he 
said, you know, Congressman, the care they wanted me to get, 
and it was not urology, it was another type of care, I could 
have got that in my local hospital and the VA would not allow 
that to happen.
    And, by the way, just five days ago, the local hospital 
announced they could be shutting their doors.
    And one issue I have had is, well, how can we make certain 
that whether on the care that you mention and the care 
Congressman Ross mentions, they can get that close to home, not 
only to, you know, help assist the VA, but also to protect our 
local hospitals.
    Any comments you might have for someone like me that serves 
in a rural area?
    Mr. Guthrie. Oh, absolutely. I think of it, sir, not just 
with my bill, but any time a service person wants or serviceman 
or woman wants service and they can get it locally and they can 
get what they need locally, you know, if they live next door to 
the VA hospital. If they live in Nashville, instead of going to 
Vanderbilt, you go to the VA hospital. I might get that because 
I live just as close to Nashville.
    But if they are, you know, out where you are, they should 
go get the service where they can get it. And I have people in 
my district like that, that are not as close to Nashville as I 
am. I know I am in Kentucky, but we are on the border.
    And so I agree with you. I think we ought to find a way to 
deliver services the best that we can to people in the way that 
they can receive it.
    Mr. Huelskamp. Yeah. I appreciate that.
    And the VA had an initiative a few years ago. They are 
proceeding with that, Project Arch, and one of the pilot spots 
was formerly in my district, but in the first year they had not 
found a single person that had received mental health services 
through that pilot project.
    And so we have a long ways to go. I appreciate your 
gentlemen's proposals and I look forward to working with those 
in the Committee.
    And, Mr. Chairman, I yield back.
    Mr. Benishek. Thank you.
    I will now yield to my colleague, Dr. Ruiz.
    Mr. Ruiz. Thank you very much, Mr. Chairman.
    Thank you both, Dennis and Brett, for your work in 
introducing these bills.
    I applaud and encourage highly the gathering of accurate 
data. I believe very much in evidence-based medicine, and I 
believe very much in evidence-based policy. And it is the best 
way that we can find the bottlenecks that is justified through 
the information that we get on performance measurements in 
order to make the best decisions and the best policy that we 
can for our veterans.
    Brett, I am a strong supporter of our urotrauma surgeons 
and making sure that we provide the best treatment. This is 
something that we need to follow through all the way to the 
outcomes and measuring what those outcomes are.
    I know that Dr. Anine has been the champion and going 
around meeting a lot of us on the Committee. And I applaud his 
work and I encourage more urologists to do the same.
    In terms of the task force, oftentimes, there is concerns 
that the task force or advisory committee recommendations are 
ignored and are not very effective. And this is something that 
we cannot let happen.
    So what can we do to ensure that any recommendation is 
actionable and we can carry through to have some actual 
outcomes?
    Mr. Guthrie. Yeah, that is frustrating. Now I say sometimes 
task forces or good ideas go to die sometimes. And we just have 
to do the oversight. They have to report two years after the 
task force is implemented. They have two years, one year for a 
report, the second year the final report.
    And I think it is our job as Members of Congress as people 
have brought this issue to us, is that to make sure these are 
implemented and have oversight of the implementation of the 
task force because it will go as far as we reflect. And 
hopefully it will go without us, oversight, but certainly our 
oversight will help it move forward. And I think that is what 
we have to do is be dedicated to this issue.
    Mr. Ruiz. Well, I look forward to working with you on this 
and after the recommendations are given.
    Mr. Guthrie. I appreciate that very much.
    Mr. Ruiz. I yield back my time.
    Mr. Guthrie. Really look forward to it.
    Mr. Benishek. Well, does anyone else have any questions of 
the panel?
    [No response.]
    Mr. Benishek. Well, I certainly appreciate your time this 
morning, gentlemen. I am looking forward to working with you on 
this legislation moving forward. Thanks.
    I would like to welcome the second panel to the witness 
table, please.
    Joining us on the second panel will be Dr. Mark Edney, a 
Member of the Legislative Affairs Committee and the Urotrauma 
Task Force for the American Urological Association; Mr. Michael 
O'Rourke who is the Assistant Director of Government Relations 
for the Blinded Veterans Association; Mr. Adrian Atizado, the 
Assistant National Legislative Director for the Disabled 
American Veterans; and Mr. Alex Nicholson, Legislative Director 
for the Iraq and Afghan Veterans of America; and Ms. Alethea 
Predeoux, Associate Director for Health Analysis for the 
Paralyzed Veterans of America.
    I hope I got your name right.
    Thank you for all your service to our Nation in uniform and 
through your advocacy work. I appreciate you all being here 
today and look forward to hearing your views.
    And let's begin the panel with Dr. Edney. Please go ahead. 
You have five minutes.

STATEMENTS OF MARK EDNEY, MEMBER, LEGISLATIVE AFFAIRS COMMITTEE 
  AND UROTRAUMA TASK FORCE, AMERICAN UROLOGICAL ASSOCIATION; 
 MICHAEL O'ROURKE, ASSISTANT DIRECTOR OF GOVERNMENT RELATIONS, 
    BLINDED VETERANS ASSOCIATION; ADRIAN ATIZADO, ASSISTANT 
NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS; ALEX 
NICHOLSON, LEGISLATIVE DIRECTOR, IRAQ AND AFGHANISTAN VETERANS 
   OF AMERICA; ALETHEA PREDEOUX, ASSOCIATE DIRECTOR, HEALTH 
            ANALYSIS, PARALYZED VETERANS OF AMERICA

                    STATEMENT OF MARK EDNEY

    Dr. Edney. Chairman Benishek, Ranking Member Brownley, 
Members of the Committee, honored guests, fellow 
servicemembers, I thank the Committee on Veterans Affairs' 
Subcommittee on Health for inviting me to testify regarding 
H.R. 984, a bipartisan bill introduced by Representative 
Guthrie, to direct the secretary of Defense to establish a task 
force on urotrauma.
    I am a urologist, a surgical specialist who treats 
genitourinary disease and injury. I am also an army reservist 
of 11 years. My active duty tours include service with the 
399th combat support hospital in Mosul, Iraq in 2006.
    I have treated genitourinary trauma in the theater of 
operations and I have also participated in its chronic 
management at our largest military medical center stateside.
    It is an honor to represent the American Urological 
Association, the world's premier professional association of 
urologists and our Urotrauma Coalition in support of H.R. 984 
on behalf of this unique class of injured servicemembers.
    Our Urotrauma Coalition includes distinguished medical 
societies including the American College of Surgeons, the 
American Congress of Obstetrics and Gynecology, the Society of 
Women's Health Research, and a diverse group of veteran service 
organizations and industry partners who all support urotrauma 
policy initiatives contained in H.R. 984.
    Fifty thousand American servicemen and women have been 
injured in Iraq and Afghanistan. A recent study indicates that 
about a thousand soldiers have sustained injury to the 
urogenital organs.
    Approximately 60 percent of these injuries involve the 
external organs including penoscrotal, testicular and urethral 
injury with another 40 percent involving kidney, ureter and 
bladder, and in women, the uterus, vagina, fallopian tubes, and 
ovaries.
    Dismounted complex blast injury is the constellation of 
lower extremity loss, often bilateral, occasionally with upper 
extremity loss, and often with genitourinary injury.
    Urotrauma is up 350 percent in Afghanistan compared to Iraq 
because of the increased necessity of soldiers to patrol on 
foot rather than in fortified vehicles.
    Although veterans suffering genitourinary injury may 
exhibit no outward evidence, they suffer the life-changing loss 
of proper urinary, bowel, and sexual function and fertility. 
These deficits have significant effects on marriages, other 
social relationships, and enormous effects on overall quality 
of life.
    The cumulative physical and psychological impact of 
urotrauma on these soldiers is no less profound than those 
recovering from extremity loss and neurocognitive injury.
    As a complex injury pattern, urotrauma has not received the 
same policy attention and care coordination that has been 
afforded the more common injury patterns such as extremity 
loss, traumatic brain injury, and eye injury, each with its own 
center of excellence.
    Genitourinary injury is increasingly a critical military 
women's health issue. With women now able to serve in direct 
combat roles, we must do better with the care and coordination 
of urotrauma.
    An AUA urotrauma work group was convened in 2009 to define 
areas of opportunity for improvement in urotrauma care. To 
broaden the discussion and establish the framework for 
accomplishing these policy objectives, the AUA with Congressman 
Guthrie has crafted H.R. 984.
    This establishes an interagency task force to study a broad 
range of opportunities for enhancing the prevention, 
management, and study of urotrauma. The task force will 
evaluate and define improvement opportunities in a variety of 
areas including an assessment of the true scope and impact of 
the injury pattern, the status of prevention, and assessment of 
current facilities and programs within the DoD and VA engaged 
in the prevention, management, and study of urotrauma with a 
special focus on the status of research, expertise, and health 
care infrastructure for female victims of urotrauma and then 
analysis of the reproductive services available to 
servicemembers who have been rendered infertile as a result of 
urotrauma.
    The care of these complicated injuries requires a 
tremendous amount of expertise in care coordination. It is 
clear that the transition of soldiers with urotrauma from the 
DoD to the VA represents an area of opportunity not only with 
respect to DoD physician to VA physician communication, but 
also with the geographic placement of soldiers with these 
unique needs in proximity to the available expertise, 
technology, and programs in the VA to provide for their needs.
    Finally, although each of the functional challenges that 
result from damage to the genitourinary organs is life 
altering, perhaps one of the most profound is the loss of 
fertility. The brave young Americans who are voluntarily 
putting themselves in harm's way in defense of our country are 
often doing so prior to their reproductive years. Some are 
suffering injuries that severely impair or eliminate their 
natural reproductive capability, shattering the dream of many 
to begin a family of their own.
    H.R. 984 seeks an analysis of the technical, 
administrative, and budgetary mechanisms to allow for enhanced 
reproductive services for members who have been affected by 
urotrauma or who are at high risk of urotrauma.
    The AUA recognizes that there is much to be done in this 
area from pre-deployment sperm banking to prior preservation of 
sperm at the initial point of care when testicular loss is 
inevitable, to providing advanced reproductive services to all 
military victims of urotrauma who are infertile and receiving 
care in the DoD and the VA.
    We are currently short of that goal and the AUA working 
group also supports legislation to enhance these policies.
    In summary, the rate of genitourinary injury suffered by 
American soldiers is up 350 percent in Afghanistan compared to 
Iraq as a result of the increased necessity of dismounted 
patrol.
    Genitourinary injuries are increasingly common, complex 
constellation of wounds with devastating long-term implications 
for urinary, bowel, and sexual function and fertility. These 
sequelae in turn have profound impacts on soldiers' mental 
health, marriages, and other social relationships and overall 
quality of life.
    H.R. 984 prescribes the comprehensive study required to 
address the variety of opportunities for improving the 
prevention, initial management, care coordination, and research 
of this devastating and increasingly prevalent pattern of 
injury. We owe these finest Americans no less for the 
sacrifices they have made for our great Nation.
    On behalf of the American Urological Association and the 
Urotrauma Coalition partners, I urge you to support H.R. 984 
and favorably report it out of the Committee.
    Again, I want to thank the Veterans' Affairs Committee for 
their invitation to testify before you, and I am available to 
answer any questions.

    [The prepared statement of Mark Edney appears in the 
Appendix]

    Mr. Benishek. Thank you, Dr. Edney. Appreciate your 
testimony.
    Mr. O'Rourke, please proceed.

                 STATEMENT OF MICHAEL O'ROURKE

    Mr. O'Rourke. Thank you, Mr. Chairman.
    On behalf of the Blinded Veterans of America, we thank you 
for this opportunity to provide testimony on current 
legislation before the Subcommittee on Health.
    Chairman Benishek, Ranking Member Brownley, and Members of 
the House Committee, we are very interested and look at 
beneficial travel for blinded veterans, H.R. 1284. We 
appreciate the Ranking Member Brownley for introducing the 
bill.
    We would like to point out that last week in the Senate, 
the VA Committee held a hearing on a companion bill, S.633, 
introduced by Senator Tester that was broadly supported by the 
witnesses.
    The legislation, H.R. 1284, would assist disabled spinal 
cord injury and blinded or visually impaired veterans who are 
currently ineligible for beneficial travel benefits. This bill 
would assist mostly low-income and catastrophically-disabled 
veterans by removing the travel financial burden to access 
vital care that will improve independence and quality of life.
    We look at the blind rehabilitation centers that the VA 
provides and the spinal cord injury centers which are probably 
two of the most renowned facilities the VA has that they 
utilize. It makes no sense to have developed over the past 
decades outstanding blind rehabilitation programs known for 
their very high quality and patient care, only to tell low-
income veterans that they are unable and, therefore, cannot 
attend these centers.
    To put this dilemma in perspective, a large number of our 
constituents are living at or below the poverty line while the 
VA means test threshold for travel is $14,340. This bill here 
would assist individuals to partake at a blind rehabilitation 
center.
    To elaborate on the challenges of the travel for a blinded 
person, we look at current facts. In a study of new 
applications for recent vision loss rehabilitative services, 
seven percent had current major depression and 26.9 percent met 
the criteria for sub-threshold depression.
    Vision loss is a leading cause of falls in the elderly. One 
study found that visual field loss was associated with a six-
fold risk. While only 4.3 percent of those 65 and older in that 
population live in nursing homes, the number rises to about six 
percent for those who are visually impaired and 40 percent for 
those who are blind. Medicare direct cost of this is $11 
billion per year.
    If blinded or spinal cord injury veterans are not able to 
obtain the rehabilitative center training to learn to function 
at home independently because of travel cost barriers, the 
alternate charges for nursing home care or assisted home care 
are far larger than they can afford. Thus, the Federal 
Government usually subsidizes in the form of Medicare.
    We caution that private agencies for the blind are located 
in large urban cities; New York City, Chicago, Seattle, 
Orlando, or Boston. So travel barriers would preclude 
utilization of many of these sites for some of our veterans.
    VA centers often use specialized nursing, physical therapy, 
audiology, pharmacy, radiology, and laboratory support services 
that are necessary for clinical care and blinded veterans.
    Again, we stress one of the big challenges is that in the 
civilian medical world, there is not a high incident of these 
kinds of facilities that are available to veterans.
    That concludes my testimony. I will be able to stand by and 
answer any questions you might so have.

    [The prepared statement of Michael O'Rourke appears in the 
Appendix]

    Mr. Benishek. Thank you very much, Mr. O'Rourke. I really 
appreciate your time.
    Mr. Atizado, you can go ahead for five minutes. Thank you.

                  STATEMENT OF ADRIAN ATIZADO

    Mr. Atizado. Thank you, Chairman Benishek, Ranking Member 
Brownley, Members of the Subcommittee.
    On behalf of DAV's 1.2 million wartime wounded and injured 
veterans, I am pleased to present our views on the legislative 
measures subject to today's hearing.
    Requesting my written testimony be made part of the record, 
I will only address those bills on today's agenda for which DAV 
has a mandate from our membership.
    The Veterans Integrated Mental Health Care Act of 2013 
would establish a new authority for VA to use in contracting 
for mental health services for eligible veterans.
    DAV national resolutions were passed at our most recent 
national convention which calls for program improvement and 
enhanced resources for VA mental health programs as well as 
care coordination when VA purchases care in the community.
    However, in light of this Subcommittee's hearing on 
September 14, 2012, and as Chairman Miller had mentioned in his 
opening statement, where we had discussed the VA's patient 
centered community care and non-VA care coordination 
initiatives. These initiatives are to promote coordinated 
contract health care services including mental health care.
    DAV believes this bill overlaid on these initiatives which 
are ongoing would hamper VA's efforts and thereby cause 
disruption and delay to reform all contract and fee-based 
health care.
    Mr. Chairman, I would like to note at this point that it 
has been years since we have been asking for care coordination 
in contract care, which is why I believe enactment of this bill 
should be done prudently.
    For these reasons, DAV recommends that this bill be held in 
abeyance at this time until we realize or at least find out in 
concrete manner how this bill if enacted would impact the 
current initiatives.
    H.R. 241, The Veterans Timely Access to Health Care Act, 
would establish a statutory access to care standard of 30 days 
within the VA health care system. The bill would also require 
VA to submit to Congress continuing semi-annual performance 
reports on waiting times.
    Timely access to needed medical care is a critical domain 
of high-quality care. Our membership approved national 
resolutions addressing timely access to VA health care services 
for service-disabled veterans.
    However, we urge the Committee against prescribing a single 
standard of waiting times across the universe of appointment 
types as was mentioned earlier with the first panel. A 30-day 
standard may lengthen waiting times considering VA's current 
access standards.
    DAV believes the transparency potential conveyed in this 
bill to document more accurate waiting times is a worthwhile 
concept. We ask for consideration and adding to the reports 
greater granularity such as including waiting times for 
purchased care, care purchased in the community whether it is 
mental health or inpatient or rehab services.
    We also ask for greater specificity in reporting such as 
performance reporting by each VA facility.
    H.R. 288, The CHAMPVA Children's Protection Act of 2013, 
would extend the maximum age eligibility of a qualifying 
veteran's child to CHAMPVA coverage from age 23 to 26 only if 
the child is pursuing a full-time course of instruction at an 
approved educational institution or is unable to continue to do 
so because of a disability not resulting from a child's willful 
misconduct.
    Now, DAV supports this measure based on resolution number 
222. However, we strongly urge amending it to conform to Public 
Laws 111-148 and 111-152. These two public laws require private 
health insurance to cover adult dependent children in covered 
families until these individuals attain the age of 26 
irrespective of marital status, financial dependency, or other 
factors, and including in this instance educational status.
    DAV urges the measure to be amended to ensure children of 
severely-disabled veterans and survivors of veterans who have 
paid the ultimate sacrifice enjoy the same rights and 
privileges as other young adults of our country.
    This concludes my testimony, Mr. Chairman. Thank you for 
allowing DAV to testify, and I would be pleased to answer any 
questions you or the Members of the Subcommittee may have.

    [The prepared statement of Adrian Atizado appears in the 
Appendix]

    Mr. Benishek. Thank you very much for your input, sir. I 
really appreciate it.
    Mr. Nicholson, please proceed with your testimony for five 
minutes.

                  STATEMENT OF ALEX NICHOLSON

    Mr. Nicholson. Thank you, Mr. Chairman, Ranking Member 
Brownley, and distinguished Members of the Subcommittee.
    On behalf of Iraq and Afghanistan Veterans of America or 
IAVA, we thoroughly appreciate the opportunity to share our 
views regarding these important pieces of legislation pending 
before you today.
    As many of you know, IAVA is the Nation's first and largest 
nonprofit, nonpartisan organization for the veterans of the 
wars in Iraq and Afghanistan and their supporters. Founded in 
2004, our mission is important but simple, to improve the lives 
of Iraq and Afghanistan veterans and their families.
    With a steadily growing base of over 200,000 members and 
supporters, we strive to create a society that honors and 
supports veterans of all generations. IAVA believes that all 
veterans must have access to quality health care and related 
services. IAVA is therefore supportive of each of the bills 
that are the subject of this hearing here today.
    With regard to H.R. 241, IAVA supports The Veterans Timely 
Access to Health Care Act because it will help hold the VA 
accountable for meeting maximum allowable wait times. A 
veteran's ability to access timely care plays a vital role in 
sustaining his or her quality of life post service. But from a 
mental health point of view in particular, the importance of 
providing timely care becomes even more critical.
    Timely mental health care can sometimes mean the difference 
between life and death for veterans in crisis. And IAVA 
believes that every VA medical center and health care provider 
should be able to provide reasonable standards of timeliness 
when providing care for veterans.
    IAVA also supports H.R. 288, The CHAMPVA Children's 
Protection Act of 2013. With the enactment of The Affordable 
Care Act, children up to age 26 can now be covered by their 
parents' health insurance plans.
    While legislation was subsequently enacted to extend this 
coverage to eligible children of TRICARE recipients, this 
legislation is still needed so that benefits can also continue 
to be similarly provided to children of our Nation's wounded 
warriors under CHAMPVA.
    IAVA also supports H.R. 984 which would establish a task 
force on urotrauma in order to expand research on and develop 
new care recommendations for these injuries. Urotrauma, which 
is often seen in servicemembers and veterans who have sustained 
blast injuries, has unfortunately become more prevalent among 
those who have served in Iraq and Afghanistan.
    Because of advances in modern treatment practices within 
the military medical community, servicemembers and veterans are 
surviving these types of injuries with greater frequency than 
in past conflicts which means that VA now finds itself treating 
more injuries such as genitourinary injuries for which there 
may not be a wide range of experience or vast body of knowledge 
extant within the system.
    IAVA sees H.R. 984 as an important step in providing the 
necessary research and treatment options to address these 
serious wounds of war.
    IAVA supports H.R. 1284, which would authorize the VA to 
reimburse the travel costs associated with seeking approved 
inpatient care at a VA special disabilities rehabilitation 
program for additional categories of catastrophically-disabled 
veterans.
    We believe this legislation will provide critical 
assistance for more disabled veterans to allow them to receive 
the specialized inpatient treatment that they need.
    IAVA also supports Chairman Miller's draft bill, The 
Veterans Integrated Mental Health Care Act. IAVA's 2013 member 
survey revealed that 80 percent of respondents do not think 
servicemembers and veterans are getting the mental health care 
they need.
    IAVA believes that one way to help address the mental 
health care needs of veterans is through building the type of 
community partnerships that are advocated for and facilitated 
by this bill, and we believe this bill was a step in the right 
direction toward building such positive and beneficial 
community partnerships.
    And finally, IAVA supports The Demanding Accountability for 
Veterans Act, which would formalize the system of 
accountability within VA, give the VA inspector generals' 
report recommendations more authority, and institute 
consequences for failing to fix problems clearly identified by 
the VA's IG.
    IAVA believes this bill will strengthen current systems of 
accountability by narrowing the focus of scrutiny as to who is 
responsible for producing and correcting IG identified public 
safety issues.
    Mr. Chairman, we at IAVA again appreciate the opportunity 
to provide our views on these important pieces of legislation 
and we look forward to continuing to work with each of you, 
your staff, and the Subcommittee to improve the lives of 
veterans and their families.
    Thank you for your time and attention.

    [The prepared statement of Alex Nicholson appears in the 
Appendix]

    Mr. Benishek. Thank you very much, Mr. Nicholson. I 
appreciate your comments.
    Ms. Predeoux, five minutes.

                 STATEMENT OF ALETHEA PREDEOUX

    Ms. Predeoux. Chairman Benishek, Ranking Member Brownley, 
and Members of the Subcommittee, Paralyzed Veterans of America 
would like to thank you for the opportunity to present our 
views on health care legislation being considered by this 
Subcommittee.
    These important bills will help ensure that veterans 
receive the best health care services available. We are 
particularly pleased that two bills, H.R. 288 and H.R. 1284, 
that are very high priorities for PVA are being considered 
today.
    My remarks will focus only on a few bills as PVA's full 
statement has been submitted to the Subcommittee.
    At this time, PVA does not support The Veterans Integrated 
Mental Health Care Act of 2013, a bill that would require the 
VA to provide veterans with an integrated delivery model for 
mental health care through care coordination contracts.
    The VA is currently working on multiple initiatives to 
improve care coordination with private providers and increase 
timely access to mental health services. More specifically, the 
VA is in the process of transforming its national non-VA care 
program in an effort to improve coordination services with non-
VA providers which includes mental health services.
    PVA believes that the current VA initiative should be 
further developed before additional resources are put into 
another program for non-VA care coordination.
    PVA generally supports the intend of The Veterans Timely 
Access to Health Care Act which proposes to direct the VA 
secretary to establish standards of access to care for veterans 
seeking services from VA medical facilities.
    If enacted, this bill would establish a standard for access 
to care that requires the date on which a veteran contacts the 
VA seeking an appointment and the date on which a visit with an 
appropriate health care provider is completed to be 30 days.
    While this legislation may potentially improve the delivery 
of VA services, the language does not take into account the 
fact that the standard for access to care may vary depending on 
the type of care needed.
    As such, PVA has concerns regarding the use of a 30-day 
standard for access to care without specifying the type of care 
that is being provided.
    While PVA believes that timely access to quality care is 
vital to VA's core mission of providing primary care and 
specialized services to veterans, it is also important that 
factors such as the nature of the services provided and 
efficient use of VA staff and resources be considered when 
developing standards for access to care.
    PVA supports H.R. 288, legislation to increase the maximum 
age for children eligible for medical care under the Civilian 
Health and Medical Program of the Department of Veterans, 
CHAMPVA.
    CHAMPVA is a comprehensive health care program in which the 
VA shares the cost of covered health care services for eligible 
beneficiaries including children up to age 23.
    As part of health reform, all commercial health insurance 
coverage increased the age for covered dependents to receive 
health insurance on their parents' plan from 23 years of age to 
26 years of age in accordance with the provisions of Public Law 
111-148, The Patient Protection and Affordable Care Act.
    This change also included health care coverage provided to 
servicemembers and their families through TRICARE.
    Today, the only qualified dependents that are not covered 
under a parent's health insurance policy up to age 26 are those 
of 100-percent service-connected disabled veterans covered 
under CHAMPVA.
    This unfortunate oversight has placed a financial burden on 
these disabled veterans whose children are still dependent upon 
their parents for medical coverage, particularly if the child 
has a preexisting medical condition.
    PVA believes that this legislation will make the necessary 
adjustment to help veterans and their families in this 
position.
    Lastly, PVA strongly supports H.R. 1284, a bill that if 
enacted would provide coverage under the Beneficiary Travel 
Program to non-service-connected veterans with a spinal cord 
injury or disorder, double or multiple amputations, or vision 
impairment.
    Too often, catastrophically-disabled veterans, particularly 
non-service-connected veterans who do not have the benefit of 
travel reimbursement, choose not to go 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.
    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, timely comprehensive care and result in 
long-term cost savings for the VA.
    Again, thank you for the opportunity to submit PVA's views 
on the legislation being considered today, and I am happy to 
answer any questions that you may have.

    [The prepared statement of Alethea Predeoux appears in the 
Appendix]

    Mr. Benishek. Thank you, Ms. Predeoux.
    I am going to yield myself a few minutes to ask a few 
questions about some of the legislation.
    I want to thank you all for your candid comments because I 
think your input is very valuable. I had some of the same 
thoughts and questions about some of the legislation myself.
    I am so happy to hear your opinion. And I hope that you all 
will be willing to work with the Committee to try to improve 
some of this legislation.
    I know that many of you had concerns about the Chairman's 
Veterans Integrated Mental Health Care Act. I am concerned 
about addressing the concerns that you brought up, so hopefully 
you will be able to work with the Committee and the Chairman to 
address that.
    I have a question concerning my legislation, The Demanding 
Accountability for Veterans Act. I sponsored this after the 
Subcommittee had a hearing where they had this IG report where 
VA has not had a plan for physician staffing the last 30 years. 
The IG had reported like eight times that we should do 
something and then the VA reported back, oh, we are going to 
have something in three years.
    I cannot imagine how we could get people to do what they 
are supposed to do at the VA. With the amount of open IG 
recommendations, do any of you have any ideas as to how we can 
make these particular managers more responsible?
    I understand that Congress has oversight responsibility, 
but, we come upon an incident somewhere in the VA and we 
highlight it here it in Committee and it is talked about 
everywhere, but there are things going on. There are a thousand 
open IG recommendations. We cannot get to every one of them in 
these committees for oversight. The IG is their own oversight.
    So shouldn't we have those IG reports have some teeth to 
them? And I would like to ask any of you if you have any 
opinion as to what my legislation does or if you have a better 
idea as to how to hold the VA accountable for getting things 
done.
    Mr. O'Rourke, do you have anything?
    Mr. O'Rourke. No, sir, not at the present time.
    Mr. Benishek. Mr. Atizado?
    Mr. Atizado. Thank you for the question, Chairman Benishek.
    I can tell you that it is an appropriate question to ask 
about IGs' recommendations. I actually had the opportunity, 
probably about a year and a half ago, to try and follow-up on 
these recommended actions and I could not follow it.
    I called between the IG and the program office at VA to see 
what the status was on the recommendations and for the most 
part, the actions that were recommended were actually 
negotiated, which means the recommended actions that were 
written on the report were not actually the recommended actions 
that VA was working on as agreed upon by OIG.
    Meaning to say, Mr. Benishek, that while this bill intends 
to put some greater enforcement and accountability on the part 
of the IG, we have to be a little bit more thoughtful on how 
this is done.
    For example, better definition of what covered reports are. 
Anything that VA does which is a public health institution 
deals with public health and safety. Does it include all the 
reports that the IG provides? What does significant progress 
mean?
    Just some thoughts, Mr. Benishek. That is all I have.
    Mr. Benishek. I understand what you are thinking, but I am 
trying to find the best way to do this too. How do we hold the 
VA accountable? How do we get people to actually produce?
    Mr. Nicholson, do you have any other ideas there?
    Mr. Nicholson. I would just add, Mr. Chairman, that I think 
we are on the same page in terms of solutions that would 
actually have teeth to them. You know, I think whether it is 
public safety issues, IG recommendations, following through on 
reducing the backlog, it does not sort of matter, you know, 
what issue you look at, you know, the VA, I think, keeps 
promising us progress year after year and, you know, we see 
backlogs and not only disability claims, you know, issues, but, 
you know, like you mentioned earlier in following through on 
all these outstanding IG recommendations.
    You know, so something, I think, that would add some teeth 
to, you know, the accountability factor, I think, would be 
certainly welcomed by us.
    You know, we hear from our members consistently year after 
year. You know, we do an annual survey of our membership which 
is one of the largest that is done independently of Iraq and 
Afghanistan era veterans. And we consistently hear that while 
veterans are satisfied with the care they receive, they 
continue to be dissatisfied overall with the VA itself. You 
know, there is sort of a disconnect between, you know, sort of 
the tactical level and the strategic level here.
    And so, you know, I would say from our perspective 
solutions like you mentioned with teeth, would certainly be 
welcome and I think it is, you know, high time that we start 
adding teeth into these types of bills.
    Thank you.
    Mr. Benishek. I want to talk a bit more about this, but I 
want to give Ms. Brownley an opportunity to ask some questions.
    Ms. Brownley. Thank you, Mr. Chair.
    Again, I also want to thank everybody here who has 
testified and appreciate your comments and recommendations. And 
I want to particularly thank Mr. O'Rourke for a detailed 
perspective on H.R. 1284 and the benefits for veterans.
    I would like to hear from the Blinded Veterans Association 
and the DAV and the PVA if they have any comments relative to 
some of the VA testimony that this particular bill as written 
might provide some disparate travel eligibility to a limited 
group of veterans and they would favor opening up the travel 
benefits to a wider group of veterans, of course contingent 
upon funding, but would like to hear your response to that 
suggestion.
    Ms. Predeoux. I can begin. PVA certainly would not be 
opposed to expanding that benefit. However, we believe that the 
three populations that are targeted is a good start simply 
because these groups have systems or centers of care within the 
VA that are not always geographically accessible for this 
population of veterans, these populations of veterans.
    When you consider that they may have clinics or other 
access to VA facilities, comprehensive care that is needed at 
least at a minimum, oftentimes more, once a year getting to 
those facilities oftentimes could be three to four hours. And 
so to ensure that they are receiving the care at least once a 
year, we wanted to make sure that cost did not prevent them 
from doing that.
    So it is those centers of care oftentimes, we cannot have 
one everywhere, and particularly in the rural areas, so I think 
this is a good first step and we would definitely support the 
expansion of the benefit to other veteran populations.
    Ms. Brownley. Thank you.
    Mr. Atizado.
    Mr. Atizado. Ranking Member Brownley, thank you for that 
question.
    So in our testimony, we talk about possibly expanding 
beyond the current statutory requirement as well as what this 
bill proposes to do. Simply because there is a provision, 
actually it is paragraph two below the one that this bill wants 
to amend, that gives the secretary discretionary authority to 
provide these benefits to any other veteran that the secretary 
deems fit or appropriate to which we do not believe it has 
actually been exercised but for very anecdotal, very specific 
instances.
    For example, facility transfers from SCI to SCI, air 
travel, things of that nature. So the need is there and there 
is a wide gap between those anecdotal incidences as well as 
these three populations. We think it should be a little bit 
more broader with a sense that there should be more parity.
    Yes, the three populations that this bill considers is 
certainly deserving, but there are others as well, whether it 
be those who are frail elderly who just cannot drive and need 
somebody to help them drive to a facility, things of that 
nature. That is where we would like to see this provision go. 
We agree with PVA that it is a good first step and would not 
oppose its enactment.
    Ms. Brownley. Thank you for that.
    Mr. O'Rourke, do you have any additional comments?
    Mr. O'Rourke. Yes, ma'am. I think the VA has some 
outstanding facilities and I think that at times they go under-
utilized. So my point being here is, we would like to expand 
into the inpatient treatment facilities more patient care from 
eligible veterans. And this would be the first step for those 
that are non-service that come down with age-related disease 
entities.
    As we progress in age, some things just happen to us. We do 
not want them to happen, but they do. Glaucoma becomes more 
constant, diabetic neuropathy with the diabetic population.
    In our veterans, we look at macular degeneration. We look 
at the many different types of wounded that are coming back 
from OIF/OEF that that IED, that blast does not just stop at 
the TBI or the traumatic brain injury. It affects the eyes. It 
affects audiology. It affects the lower abdomen.
    I wish we had Kevlar to take care of that, but we do have 
fine upstanding VA facilities that I think are going under-
utilized, if that is appropriate terminology. And I think we 
have the veterans that need and deserve the care at these 
facilities.
    And this travel bill will assist them. And they do such 
good work there that I would think that it would be 
advantageous for the VA to do it in many other arenas, but I 
understand finances. And today's society, I think it is the 
next right move.
    Ms. Brownley. Thank you very much.
    And I will yield back to the Chairman.
    Mr. Benishek. Thank you, Ms. Brownley.
    We have a few more questions, but I think maybe I will 
submit some of the questions that I have to you in writing and 
hopefully get a response from you there because I know as far 
as my legislation is concerned, I do not want to have any, you 
know, let me put it that way, that I want to have some strict 
definitions of what is going on there so that we can actually 
hold people accountable and not slip out, if you understand 
what I mean.
    So I truly appreciate all your comments here today and look 
forward to speaking to you further about these issues and these 
pieces of legislation. I truly appreciate your time and you 
being here today.
    So unless you have any other questions, you can expect a 
few written questions from us, and the panel is now excused. 
Thank you very much for being here.
    And at that point then, we are going to welcome our third 
and final panel to the witness table. And that will be from the 
Department of Veterans Affairs Dr. Robert Jesse, the Principal 
Deputy Under Secretary for Health. Dr. Jesse is accompanied by 
Susan Blauert, Deputy Assistant General Counsel.
    So, Dr. Jesse, thanks for joining us today. I appreciate 
your presence and I look forward to your comments about the 
proposed legislation before us. And you can proceed when you 
are ready.

STATEMENT OF ROBERT L. JESSE, PRINCIPAL DEPUTY UNDER SECRETARY 
FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 
    VETERANS AFFAIRS, ACCOMPANIED BY SUSAN BLAUERT, DEPUTY 
 ASSISTANT GENERAL COUNSEL, U.S. DEPARTMENT OF VETERANS AFFAIRS

    Dr. Jesse. Well, thank you, sir.
    And good morning, Chairman Benishek and Ranking Member 
Brownley and Members of the Subcommittee. And thanks for the 
opportunity to address the bills on today's agenda and the 
impact that these are going to have on the VA.
    And as you mentioned, I am accompanied by Susan Blauert, 
VA's Deputy Assistant General Counsel.
    Sir, we very much appreciate your continued efforts and 
those of the Subcommittee to support and improve veterans' 
health care.
    Because of the short time for preparation views, we do not 
have formal testimony on two of the draft bills, H.R. 241, The 
Veterans Integrated Mental Health Care Act of 2013, and H.R. 
984, Demanding Accountability for Veterans Act of 2013.
    Despite not having formal prepared views on these bills, we 
do recognize the importance of addressing these underlying 
issues and that are related in each of these bills. In fact, 
all these bills are issues that are very important to the VA.
    For example, we have worked steadily to implement the 
letter intent of the Executive Order improving access to mental 
health care services for veterans, servicemembers, and military 
families.
    We believe that we have made significant progress towards 
hiring mental health professionals and many of the other 
ongoing mental health initiatives demonstrate our strong 
commitment to ensuring the availability of mental health 
services to all of our veterans wherever and whenever it is 
needed.
    Likewise, VA understands the needs for a system and 
organizational processes that support a culture of excellence 
and one of accountability. And H.R. 241 and your draft 
Demanding Accountability for Veterans Act both seek to hold VA 
to high standards. And please know that we share those common 
values.
    And I will take a moment and explain now the position we 
have on the two bills for which we were able to complete views. 
There is a more detailed treatment of these in my written 
statement.
    VA generally support bills that expand services to veterans 
when resources permit us to do so and this would include 
increasing the maximum age to 26 for eligibility of young 
adults covered by our CHAMPVA program.
    We are concerned with the bill as it is written because we 
fear it may not accomplish the objective because it fails to 
address a technical definition of the term child contained in 
the current statute. And our written statement provides a more 
detailed explanation.
    I use the term young adults because I have kids that age 
and they do not like it when I call them children.
    Be assured that we are anxious to work with the Committee 
toward providing the best language to support the intent of the 
bill. We fully support ensuring that CHAMPVA coverage is 
consistent with private sector coverage provided under The 
Affordable Care Act.
    The second bill, H.R. 1284, would extend VA's beneficiary 
travel benefits to certain veterans with vision impairment, 
spinal cord injury or disorder, and double or multiple 
amputations.
    The eligibility provided in this bill is offered 
specifically for when this class of veterans is traveling to 
receive care from the VA's special disabilities rehabilitation 
program on an inpatient basis or when the trip qualifies for 
temporary lodging.
    And I have been well schooled by Tom Zampieri and Mr. 
O'Rourke about the complexities of getting particularly blinded 
veterans back and forth even for their primary care 
appointments.
    We believe the legislation could be improved then by 
broadening the scope. VA supports extending the beneficiary 
travel eligibility to all veterans who could most benefit from 
the program.
    VA provides rehabilitation for many injuries and diseases 
including for veterans who are catastrophically disabled. VA 
also provides care at numerous specialized centers other than 
those noted in H.R. 1284.
    For example, we have other programs for closed and 
traumatic brain injury, for post-traumatic stress disorder, 
military sexual trauma, and other various addiction programs.
    Many of these programs provide outpatient care to veterans 
who might not require lodging, but still travel significant 
distance or are challenged in traveling to those appointments 
on a daily basis. And under this proposed legislation, the 
group of veterans would not be eligible.
    For these reasons, VA does not support the legislation as 
written because it would provide disparate travel eligibility 
to a limited group of veterans.
    However, we do support the idea of travel for a larger 
group of catastrophically-disabled veterans including veterans 
who are blind or have SCI and amputees and those with special 
needs who may not otherwise be eligible for travel benefits.
    Once again, VA welcomes the opportunity to work with the 
Committee to craft appropriate language that is mindful of both 
resources and especially the needs of these veterans.
    So thank you for the opportunity to testify before the 
Committee and we will be pleased to answer your questions.

    [The prepared statement of Robert L. Jesse appears in the 
Appendix]

    Mr. Benishek. Thank you very much, Doctor.
    Let me ask you a question. How much time did you have then 
to prepare for the hearing today? When was the notice given, 
because you said you did not respond because there was not 
enough time?
    Dr. Jesse. Well, I would defer that to our congressional 
affairs people because I am not aware exactly when it came in. 
But I think it was within less than two weeks. So it was a 
relatively short notice.
    Mr. Benishek. All right.
    Dr. Jesse. We can get the exact timing for you.
    Mr. Benishek. Well, I am just curious. I think three weeks 
is probably the standard, I guess, for the hearing notice, and 
I just feel disappointed when I hear that answer in view of e-
mail and that.
    Nowadays, it usually happens pretty quickly. So it seems 
like two weeks would be a pretty good amount of time to figure 
out a response to some of these legislative ideas.
    You understand the purpose of my piece of legislation, Dr. 
Jesse?
    Dr. Jesse. Yes.
    Mr. Benishek. I am trying to figure out how to get the VA 
to get some things done that do not seem to be getting done. 
Some of the comments by the previous panel identified some 
shortcomings that I do not specifically target what exactly I 
am looking for.
    I just do not like the fact that people, managers of a 
project, that do not respond to an IG report for over a year 
and, this incident of, no physician plan for staffing has been 
going on for 30 years with eight separate IG reports over the 
past 30 years.
    And then when I had them in front of my Committee, a month 
ago, it was, well, they are going to have a plan in three 
years. They have agreed that they need a plan for the last 30 
years and, yet, nothing is getting done.
    So how do I fix that, Dr. Jesse?
    Dr. Jesse. So I can, I guess, reflect on that in my 
experience within the VA. And my job prior to this one was as 
the director of, well, initially as cardiology and then of 
medical surgical services.
    And I know that there has been work on this, in fact, so I 
am not sure about the exact date, but it was about the time 
that I became head of medical surgical services, an office was 
stood up, the Office of Productivity Evaluation, really looking 
exactly at this. And it is up in Boston.
    And we found that primary care is pretty easy. You can 
build a panel and we work on a goal of about 1,200 patients per 
primary care provider. And for specialty care, it is quite a 
bit harder and----
    Mr. Benishek. Oh, no, I understand all that for that 
particular issue. And it is not so much the physicians. The 
secretary does this kind of stuff all the time. That is just 
one of the issues that I am getting at. Okay?
    Dr. Jesse. Okay. Yeah.
    Mr. Benishek. I understand that as a physician, you kind of 
figure this out. You know what I mean? But what I am learning 
about there is some manager somewhere whose responsibility it 
was to get this done and it seems like something could have 
been done in the last 30 years with eight reports and VA 
agreeing with the reports, but nothing happening.
    And I think that identifying the person in charge of that 
program is important because when we have these people before 
us, it is never the actual person that was in charge that 
actually appears here. And then we have a hard time figuring 
out who that person actually was.
    You understand what I am saying?
    Dr. Jesse. Yes. I guess my comment to that would be often 
it is not a person that gets responsible. So it may not fall 
under one particular program office at times. And that is part 
of the problem is--I mean, you are exactly correct--in how one 
assigns the lines of accountability to get things done. These 
are often--well, everything is complex in health care.
    Mr. Benishek. I know. But, I hate when you come up here and 
you say to me there is no one who is responsible. You said that 
there. There is not one person responsible, so then how do we 
hold them accountable because everybody else, they shift that 
responsibility here and there. It was not my fault. That is not 
my department.
    You know what I mean? We need to have that better defined 
and I am trying to fix that. And my legislation is an attempt 
to do that. You know, it may not be perfect. That is why I want 
input.
    Dr. Jesse. No. And I think you are exactly correct in 
looking at these issues that are open for a long period of time 
and do not meet their deadlines because clearly there is 
something wrong if we have committed to do something in a 
certain amount of time and we are not getting there. Then we 
owe an explanation as to why.
    And sometimes there are very good explanations, but often 
there are not. And I think when we do not, then we do need to 
be held accountable for that and to you and with the 
transparency that we believe we operate under to make that 
clear.
    Mr. Benishek. Yeah. Well, I appreciate your comment and the 
fact that sometimes there is not anyone responsible. That is a 
really good point that you make there. I think maybe we can try 
to fix that as we look at, adjusting this bill and actually 
have it have some teeth. So I appreciate that.
    I will allow Ms. Brownley an opportunity to ask questions.
    Ms. Brownley. Thank you, Mr. Chair.
    And I wanted to follow-up as well on the bill that I am 
carrying, H.R. 1284. And I certainly appreciate your testimony 
with regards to expanding these kinds of services to a larger 
population.
    I am just wondering if you have any kind of cost estimate 
if it were expanded.
    Dr. Jesse. I do not have it in my head, but we could 
certainly get that to you.
    Ms. Brownley. So you have looked at it then?
    Dr. Jesse. Yeah. I think we have looked into it. I can 
probably look it up in here, but we can get a rough estimate to 
you.
    I would like to answer that from a different side because 
it is an important issue and it is not quite as quantitative.
    But we know that one of the most costly things in medicine 
is when people miss appointments and that, in general, making 
sure that patients get to appointments is in a very broad scope 
cost effective. And that is not just related to the cost of the 
travel. It is the cost of the complications of untreated 
diseases. It is the cost of compliance and all these other 
things that add in.
    And this has been a pretty consistent theme that we have 
seen, but also in a lot of the other large health systems. And 
so it is one of the reasons why we are, you know, regardless of 
the cost, we are very supportive of the ability to get patients 
to their appointments.
    It is also one of the reasons why we are so strongly 
committed to really moving health care from being about just 
the appointment to being about the sustained relationships 
because so many of these issues can be mitigated if patients 
can just reach into the system and through telehealth, securing 
messaging, and any other number.
    You have all heard a lot about where we are going in those 
directions. These are important contributors to ensuring good 
health care, but they are all part of a large package. But that 
is one of the reasons why we are so strongly committed to that, 
so that everybody does not have to come in for an appointment, 
but when they do, we want them there.
    And that is why we are very supportive of the 
transportation and particularly rural transportation. And I 
know that Mr. Michaud is very committed to this.
    Ms. Brownley. Well, just following up with that, and I 
appreciate your comments relative to that, because I think 
everybody here really does believe that a bill like this, 
providing the transportation, making sure that veterans show up 
for their appointments and so forth in the long term is a cost 
savings, will be a cost savings to the VA and really a bill 
like this, I wish it was always presented as a cost savings as 
opposed to a cost.
    And just wondering again whether the VA has done any kind 
of analysis to demonstrate and quantify, if you will, what the 
real savings are.
    Dr. Jesse. I can get back to you on the record for that. I 
just cannot tell you right now.
    Ms. Brownley. So you actually have all of that information?
    Dr. Jesse. Well, I will see what we do have. I know this is 
an area that we have been very interested in. We have got a lot 
of interest in looking at this. I just cannot tell you 
precisely the numbers and data that we have at this time. We 
will get back to you with where we are on that.
    Ms. Brownley. Okay. Great. And I just wanted to follow-up 
on my colleague's bill, Mr. Michaud's bill and the CHAMPVA, and 
appreciate your comments vis-a-vis the technical area in the 
bill and certainly will appreciate your technical assistance so 
that we can get the bill----
    Dr. Jesse. Yeah. We believe this is important. We just want 
to make sure it is correct.
    Ms. Brownley. Okay. Great. Very, very good. And the other 
thing is that I understand that in terms of identifying the 
population, the young adults, as you refer to, there were some 
statistics from the March 31st, 2010 data run.
    I am just wondering if there is any updated data on that. I 
think that the 2010 data run said that the VA estimated a 
figure of about 59,000 additional young adults would become 
CHAMPVA eligible and just wondering if you have any updates on 
that.
    Dr. Jesse. I think it is going to be in about that same 
range.
    Ms. Brownley. Okay.
    Dr. Jesse. We do know those numbers.
    Ms. Brownley. Thank you, sir.
    I yield back my time.
    Mr. Benishek. Well, I have a couple of little follow-up 
questions.
    Dr. Jesse. Sure.
    Mr. Benishek. I think we are going to end up submitting 
some written questions to you as well, Dr. Jesse, and I would 
appreciate your written response to them later.
    But one of the comments that Dr. Edney made the urologist 
that testified talked about the difficulties sometimes 
coordinating urotrauma care in the VA--when the veteran ends up 
going to a VA close to his home.
    Do you agree that a coordinated centralized effort to treat 
the long-term urotrauma would be a good idea and how do you see 
that working within the VA system?
    Dr. Jesse. So I was very interested in his testimony. A 
couple things sort of came to my mind. And one is, as he 
mentioned, the complexity of moving patients from their active 
duty into the VA system and it argues very strongly for the 
work that we are trying to get through at the VLER, the Virtual 
Lifetime Electronic Record, to make sure that moves across.
    VA already has, I think it is about 16 of our VISNs have 
centers that can deal with complex urinary trauma including the 
five polytrauma centers. And these are the kind of specialty 
care that need to go to specialty places.
    You know, this is the type of thing that I would normally 
be thinking about and my thinking on this was changed pretty 
dramatically about a year ago. I was sitting on a plane and the 
woman in the middle seat next to me was quite upset. And it 
turned out why she was upset because her husband was at the 
front of the plane and she was at the back of the plane. And 
the guy sitting up front was not willing to change seats with 
her.
    But I got to talking to her. Her husband had complex GU 
trauma. And I learned an awful lot about--you know, he was 
getting excellent care for this, but the issue was far beyond 
the technical surgical care. Really there were just so many 
complex family issues involved in this.
    And that is not the stuff that moves to the specialty 
centers. Yes, we have expertise in there, but that kind of care 
needs to go on everywhere when they get back into their 
communities and it needs to be very much a part of all the rest 
of the health care that they get.
    And that is the coordination piece that I think you talk 
about. We need to make sure that, you know, our providers are 
attuned to these issues and can deal with them in more than the 
technical medical and surgical parts, but also be very attuned 
to the, you know, the complexities that go on with these.
    So, you know, we have done a lot in educating particularly 
about military sexual trauma. The women's health program in VA 
is just astounding in the work they have done in the past four 
or five years and particularly now with work in reproductive 
health which was part of his testimony.
    So all these pieces are, in fact, coming together, but, you 
know, if it is just about the technical GU surgery piece, I 
think the specialized centers are really important. But I think 
we also need to have the windows wide open to see the entire 
complexity of the situation.
    Mr. Benishek. Well, I agree with you on that, but I think 
that the urology specialists provide more than just simply the 
technical expertise. They provide also a value in understanding 
some of these social issues sometimes----
    Dr. Jesse. Oh, absolutely.
    Mr. Benishek. --psychosocial issues associated with this 
trauma sometimes more than the person at the local VA who is 
taking care of the patient. I agree that the person at the 
local VA should be in communication with the specialist so they 
have a familiarity with those things.
    But as a general surgeon, I feel a little bit distraught 
when you say it is simply a technical----
    Dr. Jesse. No, I did not mean to imply that.
    Mr. Benishek. We have more than simply a technical ability. 
We deal with these issues.
    Let me ask you another question if you do not mind. In your 
written testimony, you stated the VA believes that eligibility 
for coverage of children under the CHAMPVA would be consistent 
with certain private sector coverage under The Affordable Care 
Act. Yet, during the consideration of and the passage of The 
Affordable Care Act, the Administration did not include in its 
budget or submit a legislative request to amend the CHAMPVA to 
extend the coverage for children up to age 26.
    Do you know why that happened?
    Dr. Jesse. I do not, but we can get that back to you. We 
are in favor of it. I do not know why it did not come through 
from us.
    Mr. Benishek. All right. Ms. Brownley, do you have any 
other questions?
    Ms. Brownley. No.
    Mr. Benishek. Well, I think that will conclude the hearing 
today. Please be ready to get the remainder of the questions 
that we want to have answered to help us formulate this 
legislation a little better.
    But I truly appreciate everyone being here and your 
comments today and feel free to follow-up with the Subcommittee 
for any other input you want to provide. And thank you so much 
for your time this morning.
    Dr. Jesse. Thank you, sir.

    [Whereupon, at 11:46 a.m., the Subcommittee was adjourned.]

















                            A P P E N D I X

                              ----------                              

           Prepared Statement of Hon. Dan Benishek, Chairman
    Good morning. The Subcommittee will come to order.
    Thank you all for joining us today as we meet to discuss six 
legislative proposals aimed at strengthening the health care and 
services we provide to our honored veterans through the Department of 
Veterans Affairs (VA).
    The six bills on our agenda this morning are:
    - draft legislation, the Veterans Integrated Mental Health Care Act 
of 2013;
    - draft legislation, the Demanding Accountability for Veterans Act 
of 2013;
    - H.R. 241, the Veterans Timely Access to Health Care Act;
    - H.R. 288, the CHAMPVA Children's Protection Act of 2013;
    - H.R. 984, to direct the Secretary of Defense to establish a task 
force on urotrauma; and,
    - H.R. 1284, to provide for coverage under VA's beneficiary travel 
program for certain disabled veterans for travel for certain special 
disabilities rehabilitation.
    These bills seek to address a number of important issues facing our 
veterans.
    I expect today's hearing to encompass a highly detailed and 
thorough discussion of the potential merits, challenges, and 
implications of each proposal before us.
    I look forward to working with the Ranking Member, the bill 
sponsors, and our Subcommittee colleagues to fully evaluate these 
proposals and ensure that we advance meaningful and appropriate 
legislation to fulfill the promise we made to our veterans.
    My bill - the Demanding Accountability for Veterans Act - is 
intended to address the pervasive lack of action taken by VA based on 
their own agreed upon timelines for remediation of issues and 
recommendations included in VA Inspector General (IG) reports.
    Currently, the IG tracks open recommendations on their Web site and 
in their Semiannual Report to Congress, the latest of which showed that 
there were 177 total open reports and 1,140 total open recommendations. 
Of those, 33 reports and 93 recommendations had remained open for more 
than one year.
    My bill would require the IG to make a determination whether VA is 
making ``significant progress'' on implementing VA's own agreed upon 
action plan and timeline to implement the recommendations made by the 
IG in a report concerning public health or patient safety.
    Under the bill, if the IG determines that ``significant progress'' 
has not been made, the IG would be required to notify the Committees 
and the Secretary of the Department's failure to respond appropriately. 
Following notification, the Secretary, would be given fifteen days to 
submit the names of each VA manager responsible for taking action to 
the IG.
    In turn, the Secretary would be required to promptly notify each 
responsible manager of the issue requiring action, direct that manager 
to resolve the issue, and provide him or her with appropriate 
counseling and a mitigation plan.
    The Secretary would also be required to include in the responsible 
manager's performance review an evaluation of actions in response to a 
relevant IG report and prohibit the individual from receiving a bonus 
or other performance award for failure to take action.
    The goal of this legislation is simple - to create a culture within 
VA where problems that go unresolved are unacceptable.
    Far too often, I have seen serious issues that the IG has 
identified go unaddressed by the Department.
    Such inaction is intolerable where the care and services provided 
to our veterans is concerned and it is well past time for those at VA 
who are responsible for implementing needed changes to be held 
accountable for their work.
    I am hopeful that the Demanding Accountability for Veterans Act is 
the first step in ensuring that they are.
    I am happy to answer any questions my colleagues may have on this 
bill and to listen to the views of all of our witnesses.
    To that end, I would like to thank all the sponsors for taking the 
time to speak with us about their proposals today. I am grateful to 
each for their leadership and advocacy efforts on behalf of our 
veterans and their families.
    I would also like to thank our veteran service organization 
partners and other stakeholders - both those who will testify here this 
morning and those who submitted statements for the record - for their 
valuable input.
    I am also grateful to VA for being here to provide the Department's 
views on these important proposals.
    With that, I now yield to Ranking Member Brownley for any opening 
statement she may have.
    Thank you.

                                 
               Prepared Statement of Hon. Julia Brownley
    Thank you Mr. Chairman.
    Today, we have a full schedule that includes six bills before us 
that address some of the unique needs of our Nation's veterans' 
population. The bills pertain to a variety of areas that affect the 
lives of veterans every day and this Subcommittee has conducted many 
oversight hearings to understand the problems and then fix them.
    The first two bills on today's agenda, including one of your 
proposals, Mr. Chairman, are pieces of draft legislation to address 
mental health concerns and increasing accountability at the VA.
    The next bill, H.R. 241, the Veterans Timely Access to Health Care 
Act, was introduced by Mr. Ross of Florida and pertains to timely 
organized and scheduled visits to VA Medical facilities.
    H.R. 288, the CHAMPVA Children's Protection Act of 2013 sponsored 
by Mr. Michaud, Ranking Member of the Full Committee, would amend the 
maximum age for children to obtain medical care under CHAMPVA from 23 
to 26 and effectively reflect the Patient Protection and Affordable 
Care Act enacted in 2010. I will speak further on this bill during the 
first panel.
    Next, H.R. 984, introduced by Mr. Guthrie of Kentucky, would direct 
the Secretary of Defense to establish a National Taskforce on 
Urotrauma.
    And finally, my bill, H.R. 1284, the Veterans Medical Access Act, 
would provide better access for blind and severely disabled veterans 
who need to travel long distances to obtain care at a special 
rehabilitation center. Oftentimes blind and catastrophically disabled 
veterans choose not to travel to VA medical centers for care because 
they cannot afford the costs associated with the travel. Currently, the 
VA is required to cover the cost of transportation for veterans 
requiring medical care for service-connected injuries. H.R. 1284 would 
extend these travel benefits to a veteran with vision impairment, a 
veteran with a spinal cord injury or disorder, or a veteran with double 
or multiple amputations whose travel is in connection with care 
provided through a special disabilities rehabilitation program of the 
VA. Our disabled veterans have already made the greatest of sacrifices 
and I firmly believe, as I am sure many people in the room here today 
do, that no veteran should be denied needed medical care.
    I thank all of the Members for their thoughtful legislation and I 
want to thank you, Mr. Chairman, for including my bill here today.
    Thank you and I yield back.

                                 
                 Prepared Statement of Hon. Jeff Miller
    Thank you, Dan.
    It is a pleasure to be here today with you, the Members of the 
Subcommittee on Health, representatives from our veterans service 
organizations, and other interested stakeholders and audience members 
to discuss my draft bill, the Veterans Integrated Mental Health Care 
Act of 2013.
    Two weeks ago yesterday, I spent the day in Atlanta, Georgia, with 
several Members of the Georgia delegation to discuss inpatient and 
contract mental health program mismanagement issues at the Atlanta 
Department of Veterans Affairs Medical Center (VAMC)
    This visit occurred after the VA Inspector General (IG) issued two 
reports, which found that failures in management, leadership, 
oversight, and care coordination at the Atlanta VAMC contributed to the 
suicide deaths of two veteran patients and the overdose deaths of two 
others.
    Alarmingly, the IG found that approximately four-to-five-thousand 
veteran patients fell through the cracks and were lost in the system, 
after the Atlanta VAMC failed to adequately coordinate or monitor the 
care they received under VA's contracts with community mental health 
providers.
    I wish that I could say that the issues in Atlanta are an isolated 
aberration. Unfortunately, that would be far from the truth.
    Rather, the Atlanta story is just the latest in a tragic series of 
incidents highlighting serious and systemic deficiencies plaguing the 
provision of mental health care to at-risk veterans through the VA 
health care system.
    Since 2007, VA's mental health care programs, budget, and staff 
have increased significantly.
    Yet, the numbers of veterans taking their own lives has remained 
stagnant for the past twelve years - with eighteen to twenty-two 
veteran suicide deaths per day since 1999, according to VA's own 
numbers.
    I could go on but the bottom line is this - the one-size-fits-all 
path to mental health care that the Department is on is failing the 
veterans most in need of its services. And, the time to act is now.
    I have been and will certainly continue to be a strong and 
supportive advocate of the VA taking action to hire staff, and address 
the continued failures of mental health care provided within its own 
walls.
    However, it has become abundantly clear - through the data I have 
discussed this morning, through Committee oversight, through numerous 
IG and Government Accountability Office reports, and through the 
personal accounts of the veteran constituents that call my office and 
the offices of my colleagues on a daily basis to ask for help - that VA 
cannot cope with the magnitude of mental health needs our veterans 
experience in a bureaucratic vacuum with the normal VA business-as-
usual approach.
    In order to truly maximize mental health care access for today's 
veterans, VA must embrace an approach to care delivery that treats 
veterans where and how they want, not just where and how VA wants. Some 
have said this could undermine VA health care as we know it. Nothing 
could be further from the truth. This isn't about supplanting the VA 
health care system, it's about supporting it.
    To the contrary, to truly address and resolve the breakdown in the 
provision of mental health care services to veteran patients, VA must 
adopt a proactive, integrated, coordinated care delivery model for 
mental health care.
    Most importantly, VA must adopt a mental health care delivery model 
that is truly veteran-centric - one that meets and cares for veteran 
patients where they are, treats the entirety of their concerns with 
supportive and timely wraparound services, and recognizes and respects 
their unique circumstances, goals, and health care needs throughout 
their lives as veterans.
    That is why I have proposed this draft Veterans Integrated Mental 
Health Care bill before us. It would take the first important step to 
help veterans in need, whether those services are provided in or out of 
VA facilities.
    Specifically, the draft bill would:
    - require VA to provide mental health care to an eligible veteran 
who elects to receive such care at a non-VA facility through a care 
coordination contract with a qualified entity; and,
    - require such entity to meet specific performance metrics 
regarding quality and timeliness of care and exchange relevant clinical 
information with VA.
    It would ensure that existing mental health care resources - both 
those found within VA facilities and those provided to veterans through 
fee basis care - are managed effectively.
    It would also ensure that the care provided to veteran patients in 
need of mental health services is timely, convenient, and coordinated 
from the initial point of contact throughout the recovery process.
    I understand that some veterans service organizations (VSOs) have 
expressed concern about waiting until VA rolls out its own new contract 
care initiatives.
    And - while I appreciate, understand, and respect these views, I 
look forward to working closely with them to address their concerns - 
but the time for waiting is over.
    Last year, the IG found that more than half of the veterans who go 
to VA seeking mental health care services wait fifty days on average to 
receive even an initial evaluation.
    This year, the IG found that thousands of Georgia veterans had 
fallen through giant cracks in VA's mental health care system and may 
or may not have received the care they so desperately needed.
    We cannot wait to see what next year brings.
    When a veteran is need of mental health care services, the 
difference of a day or a week or a month can be the difference between 
life and death, between contentment and struggle.
    The time to act is now.
    I look forward to working hand-in-hand with Committee Members, our 
VSO partners, and other stakeholders to strengthen the language in this 
draft bill and address any issues that may be raised during the 
Subcommittee's discussion this morning.
    Thank you once again, Dan, for holding this hearing today and for 
your hard work and steadfast leadership of the Subcommittee on Health. 
I appreciate the opportunity to be with you all today.
    With that, I yield back.

                                 
                 Prepared Statement of Hon. Dennis Ross
    Thank you, Chairman Benishek, for holding this hearing today, and 
for allowing me to testify on behalf of legislation I introduced 
entitled the Veterans Timely Access to Health Care Act.
    America's Veterans are the backbone of the freedom and prosperity 
this country has enjoyed for over two hundred years. We owe them a debt 
that we can never truly repay.
    Unfortunately, across the country, and across Florida's 15th 
Congressional District, Veterans continue to encounter unacceptable 
problems and delays receiving appointments from the Veterans 
Administration (VA) for essential medical and specialty health care 
needs.
    For instance, the VA has set a goal to provide an initial mental 
health examination within 14 days from the time a Veteran contacts a VA 
medical provider to schedule a consultation. They have claimed to meet 
this goal with a 95% success rate.
    However, an Inspector General (IG) 2012 report published greatly 
contradicts these claims. In fact, this IG report determined the VA 
only met its goal 49% of the time - with the remaining patients being 
forced to wait approximately 50 days for the VA to provide this 
critical mental health evaluation.
    To be clear - more than 184,000 Veterans waited approximately 50 
days to receive a critical mental health evaluation. Not treatment - 
just the formal evaluation. This is a disgrace to our Veterans, and 
something that should not be tolerated.
    Additionally, Chairman Mike Coffman of the Subcommittee on 
Oversight and Investigations held a hearing on March 14, 2013 to 
examine patient wait times at VA medical facilities. Sadly, the 
Chairman revealed that according to VA documents, at least two Veterans 
died last year from diseases while awaiting a medical consultation at 
the VA.
    That is why I am proud to have introduced H.R. 241, the Veterans 
Timely Access to Health Care Act.
    This legislation, supported by the Military Officers Association of 
America (MOAA) and The Retired Enlisted Association (TREA), will ensure 
Veterans seeking primary and specialty care from a VA medical facility 
receive an appointment within 30 days - period.
    This legislation also contains a number of detailed reporting 
requirements, so that Congress may better track the VA's progress. And 
if the VA discovers they are not meeting their goals and mandated 30-
day access to care, it is my hope that they will reach out to Congress 
before their reports are filed so we can work together to meet the 
needs of our nation's brave and courageous Veterans.
    We are all on the same team, with the same goal of providing 
timely, high quality care to our Veterans.
    However, this legislation will go a long way in ensuring Veteran's 
critical medical needs, like those needs of more than 184,000 Veterans 
who waited 50 days for an initial mental health screening, no longer 
slip through the cracks of the system. It will also prevent the 
unnecessary loss of life of those Veterans in need of medical care and 
consultation.
    Moving forward, I would like to work with this Subcommittee to 
strengthen this legislation - potentially including additional access-
to-care standards. Today, this legislation is a first step to hold the 
VA accountable.
    Thank you Mr. Chairman, and I yield back the balance of my time.

                                 
                Prepared Statement of Hon. Brett Guthrie
    Good morning and thank you, Chairman Benishek, Ranking Member 
Brownley, and distinguished colleagues of the House Committee on 
Veterans' Affairs.
    I come before you today as both a Member of Congress and a former 
Army Officer, to thank you for your past support of a priority issue 
for wounded warriors, and to ask that you continue to pursue needed 
work on the subject
    As you may know, genitourinary trauma, or simply urotrauma, is a 
class of wounds that literally hit below the belt. Urotrauma accounts 
for wounds to the kidneys, reproductive organs, and urinary tract 
organs. These injuries are some of the most common and debilitating 
suffered by our veterans from IED detonations and have long-lasting 
physical and psychological impacts. Urotrauma is one of the signature 
wounds of the IED and now accounts for one-eighth of all injuries 
suffered by our troops in Afghanistan. Unfortunately, the most recent 
available data suggests that this figure is still rising, even after 
nearly doubling in incidence between 2009 and 2010.
    I know that we're in the Veterans' Committee today, but by way of 
background, let me paraphrase the Department of Defense's report to 
Congress titled ``Genitourinary Trauma in the Military,'' and the Army 
Surgeon General's report titled ``Dismounted Complex Blast Injury''.
    According to these papers, urotrauma on today's battlefield exceeds 
incidence rates of all prior conflicts by at least 350 percent. And 
yet, the DoD Under Secretary for Personnel and Readiness concedes that 
``urotrauma injury is not part of the standards of pre-deployment 
training for U.S. military surgeons and nurses,'' and that the existing 
infrastructure for tracking these casualties ``is not sufficient to 
assess the long-term prognosis of GU trauma injuries.'' This lack of 
adequate infrastructure is exacerbated by the inherent complications of 
transitional care from DoD to VA, where most victims will receive 
treatment for the remainder of their lives.
    Now let me say that it is not my view that the VA and DoD are 
ignoring urotrauma. To the contrary, I believe that many skilled 
professionals are hard at work on the issue; but as is often the case 
in government, their efforts are divided, un-integrated, and because of 
this, less effective.
    By my tally, there are six government agencies currently working on 
urotrauma. And while I'm heartened that this research is occurring, I'm 
discouraged that there seems to be little dialogue or centralization of 
information. Put simply, we aren't learning from experience and if we 
are, we're learning too slowly.
    And that's why I introduced H.R. 984, a bill that I have authored 
with the help of practicing urologists who have cared for wounded 
warriors in Iraq and Afghanistan. This bill would unite public and 
private resources to address the growing problem that is urotrauma.
    I'd like to highlight two specific opportunities for improved care 
that are within this committee's jurisdiction.
    First, the existing infrastructure to track urotrauma patients is 
not sufficient. We need the research infrastructure to facilitate 
urotrauma outcomes research and corresponding follow-up within DoD and, 
most critically, after transition to the VA. Unfortunately, one thing I 
have heard time and time again is that the Joint Theater Trauma 
Registry (JTTR), which tracks approximately 16,000 trauma victims, 
lacks the specificity of detail needed to accomplish this end. VA, DoD, 
and health care providers need a better platform to coordinate care 
across a lifetime for our wounded warriors.
    Related to this is the second issue I'd like to focus on - 
transition of care. Rather than mincing words, I will quote the 
American Urologists Association's Urotrauma Task Force directly:

    ``It is clear to those urologists in DoD who care for soldiers with 
complex urotrauma that the transition to the VA is currently fraught 
with barriers. These barriers include deficits of communication of the 
detailed medical and surgical history of injured service members from 
DoD physicians to VA physicians. Another problem continues to be GU-
injured soldiers within the VA system being cared for in locations 
where access to expertise in GU trauma is lacking.''

    One solution to this problem would be to designate care 
coordinators to urotrauma victims. These coordinators would need access 
to DoD and VA health information and guide our wounded warriors towards 
existing centers of excellence in polytrauma care.
    However, as a Member of Congress, I am not wedded to a single 
solution to this or any other improvement to urotrauma care. That is 
why H.R. 984 allows for a ``big tent'' solution. As DoD has said in 
writing, we need ``inter-Service and inter-agency relationships to 
facilitate aggressive, innovative, and relevant translational and 
outcomes-based clinical research,'' and that's what H.R. 984 does: 
bring together VA, DoD, HHS, the Surgeon Generals of each of our Armed 
Services, and civilian expertise to create a plan to care for these 
wounded warriors from the point of injury to their final resting place, 
decades from now.
    This is a bipartisan bill with many cosponsors who represent 
communities like Ft. Knox, in my district, where their constituents are 
frequently deployed to the front lines. These communities understand 
the frequency and severity of these wounds at a human level and a 
professional one. We have all met families who show true courage as 
they care for their gravely wounded loved ones; and we have met the men 
who march into harm's way knowing that the next IED could have their 
name on it.
    Let me say in closing that the miracles of modern medicine, 
combined with the devotion of our military medical corps, have allowed 
many of these wounded warriors to live long lives rather than dying in 
the line of duty. However, giving these service men and women the 
ability to survive is not enough. We have a responsibility to do what 
we can to ensure that they are allowed to live as full a life as 
possible. That's the debt we owe to those who defend freedom.
    I urge this committee to continue the work it has already done to 
further our care for these wounded warriors suffering the effects of 
urotrauma and yield back my time.

                                 
                  Prepared Statement of Mark T. Edney
    Chairman Benishek, Ranking Member Brownley, Members of the 
Committee, honored guests, fellow service members; I thank the 
Committee on Veterans Affairs, Subcommittee on Heath for inviting me to 
testify regarding HR 984, a bipartisan bill introduced by 
Representative Guthrie to direct the Secretary of Defense to establish 
a task force on urotrauma.
    I am a urologist, a surgical specialist who treats genitourinary 
disease and injury, in private practice in Salisbury, MD. I am also an 
Army Reservist of 11 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 treated 
genitourinary trauma, or urotrauma, in the theater of operations and 
have participated in its chronic management at our largest military 
medical centers stateside.
    It's an honor to represent the American Urological Association 
(AUA), the world's premier professional association of urologists, and 
our urotrauma coalition in support of HR 984 on behalf of this unique 
class of injured service members. Our urotrauma coalition includes a 
diverse group of medical societies, veterans' services organizations 
and industry partners who all support the policy initiatives with 
respect to genitourinary injury or urotrauma contained in HR 984. Our 
coalition partners who have pledged their organizational support to our 
urotrauma initiative include the: American College of Surgeons, 
American Congress of Obstetrics and Gynecology, American Association of 
Clinical Urologists, Large Urology Group Practice Association, American 
Fertility Association, American Society of Andrology, Society for the 
Study of Male Reproduction, Society of Male Reproduction and Urology, 
Society for Women's Health Research, Veterans of Foreign Wars (VFW), 
Disabled American Veterans (DAV), AMVETS, Paralyzed Veterans of 
America, Blinded Veterans Association, Men's Health Network, Zero- The 
Project to End Prostate Cancer, RESOLVE: The National Infertility 
Association, Blue Ribbon Advocacy Alliance, Johnson and Johnson, 
Astellas, and Endo Pharmaceuticals.
    There have been approximately 50,000 soldiers wounded in action 
since 2003 in Operation Iraqi Freedom (OIF) and Operation Enduring 
Freedom (OEF). Of those, approximately 16,000 injuries are catalogued 
in the Joint Theater Trauma Registry (JTTR), the inter-service in-
theater trauma database that has been in operation since 2003. Recent 
studies have indicated that 5-10% of battlefield injuries involve 
injury of the genitourinary (GU) organs for a total of around 1000 GU 
injuries. Of those, approximately 60% involve the external organs 
(scrotum, testicles, penis and urethra), and 40% involve other organs 
including kidneys, bladder, ureters, uterus, fallopian tubes, and 
ovaries. The DoD's Dismounted Complex Blast Injury Task Force studied 
and reported on this pattern of injury at the direction of the Army 
Surgeon General in June, 2011. Because improvised explosive devices 
(IED) are the enemy's weapon of choice and because soldiers are 
increasingly required to patrol on foot or ``dismounted'' in 
Afghanistan (as compared to Iraq), the incidence of complex blast 
injury is up 350% in OEF. Dismounted complex blast injury describes the 
constellation of catastrophic extremity injury with often bilateral 
lower limb loss, sometimes together with upper limb loss, traumatic 
brain injury, and in many cases injury to the genitourinary organs.
    Although GU-injured veterans may exhibit no outward signs of their 
injury, they suffer life-changing loss of proper sexual, bowel, and 
urinary function and fertility. These deficits have significant social 
effects on marriages and other relationships and enormous effects on 
quality of life. The cumulative physical and psychological impact of 
urotrauma on these soldiers is no less profound than for those 
recovering from extremity loss and neurocognitive injury. As a complex 
injury, urotruama has not received the same policy attention and care 
coordination that has been afforded the more common injury patterns 
such as extremity loss, traumatic brain injury and eye injury--each 
with its own DoD center of excellence. Genitourinary injury is 
increasingly a critical military women's health issue with women now 
able to serve in direct combat roles. We must do better with the study 
and care coordination of urotrauma.
    In 2009, the AUA convened a working group comprised of AUA members 
within the Department of Defense (DoD) together with civilian trauma 
and GU reconstruction experts to formulate policy, craft legislation, 
and develop a comprehensive legislative strategy. The broad goals of 
the working group were to: improve the prevention of, improve and 
educate regarding the initial management of, and better coordinate the 
chronic care of urotrauma and to enhance urotrauma's research 
infrastructure to facilitate outcomes research and longitudinal follow-
up of urotrauma cases.
    As a result of those discussions in 2009, key knowledge gaps were 
identified, necessitating a broader discussion with respect to the 
treatment of urotrauma. HR 984 ensures that broader discussions occur 
by directing the Secretary of Defense to establish a task force on 
urotrauma. The task force is required to conduct a study of urotrauma 
among members of the Armed Forces and veterans including: an analysis 
of the incidence, duration, morbidity rate, and mortality rate of 
urotrauma; an analysis of the social and economic costs and effects of 
urotrauma; with respect to the Department of Defense and Department of 
Veterans Affairs (VA), an evaluation of the facilities, access to 
private facilities, resources, personnel, and research activities that 
are related to the diagnosis, prevention, and treatment of urotrauma; 
an evaluation of the programs (including such biological, behavioral, 
environmental, and social programs) that improve the prevention or 
treatment of urotrauma; a long-term plan for the use and organization 
of the resources of the Federal Government to improve the prevention 
and treatment of urotrauma; an analysis of the shortfalls in research, 
expertise, and health care infrastructure for female victims of 
urotrauma; an analysis of the technical, administrative, and budgetary 
mechanisms to allow for enhanced reproductive services for members who 
have been affected by urotruama or who are at high risk of urotrauma; 
an assessment of opportunities to enhance the coordination of Federal 
resources used to research, prevent, and continuously improve the 
management of urotrauma; and inter-agency efforts regarding the chronic 
physical, behavioral, and emotional care of victims of urotrauma.
    With respect to research, I am aware of at least two DoD databases 
that prospectively collect data on urotrauma injuries for the purpose 
of longitudinal follow-up and outcomes research: the Walter Reed Army 
Medical Center (WRAMC)/National Naval Medical Center (NNMC)/ Walter 
Reed National Military Medical Center (WRNMMC) surgical database that 
has been in use for 6 years and the Expeditionary Medical Encounter 
Database (EMED), in operation at the Naval Health Research Center, 
Medical Modeling, Simulation and Mission Support Division in San Diego, 
CA. The JTTR, as I mentioned earlier, has catalogued more than 16,000 
battlefield traumas since 2003, but lacks specificity for details of 
urotrauma that would enable longitudinal follow-up and outcomes 
research. The VA also has a robust repository of patient-level data in 
its electronic medical record, Vista. The appropriate department should 
be tasked with coordinating these databases as well as any other 
similar databases, to ensure that they are collecting appropriate 
urotrauma measures so that they may facilitate the longitudinal follow-
up and outcomes research of urotrauma.
    The seamless transition from the DoD to the VA, of the soldier 
suffering urotrauma with his or her complex care needs, represents an 
opportunity for improvement. DoD Instruction 1300.24 directs the 
Assistant Secretary of Defense for Health Affairs under the authority, 
direction, and control of the Under Secretary of Defense for Personnel 
and Readiness to ``coordinate with the VA to develop and implement 
administrative processes, procedures, and standards for transitioning 
RSMs [recovering service members] from DoD care and treatment to VA 
care, treatment, and rehabilitation that are consistent with [language 
stipulated in the instruction].'' A critical element of the transition 
is that of the transfer of a complete medical and surgical record to 
accepting providers in the VA. The AUA's working group has heard from a 
variety of urologists in both the DoD and VA that the record transfer 
is not happening in many cases.
    DoD currently provides a high level of expertise and care 
coordination for soldiers with urotrauma. However, the difficulty 
arises when RSMs are transferred to the VA. While the VA has polytrauma 
centers of excellence with many highly trained surgeons, there are 
regions of reduced access to the technology and surgical expertise 
required to care for these complex cases. Therefore, there are 
opportunities to improve and standardize communication between DoD and 
VA physicians. There are also opportunities to optimize the placement 
of GU-injured soldiers in proximity to the expertise and technology 
that they need and to employ telemedicine and other new information 
technologies to deliver needed services reducing the impact of 
geography on access.
    Finally, although each of the functional challenges that result 
from damage to the genitourinary organs is life-altering, perhaps one 
of the most profound is the loss of fertility. The brave young 
Americans who are voluntarily putting themselves in harm's way in 
defense of our country are often doing so prior to their reproductive 
years. Some are suffering injuries that severely impair or eliminate 
their natural reproductive capability shattering a dream of many--to 
begin a family of their own. HR 984 seeks ``an analysis of technical, 
administrative, and budgetary mechanisms to allow for enhanced 
reproductive services for members who have been affected by urotrauma 
or who are at high risk of urotrauma''. The AUA recognizes that there's 
much to be done in this area from pre-deployment sperm banking, to 
cryopreservation of sperm at the initial point of care when testicular 
loss is inevitable, to providing advanced reproductive services to all 
military urotrauma victims who are infertile and receiving care in the 
DoD and VA. We are currently short of that goal and the AUA working 
group also supports legislation to enhance these policies.
    In summary, the rate of genitourinary injury suffered by American 
soldiers is up 350% in the Afghanistan theater compared to the Iraqi 
theater as a result of the increased necessity of dismounted patrol. 
Genitourinary injures are an increasingly common, complex constellation 
of wounds with devastating long term implications for urinary, bowel, 
and sexual function and fertility. These sequelae in turn have profound 
impact on soldiers' mental health, marriages, other social 
relationships and overall quality of life. HR 984 prescribes the 
comprehensive study required to address the variety of opportunities 
for improving the prevention, initial management, care coordination and 
research of this devastating and increasingly prevalent pattern of 
injury. We owe these finest of Americans no less for the sacrifices 
they have made for our great nation. On behalf of the American 
Urological Association and the urotrauma coalition partners, I urge you 
to support HR 984 and favorably report it out of the committee.
    Again, I want to thank the Veteran's Affairs Committee for their 
invitation to testify before you and I am available to answer any 
questions.

                                 
                  Prepared Statement of Mike O'Rourke
INTRODUCTION
    On behalf of BVA, thank you for this opportunity to provide 
testimony today on the current legislation before the Subcommittee on 
Health. Chairman Benishek, Ranking Member Brownley, and members of the 
House Committee, thank you for the bringing these bills before the 
committee. 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; BVA has served blinded veterans for over 68 years.
BENEFICIARY TRAVEL FOR BLINDED VETERANS: HR 1284
    We appreciate the ranking member Congresswoman Brownley for 
introducing H.R. 1284 and we would point out that last week the Senate 
VA Committee held hearing on the companion bill S 633 introduced by 
Senator Tester that was broadly supported by the witnesses. This 
legislation would assist disabled spinal cord injured (SCI) and blinded 
or visually impaired veterans who are currently ineligible for 
Beneficiary travel benefits. This bill would assist mostly low- income 
and catastrophically 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 
Blind Rehabilitation Center (BRC) or Spinal Cord Injury (SCI) VA 
medical center for either inpatient or residential bed stay while 
receiving training. The average age of blinded 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 decades, 
outstanding blind rehabilitation programs at 13 Blind Centers known for 
very high quality inpatient specialized services, only to tell low 
income, non-service connected 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 Means tested travel benefits. 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 this financial 
assistance analysis 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. Private blind outpatient agency services 
such as Lighthouse for Blind are all located in large urban cities and 
usually established as outpatient training sites, again barrier for 
rural veterans traveling long distances every day to get training 
verses VA rehabilitation centers.
---------------------------------------------------------------------------
    \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 pg9 [email protected]
---------------------------------------------------------------------------
      Vision loss is a leading cause of falls in the elderly. 
One study found that visual field loss was associated with a six-fold 
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 and Medicaid 
direct costs of $11 Billion per year. \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 2012pg 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 or spinal cord injured veterans are not able to obtain 
the rehabilitation 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. For FY 2014 
VA has proposed spending $7,637 Billion in Nursing Home Care program.
    We caution that private agencies for the blind are located in large 
urban cities in New York City, Chicago, Seattle, Orlando, or Boston, so 
the travel barriers would preclude utilization of those sites. VA 
Centers offer the full specialized nursing, physical therapy, 
audiology, pharmacy, radiology or laboratory support services that are 
necessary for the clinical care. BVA requests that private agencies 
demonstrate peer reviewed quality outcome measurements that VHA Blind 
Rehabilitative Service have and they must 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).
13 Inpatient Blind Rehabilitation Centers (BRCs)
    For those members here today we would encourage you to visit one of 
the 13 VA BRC's and to visit VA SCI locations to better understand the 
coordinated care being provided at these hub and spoke locations. The 
BRCs provide the most intense and in-depth rehabilitation to severely 
disabled blind veterans and servicemembers returning from OIF and OEF. 
Comprehensive, individualized blind rehabilitation services are 
provided in an inpatient VA Medical Center environment by a 
multidisciplinary team of rehabilitation specialists. The management of 
chronic medical conditions is addressed as part of the training regimen 
as well. Blind Rehabilitation Specialists guide the individual through 
a rehabilitation process that leads to adjustment to blindness, new 
skill development in living skills, orientation and mobility, manual 
skills, and use of prescribed adaptive technology devices and Computer 
Access Training (CAT) learning the use of this specialized technology 
and reorganization of the person's life to enhance their independence. 
All BRC's use same training approach to maximize the team approach to 
the needs of each blind veteran. These new skills and attitudes foster 
new abilities to contribute to family and community life and allow 
individuals to often regain employment.
    BVA supports the change in Beneficiary Travel being proposed in HR 
1284 and in our discussions with VA Veterans Travel Program office 
found support for this legislation that would improve access to 
rehabilitation care and services for this severely disabled population. 
Recently VHA however testified before SVAC on S 633 and stated the 
language currently in this bill was restrictive, and it should include 
other disabilities like PTSD or TBI veterans. HR 1284 addresses 
catastrophically disabled veterans going to very specialized 
rehabilitation centers, and VA operates more than 300 community-based 
PTSD Vet Center sites, has more than 50 mobile VA centers, and dozens 
of TBI centers and we would hesitate having the committee broadening 
this language trying to include many other conditions that are often 
treated at the 153 VA medical centers.
    H.R. 288 CHAMPVA Children's Eligibility Act: BVA fully supports 
this bill to amend Title 38 USC, to increase the maximum age for 
children eligible for medical care under the CHAMPVA program that would 
allow same coverage mandated in other current federal programs. 
Dependent children who currently turn age 23 have loss of insurance 
coverage under CHAMPVA and have difficulty finding and being able to 
afford health insurance. We believe to change this to age 26 is 
consistent with other mandated coverage for other insurance plans. 
Often college students or those new graduates who face difficult 
employment challenges are unable to afford their own health insurance 
and being covered by CHAMPVA would provide them protection from being 
uninsured.
Urotrauma Task Force HR 984:
    Soldiers who now survive on front line at highest percentages ever 
however now suffer much more grievous injuries. Bulletproof Kevlar 
vests protect soldiers' central chest and abdomen, but not their limbs, 
groin and genitals, and this bill highlight the need for more resources 
for better care for genito-urinary (GU) wounds. Because there's little 
research for urologists in the military to draw upon in diagnosing and 
the surgical initial management and reconstruction of treating these 
complex cases, plus the social stigma about discussing genitor-urinary 
problems, this serious life altering injury has received far less 
attention over past eight years than other combat blast injuries. Most 
urologists in training and private practices rarely treat civilian 
patients with these kinds of severe genito-urinary trauma now seen in 
the military field hospitals or large military trauma centers caused by 
IED's blasts during dismounted combat patrols.
    The Veterans Affairs Office of Public Health tracks veterans who 
have left active duty in Iraq and Afghanistan and have sought medical 
treatment in the VA system. From July 2002 through June 2009, 12.5 
percent of the 508,000 veterans who sought treatment were diagnosed 
with diseases or disorders of the genitourinary system, but the report 
doesn't specify how many of those diagnoses are related to combat 
injuries and still doesn't report specific GU trauma which we point out 
highlights growing need for joint DOD-VA urological trauma clinical 
registry for these specific injuries similar to those existing for TBI, 
amputees, and for vision and hearing.
    Again we stress one big challenge is that in the civilian medical 
world, there is not a high incidence of these kinds of blast urotrauma 
injuries so development of best practices to treat these kinds of 
battlefield genitourinary system injuries from this Task Force are 
urgently needed and DOD and VA must find improved reconstructive 
approaches for them. Genitor-urinary system mutilation can cause 
incontinence, infertility, impotence, recurrent infections in these 
young service members, plus they have emotional and psychological 
consequences of depression, and psycho-social isolation, and are at 
higher rates suicide risk in this young mostly male population. It is 
imperative, therefore, management of this complex pattern of GU injury 
requires attention paid towards surgical reconstruction and 
psychological health of these urological injuries with adequate 
deployment peer reviewed genitor-urinary trauma research funding.
GENITOURINARY (GU) RECONSTRUCTION
    GU interventions must be performed in multiple stages starting at 
front line field surgical sites. If extensive soft tissue is lost, 
finding adequate tissue to cover these wounds, debridement, immediate 
wound management, then later in evacuation chain when is best time to 
perform reconstruction is more challenging. Individuals with Dismounted 
Combat Battle Injury (DCBI) and genital injury will often require a 
protracted inpatient/outpatient stay. It is best if these injuries are 
managed by the same surgical team over time rather than transferring 
care elsewhere. Because of this, provisions must be made to have 
adequate staffing, housing, administrative, and medical support at Role 
V facilities to provide protracted care for these individuals. 
Currently, there are a limited number of providers (civilian and 
military) who perform phallic reconstruction surgery--thus indicating 
the need to train more military urologists and plastic surgeons in 
these techniques. \7\
---------------------------------------------------------------------------
    \7\ Surgeon General Army Report Dismounted Combat Battle Injury 
(DCBI) pg. 45
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GENITAL LOSS AND HORMONAL CONCERNS
    While GU injuries present complex surgical and behavioral health 
challenges, other medical issues must be addressed. Low testosterone 
levels have been reported after trauma, serum testosterone levels are 
significantly reduced. Therefore testicular loss will only complicate 
further hormone deprivation. The role of hormone replacement to promote 
soft tissue and nervous tissue healing has not yet been determined. It 
is also unknown when the optimal timing for replacement should begin. 
Given the long-term needs of hormonal replacement and monitoring, 
systems should be established to provide life-long care by medical 
specialists in this area. BVA strongly supports passage of this bill by 
the HVAC and HASC.
H.R. 241 ``Timely Access to Health Care Act''
    BVA supports the recommendations made in the Veteran Service 
Organizations Independent Budget (VSOIB) FY 2014 section on the 
problems of access to care and waiting times. VHA managers plan budget 
priorities, measure organizational and individual medical center 
directors' performance, and determine whether strategic goals are met, 
in part by reviewing data on waiting times and lists. However, they 
cannot manage and improve what they cannot measure. Unreliable data 
compromise meaningful analyses for decision making on the timeliness of 
access and trends in demand for health care services, treatments, and 
providers.
    The OIG reports of 2005, 2007, and 2012 reiterate the continuing 
weaknesses causing VA's failure to meet its own access standards. Based 
on the reports by the OIG and Booz Allen Hamilton137 on the weaknesses 
in the Department's outpatient scheduling process, the VHA needs to 
improve data systems that record and manage waiting lists for primary 
care, and improve the availability of some clinical programs to 
minimize unnecessary delays in scheduling specialty health care. \8\
---------------------------------------------------------------------------
    \8\ VSOIB FY 2014 Medical Care Access pg. 89-90.
---------------------------------------------------------------------------
    BVA appreciates that the committee has investigated the long 
standing problems over waiting times for clinic appointments and has 
heard previously in other recent hearings on March 13 about the finding 
of GAO ``Waiting For Care; Examining Patient Wait Times at VA'' the 
testimony by the Director, Health Care Government Accountability 
Office, Debra Draper provided recommendations. \9\ GAO outlined 
problems found in examining wait times at various VA clinics that 
despite attempts to solve the problem ``VHA report times are unreliable 
and there was inconsistent implementation of certain elements of VHA's 
scheduling policy.'' \10\ BVA supports the intent of HR 241 to address 
this problem.
---------------------------------------------------------------------------
    \9\ GAO ``Waiting For Care; Examining Patient Wait Times at VA'' 
Testimony Director, Health Care Government Accountability Office, Debra 
Draper March 13, 2013 pg. 3.
    \10\ Ibid VSOIB FY 2014 pg. 90
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DRAFT ``Veterans Integrated Mental Health Care Act of 2013'':
    The problems of mental health care access and wait times in this 
area are ongoing concern to BVA and the other veteran service 
organizations as suicides have increased despite numerous programs by 
both DOD and VA that have been established in the past few years and 
growing numbers of veterans are being diagnosed with variety of mental 
health disorders we feel more must be done. The number of Veterans 
receiving specialized mental health treatment from VA has risen each 
year, from 927,052 in fiscal year (FY) 2006 to more than 1.3 million in 
FY 2012 \11\. One major reason for this increase is VA's proactive 
screening of all Veterans to identify those who may have symptoms of 
depression, Post Traumatic Stress Disorder (PTSD), problem use of 
alcohol or who have experienced military sexual trauma (MST).
---------------------------------------------------------------------------
    \11\ VHA Mental Health Care Services March 2013 report.
---------------------------------------------------------------------------
    BVA applauds efforts made by VA and the DOD to improve the safety, 
consistency, and effectiveness of mental health care programs for 
servicemembers and veterans. We also appreciate that Congress is 
continuing to provide increased funding in pursuit of a comprehensive 
package of services to meet the mental health needs of veterans, in 
particular veterans with wartime service and post-deployment 
readjustment needs. \12\
---------------------------------------------------------------------------
    \12\ 12 VSOIB FY 2014 pg. 75-76
---------------------------------------------------------------------------
    While the VSOs are pleased with VA's progress in implementing its 
Mental Health Strategic Plan, and veterans who are able to get care 
from the 300 Vet Centers are very satisfied, we still have concerns 
that these goals may be frustrated unless proper oversight is provided 
and VA enforces its own mechanisms to ensure its policies at the top 
are reflected as results on the ground in VA facilities. As members 
here know VA announcement from the Secretary of Veterans Affairs Eric 
K. Shinseki the department would add approximately 1,600 mental health 
clinicians - to include nurses, psychiatrists, psychologists, and 
social workers as well as nearly 300 support staff to its existing 
workforce of 20,590 mental health staff as part of an ongoing review of 
mental health operations. \13\
---------------------------------------------------------------------------
    \13\ VA Press Release April 12, 2012 Mental Health Care Services 
Expansion
---------------------------------------------------------------------------
    While VA has increased the total numbers of full time psychiatrists 
in 2006 from 1,836 to FY 2012 up to 2,586, and the number of 
psychologists 1,788 from FY 2006 up to 4,200 in FY 2012, and VA also 
has 3,498 clinical social workers, and 645 nurse practitioners full 
time assigned to mental health clinics with additional 244 advanced 
practice nurses. \14\ Still as everyone knows here the wait times grow 
and so does the OIF OEF enrollment numbers. DOD and VA both continue 
struggling to hire the same pool of mental health providers and each 
agency will probably continue to fail to meet the growing demands. We 
must find alternatives to provide care.
---------------------------------------------------------------------------
    \14\ VHA Report Mental Health Providers Full Time 2006-2012 BVA 
request March 2012
---------------------------------------------------------------------------
    Chairman Miller draft ``Veterans Integrated Mental Health Care Act 
of 2013'' would provide mechanisms for medical centers to coordinate 
necessary clinical services through care-coordination contracts. BVA 
supports the draft version of this and stresses that ensuring that any 
veteran that obtains care has their medical records sent to the VA is 
vital. The VA should exchange clinical best practice guidelines with 
outside providers on management.
CONCLUSION
    Chairman Benishek and Ranking member Brownley, BVA again expresses 
its support for these proposed changes to VHA programs listed above 
being considered here today. BVA appreciates the opportunity to provide 
this testimony today and be glad to answer any questions now.
               DISCLOSURE OF FEDERAL GRANTS OR CONTRACTS
    The Blinded Veterans Association (BVA) does not currently receive 
any money from a federal contract or grant. During the past two years, 
BVA has not entered into any federal contracts or grants for any 
federal services or governmental programs.
    BVA is a 501c (3) congressionally chartered, nonprofit membership 
organization.

                                 
                Prepared Statement of Adrian M. Atizado
    Chairman Benishek, Ranking Member Brownley, and Members of the 
Subcommittee:

    On behalf of the DAV (Disabled American Veterans) and our 1.2 
million members, all of whom are wartime wounded and injured veterans, 
I am pleased to present our views on legislative measures that are the 
focus of the Subcommittee today, and to DAV and our members.
   Draft Bill, the Demanding Accountability for Veterans Act of 2013
    This bill would establish a requirement in law for the Department 
of Veterans Affairs (VA) Inspector General (IG) to report to the 
Secretary and to Congress any matters of public health or safety 
emanating from reports of the IG that remain unresolved by VA within a 
specified time period after the Secretary or a subordinate VA official 
agrees with the IG to address such matters. In that connection, the 
bill would require the Secretary to reveal to the IG the personal 
identities of the responsible VA official(s) and manager(s) who did not 
resolve the issue(s) (but such identities would not be released to the 
public). The bill would require the Secretary to promptly notify any 
such individual(s) to resolve the cited issue(s); to counsel the 
manager(s) concerned about the failure to resolve the issue(s) brought 
to light; and to develop mitigation plans, presumably to the 
satisfaction of the IG in resolving the matters concerned.
    The bill would prohibit the award of any performance award or bonus 
to a VA official or manager (whether in the Senior Executive Service or 
the competitive civil service) who had not resolved such IG 
recommendations under the terms of this bill, and even if they were 
resolved later, that the existence of previously unaddressed matters of 
public health and safety would be considered in future performance 
evaluations of any such official.
    DAV has received no resolution from our membership dealing with 
this specific issue and takes no position on this bill. However, we 
urge the Subcommittee to work with VA in advancing it and to ensure 
those issues raised by this bill are properly addressed.
   Draft Bill, the Veterans Integrated Mental Health Care Act of 2013
    This draft bill proposed by the Chairman of the full Committee 
would establish a new authority for VA to use in contracting for VA 
mental health care services for eligible veterans. It would place in 
the hands of a veteran certain mandatory information provided by VA to 
guide the veteran in making a voluntary decision on whether to receive 
care in a VA facility, or to receive it in a non-VA facility. The bill 
would further require VA to contract with qualified entities that 
administer networks of health care providers, including those 
experienced in administering the TRICARE networks, to provide 
coordinated mental health care. The bill would require a series of 
performance qualifications standards that must be met by such 
contractors, and would require VA to dispense or pay for prescriptions 
written for veterans under this program by contractor providers on the 
same basis as it does for other veterans receiving VA-authorized 
contract care under section 1703 of title 38, United States Code.
    Mr. Chairman, your Subcommittee held a hearing on September 14, 
2012, to discuss and consider VA's multiple approaches to providing 
contract health care services, including specific focus on the upcoming 
award of VA contracts to regionalized entities that will administer 
coordination of care through provider networks, including mental health 
care. I had the privilege of testifying on behalf of DAV at that 
hearing, and I would call your attention to my complete statement \1\ 
as well as to Dr. Robert Petzel's statement, made on behalf of VA. I 
quote a small but crucial element of VA's statement for the benefit of 
the Subcommittee with respect to this bill, as follows:
---------------------------------------------------------------------------
    \1\ http://dav.org/voters/documents/statements/Atizado20120914.pdf

    PCCC [Patient Centered Community Care] will consist of a network of 
centrally supported standardized health care contracts, available 
throughout VHA's Veterans Integrated Service Networks (VISN). This 
initiative will focus on ensuring proper coordination between VA and 
non-VA providers. PCCC is not intended to increase the purchasing of 
non-VA care, but rather to improve management and oversight of the care 
that is currently purchased. This includes improvements in numerous 
areas such as consistent clinical quality standards across all 
contracts, standardized referral processes, and timeliness of receipt 
of clinical information from non-VA providers. The goal of this program 
is to ensure Veterans receive care from community providers that is 
timely, accessible, and courteous, that honors Veterans' preferences, 
enhances medical documentation sharing, and that is coordinated with VA 
providers when VA services are not available.
    While VA intends to administer these contracts directly, it has not 
yet determined how they will be managed. Additionally, VA is currently 
researching the appropriateness of incentives tied to performance 
standards to help ensure the selected contractors provide excellent 
customer service and timely care. VA conducted a business case analysis 
which compared the cost of purchasing care through individual 
authorizations and through regional contracts. The analysis showed that 
regional contracts are more cost-effective, with the cost/benefit ratio 
improving as participation increases. The PCCC contracts will cover 
inpatient and outpatient specialty care and mental health care. 
[Emphasis added.]
    In a precedent-setting effort to reform VA contract care, the 
Department is again receiving bids under PCCC from entities that are 
qualified and prepared to deliver not only mental health services but a 
wide range of other specialty health care services, one must question 
whether Congress, in enacting a new contracting mandate exclusively 
limited to mental health services would hamper VA's efforts and inject 
additional uncertainty to those firms that bid for PCCC contracts, and 
thereby cause disruption and delay in VA's plans to reform all contract 
and fee-basis health care. For these reasons, DAV recommends this bill 
be held in abeyance at this time. Our National Resolution No. 210 calls 
for program improvement and enhanced resources for VA mental health 
care programs, but we believe this bill, overlayed on the PCCC effort, 
could have the opposite effect. Therefore, we cannot support this bill 
in its current form.
        H.R. 241, the Veterans Timely Access to Health Care Act
    If enacted, this bill would establish a statutory access-to-care 
standard of 30 days within the VA health care system, and would define 
that period as the difference between the date on which a veteran 
contacts VA seeking a health care appointment, through the date on 
which a patient care visit by that veteran actually occurs with an 
appropriate VA health care provider. The bill would require VA to 
submit continuing semi-annual reports to Congress on waiting times, 
with specified criteria to define waiting periods, and to prescribe the 
content of these reports.
    Our membership has approved National Resolution Nos. 211 and 225, 
addressing timely access to VA health care services for America's 
service-disabled veterans. Timely access to needed medical care is a 
critical domain of high quality care. Currently, VA claims to be 
largely meeting its stated timeliness standards, but DAV receives much 
anecdotal information from our members and also from VA employees that 
these standards are not being met in reality and suggest that ``gaming 
the numbers'' to meet standards may be in play.
    DAV believes the transparency potential conveyed in this bill to 
document more accurate waiting times could be a worthwhile idea. 
However, the bill would also set a statutory limit of 30 days as a 
single nationwide standard within which all types of VA medical 
appointments for veterans must be completed. The bill would prescribe a 
single maximum waiting time across the universe of primary, specialty, 
and subspecialty care, and for routine, urgent, or emergent care 
appointments. DAV questions whether one performance standard of this 
nature would be appropriate or workable, given VA's current waiting-
time standards, under which VA's performance is already reported. In 
some cases, a 30-day standard might in fact lengthen waiting times 
versus current standards; in others, it would potentially clash with 
the medical judgment of clinicians about when patients should make 
return visits for care or monitoring. Therefore, we recommend the 30-
day provision be dropped from the bill.
    Notably, VA spent about $4.6 billion in fiscal year 2011 to 
purchase health care services from non-VA entities such as other 
government agencies, affiliated universities, community hospitals, 
nursing homes, and individual providers. Yet, performance reporting 
under the timeliness standard for purchased care services remains 
largely invisible to Congress and the public.
    DAV therefore recommends this measure be amended to reflect by 
reference those timeliness standards adopted and reported by VA to the 
public, and to include such reporting the timeliness in access to care 
purchased by VA in the community. In addition, we recommend the 
required report include the performance by VA facility.
    On the strength of Resolution Nos. 211 and 225, and amending this 
worthwhile measure to include the above mentioned recommendations to 
reinforce the idea of timely access as a key element in health care 
delivery, health care quality and health care satisfaction, we would 
support the bill and urge its enactment.
        H.R. 288, the CHAMPVA Children's Protection Act of 2013
    This bill would amend title 38, United States Code, section 1781(c) 
to increase the maximum age of children eligible for medical care under 
the Civilian Health and Medical Program of the Department of Veterans 
Affairs (CHAMPVA).
    Established by law in 1973, CHAMPVA provides cost reimbursement for 
private health care services provided to dependents, survivors, and 
(via Public Law 111-163) some personal family caregivers, of certain 
disabled veterans. CHAMPVA enrollment has grown steadily over the years 
and, and as of the end of fiscal year 2011, CHAMPVA covers 
approximately 355,000 individual beneficiaries.
    A child of a veteran is eligible for CHAMPVA benefits if the 
veteran is rated permanently and totally disabled due to a service-
connected disability; was rated permanently and totally disabled due to 
a service-connected condition at the time of death; died of a service-
connected disability; or, died on active duty, and the dependent is 
ineligible for Department of Defense (DoD) TRICARE benefits. Under 
current law, a dependent child's eligibility, which otherwise 
terminates at age 18, continues to age 23 if such child is pursuing a 
VA-approved full-time course of education or instruction.
    On the strength of DAV National Resolution No. 222, DAV supports 
this measure; however, we strongly urge amending it to conform to 
Public Laws 111-148 and 111-152. In its current form, the eligibility 
of a qualifying veteran's child for CHAMPVA coverage from age 18 to 26 
is extended only if the child is pursuing a full-time course of 
instruction at an approved educational institution or is unable to 
continue such pursuit due to incurring a disabling illness or injury 
that is not the result of such child's own willful misconduct.
    DAV urges the measure be amended to ensure the eligibility of a 
qualifying veteran's child for CHAMPVA coverage is under the same 
conditions of covered adult children in private health plans under the 
landmark Patient Protection and Affordable Care Act, Public Law 111-
148, as amended by the Health Care and Education Reconciliation Act of 
2010, Public Law 111-152.
    Under Public Laws 111-148 and 111-152, private health insurers are 
required to cover young adult, but still-dependent, children in covered 
families until these individuals attain age 26, irrespective of 
educational status, and regardless of financial dependency, marital 
status, residency or other factors. Because CHAMPVA is being governed 
by a different standard in law, however, children of severely disabled 
veterans and survivors of veterans who paid the ultimate sacrifice are 
being penalized by denial of these same rights and privileges as other 
young adults.
H.R. 984, to direct the Secretary of Defense to establish a task force 
                              on urotrauma
    Mr. Chairman, DAV has not received a resolution calling for a 
special DoD task force on this particular combat injury. DAV 
understands that the small number of deserving injured veterans 
suffering from genitourinary trauma, life-defining injuries, currently 
are not afforded the same level of visibility, scrutiny or 
investigation as veterans with other injuries, such as traumatic brain 
injury or PTSD, within the DoD or VA health care systems.
    However, while the proposed DoD established urotrauma task force 
may very well meet its charge and yield fruitful results, we believe 
the report of the Dismounted Complex Blast Injury Task Force, \2\ whose 
membership consists of closer to the front line personnel involved with 
the care of severely injured service members and veterans, should also 
be considered by the Subcommittee.
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    \2\ http://www.health.mil/Libraries/110808--TCCC--Course--
Materials/0766-DCBI-Task-Force-Report-Final-Redacted-110921.pdf
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    The task force this bill would establish follows on a report issued 
December 27, 2011, by a private urology group, entitled ``Genitourinary 
Trauma in the Military.'' \3\ This report was stimulated by a previous 
report of the Dismounted Complex Blast Injury Task Force, issued June 
18, 2011, by the U.S. Army. The Army study identified and recommended 
the need for new approaches for earlier treatment of combat 
genitourinary injuries, to intervene more aggressively to treat the 
acute needs of service members with severe genitourinary injuries. 
Also, it described the need for new injury prevention measures and 
recommended urologists be deployed into combat theaters, with a focus 
on salvage, repair, and reconstruction to promote positive long-term 
outcomes. Presumably, the new task force authorized by this bill would 
address these earlier recommendations.
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    \3\ http://tricare.mil/tma/congressionalinformation/downloads/
H.Rpt.%20111-
491%20Page%20316%20Genitourinary%20Trauma%20in%20the%20Military.pdf
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                               H.R. 1284
    This bill would amend the VA beneficiary travel statute to ensure 
beneficiary travel eligibility for travel expenses in connection with 
medical examination, treatment, or care on an inpatient basis, and 
while a veteran is being provided temporary lodging at VA medical 
centers. Veterans eligible for this benefit would be restricted to 
those with vision impairments, spinal cord injury or disorder, and 
those with double or multiple amputations whose travel is in connection 
with care provided through a VA special disabilities rehabilitation 
program.
    Currently, VA is authorized to pay the actual necessary expenses of 
travel (including lodging and subsistence), or in lieu thereof to pay 
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 service-connected ratings of 30 percent or 
more; those receiving treatment for service-connected conditions; 
veterans in receipt of VA pensions; those whose incomes do not exceed 
the maximum annual VA pension rate; or veterans traveling for scheduled 
compensation or pension examinations.
    DAV has no resolution on this specific issue and thus takes no 
position on this bill. However, we would note that while the intended 
recipients of this expanded eligibility criteria would certainly 
benefit from it, we would urge the Committee to consider a more 
equitable approach rather than one based on the specific impairments of 
disabled veterans. Further, we ask that if the Committee does favorably 
consider this measure, it also take appropriate action to ensure that 
sufficient additional funding be provided to VA to cover the cost of 
the expanded program.
    DAV appreciates the opportunity to submit our views on the several 
legislative measures under consideration at this hearing. Much of the 
proposed legislation would significantly improve VA services for our 
nation's disabled veterans and their families, and would make VA more 
accountable to ensure veterans and their families receive the benefits 
and services they have earned and deserve.
    This concludes my testimony, Mr. Chairman. I would be pleased to 
answer any questions related to my statement and the views I have 
expressed on behalf of DAV.

                                 
               Prepared Statement of Alexander Nicholson


--------------------------------------------------------------------------------------------------------------------------------------------------------
                             Bill #                                                  Bill Name                          Sponsor            Position
--------------------------------------------------------------------------------------------------------------------------------------------------------
H.R. 241                                                              Veterans Timely Access to Health Care Act                Ross             Support
--------------------------------------------------------------------------------------------------------------------------------------------------------
H.R. 288                                                              CHAMPVA Children's Protection Act of 2013             Michaud             Support
--------------------------------------------------------------------------------------------------------------------------------------------------------
H.R. 984                                                           A bill to direct the Secretary of Defense to             Guthrie             Support
                                                                            establish a task force on urotruama
--------------------------------------------------------------------------------------------------------------------------------------------------------
H.R. 1284                                                            A bill to provide for coverage for certain            Brownley             Support
                                                                  eligible veterans under the beneficiary travel
                                                                                                        program
--------------------------------------------------------------------------------------------------------------------------------------------------------
DRAFT                                                             Veterans Integrated Mental Health Care Act of              Miller             Support
                                                                                                           2013
--------------------------------------------------------------------------------------------------------------------------------------------------------
DRAFT                                                                 Demanding Accountability for Veterans Act            Benishek             Support
--------------------------------------------------------------------------------------------------------------------------------------------------------

    Chairman Benishek, Ranking Member Brownley, and Distinguished 
Members of the Subcommittee:
    On behalf of Iraq and Afghanistan Veterans of America (IAVA), I 
would like to extend our gratitude for being given the opportunity to 
share with you our views and recommendations regarding these important 
pieces of legislation.
    IAVA is the nation's first and largest nonprofit, nonpartisan 
organization for veterans of the wars in Iraq and Afghanistan and their 
supporters. Founded in 2004, our mission is important but simple - to 
improve the lives of Iraq and Afghanistan veterans and their families. 
With a steadily growing base of over 200,000 members and supporters, we 
strive to help create a society that honors and supports veterans of 
all generations.
    IAVA believes that all veterans must have access to quality health 
care and related services. The men and women who volunteer to serve in 
our nation's military do so with the understanding that they and their 
families will be cared for during their period of service, and also 
after their period of service should they sustain injuries or 
disabilities while serving.
H.R. 241
    IAVA supports H.R. 241, the Veterans Timely Access to Health Care 
Act, which would mandate that an acceptable VA health care appointment 
wait time is no more than 30 days from the date requested by the 
veteran. This bill will also help hold VA accountable for meeting this 
maximum allowable wait time through mandatory quarterly reviews and 
reporting on timeliness to this Committee. IAVA believes that all 
veterans should have equal and timely access to VA health care, 
regardless of where they reside. Furthermore, IAVA believes that a 
veteran's ability to access timely care plays a vital role in 
sustaining his or her quality of life. Moreover, from a mental health 
point of view, the importance of providing timely care becomes even 
more critical. Timely mental health care can sometimes mean the 
difference between life and death for veterans in crisis. IAVA believes 
that every VA medical center and VA health care provider should be held 
to the same reasonable standards of timeliness when providing care for 
veterans.
H.R. 288
    IAVA supports H.R. 288, the CHAMPVA Children's Protection Act of 
2013. With the enactment of the Affordable Care Act, children up to age 
26 can now be covered by their parents' health insurance plans. 
However, these provisions did not extend to recipients of TRICARE and 
the Civilian Health and Medical Program of the Department of Veterans 
Affairs (CHAMPVA). While legislation was subsequently enacted to extend 
this coverage option to eligible children of TRICARE recipients, no 
action has been taken on behalf of the same population under CHAMPVA. 
IAVA believes that we must enact this bill so that CHAMPVA benefits 
continue to be provided to the children of our nation's wounded 
warriors and those who paid the ultimate price in service to our 
country.
H.R.984
    IAVA supports H.R. 984, which would direct the Secretary of Defense 
to establish a task force on urotrauma in order to expand research on 
and develop new care recommendations for these injuries. Urotrauma, 
which involves an injury to the genitourinary system and is often seen 
in service members and veterans who have sustained blast injuries, is 
becoming more prevalent among today's veteran population, especially 
among those who served in Iraq and Afghanistan. Additionally, the 
increased weight of modern body armor and gear worn by today's service 
members can strain the abdominal muscles over time, which can also 
damage urinary function and other parts of the genitourinary system. 
While the number of urotrauma injuries has continued to rise, the body 
of knowledge on and available treatment options for these injuries have 
remained relatively stagnant. IAVA believes H.R. 984 is an important 
step in providing the necessary research and treatment options to 
address these serious wounds of war.
H.R.1284
    IAVA supports H.R. 1284, which would authorize the VA to reimburse 
the travel costs associated with seeking approved in-patient care at a 
VA Special Disabilities Rehabilitation Program for additional 
categories of catastrophically disabled veterans. Under current law, 
the VA reimburses certain veterans for costs associated with travel to 
and from approved VA medical facilities. However, there are certain 
categories of catastrophically disabled veterans who are not entitled 
to this reimbursement. We believe this legislation would provide 
critical assistance for more disabled veterans to allow them to receive 
the specialized in-patient treatment they need.
DRAFT BILL (Rep. Miller)
    IAVA supports the Veterans Integrated Mental Health Care Act of 
2013, which would assist veterans with accessing quality mental health 
care through VA-approved providers and TRICARE program networks. The 
overall shortage of mental health care providers is seriously impacting 
both VA and DoD. IAVA's 2013 membership survey revealed that 80 percent 
of our respondents don't think service members and veterans are getting 
the mental health care they need. IAVA believes that one way to help 
address the mental health care needs of veterans is through building 
the type of community partnerships that are advocated in and 
facilitated by this bill. These partnerships, which VA can use to help 
fill in gaps in its ability to deliver care and services, will allow 
veterans who would have otherwise had very lengthy wait times the 
opportunity to receive timely mental health care in their local 
communities. We believe this bill is a step in the right direction 
toward building such positive and beneficial community partnerships.
DRAFT BILL (Rep. Benishek)
    IAVA supports the Demanding Accountability for Veterans Act, which 
would formalize a system of accountability within VA, give the VA's 
Office of the Inspector General (OIG) report recommendations more 
authority, and institute consequences for failing to fix problems 
clearly identified by the OIG. IAVA believes this bill will strengthen 
current systems of accountability by narrowing the focus of scrutiny as 
to who is responsible for producing and correcting OIG-identified 
public safety issues.
    Mr. Chairman, we at IAVA again appreciate the opportunity to offer 
our views on these important pieces of legislation, and we look forward 
to continuing to work with each of you, your staff, and the 
Subcommittee to improve the lives of veterans and their families. Thank 
you for your time and attention.

                                 
                 Prepared Statement of Alethea Predeoux
    Chairman Benishek, Ranking Member Brownley, and members of the 
Subcommittee, Paralyzed Veterans of America (PVA) would like to thank 
you for the opportunity to present our views on health care legislation 
being considered by the Subcommittee. These important bills will help 
ensure that veterans receive the best health care services available. 
We are particularly pleased that two bills--H.R. 288 and H.R. 1284 that 
are very high priorities for PVA--are being considered.
       The ``Veterans Integrated Mental Health Care Act of 2013''
    PVA does not support the, ``Veterans Integrated Mental health Care 
Act of 2013,'' a bill to amend title 38, U.S.C. to direct the Secretary 
of Veterans Affairs to provide certain veterans with an integrated 
delivery model for mental health care through care-coordination 
contracts. The VA is currently working on multiple initiatives to 
improve care-coordination with private providers and increase timely 
access to mental health services. Specifically, the VA is developing 
mental health contracts with community based providers as required by 
the President's Executive Order #13625--``Improving Access to Mental 
Health Services for Veterans, Service Members, and Military Families,'' 
and is also in the process of transforming its national non-VA care 
program in an effort to improve coordination services with non-VA 
providers, which includes mental health services. PVA believes that the 
current VA initiatives should be further developed before additional 
resources are put into another program for non-VA care-coordination.
           The ``Veterans Timely Access to Health Care Act''
    PVA generally supports the intent of the, ``Veterans Timely Access 
to Health Care Act,'' which proposes to direct the Secretary of the VA 
to establish standards of access to care for veterans seeking health 
care from VA medical facilities. If enacted, this bill would establish 
a standard for access to care that requires the date on which a veteran 
contacts the VA seeking an appointment and the date on which a visit 
with an appropriate health care provider is completed to be 30 days. 
While this legislation may potentially improve the delivery of VA 
services, the language does not take into account the fact that the 
standard for access to care may vary depending on the type of care 
needed. As such, PVA has concerns regarding the use of a 30 day 
standard for access to care without specifying the type of care that is 
being provided. While PVA believes that timely access to quality care 
is vital to VA's core mission of providing primary care and specialized 
services to veterans, it is also important that factors such as the 
nature of the services provided and efficient use of VA staff and 
resources be considered when developing standards for access to care.
      H.R. 288, the ``CHAMPVA Children's Protection Act of 2013''
    PVA supports H.R. 288, legislation to amend title 38, United States 
Code, to increase the maximum age for children eligible for medical 
care under the Civilian Health and Medical Program of the Department of 
Veterans Affairs (CHAMPVA). CHAMPVA is a comprehensive health care 
program in which the VA shares the cost of covered health care services 
for eligible beneficiaries, including children up to age 23. As a part 
of health reform, all commercial health insurance coverage increased 
the age for covered dependents to receive health insurance on their 
parents plan from 23 years of age to 26 years, in accordance with the 
provisions of P.L. 111-148, the ``Patient Protection and Affordable 
Care Act.'' This change also included health care coverage provided to 
service members and their families through TRICARE.
    Today, the only qualified dependents that are not covered under a 
parent's health insurance policy up to age 26 are those of 100 percent 
service-connected disabled veterans covered under CHAMPVA. This 
unfortunate oversight has placed a financial burden on these disabled 
veterans whose children are still dependent upon the parents for 
medical coverage, particularly if the child has a preexisting medical 
condition. PVA strongly supports this legislation because it will make 
the necessary adjustment in this VA benefit.
                     H.R. 984, Urotrauma Task Force
    PVA supports H.R. 984, legislation that would establish a national 
Task Force on Urotrauma. Since 2005, the rate of injury to the 
urogenital organs of service men and women has increased to 
approximately 10 percent of all war injuries in both Iraq and 
Afghanistan. The majority of these devastating injuries are the result 
of exposure to improvised explosive devices (IEDs), with many others 
from gunshot wounds to the pelvis or abdomen. Similarly, non-urologic 
injuries such as spinal cord injury affect urologic function. Although 
less common than extremity injury, trauma to the urogenital organs is 
no less debilitating both physically and psychologically.
    This proposed bill requires the Department of Defense, in 
conjunction with the VA and the Department of Health & Human Services, 
to establish a national commission on urotrauma. The commission's 
objectives are:

    1) to conduct a comprehensive study of the present state of 
knowledge of the incidence and duration of, and morbidity and mortality 
rates resulting from urotrauma;

    2) to study the social and economic impact of such conditions;

    3) evaluate the public and private facilities and resources 
(including trained personnel and research activities) for the 
prevention, diagnosis, treatment of, and research in such conditions; 
and

    4) to identify programs (including biological, behavioral, 
environmental, and social) through which improvement in the management 
of urotrauma can be accomplished.

    The nature of the sacrifice that the service men and women who have 
experienced urogenital injuries have made is beyond measure. It is 
incumbent upon Congress and the Administration to take every step 
necessary to help make these men and women as whole as possible. This 
task force is a necessary first step.
                               H.R. 1284
    PVA strongly supports H.R. 1284, a bill to amend title 38, U.S.C., 
to provide for coverage under the beneficiary travel program of the VA 
of certain non-service connected catastrophically disabled veterans for 
travel in connection with certain special disabilities rehabilitation. 
This legislation is one of our priorities for the current Congress. If 
enacted, this legislation would provide reimbursement for travel that 
is in connection with care provided through a VA special disabilities 
rehabilitation program to veterans with a spinal cord injury or 
disorder, double or multiple amputations, or vision impairment. Such 
care must also be provided on an inpatient basis or during temporary 
lodging at a VA facility.
    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. Too often, 
catastrophically disabled veterans, particularly non-service connected 
veterans who do not have the benefit of travel reimbursement, 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.
    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, timely 
comprehensive care, and result in long-term cost savings for the VA. 
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 exacerbated health conditions due to postponed care.
       The ``Demanding Accountability for Veterans Act of 2013''
    PVA does not have an official position on the, ``Demanding 
Accountability for Veterans Act of 2013.'' If enacted, this bill would 
amend title 38 U.S.C. to improve the accountability of the VA secretary 
to the Inspector General of the VA. PVA supports the overall intent of 
this legislation to guarantee that systems of checks and balances are 
in place to help make certain that federal services are effective and 
provided in a timely manner. PVA believes that it is the responsibility 
of the VA to provide an action plan in response to VA Inspector General 
Reports, and carry out such plans as determined appropriate for the 
successful delivery of veterans' benefits and health care services. 
Yet, we must question the need for such legislation when Congress 
already has the authority to conduct oversight.
    We would once again like to thank the Subcommittee 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 services available to veterans, service 
members, and their families. We would be happy to answer any questions 
that you may have for the record.
Information Required by Rule XI 2(g)(4) of the House of Representatives
    Pursuant to Rule XI 2(g)(4) of the House of Representatives, the 
following information is provided regarding federal grants and 
contracts.
                            Fiscal Year 2013
    No federal grants or contracts received.
                            Fiscal Year 2012
    No federal grants or contracts received.
                            Fiscal Year 2011
    Court of Appeals for Veterans Claims, administered by the Legal 
Services Corporation--National Veterans Legal Services Program-- 
$262,787.

                                 
                 Prepared Statement of Robert L. Jesse
    Good Morning Chairman Benishek, Ranking Member Brownley, and 
Members of the Subcommittee. Thank you for inviting me here today to 
present our views on several bills that would affect Department of 
Veterans Affairs (VA) health programs and services. Joining me today is 
Susan Blauert, Deputy Assistant General Counsel.
    Because of the time afforded for preparation of views, we do not 
yet have cleared views on H.R. 241, H.R. 984, the draft bill ``the 
Veterans Integrated Mental Health Care Act of 2013'' and the draft bill 
``the Demanding Accountability for Veterans Act of 2013''.
H.R. 288 Increase of Maximum Age for Children Eligible for Medical Care 
                         Under CHAMPVA Program.
    The intent of H.R. 288 as expressed in its subtitle is to increase 
the maximum age for children eligible for medical care under the 
Civilian Health and Medical Program of the Department of Veterans 
Affairs (CHAMPVA). However, VA believes the language in H.R. 288, as 
written, may not accomplish this intent because it does not address the 
definition of ``child'' in 38 U.S.C. Sec.  101 which limits eligibility 
for children under CHAMPVA in 38 U.S.C. Sec.  1781. VA would be glad to 
provide technical assistance to the Subcommittee if it does intend to 
extend eligibility for coverage of children under CHAMPVA until they 
reach age 26. VA believes that eligibility for coverage of children 
under CHAMPVA should be consistent with certain private sector coverage 
under the Affordable Care Act.
    Assuming the intent of H.R. 288 is to accord the eligibility for 
medical care under CHAMPVA to children until they reach the age of 26, 
VA supports it, contingent upon Congress providing additional funding 
to support the change in eligibility. Should the bill carry out that 
intent, VA estimates costs of $51 million in FY 2014; $301 million over 
5 years; and $750 million over 10 years.
  H.R. 1284 Coverage Under Department of Veterans Affairs Beneficiary 
      Travel Program of Travel in Connection with Certain Special 
                      Disabilities Rehabilitation.
    H.R. 1284 would amend VA's beneficiary travel statute to ensure 
beneficiary travel eligibility for Veterans with vision impairment, 
Veterans with spinal cord injury (SCI) or disorder, and Veterans with 
double or multiple amputations whose travel is in connection with care 
provided through a VA special disabilities rehabilitation program 
(including programs provided by spinal cord injury centers, blind 
rehabilitation centers, and prosthetics rehabilitation centers), but 
only when such care is provided on an in-patient basis or during a 
period in which VA provides the Veteran with temporary lodging at a VA 
facility to make the care more accessible. VA would be required to 
report to the Committees on Veterans' Affairs of the Senate and House 
of Representatives no later than 180 days after enactment on the 
beneficiary travel program as amended by this legislation, including 
the cost of the program, the number of Veterans served by the program, 
and any other matters the Secretary considers appropriate. The 
amendments made by this legislation would take effect on the first day 
of the first fiscal year that begins after enactment.
    VA supports the intent of broadening beneficiary travel eligibility 
for those Veterans who could most benefit from the program, contingent 
on provision of funding, but believes this legislation could be 
improved by changing its scope. As written, the bill could be construed 
to apply for travel only in connection with care provided through VA's 
special rehabilitation program centers and would apply only when such 
care is being provided to Veterans with specified medical conditions on 
an inpatient basis or when the Veteran must be lodged. VA provides 
rehabilitation for many injuries and diseases, including for Veterans 
who are ``Catastrophically Disabled,'' at numerous specialized centers 
other than those noted in H.R. 1284, including programs for Closed and 
Traumatic Brain Injury (CBI+TBI), Post-traumatic Stress Disorder and 
other mental health issues, Parkinson's Disease, Multiple Sclerosis, 
Epilepsy, War Related Injury, Military Sexual Trauma, Woman's Programs, 
Pain Management, and various addiction programs. In addition, many of 
these programs provide outpatient care to Veterans who might not 
require lodging but must travel significant distances on a daily basis 
who would not be eligible under this legislation.
    Therefore, VA feels that the legislation as written would provide 
disparate travel eligibility to a limited group of Veterans. However, 
VA does support the idea of travel for a larger group of 
``Catastrophically Disabled'' Veterans (including Veterans who are 
blind or have SCI and amputees) and those with 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.
    VHA estimates costs for this provision as $2.4 million for FY 2014; 
$13.1 million over 5 years; and $29.8 million over 10 years.
    Mr. Chairman, this concludes my statement. Thank you for the 
opportunity to appear before you today. I would be pleased to respond 
to questions you or the other Members may have.

                                 
                       Statements For The Record

                          THE AMERICAN LEGION
 Draft Legislation, the Veterans Integrated Mental Health Care Act of 
                                  2013
    To amend title 38, United States Code, to direct the Secretary of 
Veterans Affairs to provide certain veterans with an integrated 
delivery model for mental health care through care-coordination 
contracts.
    The American Legion believes that veterans should not be denied 
earned care based on where they choose to live. While we understand 
that it is not feasible for every community to have a full slate of VA-
administered services, every community has access to medical care in 
some form. For example, The American Legion conducted a site visit to 
Martha's Vineyard last year for our report on Rural Health Care. In 
2000, a contract was signed between the Providence VA Medical Center 
and Martha's Vineyard Hospital. Through the contract, veterans living 
on Martha's Vineyard were able to receive care at Martha's Vineyard 
Hospital through fee-basis instead of having to travel off of the 
island. The contract lapsed around 2004, but the VA failed to realize 
this until 2008, when the hospital acquired new management. Veterans 
who were being treated under the original contract found out that the 
contract had lapsed when Martha's Vineyard Hospital sent collection 
bill notices to those veterans for medical expenses previously covered 
under the contract. Though a new contract was finally signed in the 
fall of 2012, it took four years for this to be arranged, with the 
veteran residents of Martha's Vineyard being forced to commute from 
their homes to Providence VA Medical Center - a trek involving a ferry 
ride and a two hour drive - each time they needed care.
    Though there are only a few veterans living on the island, these 
veterans deserve fair treatment, and access to the benefits they have 
earned through their service. This delay illustrates the frustrations 
that veterans living in rural and isolated locations or other areas 
across the country experience in waiting for contracts and receiving 
assurances from VA that the contract will be resolved. VA should 
develop and implement a process to ensure all VA and non-VA purchased 
care contracts are inputted into a tracking system to ensure they 
remain current and do not lapse. If there are instances with a contract 
lapsing, such as in Martha's Vineyard, VA should make every effort to 
hold stakeholder meetings with veterans from those communities to 
solicit input and keep veterans enrolled in these contracts/services 
informed.
    Exacerbating this problem are mental health issues which many 
veterans suffer - PTSD and TBI - which at times may require immediate 
care in order to prevent veterans from harming themselves or others. 
This legislation would make strides toward addressing this issue by 
facilitating contracts between VA and non-VA facilities to provide 
mental health care to veterans who live in areas which do not have VA 
medical facilities.
The American Legion supports this bill.
  Draft Legislation, the Demanding Accountability for Veterans Act of 
                                  2013
    To amend title 38, United States Code, to improve the 
accountability of the Secretary of Veterans Affairs to the Inspector 
General of the Department of Veterans Affairs.
    The American Legion's Resolution No. 99, passed at National 
Convention 2012 states that ``bonuses for VA senior executive staff 
[should] be tied to qualitative and quantitative performance measures 
developed by VA.'' While The American Legion refrains from commenting 
on the specific nature of these qualitative and quantitative 
performance measures - these decisions are left to the discretion of 
Congress and the administration - The American Legion believes that the 
implementation of such measures are a necessary step toward creating a 
culture of accountability within the VA. This bill, by establishing 
particular performance standards tied to bonuses received by VA senior 
executive staff, moves toward addressing this issue.
The American Legion supports this bill.
        H.R. 241, the Veterans Timely Access to Health Care Act
    Veterans Timely Access to Health Care Act - Directs the Secretary 
of Veterans Affairs to ensure that the standard for access to care for 
a veteran seeking hospital care and medical services from the 
Department of Veterans Affairs (VA) is 30 days from the date the 
veteran contacts the VA.
    Directs the Secretary to periodically review the performance of VA 
medical facilities in meeting such standard.
    Requires quarterly reports from the Secretary to the congressional 
veterans' committees on the VA's experience with respect to appointment 
waiting times.
    The American Legion has long been concerned with the inordinate 
wait times experienced by many veterans when attempting to access VA 
medical care. In 2002, the inaugural year for The American Legion's 
System Worth Saving initiative, the resulting report found that over 
300,000 veterans were waiting for health care appointments. Of those, 
over half were waiting more than eight months for primary care 
appointments. In the intervening decade since then, little has changed, 
as is demonstrated by the ongoing System Worth Saving reports. While VA 
medical care is among the best in the world, access has proven to be a 
problem for far too many of those who have earned it through their 
service.
    On March 6th of this year, this committee's Subcommittee on 
Oversight and Investigations held a hearing entitled ``Waiting for 
Care: Examining Patient Wait Times at VA'' aimed at examining this 
issue. The American Legion, in addition to submitting testimony, 
provided an attachment for the record containing numerous stories from 
Veteran Integrated Service Networks (VISNs) across the nation, 
detailing first-hand accounts of the barrier to care that these wait 
times present - up to eight months, in some cases. This bill would 
address this issue, and while The American Legion would prefer a 
standard of less than 30 days - a goal of 14 days would be preferable - 
this legislation is a step in the right direction.
The American Legion supports this bill.
             H.R. 288, the CHAMPA Children's Protection Act
    CHAMPVA Children's Protection Act of 2013 - Increases from 23 to 26 
the maximum age of eligibility for certain dependent children of 
veterans for medical care under CHAMPVA (the Civilian Health and 
Medical Program of the Department of Veterans Affairs [VA]).
The American Legion has no position on this bill.
     H.R. 984, To Direct DOD to Establish a Task Force on Urotrauma
    Directs the Secretary of Defense (DOD), in order to continue and 
expand the DOD report submitted in 2011, to establish the Task Force on 
Urotrauma to: (1) conduct a study on urotrauma (injury to the urinary 
tract from a penetrating, blunt, blast, thermal, chemical, or 
biological cause) among members of the Armed Forces and veterans; and 
(2) provide an interim and final report to the congressional defense 
and veterans committees on such study.
The American Legion has no position on this bill.
H.R. 1284, To Provide Coverage Under VA's Beneficiary Travel Program of 
 Certain Disabled Veterans for Travel for Certain Special Disabilities 
                             Rehabilitation
    Authorizes payment under the Department of Veterans Affairs (VA) 
beneficiary travel program of travel expenses in connection with 
medical examination, treatment, or care of a veteran with vision 
impairment, a spinal cord injury or disorder, or double or multiple 
amputations whose travel is in connection with care provided through a 
VA special disabilities rehabilitation program, if such care is 
provided: (1) on an inpatient basis, or (2) while a veteran is provided 
temporary lodging at a VA facility in order to make such care more 
accessible.
    Requires a report from the Secretary to the congressional veterans 
committees on the travel program.
The American Legion has no position on this bill.
    For additional information regarding this testimony, please contact 
Mr. Shaun Rieley at The American Legion's Legislative Division, (202) 
861-2700 or [email protected].

                                 
    OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS
    Mr. Chairman, Ranking Member Brownley, and Members of the 
Subcommittee, thank you for the opportunity to discuss how the 
Chairman's draft bill, Demanding Accountability for Veterans Act of 
2013, will affect the operations of the Office of Inspector General 
(OIG).
    Timely implementation of OIG recommendations is critical to 
improvement of VA programs and delivery of services to our Nation's 
veterans, and we share the Subcommittee's interest in seeing that 
responsible VA program officials are held accountable for correcting 
program deficiencies. In considering the proposed legislation, we 
believe it will be helpful for the Subcommittee to understand the OIG's 
Follow-Up Program, which is the principal means by which we track VA's 
progress implementing our recommendations.
OIG FOLLOW-UP PROGRAM
    Follow-up is an important component of OIG oversight work. The 
Office of Management and Budget requires a process to follow up and 
report on the status of OIG report recommendations. The OIG is also 
required to report in its Semiannual Report to Congress on the status 
of report recommendations. Moreover, after the Inspector General 
testified before this Committee in February 2007, we began providing 
quarterly updates \1\ to Congress and the VA Secretary on the status of 
open report recommendations, with an emphasis on those recommendations 
pending over 1 year. In June 2010, the Deputy Inspector General 
testified before the full Committee about the Department's progress 
toward implementing recommendations.
---------------------------------------------------------------------------
    \1\ The update for the 2nd and 4th quarter of the fiscal year is 
the Semiannual Report to Congress.
---------------------------------------------------------------------------
    Included in each OIG final report is VA's response to the report, a 
statement whether they concur with each recommendation, and an 
implementation plan for the recommendations, that includes target 
dates. Those dates are determined by VA.
    OIG staff take great care in developing recommendations to correct 
identified deficiencies to ensure that they are clear and specific; 
provide a yardstick to measure improvement; and gauge full 
implementation. Since 2007, we have worked closely with VA officials to 
develop recommendations for corrective action that can be realistically 
implemented within a year. As such, the OIG no longer accepts VA 
implementation plans that take more than a year to complete, except 
under the rarest of circumstances and only when measurable timelines 
are provided. In some instances, based on OIG staff evaluation, VA 
program offices take corrective action while we are onsite or during 
the period between the issuance of the draft report and when the final 
report is published. When this happens, we close out the recommendation 
as fully implemented and reflect the action in our final report.
    However, a majority of the reports we issue contain open 
recommendations. Once a final report is issued, OIG follow-up staff 
begin a process of tracking each recommendation until fully 
implemented. The first OIG follow-up request is sent to the responsible 
VA program office 90 days after the report is published. 
(Recommendations in the annual audits related to the Federal 
Information Security Management Act of 2002 and VA's Consolidated 
Financial Statements are tracked separately by our independent public 
accounting firm and the results published annually in separate 
reports.)
    In each follow-up status request we seek a description of what 
actions have occurred toward implementing the recommendations during 
the preceding 90 days. We set a 30-day deadline for VA officials to 
respond in writing. The response must contain documentary evidence such 
as issued policies, certifications, or other material supporting any 
request to close recommendations. Our intermediate goal is to obtain 
evidence that VA is making progress in implementing recommendations. If 
we do not receive a timely reply, or if we determine VA's efforts 
appear to be falling behind schedule, we schedule a face-to-face 
meeting to discuss how to get implementation back on track.
    OIG follow-up staff coordinate with OIG line officials who worked 
on the report. To ensure VA's implementation plans remain on track, 
they discuss the documentary evidence VA submits with the status 
reports. If a report recommendation remains unimplemented, OIG staff 
repeat this follow-up cycle every 90 days. Once a report passes the 6-
month mark and we determine implementation is unlikely within the 1-
year goal, we increase the frequency of discussions with OIG line staff 
and VA program officials, and ensure the appropriate senior management 
officials in the OIG and VA recognize the probability of missing the 1-
year target for implementation.
    In Appendix B of our Semiannual Report to Congress, we present 
tables on open reports and recommendations. In the first table, we 
provide a matrix with totals for both open reports and the associated 
unimplemented recommendations. The table further breaks the data into 
those open less than or more than 1 year, and provides the same data by 
VA Administration or Staff Office. The second table shows only those 
reports and recommendations that are unimplemented for more than 1 
year. In this table, we show the report title, date of issue, 
responsible VA organization, monetary impact, full text of each 
recommendation, and an indication of how many recommendations on each 
report are still open.
NAME CHECK PROCESS
    To promote accountability, VA has a process in place to consult 
with the OIG and certain VA staff offices to assist the Secretary in 
making his decisions on performance awards and nominations for 
Presidential Rank Awards for members of the Senior Executive Service 
and Title 38 equivalents. The OIG performs name checks where the list 
of potential award recipients are checked against OIG records to 
determine whether there are any open criminal or administrative 
investigations involving the individuals or whether there are any 
adverse findings in closed cases involving the individuals. These 
results are provided to VA for consideration by the Secretary when 
making final decisions on executive awards. We have made it clear to VA 
that nominating officials are responsible for considering the results 
of OIG audits and inspections because these results may not be 
associated with individual executives in our reports or record system.
DRAFT LEGISLATION
    We offer the following comments on the draft legislation:

      Page 2, Line 19, Notifying the OIG of responsible 
managers by the Secretary - It would be helpful when identifying the 
manager, if there was a requirement to identify which recommendation(s) 
that manager was responsible for implementing.
      Page 3, Line 3, Notifying the manager - ``Promptly 
notify'' should be defined in terms of number of days.
      Page 4, Line 16, Defining responsible managers - Because 
VA has many positions covered under Title 38 of the United State Code, 
the section defining managers should include employees covered under 
Title 38 in addition to employees covered under Title 5 in the 
competitive service and Senior Executive Service.

CONCLUSION
    The OIG appreciates the Subcommittee's interest in our work and 
ensuring that VA takes the necessary steps to address recommendations 
that the OIG and VA have agreed will remediate identified problems. We 
also appreciate the willingness of Subcommittee staff and Chairman 
Benishek's staff to discuss the draft bill and make clarifying edits.
    We will continue to work actively with VA to ensure that OIG 
recommendations are implemented and to keep Congress advised on the 
status of those recommendations.

                                 
            MILITARY OFFICERS ASSOCIATION OF AMERICA (MOAA)
    CHAIRMAN BENISHEK, RANKING MEMBER BROWNLEY AND DISTINGUISHED 
MEMBERS OF THE COMMITTEE, on behalf of the over 380,000 members of The 
Military Officers Association of America (MOAA), we are pleased to 
present the Association's views on selected bills that are under 
consideration at today's hearing.
    MOAA does not receive any grants or contracts from the federal 
government.
    Thank you for the opportunity to submit comments and 
recommendations on the following pending legislative provisions:

      Draft, Veterans Integrated Mental Health Care Act of 2013
      Draft, Demanding Accountability for Veterans Act of 2013
      H.R. 241, Veterans Timely Access to Health Care Act
      H.R. 288, CHAMPVA Children's Protection Act of 2013
      H.R. 984, Direct the Secretary of Defense to Establish a 
Task Force on Urotrauma
      H.R. 1284, Amend Title 38 U.S.C. to Provide Coverage 
Under the Beneficiary Travel Program of the Department of Veterans 
Affairs (VA) of Certain Disabled Veterans for Travel for Certain 
Special Disabilities Rehabilitation

    MOAA supports all the above provisions with only minor additions as 
noted below. We believe strongly that such legislation will strengthen 
existing programs and services under VA's purview, addressing some 
existing gaps in care, while providing additional tools for oversight 
and accountability across the medical system.
PENDING PROVISIONS
    Draft, Veterans Integrated Mental Health Care Act of 2013. This 
provision would require the Secretary of VA to furnish mental health 
care to eligible veterans that is provided by a non-Department 
facility.
    MOAA recognizes that more needs to be done to address the rapidly 
growing demand for veterans' mental health services. This provision 
allows more opportunities for care and provides an integrated model for 
addressing access issues by using network providers outside the VA. 
Further, greater coordination and oversight of contracts and data 
sharing between government and non-government entities is supported by 
this legislation.
    We have long supported leveraging existing civilian network 
providers, such as the TRICARE purchased care network to address the 
demand. This provision will do just that, as well as help provide 
necessary data to effectively measure patient outcomes.
MOAA fully supports this provision.
    Draft, Demanding Accountability for Veterans Act of 2013. The 
purpose of this bill is to improve the accountability of the Secretary 
to the Inspector General (IG) of the VA.
    Specifically, the provision requires the IG to notify Congress 
should the Secretary not appropriately respond with significant 
progress to a report issued by the IG by the required deadline of the 
covered report.
    MOAA is encouraged by this provision, allowing additional authority 
to address reporting shortfalls with the Secretary. We see this as a 
positive way for both the Secretary and Congress to exercise additional 
oversight capability to improve accountability across the Department.
MOAA fully supports the draft provision.
    H.R. 241, Veterans Timely Access to Health Care Act. The bill 
mandates the Secretary to establish standards of access to care for 
veterans seeking health care from VA medical facilities.
    Our Association believes this legislation provides the forcing 
mechanism needed for VA to standardize access--an important step in 
eliminating the significant wait times facing veterans trying to 
schedule initial and follow-on appointments.
    MOAA is also concerned about veterans needing immediate follow-up 
care after presenting in a VA emergency room (ER). Recently a caregiver 
took her veteran to a VA ER and was told after discharge to make an 
appointment for immediate follow-up but was told the earliest appoint 
available was in 3 months--a common scenario we hear.
MOAA supports the draft provision and would ask the Subcommittee to 
        consider adding language requiring:

      Completing appointments within 5-15 days (or some 
medically-appropriate timeframe) following an urgent care visit to an 
ER if prescribe by a VA provider.

      Breaking out and tracking of veteran access by Enrollment 
Priority Groups 1-8.

      Adding a patient satisfaction rate measurement as a 
metric of effectiveness.

    H.R. 288, CHAMPVA Children's Protection Act of 2013. The provision 
would amend Title 38, U.S.C. to increase the maximum age for children 
eligible for medical care under CHAMPVA program from age 23 to 26.
    The expansion of eligibility for CHAMPVA for eligible children up 
to age 26 is in line with provisions in the Patient Protection and 
Affordable Care Act (ACA) and the TRICARE Young Adult benefit.
    According to a new GAO Report on the relationship of TRICARE and VA 
care to the ACA, ``[the] ACA requires that if a health insurance plan 
provides for dependent coverage of children, the plan must continue to 
make such coverage available for an adult child until age 26. This 
requirement relating to coverage of adult children took effect for the 
plan years beginning on or after September 23, 2010. Under ACA, both 
married and unmarried children qualify for this coverage. The 
authorizing statute for CHAMPVA currently does not conform to this ACA 
requirement.''
MOAA fully supports H.R. 288.
    H.R. 984, Direct the Secretary of Defense to Establish a Task Force 
on Urotrauma. Subject to availability of appropriations, H.R. 984 would 
require the Secretary of Defense, in consultation with VA and the 
Department of Health and Human Services to establish a Task Force to 
conduct a study on urotrauma for a four-year period.
    Given the severity of wounds and the changing combat environment, 
MOAA supports the need for more research and analysis, particularly in 
assessing incidents of urotrauma among our military members.
    An important part of national security and readiness of our 
military force is to have a good understanding of the effects of war. 
This bill allows an opportunity to study significant injuries as a 
result of the wars in Iraq and Afghanistan. Timing is crucial for this 
provision as the need to capture useful data is essential in order to 
apply what we learn in these wars and to be able to deploy in future 
conflicts.
MOAA supports the provision and suggests adding to the Ex Officio 
        members list, military and veteran patient(s)/beneficiaries to 
        ensure the warrior's perspective is considered in task force 
        deliberations.
    H.R. 1284, Amend Title 38 U.S.C. to Provide Coverage Under the 
Beneficiary Travel Program of the Department of Veterans Affairs (VA) 
of Certain Disabled Veterans for Travel for Certain Special 
Disabilities Rehabilitation. Under this provision travel would be 
authorized for a veteran with a vision impairment, a veteran with 
spinal cord injury or disorder, or a veteran with double or multiple 
amputations whose travel is in connection with care provided through a 
special disabilities rehabilitation program of the VA (including spinal 
cord injury center programs, blind rehabilitation center programs, and 
prosthetics rehabilitation center programs).
    Veterans with catastrophic non-service connected (NSC) disabilities 
are currently ineligible for travel benefits associated with their 
visits to one of the 13 Blind Rehabilitation Centers or 29 Spinal Cord 
Injury locations around the country. These veterans must bear 
significant financial costs, including air travel which often deters 
them from getting the necessary training they need to live an 
independent lifestyle.
    Additionally, 32 percent of the NSC blind veterans live at the 
poverty level and the average age of this population is 67 years old.
    This issue is also outline in the Independent Budget, highlighting 
that, ``When veterans do not meet the eligibility requirement for 
travel reimbursement, and they do not have the financial means to 
travel, the chances of their receiving the proper medical attention are 
significantly decreased . . . For veterans who have sustained a 
catastrophic injury like spinal cord injury, blindness, or limb 
amputation, time and appropriate medical care is vital to their overall 
health and well-being.''
    We agree with our VSO colleagues that this provision is a 
`preventive medicine' bill.
MOAA fully supports H.R. 1284.
CONCLUSION
    The Military Officers Association of America is grateful to the 
members of the Subcommittee on Health. Thank you for your leadership in 
keeping these important issues before the Congress and for your 
commitment to our Nation's heroes and their families.

                                 
             VETERANS OF FOREIGN WARS OF THE UNITED STATES
    MR. CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE:

    On behalf of the men and women of the Veterans of Foreign Wars of 
the United States (VFW) and our Auxiliaries, I would like to thank you 
for the opportunity to offer testimony on today's pending legislation.
H.R. 241, Veterans Timely Access to Health Care Act
    This legislation would direct the Secretary of Veterans Affairs to 
ensure that all medical visits to Department of Veterans Affairs (VA) 
facilities are completed no more than 30 days after the veteran 
contacts VA to schedule an appointment. Additionally, it would require 
that VA submit a detailed report to Congress on scheduled wait times no 
later than 60 days after the end of each quarter.
    The VFW understands that unacceptably long appointment wait times 
present a serious and ongoing problem, especially for new enrollees and 
those seeking specialty care, and agrees with the intent of this 
legislation to address that issue. We are concerned, however, that its 
enactment would remove too much flexibility from the scheduling 
process. Appointment wait times can be measured either from the date 
the veteran schedules the appointment or the date that the veteran 
desires the appointment to take place. The date of contact, or create 
date, could be several months in advance of the desired date, 
specifically when the veteran takes the opportunity to schedule a 
follow-up at the conclusion of his or her current appointment. Many 
medical conditions require periodic visits with the veteran's health 
care provider on a less than monthly basis. Legally mandating that all 
appointments must take place within 30 days of the create date could 
prevent VA from being able to offer long-term scheduling even when the 
veteran and the provider agree that it is appropriate. A veteran 
desiring an appointment 60 days in the future would have until 30 days 
prior to the desired date to schedule. This would greatly complicate 
the VA appointment reminder policy by necessitating reminders for when 
veterans should be making their appointments in addition to when those 
appointments occur. For these reasons, we feel that eliminating the 
ability of VA to schedule appointments based on a distant desired date 
would inevitably lead to missed appointments, creating unnecessary cost 
to VA and diminished care for veterans.
    The failure of VA scheduling staff to accurately establish 
veterans' desired dates, however, has led to exceedingly long and 
inaccurately reported wait times in the past, as highlighted by the 
December, 2012 Government Accountability Office (GAO) report, 
Reliability of Reported Outpatient Medical Appointment Wait Times and 
Scheduling Oversight Need Improvement. To correct this problem, GAO 
recommended that VA adopt a scheduling policy which more clearly 
defines the desired date or adopt new wait time measures that are not 
subject to interpretation. In response, VA has adopted the use of the 
create date to determine the appointment wait times for all new 
enrollees. VA has further stated that it will move to a policy which no 
longer uses the desired date as determined by the scheduler, and 
instead begin using an ``agreed upon date'' which is determined jointly 
by the provider and the veteran to track appointment wait times for 
established enrollees. The VFW will be closely monitoring these reforms 
and encourages Congressional oversight of their progress and 
effectiveness.
    The VFW believes that, if executed properly, this new scheduling 
policy creates an accurate and reliable method of determining wait 
times and will increase veteran satisfaction while maintaining the 
current level of scheduling flexibility. Consequently, we cannot 
support H.R. 241 in its current form. The VFW would, however, consider 
supporting similar legislation requiring VA to schedule all appointment 
requests no more than 30 days after the agreed upon date for 
established enrollees, and the create date for new enrollees and all 
those seeking referrals from their current providers to new providers 
or specialty care.
H.R. 288, CHAMPVA Children's Protection Act of 2013
    The VFW supports this legislation to extend the age limit for 
coverage of certain veterans' dependents through the Civilian Health 
and Medical Program of the Department of Veterans Affairs (CHAMPVA) to 
the level set by the Patient Protection and Affordable Care Act (ACA).
    The ACA, passed in early 2010, allowed families with private health 
insurance coverage to keep their children on their plans until age 26. 
TRICARE and CHAMPVA recipients were not included in that change. Thanks 
to responsible leaders in Congress, TRICARE coverage has been 
guaranteed to this age group. Unfortunately, CHAMPVA beneficiaries have 
not been afforded the same privileges. This remains an outstanding 
issue that must be rectified.
    The VFW urges, however, that this legislation be strengthened to 
explicitly provide coverage to all children of CHAMPVA beneficiaries 
under the age of 26, not just those who are enrolled full-time at an 
approved educational institution or are unable to do so because of 
disability. Such a change would provide the standard of coverage 
offered under the ACA, as amended by the Health Care and Education 
Reconciliation Act of 2010, which offers coverage to all dependent 
children until age 26, regardless of educational status. The VFW 
strongly believes that CHAMPVA, which was established in 1973 and has 
more than 378,000 unique beneficiaries comprised of dependents and 
survivors of certain veterans, should in no instance ever receive less 
than the national standard.
H.R. 984, To direct the Secretary of Defense to establish a task force 
        on urotrauma.
    The VFW is pleased to offer our support for this legislation which 
would establish an interagency task force on genitourinary organ 
injuries (urotrauma) to advise on research and action needed to advance 
the care and treatment of urotrauma.
    The American Urological Association has reported that urotrauma 
injuries account for 10 percent of battlefield injuries with a 350 
percent increase in incidence for those serving in Afghanistan compared 
to those who served in Iraq. Although less common than other physical 
injuries, the long-term emotional yet publicly invisible wounds from a 
genitourinary injury can mean loss of function and fertility for many 
service members. The psychological outcome of these battlefield 
injuries for both men and women can be devastating.
    The VFW believes that this legislation will begin to address some 
of those needs by bringing together the Departments of Defense, 
Veterans Affairs, and Health and Human Services to study current 
incidence, morbidity and mortality rates, as well as the social and 
economic impact. It would also task the agencies to evaluate public and 
private resources for the diagnosis, prevention, treatment and most 
importantly, research of these injuries. Finally, it would focus on 
identifying programs and best practices among stakeholders to improve 
the coordination and management of urotrauma injuries.
    Better coordination and efficient use of resources both public and 
private will provide the key to improved care, treatment and management 
of those suffering from the residuals of these injuries. We urge 
Congress to pass this bill quickly.
H.R. 1284, To amend title 38, United States Code, to provide for 
        coverage under the beneficiary travel program of the Department 
        of Veterans Affairs of certain disabled veterans for travel for 
        certain special disabilities rehabilitation, and for other 
        purposes.
    The VFW supports this legislation which would extend beneficiary 
travel benefits to veterans with certain severe non-service connected 
disabilities who travel to receive care provided through a VA special 
disabilities rehabilitation program. Veterans who are catastrophically 
disabled due to spinal cord injuries, visual impairments, and multiple 
amputations often require in-patient care in order to achieve full 
rehabilitation. Not all VA facilities, however, offer the specialized 
programs of care needed to properly treat these severe disabilities, 
and many veterans are forced to travel great distances to receive the 
care they need. Those not eligible for travel reimbursement must do so 
at great personal cost and, as a result, may be forced to forego 
essential primary or preventative care for financial reasons. This 
legislation would alleviate that hardship for this small but vulnerable 
population of veterans.
Draft Bill, Veterans Integrated Mental Health Care Act of 2013
    The VFW does not support this legislation which would require VA to 
furnish non-VA mental health care to any eligible veteran who elects to 
receive such care at a non-VA facility that is able to meet certain 
care-coordination standards. The VFW strongly believes that veterans 
deserve access to timely and high quality mental health care that is 
fully integrated and responsive to their needs. However, VA must remain 
firmly in control of health care delivery. VA is currently moving 
forward with a major national initiative to revolutionize fee basis 
care, the Patient Centered Community Care (PCCC) program, which would 
establish contracts to provide a number of managed care services at 
non-VA facilities based upon individual need, including mental health 
services. The VFW believes that mandating new contracting requirements 
when VA is on the cusp of awarding PCCC contracts could create 
confusion within VA, halting or disrupting the progress of PCCC reform.
Draft Bill, Demanding Accountability for Veterans Act of 2013
    The VFW cannot support this legislation in its current form, which 
dictates specific disciplinary actions on any responsible manager 
following a failure by VA to properly respond to the recommendations of 
a covered report of the Inspector General (IG), as determined by IG. We 
understand and agree with its intent, but are concerned with the 
precedent set by placing IG in a personnel management role. Managers 
must be held responsible for failing to properly perform their duties, 
but VA must maintain direct control over the accountability of its 
employees.
    Mr. Chairman, this concludes my testimony.
 Information Required by Rule XI2(g)(4) of the House of Representatives
    Pursuant to Rule XI2(g)(4) of the House of Representatives, VFW has 
not received any federal grants in Fiscal Year 2013, nor has it 
received any federal grants in the two previous Fiscal Years.

                                 
                  VETSFIRST/UNITED SPINAL ASSOCIATION
    Chairman Benishek, Ranking Member Brownley, and other distinguished 
Members of the Subcommittee, thank you for the opportunity to submit 
written testimony regarding VetsFirst's views on the CHAMPVA Children's 
Protection Act of 2013 (H.R. 288) and H.R. 1284.
    VetsFirst, a program of United Spinal Association, represents the 
culmination of over 60 years of service to veterans and their families. 
We provide 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, we are not only 
a VA-recognized national veterans service organization, but also a 
leader in advocacy for all people with disabilities.
CHAMPVA Children's Protection Act of 2013 (H.R. 288)
    The Civilian Health and Medical Program of the Department of 
Veterans Affairs (CHAMPVA) is a comprehensive health care program for 
the spouses and dependent children of veterans who are permanently and 
totally disabled, died while on active duty, or died due to a service-
connected disability. For the families of these veterans, CHAMPVA 
provides critical physical and mental health care benefits. Children 
who are CHAMPVA beneficiaries typically lose coverage at age 18 unless 
they are full-time students, in which case they maintain benefits until 
age 23.
    The Affordable Care Act (ACA) allows a child to remain on a 
parent's health insurance until age 26. However, TRICARE and CHAMPVA 
child beneficiaries were not covered by this provision. The National 
Defense Authorization Act (NDAA) for FY 2011 brought TRICARE into 
alignment with the ACA provision by extending coverage to age 26 for 
TRICARE beneficiaries. CHAMPVA child beneficiaries, however, were not 
included in the NDAA provision.
    Thus, CHAMPVA child beneficiaries are prohibited from receiving a 
benefit similar to that provided to other adult children in our nation. 
H.R. 288 will correct this injustice by allowing child beneficiaries to 
continue to receive health care benefits under the CHAMPVA program 
until age 26. This legislation will ensure parity for the children of 
permanently and totally disabled veterans and those who died in service 
to our nation.
    VetsFirst supports the CHAMPVA Children's Protection Act of 2013 
because it will ensure that the children of men and women who have 
greatly sacrificed for our nation will be able to finish educational 
opportunities and begin careers without having to forgo access to 
critical health care benefits. We urge swift passage of this important 
legislation.
    To provide coverage under VA's beneficiary travel program for the 
travel of certain disabled veterans for certain special disabilities 
rehabilitation (H.R. 1284)
    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 can be very burdensome. In addition, few of 
these services are available locally, particularly to veterans who live 
in rural areas.
    All disabled veterans who need to travel to receive in-patient care 
at special disabilities rehabilitation programs should be eligible to 
receive travel benefits from VA. 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.
    VetsFirst supports H.R. 1284 because it will improve access to 
rehabilitation services for all veterans who have spinal cord injuries 
or disorders, vision impairments, or double or multiple amputations.
    Thank you for the opportunity to submit written testimony 
concerning VetsFirst's views on H.R. 288 and H.R. 1284. We appreciate 
your leadership on behalf of our nation's disabled veterans and their 
families.
    Information Required by Clause 2(g) of Rule XI of the House of 
                            Representatives
    Written testimony submitted by Heather L. Ansley, Vice President of 
Veterans Policy; VetsFirst, a program of United Spinal Association; 
1660 L Street, NW, Suite 504; Washington, D.C. 20036. (202) 556-2076, 
ext. 7702.
    This testimony is being submitted on behalf of VetsFirst, a program 
of United Spinal Association.
    In fiscal year 2012, United Spinal Association served as a 
subcontractor to Easter Seals for an amount not to exceed $5000 through 
funding Easter Seals received from the U.S. Department of 
Transportation. This is the only federal contract or grant, other than 
the routine use of office space and associated resources in VA Regional 
Offices for Veterans Service Officers that United Spinal Association 
has received in the current or previous two fiscal years.

                                 
                        WOUNDED WARRIOR PROJECT
    Chairman Benishek, Ranking Member Brownley, and Members of the 
Subcommittee:
    Thank you for inviting Wounded Warrior Project (WWP) to provide 
views on pending health-related legislation. Several of the measures 
under consideration address issues of keen importance to wounded 
warriors and their family members.
                           Mental Health Care
    Provision of timely, effective mental health care for warriors is a 
matter of the greatest concern to Wounded Warrior Project. As such, we 
appreciate the effort in the draft Veterans Integrated Mental Health 
Care of 2013 to improve access to such care for those with service-
incurred mental health conditions.
    The draft bill proposes to give veterans who seek treatment for a 
service-incurred mental health condition (or who have a total and 
permanent disability resulting from service-connected disability) a 
choice between VA care and care provided under contract with an entity 
that administers a provider-network. Under the draft bill, VA would be 
required to inform those veterans when, where and who would provide 
such needed VA treatment, and the veteran could choose to receive that 
care from VA or instead from a contract provider. The measure would 
permit VA to award a contract only if an entity demonstrates that it 
can meet certain capabilities, including the ability to provide 
nonurgent mental health care with access to a care-coordinator; the 
ability to ensure an acceptable no-show rate and to exchange relevant 
clinical information with VA within 30 days after an appointment; and 
the ability to meet performance metrics regarding the quality of care 
provided, patient satisfaction, timely access, and cost-effectiveness.
    We welcome consideration of the principle of offering a warrior 
choice regarding treatment for a service-connected condition. At the 
same time, the draft bill raises a number of questions. It is not 
clear, for example, how informed a veteran's choice would be under the 
proposed framework and whether the treatment modalities available to 
the veteran through a contract provider would be as extensive as they 
might from VA. More specifically, the bill does not make clear whether 
the veteran would have the same information regarding the contract-care 
option as regarding the VA option (who would provide treatment and 
when). And would the veteran have access to the same treatment 
modalities under the contractor option as through VA? We infer not. For 
example, the contractor would be responsible for providing ``nonurgent 
mental health care or medical services.'' That suggests that a veteran 
whose care needs become urgent or critical would be referred back to 
the care-option he or she had earlier rejected, the VA. The reference 
to ``or medical services'' (in the phrase ``the term'covered mental 
health care' means nonurgent mental health care or medical services . . 
. '') raises the question, what kind of providers could furnish the 
required services and whether those services could simply be provided 
by primary care physicians rather than behavioral health specialists. 
The measure also raises the question, what would be the scope of care 
provided under contract arrangements? Would psychotherapy be routinely 
available, or would the first-choice (or only) treatment modality be 
limited to prescribing and managing medications? Real choice surely 
calls for a patient to have full information regarding the options, 
particularly if they do not involve an ``apples to apples'' choice. 
There are certain reasons why a veteran might elect to receive 
treatment from a contract provider, but a veteran would likely also 
want to understand the implications of first electing the contractor 
option and subsequently seeking to opt-out. Could that veteran return 
to the VA under those circumstances? And, if so, would VA still be 
responsible for payment for a full course of treatment?
    The principle of choice is an important one, but the goal, in our 
view, should not be simply to afford a choice, but to provide timely, 
effective mental health care. The draft bill reflects concern for 
issues of quality, but its language sets no specific expectation as to 
patient outcomes or effectiveness of treatment. Yet a relatively recent 
study by the Institute of Medicine on the quality of behavioral health 
care in this country stated that ``despite what is known about 
effective care for M/SU [mental health and substance use] conditions, 
numerous studies have documented a discrepancy between M/SU care that 
is known to be effective and care that is actually delivered. \1\
---------------------------------------------------------------------------
    \1\ Institute of Medicine Committee on Crossing the Quality Chasm: 
Adaptation to Mental Health and Addictive Disorders, ``Improving the 
Quality and Health Care for Mental and Substance-Use Conditions,'' (The 
National Academies Press 2006), 5.
---------------------------------------------------------------------------
    At its most basic, for care to be effective, there must be a 
relationship of trust between provider and patient. \2\ We know from 
many of our warriors, however, that one critical element of that trust, 
particularly as it relates to a highly sensitive subject like mental 
health, is the provider's understanding of the warrior experience and 
ability to relate, accordingly. Comments we have received from our 
field staff regarding warriors' experience with mental health care are 
illuminating in that regard. The following are typical:
---------------------------------------------------------------------------
    \2\ Lambert, Michael J.; Barley, Dean E. ``Research summary on the 
therapeutic relationship and psychotherapy outcome,'' Psychotherapy: 
Theory, Research, Practice, Training, Vol 38(4), 2001, 357-361.

    ``The biggest [warrior] complaint seems to be . . . [that providers 
have] no military background and they don't `get it' or understand what 
I am going through and struggling with . . . .[It's] hard to connect 
---------------------------------------------------------------------------
with someone when they haven't been in your shoes.''

    ``I ask warriors how they are coming along in their recovery; in 
more cases than not, warriors do not want to talk about their war time 
experiences with non-vets.''1A\3\
---------------------------------------------------------------------------
    \3\ Conference call with WWP alumni managers; May 1, 2013.

    ``Cultural competence'' is an important component of building a 
therapeutic alliance, but the draft bill does not specify that the 
contract entity meet any cultural training requirements. So there is 
little reason to believe that contract providers under the proposed 
framework would have the training and experience to address military 
and veteran-specific ``cultural'' issues.
    These questions and concerns cited above argue, in our view, not 
only for addressing the kinds of issues we have raised, but for 
proceeding cautiously. Rather than directing VA to offer contract care 
to all veterans who need treatment for service-connected mental health 
conditions (as the draft bill appears to do), we urge consideration of 
developing a limited pilot program. Such a pilot could test the 
underlying principle of providing service-connected veterans choice. 
But that choice should not only be fully informed, but should optimally 
offer the veteran a similar range of covered services under a framework 
that provides reasonable assurance that they would receive both timely 
and effective mental health care.
                               Urotrauma
    H.R. 984 would direct the Secretary of Defense, subject to the 
availability of funds for such purpose, to establish a ``Task Force on 
Urotrauma'' to conduct a broad study of that subject that includes 
analyzing data on incidence, morbidity and mortality; social and 
economic costs and effects; evaluation of pertinent capabilities and 
programs; and analyses, including an analysis of mechanisms to allow 
for enhanced reproductive services for servicemembers.
    We note that several of these topics were the subject of relatively 
recent study by an Army task force; \4\ as such, we are not clear on 
the rationale for establishing the proposed entity. Since that Army 
task force completed its report, DoD has developed new policy relating 
to advanced reproductive services, and broad legislation has been 
introduced in the House that would authorize VA to provide reproductive 
services to assist in helping severely wounded veterans who have 
service-incurred infertility conditions to have children. \5\
---------------------------------------------------------------------------
    \4\ Dismounted Complex Injury Task Force, ``Dismounted Complex 
Blast Injury: Report of the Army Dismounted Complex Injury Task 
Force,'' I (June 18, 2011) available at: http://
www.armymedicine.army.mil/reports/
DCBI%20Task%20Force%20Report%20%28Redacted%20Final%29.pdf.
    \5\ See H.R. 958, accessed at http://thomas.loc.gov/cgi-bin/query/
z?c113:H.R.958:
---------------------------------------------------------------------------
    In WWP's view, the experience of our operations in Iraq and 
Afghanistan has heightened the importance of grappling with the issue 
of reproductive services. Blasts from widespread use of improvised 
explosive devices (IED's) in Iraq and Afghanistan, particularly in the 
case of warriors on foot patrols, have increasingly resulted not only 
in traumatic amputations of at least one leg, but also in pelvic, 
abdominal or urogenital wounds. \6\ While not widely recognized, the 
number and severity of genitourinary injuries has increased over the 
course of the war, with more than 12% of all admissions in 2010 
involving associated genitourinary injuries. \7\ With that increase has 
come not only DoD acknowledgement of the impact of genitourinary 
injuries on warriors' psychological and reproductive health, \8\ but 
recent adoption of a policy authorizing and providing implementation 
guidance on assisted reproductive services for severely or seriously 
injured active duty servicemembers. \9\ DoD's policy, set forth in 
recent revisions to its TRICARE Operations Manual, applies to 
servicemembers of either gender who have lost the natural ability to 
procreate as a result of neurological, anatomical or physiological 
injury. The policy covers assistive reproductive technologies 
(including sperm and egg retrieval, artificial insemination and in 
vitro fertilization) to help reduce the disabling effects of the 
servicemember's condition to permit procreation with the 
servicemember's spouse. \10\
---------------------------------------------------------------------------
    \6\ Dismounted Complex Injury Task Force, supra.
    \7\ Id. at 16.
    \8\ Id.
    \9\ Asst. Secretary of Defense (Health Affairs) & Director of 
TRICARE Management Activity, Memorandum on Policy for Assisted 
Reproductive Services for the Benefit of Seriously or Seriously Ill/
Injured (Category II or III) Active Duty Service Members (April 3, 
2012) available at: http://www.veterans.senate.gov/upload/DOD--
reproductive--letter.pdf.
    \10\ Dept. of Defense, TRICARE Operations Manual 6010.56-M, Chapter 
17, Section 3, para. 2.6 (Sept. 19, 2012).
---------------------------------------------------------------------------
    For veterans, however, VA coverage is very limited in scope. The 
regulation describing the scope of VA's ``medical benefits package'' 
states explicitly that in vitro fertilization is excluded \11\ and that 
``[c]are will be provided only . . . [as] needed to promote, preserve, 
or restore the health of the individual . . . .'' \12\ Consistent with 
that limiting language, the VA's benefits handbook advises women 
veterans with regard to health coverage that `` . . . infertility 
evaluations and limited treatments are also available.'' \13\
---------------------------------------------------------------------------
    \11\ 38 C.F.R. Sec.  17(c )(2).
    \12\ 38 C.F.R. Sec.  17(b) (Emphasis added).
    \13\ Dept.of Veterans Affairs, ``Federal Benefits for Veterans, 
Dependents and Survivors'' available at http://www.va.gov/opa/
publications/benefits--book/benefits--chap01.asp
---------------------------------------------------------------------------
    In a departure from longstanding policy, VA stated last year that 
``[t]he provision of Assisted Reproductive Services (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.'' \14\ In its 
statement, VA also expressed support in principle for legislation 
authorizing VA to provide assistive reproductive services to help a 
severely wounded veteran with an infertility condition incurred in 
service and that veteran's spouse or partner have children. It 
conditioned that support, however, on ``assurance of the additional 
resources that would be required.'' \15\
---------------------------------------------------------------------------
    \14\ Health and Benefits Legislation Hearing Before the S. Comm. on 
Veterans Affairs, 112th Cong. (2012).
    \15\ Id.
---------------------------------------------------------------------------
    Certainly the administration of a VA program that would assist 
wounded warriors and their spouses to conceive children would require 
careful attention to ethical \16\ and regulatory \17\ issues associated 
with providing advanced reproductive services. Economic considerations 
certainly can arise in that regard. \18\ But while these advanced 
interventions can be quite costly, cost should not be a barrier as it 
relates to this country's obligation to young warriors who sustained 
horrific battlefield injuries that impair their ability to father or 
bear children.
---------------------------------------------------------------------------
    \16\ See Meena Lal, ``The Role of the Federal Government in 
Assisted Reproductive Technologies, 13 Santa Clara Computer and High 
Tech. L. J. 517 (1997).
    \17\ See Michelle Goodwin ``A Few Thoughts on Assisted Reproductive 
Technology,'' 27 L. & Ineq. 465 (2009). Among these regulatory issues, 
VA would have to address the need for physicians providing advanced 
reproductive technologies to fully inform couples as to their risks, 
including greater health risks in children born through these 
technologies. See N.Y. State Dept. of Health Task Force on Life and the 
Law, Assisted Reproductive Technologies: Analysis and Recommendations 
for Public Policy, available at: http://www.health.ny.gov/regulations/
task--force/reports--publications/execsum.htm
    \18\ Id.
---------------------------------------------------------------------------
    WWP urges the Subcommittee to take up legislation to enable couples 
unable to conceive because of the warrior's severe service-incurred 
injury or illness to receive fertility counseling and treatment, 
including assisted reproductive services, subject to reasonable 
regulations.
                                CHAMPVA
    Under current law CHAMPVA coverage expires at age 18 except in the 
case of a full-time student when it may be extended until age 23 if the 
student incurs a disabling illness or injury while pursuing a course of 
study). H.R. 288 would extend that student coverage until age 26. We 
support this legislation, which brings CHAMPVA into closer alignment 
with the Affordable Care Act, which allows children to remain on a 
parent's health plan until age 26.
                           Timeliness of Care
    H.R. 241 would direct VA to establish a 30-day timeliness standard 
with respect to the numbers of days between the date on which a veteran 
seeks care until the date on which a visit with an appropriate health 
care provider is completed. The measure would also require the 
Department to provide a detailed semi-annual report to the Veterans 
Affairs Committees of Congress with respect to the waiting times 
veterans experience.
    We applaud the focus on timeliness of care, but would caution 
against establishing in law any single measure of timeliness. Thirty-
days would be an unacceptably long wait in the event of a medical or 
psychiatric emergency. Yet it might be an unnecessarily strict standard 
with respect to VA's performing a truly elective procedure or providing 
health-promotion services, for example.
    It is also important that there be rigor and integrity with respect 
to any VA methodology for reporting and determining timeliness. The 
Subcommittee would surely find instructive the experience associated 
with VA's establishment of timeliness standards for mental health care 
and the Inspector General's finding wide disparity between VA-reported 
timeliness-performance data and its own data analysis. \19\
---------------------------------------------------------------------------
    \19\ VA Inspector General, ``Review of Veterans Access to Mental 
Health Care'' (April 23, 2012) accessed at http://www.va.gov/oig/pubs/
VAOIG-12-00900-168.pdf
---------------------------------------------------------------------------
                           Beneficiary Travel
    H.R. 1284 would amend current law governing VA's ``beneficiary 
travel'' program to cover certain severely disabled veterans' travel in 
connection with care provided on an inpatient (or lodger-basis) through 
a special VA disability-rehabilitation program.
    WWP works extensively across the country with wounded warriors, 
specifically veterans and servicemembers who were injured, wounded or 
developed an illness or disorder of any kind in line of duty during 
military service on or after September 11, 2001. Our warriors certainly 
encounter barriers to receiving needed VA services - barriers that 
include sometimes-rigid VA appointment-scheduling, long-distance 
travel, and instances of inflexible program requirements. We are not 
aware, however, of problems that warriors have encountered regarding 
receipt of beneficiary travel generally or with respect to travel to 
special disability-rehabilitation programs. As such, we have no 
position on H.R. 1284.
    Thank you for your consideration of WWP's views on these measures.

                                 
                        Questions For The Record
    July 11, 2013

    The Honorable Dan Benishek, Chairman
    Subcommittee on Health
    House Committee on Veterans' Affairs
    335 Cannon House Office Building
    Washington, DC 20515

    Dear Chairman Benishek:

    Thank you for giving PVA the opportunity to testify during the May 
21, 2013 hearing on pending health care legislation being reviewed by 
the Subcommittee. As requested, enclosed you will find the responses to 
your follow-up questions from that hearing. Paralyzed Veterans of 
America thanks the Subcommittee's for their attention to these 
important issues. Please do not hesitate to contact me with any 
questions that you may have regarding the responses, or involving 
veterans' health care issues.

    Again, thank you and we look forward to working with you and the 
Subcommittee on these issues.

    Sincerely,

    Douglas K. Vollmer
    Associate Executive Director, Government Relations

                                 
    Questions for the Record from the Honorable Dan Benishek M.D., 
                Subcommittee Chairman and PVA Responses
Draft Legislation, ``The Veterans Integrated Mental Health Care Act of 
        2013''
    1. In a statement for the record, the Wounded Warrior Project urged 
consideration of a limited pilot program to test the underlying 
principles of the ``Veterans Integrated Mental Health Care Act.''

    -Would you be supportive of such an arrangement? Please explain?

    PVA believes that timely and quality care, as well as care 
coordination are the top priorities when providing veterans with mental 
health care services. During the hearing on May 21, 2013, PVA's written 
statement to the Subcommittee stated that the Department of Veterans 
Affairs (VA) is in the process of transforming its national non-VA care 
program in an effort to improve coordination services with non-VA 
providers, which includes mental health services. As a result of such 
efforts, it is our position that these initiatives should be further 
developed before additional resources are put into another program for 
non-VA care-coordination. However, we would not be opposed to 
incorporating specific provisions from this legislation into one of the 
mental health pilots that the VA is currently developing under the 
President's Executive Order #13625--``Improving Access to Mental Health 
Services for Veterans, Service Members, and Military Families.'' If 
such action is possible, we believe that these mental health pilots 
serve as a good starting point to test the underlying principles of the 
``Veterans Integrated Mental Health Care Act.''
    Additionally, we urge the Subcommittee and the VA to consider 
incorporating some of the underlying principles from this legislation 
into its non-VA care coordination program. As the VA is currently 
developing the Patient Centered Care Coordination (PCCC) initiative, 
which will manage non-VA mental health services, aspects of this bill 
may help improve coordination of such care.
H.R. 241, the Veterans Timely Access to Health Care Act
    1. Given Concerns raised during the hearing regarding establishing 
a single Department-wide timeliness measure in law, please provide your 
views as to how to facilitate timeliness standards that take into 
account the need for separate standards depending on the type of care 
that is being provided - i.e. primary, specialty, and mental health 
care services for both new and established veteran patients.

    The establishment of timeliness standards for primary, specialty, 
and mental health care services must include, to some degree, clinical 
expertise and input. Therefore, PVA first recommends that the 
Subcommittee and the VA work together to better develop timeliness 
standards for VA services. Second, we suggest defining an 
``acceptable'' time frame during which a veteran should be able to 
schedule an appointment and have a visit with a medical professional. 
As discussed in previous hearings held by the Subcommittee, the VA 
defines access standards in many different ways, which leads to patient 
confusion and can also be misleading when evaluating timely access, 
particularly in the area of mental health.
    Lastly, when reviewing H.R. 241, the Subcommittee may want to 
consider requiring the VA to make a distinction between the types of 
appointments being scheduled. The types of appointments can be divided 
into categories that include first time appointments, follow-up visits, 
and emergency visits. Each category may or may not have different 
timeliness standards. Additionally, as the VA has multiple ways to 
provide care, timeliness standards should take into consideration how 
and where the care will be provided. Methods to provide care include 
telehealth via the telephone and using the computer, or peer 
counseling.
H.R. 1284, to amend title 38, United States Code, to provide for 
        coverage under the beneficiary travel program of the Department 
        of Veterans Affairs (VA) of certain disabled veterans for 
        travel for certain special disabilities rehabilitation, and for 
        other purposes
    1. In their written testimony, VA states that, `` . . . VA feels 
that the legislation as written would provide disparate travel 
eligibility to a limited group of veterans.''

    -Do you agree with the Department's assessment?

    PVA does not fully agree with VA's statement that the H.R. 1284 as 
written would provide disparate travel eligibility to a limited group 
of veterans. Ultimately, PVA advocates the VA providing travel 
reimbursement to all catastrophically disabled veterans [as defined by 
the Secretary] whose travel is in connection with receipt of VA medical 
services. However, we believe that providing the veteran populations 
described in H.R. 1284 with VA travel reimbursement is a good first 
step to eliminating the burden of transportation costs as a barrier to 
care for severely disabled veterans, and improving access to VA care.
    H.R. 1284 provides travel benefits to specific groups of veterans 
that require chronic, expert care from designated VA specialized 
systems of care, the Spinal Cord Injury/Disorder System of Care, the 
Amputation System of Care, and the Blind Rehabilitation Service. These 
groups of veterans can only receive their primary health care services 
from a limited number of health care centers that are sparsely located 
across the United States. Receiving services from primary care 
providers that are not a part of their VA system of care, or from 
providers who do not have the specialized expertise will jeopardize the 
health and well being of these veterans. For instance, SCI/D annual 
exams average two to three days because of the comprehensive testing 
that takes place, such as image testing and physical examinations. 
Often, our members drive to such visits and return home at the end of 
the first day, and return each day until the exams and all required 
procedures are complete. Driving to these appointments can be very 
costly to the veteran when paying for gas of trips that can range up to 
6 hours or more round trip. PVA members choose to drive because they 
need accessible transportation and lodging that is safe and 
comfortable. Driving is also a much cheaper option than admitting them 
into an SCI/D unit for two to three days, and allows them to maintain 
their personal independence.

    2. In a statement for the record, the Wounded Warrior Project 
states that, ``[w]e are not aware . . . of problems that warriors have 
encountered regarding receipt of beneficiary travel generally or with 
respect to travel to special disability-rehabilitation programs.''

    -Please respond to that statement.

    At this time, PVA does not purport to have knowledge of problems 
that service-connected veterans have encountered regarding receipt of 
beneficiary travel reimbursements. However, we do have PVA members who 
are non-service connected, catastrophically disabled veterans, who are 
not eligible for VA beneficiary travel benefits and have difficulty 
affording the costs associated with traveling for medical visits. It is 
for this reason, we strongly support H.R. 1284.
    3. Do you see other avenues - such as through non-profit entities 
or community groups - to provide transport to those certain non-service 
connected individuals - that cannot defray the cost of air-fare and 
other travel needs themselves?
    PVA recognizes that other avenues of transportation are available, 
and very much necessary. However, it is our position that many veterans 
who have a catastrophic injury or disability, particularly, the three 
populations identified in H.R. 1284, require adaptive equipment and 
automobiles when traveling. It is not always the case that the 
transportation provided by non-profit entities or community groups meet 
the accessibility needs of catastrophically disabled veterans. Further, 
arranging for accessible transportation can be very arduous and time 
consuming, and as a result, it is common for disabled veterans who are 
not able to drive themselves to medical appointments to delay health 
care until transportation can be arranged, or forgo medical attention 
completely. Many PVA members prefer to use personal transportation 
options for reasons involving their comfort and safety; H.R. 1284 will 
allow severely disabled veterans this option.

                                 
              Inquiry from: Representative Julia Brownley
Context of Inquiry:
    During the May 21, 2013 HVAC Health Subcommittee Legislative 
Hearing, Representative Brownley requested updated CHAMPVA data. We 
last sent her data on the program in 2010.
Response:
    Analysis of the Child Population in the CHAMPVA Program Enrollment 
File.
    The current program-wide eligible count for CHAMPVA is 378,277 as 
of 30 April 2013. This includes all persons that are eligible to file a 
claim for healthcare services received during FY13. About 8,942 of 
these individuals have already been declared ineligible for further 
benefits this year, due mainly to divorce, death, or children that have 
lost eligibility due to reaching one of the age restrictions.
    The remainder of the analysis will deal with the child population, 
and will be based on data that is current as of 5/1/2013. All age 
groupings presented below are as of 5/1/2013 and based on the 
individual's DOB in the enrollment file.
    The number of covered children and students currently eligible for 
benefits on 5/1/2013 was 52,975. The current population is slightly 
smaller than the population review in FY 2009 that we were asked to 
update (55,037). These children can be broken down into the following 
groups


----------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------
Birth -18th Birthday...................................                                    Children      45,573
----------------------------------------------------------------------------------------------------------------
Age 18 - 23rd Birthday.................................                            Students               7,362
----------------------------------------------------------------------------------------------------------------
23 - 25th Birthday.....................................                    Extended Benefit                  40
----------------------------------------------------------------------------------------------------------------

    CHAMPVA coverage can be extended when a covered child over age 18 
suffers and injury, accident or other medical condition that makes them 
unable to maintain their full-time student status. By regulation, these 
individuals continue to receive coverage for up to two years from the 
date of the event.
    Based on the current enrollment file, there are 51,599 children 
that have lost eligibility under the current CHAMPVA regulations, but 
are still under the age of 26. The ``Ineligible'' counts provided on 
the table and chart below only include children that have lost coverage 
specifically due to age considerations. Other losses of eligibility, 
such as marriage, death, or step-children that have left the qualifying 
sponsor's household are not included in the ineligible child 
population. This ineligible group can be identified by name, SSN and 
last known address/phone number in our enrollment file.
    Additionally, there is a cohort of children that have never applied 
for benefits because their parent became a CHAMPVA eligible sponsor 
after the child was no longer eligible due to current age restrictions. 
We do not have any way to specifically count these individuals, but we 
are providing a best estimate of this group under the category of 
``Unregistered''.


--------------------------------------------------------------------------------------------------------------------------------------------------------
                    AGE                       TOTAL       0-17        18         19         20         21         22         23         24         25
--------------------------------------------------------------------------------------------------------------------------------------------------------
ELIGIBLE..................................     52,975     45,573      2,648      1,571      1,260      1,070        813         24         12          4
PENDING...................................        163        115         12          9          9          8          6          3          1
INELIGIBLE................................     51,599          0      3,445      5,033      6,023      6,583      7,077      8,082      7,675      7,681
UNREGISTERED*.............................      2,699          0                    92          0        231        365        387      1,021        603
--------------------------------------------------------------------------------------------------------------------------------------------------------

    The following chart provides a graphical representation of the data 
in the table.


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]





                                 
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