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




LEGISLATIVE HEARING ON `DRAFT LEGISLATION, THE LONG-TERM CARE VETERANS 
        CHOICE ACT'; H.R. 1443; H.R. 1612; H.R. 1702; H.R. 2065

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

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

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

                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                               __________

                         TUESDAY, JULY 9, 2013

                               __________

                           Serial No. 113-28

                               __________

       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

                               __________

                              July 9, 2013

                                                                   Page

Legislative Hearing On `Draft Legislation, The Long-Term Care 
  Veterans Choice Act'; H.R. 1443; H.R. 1612; H.R. 1702; H.R. 
  2065...........................................................     1

                           OPENING STATEMENTS

Hon. Dan Benishek, Chairman, Subcommittee on Health..............     1
    Prepared Statement of Hon. Benishek..........................    32
Hon. Julia Brownley, Ranking Minority Member, Subcommittee on 
  Health.........................................................     2
    Prepared Statement of Hon. Brownley..........................    32
Hon. Jeff Miller, Chairman, Full Committee on Veterans' Affairs, 
  U.S. House of Representatives..................................    18
    Prepared Statement of Chairman Miller........................    33
Hon. Jackie Walorski, Member, Committee on Veterans' Affairs, 
  U.S. House of Representatives, Prepared Statement only.........    34

                               WITNESSES

Hon. Mike Rogers, U.S. House of Representatives, 3rd District, 
  Alabama........................................................     3
    Prepared Statement of Hon. Rogers............................    34
Hon. David McKinley, U.S. House of Representatives, 1st District, 
  West Virginia..................................................     4
    Prepared Statement of Hon. McKinley..........................    34
Jacob Gadd, Deputy Director for Health Care, Veterans Affairs and 
  Rehabilitation Commission, The American Legion.................     9
    Prepared Statement of Mr. Gadd...............................    35
Susan E. Shore, Ph.D., Chair, Scientific Advisory Committee, 
  American Tinnitus Association..................................    11
    Prepared Statement of Ms. Shore..............................    38
Adrian Atizado, Assistant National Legislative Director, Disabled 
  American Veterans..............................................    12
    Prepared Statement of Mr. Adrian Atizado.....................    42
Robert Drexler, Member, Board of Directors, International Code 
  Council........................................................    14
    Prepared Statement of Mr. Drexler............................    45
Raymond C. Kelley, Director, National Legislative Service, 
  Veterans of Foreign Wars.......................................    16
    Prepared Statement of Mr. Kelley.............................    46
Robert L. Jesse, M.D., Ph.D., Principal Deputy Under Secretary 
  for Health, Veterans Health Administration, U.S. Department of 
  Veterans Affairs...............................................    26
    Prepared Statement of Dr. Jesse..............................    48
    Accompanied by:

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

                       STATEMENTS FOR THE RECORD

Hon. Ron Barber, 2nd District, Arizona, U.S. House of 
  Representatives................................................    51
National Association of State Fire Marshals......................    52
National Coalition for Homeless Veterans.........................    53
Paralyzed Veterans of America....................................    55
Vietnam Veterans of America......................................    57
Wounded Warrior Project..........................................    58

 
LEGISLATIVE HEARING ON `DRAFT LEGISLATION, THE LONG-TERM CARE VETERANS 
        CHOICE ACT'; H.R. 1443; H.R. 1612; H.R. 1702; H.R. 2065

                         Tuesday, July 9, 2013

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 10:08 a.m., in 
Room 334, Cannon House Office Building, Hon. Dan Benishek 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Benishek, Huelskamp, Brownley, 
Ruiz, 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 this morning to discuss pieces 
of legislation concerning health care and services available to 
the Department of Veterans Affairs' VA health care system.
    The five bills that we will discuss today are draft 
legislation, the Long-Term Care Veterans Choice Act; H.R. 1443, 
the Tinnitus Research and Treatment Act of 2013; H.R. 1612, to 
direct the secretary of Veterans Affairs to convey a parcel of 
land in Tuskegee, Alabama, to Tuskegee University; H.R. 1702, 
the Veterans Transportation Service Act; and H.R. 2065, the 
Safe Housing for Homeless Veterans Act.
    From ensuring the safety of homeless veterans residing in 
VA homeless grant and per diem facilities to ensuring that 
veterans eligible for VA-paid nursing home care are able to 
receive care in certified medical foster homes should they 
choose, these five bills address a number of critical issues 
facing today's veterans and all of us charged with caring for 
them.
    I am eager to discuss each of these proposals in depth to 
ensure a thorough understanding of their purpose, intended 
benefits, and unintended consequences.
    I am grateful to my colleagues who sponsored these bills 
and to our witnesses for being here to discuss them with us. I 
look forward to our conversation.
    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 we do have five important bills here today and look 
forward to the discussion. And to allow maximum time for that 
discussion, I will limit my opening remarks primarily to H.R. 
1443 and H.R. 1702.
    H.R. 1443, the Tinnitus Research and Treatment Act of 2013, 
as offered by Ranking Member Michaud, according to the VA, 
tinnitus is the number one service-connected disability for 
veterans from all periods of service affecting over 840,000 
veterans.
    Since 2005, the number of veterans receiving service-
connected disability for tinnitus has increased by at least 15 
percent each year and the VA has been paying out over $1.2 
billion annually to veterans for tinnitus disability 
compensation.
    At the current rate of increase, service-connected 
disability payments to veterans for tinnitus will cost $2.26 
billion annually by 2014. Nevertheless only about $10 million 
is dedicated to researching tinnitus in the public and private 
sectors.
    H.R. 1443 will allow for appropriate research time and 
resources by directing the VA to recognize tinnitus as a 
mandatory condition for research and treatment by the VA 
auditory centers for excellence.
    This will make certain that research is conducted at the VA 
facilities on the prevention and treatment of this condition 
and that the VA cooperates with the Department of Defense's 
hearing center of excellence to further research on tinnitus.
    H.R. 1443 would ensure that we remain on the cutting edge 
for research and treatment of this issue facing veterans of all 
ages.
    Next, H.R. 1702, introduced by Mr. Barber of Arizona, would 
permanently authorize the VA to operate the Veterans 
Transportation Service which provides transportation for 
individuals to and from the VA medical facilities in connection 
with vocational rehabilitation, counseling, examination, 
treatment, or care.
    VTS was launched in 2010 and the VA's current authority to 
operate the program is set to expire in January of next year. I 
did want to emphasize the critical need for this legislation in 
helping to increase access to care for those who would 
otherwise face challenges in getting to and from their 
appointments at the VA.
    I also wanted to highlight that VA has estimated VTS to 
save up to $19.2 million in fiscal year 2014 and $102.7 million 
over five years because it is less expensive for the VA to hire 
drivers through VTS than to contract with ambulance services or 
to provide mileage reimbursement. So this is simply a common-
sense initiative.
    Thank you, Mr. Chairman, for including these bills in the 
agenda and I look forward to hearing the views of our witnesses 
on the legislation before us today. And I yield back my time.

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

    Mr. Benishek. Thank you.
    The Chairman of the Full Committee, Jeff Miller from 
Florida's 1st Congressional District, will be joining us later 
this morning to discuss his draft legislation, the Long-Term 
Care Veterans Choice Act. I will yield to him when he arrives.
    In the meantime, it is an honor to be joined by my friends 
and colleagues, Mike Rogers, Representative from Alabama's 3rd 
Congressional District, and David McKinley, Representative from 
West Virginia's 1st Congressional District.
    Thank you for your leadership on behalf of our veterans and 
for being with us this morning to discuss your proposals. It is 
an honor and pleasure to have you here this morning.
    I would like to mention for the record that Mr. Barber will 
not be with us today due to the tragic circumstances that have 
taken place in Arizona and our thoughts and prayers are with 
the families of the first responders there who have perished. 
Their loved ones are true heroes and their sacrifice will never 
be forgotten.
    Mike, we will begin with you. Please proceed with your 
testimony. You have five minutes.

 STATEMENTS OF HON. MIKE ROGERS, A REPRESENTATIVE IN CONGRESS 
       FROM THE STATE OF ALABAMA; HON. DAVID MCKINLEY, A 
   REPRESENTATIVE IN CONGRESS FROM THE STATE OF WEST VIRGINIA

                 STATEMENT OF HON. MIKE ROGERS

    Mr. Rogers. Thank you, Mr. Chairman and Ranking Member 
Brownley.
    First I want to thank the Chairman and the staff for 
holding this hearing. I also want to thank the Full Committee 
Chairman, Jeff Miller, for his leadership on behalf of our 
Nation's veterans.
    Mr. Chairman, H.R. 1612 will benefit the Department of 
Veterans Affairs and the people of Tuskegee, Alabama.
    In 1922, the Board of Tuskegee University voted to donate 
300 acres of land to the Federal Government for a veterans' 
hospital. Since that time, Tuskegee VA Hospital and Tuskegee 
University have grown into integral parts of the community and 
serve important roles for our Nation.
    Now as the VA refocuses its mission to better serve our 
veterans, some of the donated land near the university's campus 
no longer fits the VA's needs.
    My bill would transfer back 64.5 acres of land at 2400 
Hospital Road back to Tuskegee University so that the land can 
better serve the community.
    This transfer also creates new opportunities for the VA by 
reducing substantial overhead and maintenance costs and 
providing cooperative authority to leverage the strengths of 
both institutions.
    This bill is supported by the VFW, the Vietnam Veterans of 
America. Both organizations know well Tuskegee's place in our 
history and I appreciate their continued support for the 
community.
    I thank you again, Mr. Chairman and Ranking Member 
Brownley. And with that, I will yield back.

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

    Mr. Benishek. Thank you very much.
    David.

                STATEMENT OF HON. DAVID MCKINLEY

    Mr. McKinley. Thank you, Mr. Chairman.
    Ranking Member Brownley and the rest of you on the 
Subcommittee, thank you for holding this hearing. I appreciate 
the opportunity to give these remarks about H.R. 2065 called 
the Safe Housing for Homeless Veterans Act.
    This is the same bill that we passed last year, slightly 
modified, but it is essentially the same bill for the homeless 
veterans.
    Currently, there are over 2,100 community-based homeless 
veteran service providers across the country and many other 
homeless assistance programs that have all demonstrated an 
effort to try to take care of our homeless veterans.
    I visited some of these shelters throughout West Virginia, 
not only in my district, but elsewhere.
    You have to understand my background. I come from the 
construction industry. I am one of two licensed engineers in 
Washington, in Congress. So it does not take me long to walk 
into a building and I can tell you whether or not that building 
meets code.
    And when I walked into some of these shelters, I was 
appalled with what we have done to our veterans. They have been 
in harm's way and they come back and their lives are challenged 
in some of these facilities.
    There is no current law. There is a policy within the VA to 
comply with building codes. Think about that. It is a policy, 
not a requirement. It is a policy. I think this is an omission 
governing our veterans' homeless program funds.
    H.R. 2065 would require that any organization that seeks 
funding from VA for services to homeless veterans have 
documentation that their building meets or exceeds building 
code. Not a policy. It shall. These men and women sacrificed 
for our country, they must have a safe home.
    This bill makes it easier for facilities to be certified as 
we open up these requirements beyond just the life safety code, 
which is 101, NFPA-101, to international building code and the 
fire codes and other versions of these codes.
    Essentially what the local jurisdiction has adopted, work 
with them, but make it a requirement, not a policy.
    Furthermore, the legislation would require adding a section 
to VA annual report to Congress that would report the number of 
grant recipients or eligible entities who have submitted a 
certification, that their facility will meet all building 
codes.
    I understand there is some concern over the undue burden 
for these facilities, but as you will see in the questions, I 
will be able to expound a little bit further about that, that 
is not quite accurate. When you travel, do your research in 
other facilities around the country, annual inspections are 
expected and demanded. And it is not an undue burden.
    In West Virginia, it is at no cost to the facility provider 
to have an inspection done to see that you are in compliance.
    I am pleased. I want you to know that we have already begun 
our discussions with those individuals that may have some 
concerns with this, particularly the VA and others, that may 
have a concern that we are undue burden.
    Quite frankly, Mr. Chairman, I am more interested in the 
veterans than I am about bureaucracy. If we are going to put 
these men and women in harm's way, I want to take care of the 
problem. And if it costs us $100 a year to have an inspection, 
then that is the least of my concerns.
    These men and women deserve to have a focus for them so 
that when they come home and they have, for whatever the 
circumstances are that they have to live in a homeless shelter, 
they should feel comfortable that they are going to wake up in 
the morning and there is not going to be a catastrophe wrapping 
around them.
    So with that, I will yield back my time and hope that we 
have an opportunity to have further discussion and I hope you 
will be able to support this effort to take care of our 
homeless veterans. Thanks you.

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

    Mr. Benishek. Thank you, Mr. McKinley.
    I will now yield to Ms. Brownley who will provide testimony 
on H.R. 1443. No?
    Ms. Brownley. No.
    Mr. Benishek. Well, I think that I will proceed with the 
questions. And I will start out.
    Mr. Rogers, what is the key benefit for this piece of 
legislation?
    Mr. Rogers. Well, it is twofold. The university needs the 
land back for its expansion, but more importantly the VA does 
not need it and it has just been a maintenance burden for them 
financially.
    There is a large part of their campus that has not been 
used for years. It is deteriorating. They are going to have to 
spend money to either bring those buildings back or at least 
make them safe or tear them down. And they do not really want 
to do either.
    Mr. Benishek. So there are some unused buildings there?
    Mr. Rogers. That is exactly what it is, as well as land.
    Mr. Benishek. Does the university have plans to do 
something right away with the land?
    Mr. Rogers. Not right away, but they would like to use it 
for long-term plans.
    Mr. Benishek. All right. Thank you.
    Mr. McKinley, I appreciate your continued advocacy on this 
issue and I completely agree with the need for safe shelters.
    Can you comment on the scope of the problem and tell me 
what you see as the lack of VA oversight?
    Mr. McKinley. Thank you.
    I do not want to speak necessarily for the VA. I think they 
can speak for themselves. But it is my understanding that there 
is an effort. They think they are handling these issues 
internally. They may believe that.
    But, again, my training, and I started in construction in 
1965. Think about that, the age. That gives me away a little 
bit, doesn't it, Ms. Brownley?
    But it does not take me long to understand there is a 
violation. And if they, Chairman, have that knowledge, then why 
didn't they correct it?
    Example could be down in Atlanta. We have from the Joint 
Commission this report in Atlanta that says the Atlanta Medical 
Center was supposed to take care of their facility, that they 
have violations that are listed on page nine, insufficient 
compliance on meeting the requirements under the NFPA-101. 101 
is life safety.
    Under the door category, insufficient compliance, space 
around pipes, conduit where fire and smoke and gases, 
insufficient compliance. I could go on. But here it is a 
facility that should have the knowledge and they are not 
fulfilling that.
    We have examples around the country of fires.
    Mr. Benishek. May I ask a question?
    Mr. McKinley. Five people were killed in a Texas shelter.
    Mr. Benishek. Mr. McKinley, let me ask you this question.
    Mr. McKinley. I could go on. There are just examples like 
that, Mr. Chairman--of examples where people have not followed 
the code. They do a wink and a nod. But there are people that 
are dying every day and there is needless deaths that are 
occurring or harm coming to individuals because they are not 
following the building code.
    Mr. Benishek. Can you give me a couple examples of the 
things that you saw yourself when you were there? You mentioned 
that you are an engineer and you noticed some things right 
away. What were some of the things that you noticed?
    Mr. McKinley. I have seen lack of sprinkler systems and I 
know that if you are going to have a combined-use where you 
have counseling and housing, there is a requirement to have a 
fire separation, a two-hour separation, as well as sprinkler 
systems required by 101. Not what is happening time and time 
again.
    You are fortunate if you get an alarm system. I saw doors 
that are not rated. When I mean rated doors, you can have 
ratings that maybe have to be as long as two hours before the 
door will burn. I can tell you these doors are not rated 
because on the inside panel on the door, there is a chip that 
is affixed. They have a label and it will tell you whether it 
is rated. I went through, I do not know how many facilities and 
I have looked for those labels and they are not there.
    We see fire exit ways. They are supposed to be lit. There 
are strobe lights that were not there at these facilities.
    These people, Mr. Chairman, are trying to help out the 
veterans, but in so doing they are cutting corners. And I just 
want them to comply with the standards. This is not going to 
cost the VA one additional dollar. But the owners of these 
facilities are going to have to have proper compliance with the 
code, not a wink and a nod, so our men and women are safe when 
they go to bed at night.
    Mr. Benishek. Thank you.
    Ranking Member Brownley, do you have any questions?
    Ms. Brownley. No.
    Mr. Benishek. Dr. Ruiz.
    Mr. Ruiz. Thank you both for your work and your support for 
veterans.
    I have a question for you, Honorable McKinley. The 
veterans, do we now have a sense of how many go to veteran-
specific shelters versus general homeless shelters?
    Mr. McKinley. That is a fair question. No, I do not know. 
It is just a troubling statistic that anyone winds up in a 
homeless shelter.
    But when I have talked to some of them that are there, 
keeping it certainly anonymous to keep their identify, just for 
whatever has happened, whether it can be they are having post-
traumatic, they cannot keep a job, they have lost their family 
life because of their issues, series of issues. Unfortunately, 
they are there.
    The VAs do not have the bed capacity to be able to keep 
them there, so they are providing space for them here at, I 
guess, a per diem basis for them to be able to stay at these 
facilities.
    So I do not know how many would be there in a VA sponsored 
versus one that might be just a non-veterans' homeless shelter. 
But I can tell you, Congressman, I am seeing the problems in 
both. It is not just the VAs. The VAs, I think, want to do what 
is right, but they want to use a policy.
    I think we ought to make it statutory so that it does not 
vary from state to state to state and municipality where there 
is a wink and a nod that they will let them stay there. Let's 
give people ability to have safe housing whether they are in a 
public one or in a VA sponsored facility.
    Mr. Ruiz. And that is the point of my question was to 
figure out if--you know, our primary concern with this bill is 
to make sure that veterans themselves have a safe place to rest 
given the special covenant that we have with our veterans. And 
in general, we should strive to make sure that any homeless 
could have a safe place to stay at night as well.
    But in this special case, if the majority go to private or 
non-profit shelters, which is usually the case, the non-profit 
organizations, then my concern is are we still reaching out to 
those homeless shelters for them so they can have their place 
to sleep?
    Mr. McKinley. In my jurisdiction, in the 1st district of 
West Virginia, whenever I see one of these in a non-VA related 
facility, I talk to the municipality about whether or not to 
make them in compliance.
    Mr. Ruiz. Okay.
    Mr. McKinley. But we do not have jurisdiction over those 
facilities. We have the jurisdiction where there is Federal 
money being used to help these individuals. That is why I am 
dealing with it here, but I am dealing with the other in 
another matter. And it has to be done on a case by case, 
municipality by municipality.
    Mr. Ruiz. Thank you very much.
    Mr. McKinley. Thank you.
    Mr. Benishek. Ms. Kuster, you have any questions?
    Ms. Kuster. Just briefly. Thank you very much.
    Thank you very much for your testimony and for bringing 
these bills forward. And I just want to address a question to 
Mr. McKinley.
    And you seem well-versed in this, so I just want to 
understand. I have worked in the past in my State of New 
Hampshire with colleges and universities in dormitories and 
housing and trying to comply with local codes. And I know that 
there is a distinction between the international building and 
fire codes and the life safety codes.
    Mr. McKinley. Yes.
    Ms. Kuster. And I am just wondering what the impact--I 
agree with your intent and I want homeless veterans to be in 
safe conditions.
    In New Hampshire, the facilities that I have seen have been 
very safe. But my concern is not to add to the burden and have 
an unintended consequence of inadvertently making housing less 
available to homeless veterans.
    So if you could comment on how this will work with the 
international code, the life safety code, and that there is 
local approvals that might be required.
    Mr. McKinley. Let me see. I will try to answer that.
    Ms. Kuster. For the layperson.
    Mr. McKinley. We took some time yesterday and I think it 
also began on Friday trying to contact some other states to 
find out how they deal with these shelters because if the 
concern is over the $100 or whatever the cost, $200, if that is 
going to be a burden.
    Ms. Kuster. We can deal with it.
    Mr. McKinley. Think about it. Think about that.
    Ms. Kuster. Yes.
    Mr. McKinley. An annual cost of $100 spread out over your 
facility or $200. We found out again in West Virginia, those 
inspections to see that they are in compliance are done at no 
cost. In Virginia, they have an annual state requirement that 
no one is complaining about in Virginia.
    In New York, there is an annual local level for all 
publicly accessed buildings and Utah performs the same thing, 
fire safety. In fact, in Utah, they have to fill out this 60-
page document every year to give everyone a comfort level that 
the buildings are safe and that we can put human occupants in 
that building and they can walk out the next day.
    So I think the little bit of burden of having to do 
paperwork once a year, I think, is certainly appropriate given 
that we are putting people that are hurting emotionally to give 
them the comfort that their living conditions and their 
environment, that they will be safe.
    And I think we will find if we continue doing the research, 
we will find that all across America there are those 
requirements either to comply with life safety, the 101 and the 
National Fire Protection Agency or some of these other codes, 
the ICC which is generally observed for most of the states 
around the country, but I think every state has to comply with 
the NFPA-101.
    Ms. Kuster. Good. Thank you.
    Mr. McKinley. That is what we are asking for here. Do not 
make it a policy.
    Ms. Kuster. Uh-huh.
    Mr. McKinley. Make it a requirement when they get their 
license every year and it may not cost anything depending upon 
your state.
    Ms. Kuster. Okay. Thank you very much.
    I yield back.
    Mr. Benishek. Mr. Huelskamp, do you have any questions?
    Mr. Huelskamp. No thanks.
    Mr. Benishek. Well, thank you. Thank you again for coming. 
Since there are no further questions, the first panel is now 
excused.
    I welcome our second panel to the witness table. Joining us 
on the second panel is Mr. Jacob Gadd, the Deputy Director for 
Health Care for the Veterans Affairs and Rehabilitation 
Division in The American Legion; Dr. Susan Shore, Chair of the 
Scientific Advisory Committee for the American Tinnitus 
Association; Mr. Adrian Atizado, the Assistant National 
Legislative Director for the Disabled American Veterans; Robert 
Drexler, member of the Board of Directors for the International 
Code Council; and Mr. Raymond Kelley, the Director of the 
National Legislative Service for the Veterans of Foreign Wars.
    Thank you all for being here this morning and for your hard 
work and advocacy for our veterans. I appreciate you coming 
here to present your views of your members and I anticipate 
your testimony with eagerness.
    We will begin with Mr. Gadd. Please begin your testimony. 
You have five minutes.

 STATEMENTS OF JACOB B. GADD, DEPUTY DIRECTOR FOR HEALTH CARE, 
  NATIONAL VETERANS AFFAIRS AND REHABILITATION DIVISION, THE 
  AMERICAN LEGION; SUSAN E. SHORE, CHAIR, SCIENTIFIC ADVISORY 
   COMMITTEE, AMERICAN TINNITUS ASSOCIATION; ADRIAN ATIZADO, 
  ASSISTANT NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN 
     VETERANS; ROBERT DREXLER, MEMBER, BOARD OF DIRECTORS, 
   INTERNATIONAL CODE COUNCIL; RAYMOND C. KELLEY, DIRECTOR, 
     NATIONAL LEGISLATIVE SERVICE, VETERANS OF FOREIGN WARS

                   STATEMENT OF JACOB B. GADD

    Mr. Gadd. On behalf of the 2.4 million members of The 
American Legion, I would like to thank you, Chairman Benishek, 
Ranking Member Brownley, and Members of the Committee, for the 
opportunity to provide comments on these health care bills.
    H.R. 1702 is needed to ensure that Veterans Transportation 
Service program is authorized as a permanent authority. For 
years, VA transportation programs and initiatives have been 
viewed as an ancillary or secondary service area, but The 
American Legion recognizes that veterans' transportation 
programs are vital and often the difference between whether a 
veteran is seen for care or not.
    VTS originated as a VA transformation initiative to ensure 
veterans with serious injury, illness, and those who live in 
remote areas receive travel.
    In May 2012, VA general counsel rendered an opinion which 
found that VA only has the authority to use volunteer drivers 
to provide veterans transportation to and from VA health 
facilities, not paid employees.
    The American Legion became involved after the general 
counsel ruling as we had just finished up our system worth 
saving report on rural health care.
    In this report, we visited VA medical centers and hosted 
town hall meetings with veterans to understand firsthand what 
challenges veterans face in highly remote areas such as in 
Maine, Kansas, Missouri, New Mexico, and Wyoming.
    We found that for many veterans driving long distances were 
a disincentive and barrier to them receiving care. We found 
that VTS was a viable solution as it offered veterans a 
secondary option to supplement current VA transportation 
programs.
    We found concerns with VA's current organizational 
structure of transportation programs in VA medical facilities 
which is fragmented and disjointed with different 
transportation programs located throughout the hospital instead 
of in one central place.
    Based on the findings of the report and in response to VA's 
general counsel ruling, The American Legion adopted Resolution 
293, the veterans transportation system and benefits travel. 
This resolution urged VA to establish a transportation 
department within each VA medical center to coordinate and 
oversee all transportation programs in the hospitals such as 
conducting transportation catchment analysis, Veterans 
Transportation Service program initiatives, volunteer 
transportation drivers, beneficiary travel programs, and valet 
programs.
    As one veteran recently told us in Nevada, veterans travel 
as far as 200 miles to the VA medical center for required 
appointments as the service is not available in their CBOCs.
    These van pools require them to leave their residence very 
early in the morning and not return home until later in the 
day. Due to medical conditions, not all veterans can withstand 
this type of travel and instead take their personal vehicles. A 
number of these veterans are subjected to a fixed budget and 
often find the cost of travel for medical care a rather large 
burden.
    Veterans have a choice where they want to receive their 
health care. If their transportation needs are not met or 
fulfilled by VA, they may not receive care at VA or worse not 
receive care at all.
    The American Legion supports this legislation but urges 
this Committee to include provisions requiring the VA to 
establish veterans' transportation departments within VA 
medical centers to maximize coordination, efficiency, and 
availability of transportation options for veterans.
    Regarding draft legislation on the Long-Term Care of 
Veterans Choice Act, while The American Legion does not have an 
official position on medical foster programs, we have noted 
VA's trend in several years of reducing institutional care beds 
in lieu of other community options.
    American Legion Resolution 121 has three actions that we 
stated VA be required by the 1998 Millennium Health Care Act to 
maintain and restore its in-house nursing home capacity to 
13,391 beds; second that VA create incentives and receive 
appropriate funding to maintain its nursing home beds rather 
than abandon them to alternative sources; third that Congress 
appropriate sufficient funds to support the provisions of the 
Millennium Health Care Act so VA is not forced to reduce its 
nursing home care unit capacity.
    Understanding that not every veteran requires long-term 
care or skilled nursing in an institutionalized setting, it is 
important to The American Legion and America's veterans that 
the availability is there if the need in the VA exists, 
particularly as the number of World War II veterans and Vietnam 
veterans needing skilled care is poised to increase over the 
coming years.
    Now is not the time to be reducing capacity or availability 
of long-term care. The consequence of not having availability 
of long-term beds is that state veterans' homes and other non-
VA long-term care options will be overtaxed and unable to admit 
veteran patients.
    Once again, American Legion thanks you for this opportunity 
to testify on these important bills today.

    [The prepared statement of Jacob B. Gadd appears in the 
Appendix]

    Mr. Benishek. Thank you very much. I appreciate your 
testimony.
    Dr. Shore, why don't you please start.

                  STATEMENT OF SUSAN E. SHORE

    Ms. Shore. Good morning. Thank you for this opportunity to 
give testimony on H.R. 1443, the Tinnitus Research and 
Treatment Act of 2013.
    Good morning, Chairman Benishek and Ranking Member Brownley 
and the rest of the distinguished Members of the Health 
Subcommittee.
    My name is Dr. Susan Shore and I am the chair of the 
Scientific Advisory Board for the American Tinnitus Association 
often called ATA.
    This is a very important issue, the issue of tinnitus 
sometimes pronounced tinnitus, and it is especially important 
because it is often ignored as it is viewed as an invisible 
disorder, an invisible disorder because nobody but the people 
who are suffering from it know that it is there. It is a 
subjective phenomenon.
    And because of this, I think this is one of the reasons 
that it is underfunded. So on behalf of the ATA and the 50 
million Americans afflicted with tinnitus, I am going to give 
you some background on why I think it is so important to get 
more money for research.
    So the ATA funds research grants and it is the only member-
based and non-profit organization dedicated to finding a cure 
for tinnitus in the United States. Since 1980, we funded grants 
towards better understanding of the mechanisms that are 
responsible and underlying the genesis of tinnitus.
    The advances in tinnitus research over the past decade have 
been extraordinary. One of the most important advances has been 
the ability to visualize tinnitus through the use of advanced 
functional imaging technologies and also through the 
development of animal models that can behaviorally assess the 
presence of tinnitus in animals. These methods allow us to 
pinpoint tinnitus to certain regions of the brain.
    Another important advancement that has occurred mostly 
through the use of animal models is the discovery that tinnitus 
is a result of brain plasticity or disorganization of the 
brain. And these developments have led the scientific community 
to understand that tinnitus is a disorder of brain function and 
not a disorder of the ear that has been the common 
misconception for decades.
    So while noise overexposure is still the number one cause 
of tinnitus, it can also develop in the absence of hearing loss 
and absence of hearing damage and because of the result of head 
and neck injury.
    Tinnitus is the number one service-connected disability for 
returning veterans from Iraq and Afghanistan and elsewhere and 
as mentioned in the introduction, tinnitus in these veterans is 
most often the result of extreme noise exposure from either a 
single impulse or the accumulation of noise exposures.
    However, head and neck injuries are also a leading 
complaint of these veterans. In fact, lumbosacral and cervical 
strain account for 23 percent of service-connected disabilities 
for Iraq and Afghanistan veterans.
    And so in addition to these factors that cause hearing 
loss, there are other factors that result from somatic insults 
including lumbosacral and cervical strain.
    Research into how these systems interact in the brain has 
the potential to lead to treatment such as tailored devices 
that aim to ameliorate the aberrant brain circuitries resulting 
from both a combination of hearing loss and head and neck 
injuries.
    When you consider the costs that have already been 
mentioned for disabilities and in comparison to what is being 
spent on tinnitus research in the U.S., there is a severe 
disconnect.
    Up until very recently, the amount of money being spent on 
tinnitus research has been negligible and amounts to about $10 
million most recently which is up from $5 million in 2005, but 
still it is not nearly enough to address a disorder that 
affects so many millions of people.
    I would like to just quickly address the current treatments 
that are offered in the VA. And while we applaud the efforts of 
the VA, current treatments that are offered as part of the 
progressive tinnitus management program, while applaudable are 
not addressing issues that have been highlighted through 
research.
    For example, they use sound therapy as their only treatment 
which is not effective for many patients. And so because of 
this, this is why expanded research is necessary to move 
forward and use the discoveries that are being made throughout 
the United States in laboratories as we speak.
    So I would like to urge you to passage this legislation and 
this important one, H.R. 1443. This will go a long way to 
helping us achieve our goals of improving tinnitus treatment 
and ultimately finding a cure for this disorder.
    Thank you.

    [The prepared statement of Susan E. Shore appears in the 
Appendix]

    Mr. Benishek. Thank you very much for your testimony. I 
really appreciate it.
    Mr. Atizado, I think you are up next.

                  STATEMENT OF ADRIAN ATIZADO

    Mr. Atizado. Thank you, Chairman.
    Ranking Member Brownley, Members of the Subcommittee, on 
behalf of DAV and our 1.2 million members who are wounded and 
injured veterans, I am pleased to provide our views on the 
legislation that is on today's agenda.
    I would like to highlight two bills to the Subcommittee, 
the first of which is H.R. 1702. This bill would provide VA a 
renewed and permanent authority to transport individuals in 
connection with receiving VA benefits and services.
    As mentioned earlier, previously enacted law prompted VA to 
initiate the Veterans Transportation Service or VTS which were 
it not for the expiration of its one-year statutory authority 
would have extended to all VA locations by 2015.
    Now, DAV believes VTS can be an ideal partner with our 
transportation network, the DAV transportation network or 
DAVTN. While the DAVTN continues to show tremendous growth as 
an indispensable resource for veterans, VTS serves a special 
subset of the veteran patient population, one which our 
transportation network is unable to serve. And that deals 
specifically with veterans in need of special mode of 
transportation because of certain aspects of their conditions.
    We believe that with a truly collaborative relationship 
that DAVTN and VTS will meet the growing transportation needs 
of ill and injured veterans in a cost-effective manner.
    Now, as this Subcommittee may be aware, VTS operates on 
funds that would otherwise go directly to medical care for 
veterans. Thus, our current support for this bill is based on 
the progress gained through our working relationship with VA to 
resolve weaknesses that we have observed with VTS.
    Like VA, we want to ensure VTS will indeed work in concert 
with all existing and emerging transportation resources for 
veterans who need VA care and to guard against fraud, waste, 
and abuse of these limited resources.
    The second bill is the Long-Term Care Veterans Choice Act 
which we support based on our national resolution calling for 
legislation to expand VA's long-term services and supports for 
service-connected disabled veterans.
    Established in 2000 and operating under the same authority 
as VA's community residential care program, VA's medical foster 
home approves a private home and the caregiver to care for no 
more than three veteran residents in any one location.
    Caregiver support is provided by the medical foster home 
attendant. They are provided training and it is required that 
these attendants have a secondary respite option.
    Medical care under the medical foster home is supervised 
through VA's home-based primary care program or VA's spinal 
cord injury home care program. Patient participation in this 
program is voluntary and veteran residents report very high 
satisfaction ratings.
    A lot of veterans that we hear from who would like to go in 
a medical foster home are not able to do so simply because 
veterans must pay out of pocket for both room, board, as well 
as caregiver services. And that amount ranges anywhere from 
$1,500 to $4,000 a month.
    Even veterans who are otherwise entitled to the more costly 
long-term nursing home care paid fully for by VA either by law 
or policy cannot get in because they have no means to pay.
    DAV is pleased with VA's innovation by offering the medical 
foster home program as one part of its long-term services and 
support portfolio and we applaud the intent of this draft 
legislation to give VA the authority to enter into agreement or 
contract with a VA approved medical foster home as well as pay 
for the room, board, and caregiver services.
    Mr. Chairman, DAV believes favorable consideration of this 
draft bill is a good first step for this Subcommittee to ensure 
veterans have access to a full array of home and community-
based long-term services and supports.
    Oversight by this Subcommittee is sorely needed as VA 
endeavors to shift more of its resources away from nursing home 
care in order to serve more veterans in a cost-effective manner 
while honoring their preferences in how they live the rest of 
their lives in light of their impairments.
    We urge this Subcommittee to ensure VA innovations and home 
and community-based services are not stifled and that VA's 
long-term services and supports provide the broadest array of 
assistance as possible regardless of age to those veterans who 
have lost the ability to function or maintain independence in 
their community.
    Mr. Chairman, we look forward to working with the 
Subcommittee on these two bills and for its passage. I would be 
happy to answer any questions that you or other Members of the 
Subcommittee may have.
    Thank you.

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

    Mr. Benishek. Thank you, Mr. Atizado.
    Mr. Drexler, your testimony, please.

                  STATEMENT OF ROBERT DREXLER

    Mr. Drexler. Good morning, Mr. Chair and Members of the 
Subcommittee. My name is Rob Drexler, member of the Board of 
Directors for the International Code Council. I also serve as 
Fire Marshal for the town of Greece in New York.
    With 26 years in the building and fire code profession and 
have participated in both the NFPA and ICC code development 
process, I am pleased to be here today to discuss the 
importance of compliance with building and fire codes, speaking 
on behalf of over 50,000 building and fire code officials and 
other professionals across the United States who are the 
members of the code council.
    The code council was formed in 1994 as a non-profit 
organization dedicated to developing a single set of 
comprehensive and coordinated national model construction 
codes.
    The founders of the ICC were BOCA, ICBO, and SBCCI. We 
joined these three groups together and published a single code 
for the United States called the international codes.
    In 2003, the International Code Council became the 
successor organization to the three legacy code groups. We now 
celebrate our tenth anniversary.
    Today our international model codes have been adopted at 
the state or local level in all 50 states and the District of 
Columbia. Numerous Federal agencies including General Service 
Administration, the Department of Defense, and the Architect of 
Capitol have implemented the I codes as have Puerto Rico and 
the U.S. Virgin Islands.
    The code council's 50,000 members and over 300 chapters 
include state, county, municipal code enforcement, fire 
officials, architects, engineers, builders, contractors, 
elected officials, manufacturers, and other construction 
industry professionals.
    I come before you today to encourage support of H.R. 2065, 
the Safe Housing for Homeless Veterans Act, sponsored by 
Representative David McKinley of West Virginia and 
Representative Grace Napolitano of California.
    Those of us who work to achieve building safety at both the 
state and local level appreciate the concern that this bill has 
for the welfare of our veterans who are living in housing 
subsidized by the Department of Veterans Affairs.
    In the building sector, the IRC, the IBC, and the IFC 
established basic requirements for building safety at the time 
of construction and in the case of the fire code at the time of 
annual inspections.
    The codes assure that when faced with hazards including 
fire, windstorm, flooding, and normal or daily use, the 
building will allow for residents and users to survive and the 
first responders to safely rescue building occupants and 
minimize property damage.
    Around the country either at the state or at the local 
level, both the IBC and the IFC assure that buildings used for 
residential care and housing are safe. Local code officials 
around the country inspect veterans' homes and assure that they 
meet current code requirements just as they do with any other 
building within their community.
    Michigan as well as 42 other states have adopted both the 
IBC and the IFC. In fact, all 50 states have adopted the IBC 
while a significant number also adopt the life safety code 
which is the LSC.
    H.R. 2065 wisely does not attempt to mandate one code or 
the other for compliance in facilities approved by the 
Department of Veterans Affairs for reimbursement but requires a 
certification for all homes that they meet either the IBC, the 
IFC, or the LSC which are functionally and for a safety 
standpoint equivalent code requirements.
    In addition, the bill does not impose any onerous 
administrative burden on the Department of Veterans Affairs, 
only to assure that each facility receiving reimbursement has 
obtained a certificate of compliance from the local code 
official or from a competent third party. This requirement 
mirrors similar requirements for other medical facilities that 
must provide assurance to the centers for Medicaid and 
Medicare.
    I only had a few moments this morning to review the 
statements that will be presented by the VA today, but I would 
respectfully disagree with many of the talking points in that 
statement.
    It is true that veterans' homes covered by this requirement 
that are located in jurisdictions that does not adopt and 
enforce either the IFC or the LSC, there will be a small 
additional burden of obtaining an annual inspection.
    However, it is the clear intent of the bill's sponsors and 
a worthy goal in our opinion that our veterans who sacrificed 
so much for our freedoms should be provided with safe housing, 
especially when the taxpayer is subsidizing that housing.
    It is hard to argue that our veterans should not be assured 
of minimal safety in their home when the cost of assuring 
safety is only a couple of hundred dollars.
    In closing, the International Code Council is proud of our 
work in developing the model codes to assure basic level of 
safety in the built environment and we applaud your efforts to 
use those codes to protect the safety of our veterans.
    I respect the work of your Subcommittee and encourage 
continued collaboration between the public and private sectors 
to achieve the important goal of increased safety in our 
Nation's buildings.
    Thank you very much for the opportunity today and I would 
be happy to answer any questions.

    [The prepared statement of Robert Drexler appears in the 
Appendix]

    Mr. Benishek. Thank you, Mr. Drexler.
    Mr. Kelley.

                  STATEMENT OF RAYMOND KELLEY

    Mr. Kelley. Mr. Chairman, Members of the Committee, on 
behalf of the men and women of the Veterans of Foreign Wars, 
thank you for the opportunity to testify today.
    The VFW supports H.R. 1443 which would require the 
Department of Veterans Affairs to recognize tinnitus as a 
mandatory condition for research and treatment by the VA 
auditory center of excellence in coordination with the 
Department of Defense hearing center of excellence.
    Although there is no known cure for tinnitus, it should not 
be assumed that the condition is untreatable. VA's progressive 
tinnitus management approach which assists tinnitus sufferers 
through individual counseling and support is helping veterans 
better manage their symptoms. Still more research is needed in 
order to identify truly effective treatments in alleviating 
these symptoms. This bill represents a positive first step 
towards achieving that goal.
    The VFW supports H.R. 1612, a bill that directs the 
secretary of VA to convey a parcel of land to Tuskegee 
University. More than 90 years ago, Tuskegee University donated 
the land, nearly 300 acres, to the United States Government to 
build a veterans' hospital. Today 21 of those buildings 
accounting for nearly 280,000 square foot of space sit vacant 
on that property.
    Annually, VA spends approximately $2.00 a square foot to 
maintain vacant space. For the buildings that fall within this 
land transfer, VA spends more than $500,000 a year in 
maintenance. Reducing the financial burden for upkeep of these 
buildings and grounds will allow VA to better use those funds 
to ensure the highest level of maintenance for the facilities 
to provide care and services to our veterans and not to 
buildings that are sitting vacant.
    The VFW supports H.R. 1702 which permanently authorizes the 
Veterans Transportation Service or VTS. This program 
commissioned by the Office of Rural Health in 2010 has greatly 
improved access to care for rural and seriously-disabled 
veterans by allowing VA facilities to establish and coordinate 
a network of local transportation providers.
    In 2012, the program was temporarily suspended following a 
determination by VA Office of General Counsel that VA lacked 
the statutory authority to hire paid drivers to transport 
veterans.
    Congress wisely passed a one-year authorization of the VTS 
program in January of 2013, but a long-term fix is still 
needed. This legislation would guarantee the continuation of 
and further expansion of VTS which plays a critical role in 
minimizing the challenges many veterans face in traveling to 
their appointments due to physical disabilities or great 
distances.
    The VFW supports H.R. 2065 which would require facilities 
that house homeless veterans to meet the relevant local 
building codes in order to receive per diem payments under VA 
homeless providers grant and per diem program.
    Currently the VA is required to check housing certificates 
before awarding grants for housing services provided to 
homeless veterans. However, thorough checks of fire and safety 
requirements as well as structural conditions of buildings are 
often overlooked.
    This bill requires that current recipients of the per diem 
payment submit a certification of compliance with local codes 
within two years of the enactment of this act, giving them 
ample time to make the necessary improvements.
    The VFW believes that VA-funded transitional housing must 
be safe, secure, and sanitary. This bill will ensure that those 
standards are met, providing homeless veterans with the best 
chance of successful community reintegration.
    The VFW supports the Long-Term Care Veterans Choice Act 
which would add language to Section 1720 of Title 38 to allow 
veterans to receive VA care and require a protracted period of 
nursing care to provide transfer into adult foster home at 
their request.
    To grant VA the authority to reimburse adult foster homes 
would provide veterans with the additional residency choice, 
potentially improving the quality of life for those who would 
prefer this option.
    The VFW strongly believes that all non-VA services should 
be provided in conjunction with proper care coordination. 
Currently VA handbook 1141.02, the medical foster home 
procedures, establishes the policies and standards for VA care 
coordination for veterans who choose to live in medical foster 
homes.
    The VFW feels that these procedures would ensure adequate 
care coordination for veterans who choose to participate in 
fully-funded adult foster care programs. However, these 
procedures are now set to expire in 2014 and the VFW recommends 
the care coordination policies outlined in that document should 
be made permanent by adding them to the language of this 
legislation.
    Mr. Chairman, this concludes my testimony. I look forward 
to any questions from you or the Committee.

    [The prepared statement of Raymond C. Kelley appears in the 
Appendix]

    Mr. Benishek. Thank you very much for your testimony.
    Well, we have the Chairman of the Full Committee. Would you 
like to discuss your piece of legislation before we get to the 
questions?

               STATEMENT OF CHAIRMAN JEFF MILLER

    Mr. Miller. If I could. I appreciate it. I did not walk in 
here to automatically start talking about my piece of 
legislation, but----
    Mr. Benishek. If it is all right with the Committee, we 
will let the Chairman go for five minutes.
    Mr. Miller. Thank you very much. I appreciate it, Mr. 
Chairman.
    Thank you to the witnesses.
    I apologize for stepping in front of the questioning, but I 
want to talk to you about the Long-Term Veteran Care Choice Act 
and I think it is something that this Committee can certainly 
get behind and support because this act would authorize the 
Department of Veterans Affairs to enter into a contract or 
agreement with a certified medical foster home to pay for the 
residential long-term care of service-connected veterans who 
are eligible for VA-paid nursing home care.
    As a component of such care, eligible veterans would also 
be required to receive VA home health services.
    VA medical foster homes for those of you who do not know 
are private homes in which a trained caregiver provides 24-hour 
around-the-clock care to a few individuals. They are designed 
to provide a non-institutional long-term care alternative to 
those who prefer a smaller, more like home setting, one that 
they are more accustomed to in their own homes than traditional 
nursing homes are able to provide.
    VA has been helping to place veterans in medical foster 
homes now for well over a decade. MFH are limited to no more 
than three veterans at a time and veterans living in such homes 
are provided with VA, with home-based primary care services.
    They also provide safeguards to ensure that veterans 
themselves are safe, that they receive high-quality care by 
requiring the MFH caregivers to pass a Federal background check 
and VA screening and agree to undergo annual training. And they 
also allow VA adult foster home coordinators and members of a 
VA home care team to make both announced and unannounced 
visits.
    Today, according to VA, over 400 approved caregivers 
provide this type of care in their homes to over 500 veterans 
daily in over 35 states.
    The problem is, however, that VA does not have the 
authority to pay for the cost of this care. So the veteran who 
chooses to live in an MFH must pay out-of-pocket with their own 
personal funds regardless of whether or not such veteran is 
eligible for VA-paid nursing home care.
    What this does is create a situation where many service-
connected veterans with limited financial resources who would 
prefer to live in a medical foster home go to a nursing home 
institution instead because VA will cover the cost of the 
nursing home but not the foster home.
    And while traditional nursing homes will always be a vital 
component of long-term care, medical foster homes provide a 
worthy alternative for many of our veterans.
    According to the department itself, many more veterans 
would elect to receive care in a medical foster home should VA 
be granted the authority to pay for such care.
    And I am sure we all agree that one thing we owe our 
veterans, particularly those who are service-connected and in 
need of long-term care, is the luxury of choice, the choice to 
decide where, whether, and how they receive care.
    As the veteran population continues to age, the need for 
long-term care services will, in fact, continue to grow. The 
Long-Term Care Veterans Choice Act would expand the long-term 
care choices that are currently offered to veterans beyond 
traditional services.
    In addition to being beneficial for the health and the 
well-being of veterans, the average cost of a medical foster 
home is less than half the monthly cost of a nursing home, 
making this legislation a very cost-effective health care 
option.
    This is a common-sense veteran-centric bill that will free 
many veterans from financial turmoil and allow them to make 
their own decisions about what kind of long-term care they 
themselves want to receive.
    I looked forward to working with all the interested parties 
to resolve any issues they may have during today's discussion.
    And, Mr. Chairman, thank you so much for allowing me the 
opportunity to talk about this particular piece of legislation 
at today's hearing.
    And I also want to personally thank you for your hard work 
as Chairman of this Subcommittee. It is very critical work for 
the veterans of this country and your leadership is greatly 
appreciated, and I yield back.

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

    Mr. Benishek. Thank you, Mr. Chairman.
    I am going to yield myself five minutes for a few questions 
for the panel.
    Dr. Shore, I have a great interest in tinnitus as well 
because I realize it is a very prominent and probably the most 
frequent disability that we see from our veterans returning 
home now.
    Several veteran service organizations with the Independent 
Budget raised concerns about protecting and preserving the VA 
research funding decisions by the scientific merit-based peer 
review process without interference from outside stakeholders.
    Please comment on that concern. Do you feel that this would 
compromise in any way the current peer review system already in 
place?
    Ms. Shore. I am not sure what you are referring to by 
outside----
    Mr. Benishek. Well, I think the VA contends that they have 
a peer review process for determining how to fund research and 
they feel that, outside influences like Congress directing the 
way that we conduct research would take away from, the peer 
reviewed medical decision-making process of determining where 
the funds should go.
    Ms. Shore. Right. No, I do not agree, but I would----Yeah, 
I see where you are coming from. I do not think that it would 
interfere with that. I think it would enhance that process as 
long as you have people that you are deferring to or consulting 
with who know something about the way tinnitus works.
    Mr. Benishek. Right.
    Ms. Shore. So----
    Mr. Benishek. What is the current funding level for 
tinnitus research?
    Ms. Shore. It is about $10 million everywhere.
    Mr. Benishek. That is the total----
    Ms. Shore. Yeah.
    Mr. Benishek. --for this country, $10 million a year for 
the research in tinnitus or is that just the VA?
    Ms. Shore. Yes, it is--no, no. That is the total. So that 
is much, much, much lower than it should be. So we have 
increased the funding from what it used to be five years ago.
    NIH is now recognizing tinnitus as a separate disorder that 
needs to be considered for funding. The DoD is also putting 
forth opportunities for people to submit grants to study 
tinnitus. But it still is not nearly enough to bring the 
research into reality because it takes a long time for our 
research finding to then be taken into a clinical trial.
    And we do not want to take research findings into clinical 
trials unless they have been proven in the laboratory. So it 
takes a lot of money for research to end up helping patients.
    Mr. Benishek. No, I realize that amount seems very small 
considering the number of veterans that are coming home with 
the problem.
    Ms. Shore. Oh, it is extraordinarily small, yeah.
    Mr. Benishek. Especially due to the fact that we do not 
really have much in the way of treatment or understanding of 
the disease.
    Ms. Shore. Right.
    Mr. Benishek. So----
    Ms. Shore. Well, I think it is progressing, but we are not 
there yet. I mean, there has been a lot of progress in the last 
decade. And as I said, one of the big jumps was in recognizing 
tinnitus as a brain disorder and not just a disorder of the 
ear.
    Mr. Benishek. Right. Right. I did not realize that myself.
    Ms. Shore. Yeah. So it is often triggered by damage to the 
ear, but the reason that it is a brain disorder is because the 
brain reacts to the lack of input from the ear and it starts 
doing its own thing which is what produces the tinnitus.
    Mr. Benishek. Right.
    Ms. Shore. And many systems within the brain are acting 
together and so treatments have to involve things other than 
just sound therapy which is the most available treatment, but 
not really very effective and in some people, not even 
effective at all.
    Mr. Benishek. Right.
    Ms. Shore. So now there is the development of devices that 
take into account other etiologies than just the ear. For 
example, the somatosensory side of things which is going to be 
even more prevalent in the veterans' population than it is even 
in the normal population because they get head and neck 
injuries as well.
    Mr. Benishek. Right.
    Ms. Shore. And so the hearing loss combined with the head 
and neck injuries which themselves can cause tinnitus makes, 
you know, that the reason----
    Mr. Benishek. I think you explained that we need a little 
more research in this department----
    Ms. Shore. Yeah.
    Mr. Benishek. --pretty well. I want to get to one other 
topic before my time runs out. I thank you for your answer.
    Mr. Gadd or Mr. Kelley, I have an issue with VA 
transportation in rural areas. I am representative of rural 
northern Michigan. And the DAV vans are being manned by more 
and more elderly veterans and we have difficulty in providing 
adequate transportation for veterans.
    I guess my concern about VA--I want to be sure that we use 
that money very efficiently. Like some of you mentioned, that 
money is being diverted for transportation away from patient 
care.
    So how do you think that we should do oversight? I am 
concerned about the fact that we hire a driver, we buy a van, 
and then they sit there for 80 percent of the time, How do we 
conduct of oversight that to ensure it is an efficient system 
within the VA?
    Mr. Gadd, do you have an idea or Mr. Kelley?
    Mr. Gadd. Sure, I can respond to that. And thank you for 
the question.
    So I believe it was mentioned earlier and the VA will have 
their particular figures on the cost savings, but when these 
mobility managers came in with the VTS program, they really 
aligned, they worked together with beneficiary travel. And so 
there are some reduced cost savings from beneficiary travel. 
And, you know, in addition to that, they were developing a tool 
to be able to manage the cost and looking at cost and trying to 
reduce the cost.
    The other point that was mentioned earlier was about 
special mode transportation. And the VA would have to contract 
with third-party providers to, you know, provide that 
transportation. But if they are able to have the ability 
through the VTS program to do that in-house, there would be 
some reductions in cost there.
    And then, too, it just makes sense because it is one 
additional option that, you know, if veteran service 
organization drivers cannot take that, you know, van to that 
veteran, you know, and they are outside of an area where 
transportation is not offered, it could reach those particular 
veterans.
    So we see it as a win-win for veterans.
    Mr. Benishek. Right. Mr. Kelley, you have any input there?
    Mr. Kelley. I will just echo a sentiment. Beneficiary 
travel is hard to have oversight of. Veterans come in and make 
a claim that they traveled to their appointment. VA receives 
the claim and then provides a check in return.
    With this, I think it would be easier to do accountability 
if you have a contractor who says we went to pick up these ten. 
There is evidence of that, that they brought them to their 
appointment and then took them home.
    So I think in the long run, the oversight would be much 
easier doing this VTS than beneficiary travel. And I think Mr. 
Gadd said there is evidence that it will be a cost savings.
    Mr. Benishek. Thank you, gentlemen.
    I have overstepped my time a bit, but, Ms. Brownley, do you 
have questions?
    Ms. Brownley. Yes. Thank you, Mr. Chair.
    I wanted to go back, Dr. Shore, and ask you a few more 
questions about tinnitus.
    So I am happy to hear that actually NIH and DoD are getting 
involved in recognizing this as a serious problem. I am 
interested to know. You talked a little bit about the research 
or the lack thereof, but I am interested to know where the 
promising research is. You talked about, you know, damage to 
the ear, the brain being two possible causes for this disease.
    Is the research going more towards, being more directed to 
brain research or----
    Ms. Shore. Yeah. I think the strong research that has begun 
over the past decade or so has been targeting brain mechanisms. 
And so there are many laboratories now around the country. Some 
of them do imaging studies with humans. Many of them use animal 
models because with the animal models, you can go into the 
brain and record from single cells and see what happens to 
those single cells after a noise exposure or after a head and 
neck injury.
    And so a lot of our understanding has come from those 
animal models that show that after, especially after noise 
exposure which is a lot of where the studies focus on, the 
neurons in certain specific parts of the brain become 
hyperactive.
    So they are firing along as if there were a sound there and 
higher neurons up there are interpreting that as a sound 
whereas, in fact, there is no sound.
    And then another thing that is being discovered is that it 
is not only auditory centers in the brain that are involved in 
tinnitus but non-auditory centers as well. Some of those I have 
already mentioned such as the somatosensory system.
    So many people who have tinnitus, if they clench their jaw 
or push on their face, they can make their tinnitus louder or 
softer or change the frequency or even make it go away. And 
that highlights this interaction between the touch sensitive 
neurons and the auditory neurons.
    Another area of strong research over the past few years has 
been the connection between tinnitus and depression. And it is 
often comorbid and it is often comorbid again in disorders such 
as PTSD. And it could be that the reason for that is because 
the brain mechanisms are targeting both of these centers.
    So it is, you know, not necessarily, you know, the chicken 
and the egg stories. It may be that these conditions developed 
together and you do not just get depressed because you have 
tinnitus, but that depression and tinnitus sort of exhibit 
themselves together.
    And so some of the research is targeting those areas. I 
could go on for a long time.
    Ms. Brownley. But the damage to the ear then, it seems to 
me as someone who does not have a medical background or a 
science background really at all, it seems if there was damage 
to the ear that that is something that could be fixed, that 
perhaps would be a cure. So it seems to me that it is much more 
on the brain sensory side.
    Ms. Shore. Yeah. So one of the big questions with tinnitus 
is that even some people who have noise damage and hearing loss 
do not get tinnitus and why is that? We need to understand that 
because if we understand that, maybe we could prevent the 
people who do get tinnitus from getting it.
    But even if somebody does not have a hearing loss, they can 
get tinnitus. And that has been a big area of research recently 
because audiology clinics, you know, can measure and they can 
show that people do not have hearing loss. But if you do more 
sophisticated hearing tests, you can show that hearing actually 
is affected at a much milder level, enough to trigger a 
tinnitus in the brain.
    Ms. Brownley. Thank you.
    And any research, we have talked about the research in the 
United States, is there any research outside of the United 
States internationally that is any different than what you have 
just discussed?
    Ms. Shore. Well, there are some research organizations 
outside of the U.S. that have actually been very instrumental 
in pushing tinnitus researchers forward even within the U.S. 
And some of them are based in Germany and England. And they are 
trying their best as well separately and together to try to 
push tinnitus research forward so that we can find a cure.
    Ms. Brownley. And is there some coordination that we are 
doing between investments in the research now that other 
agencies, NIH and you said DoD is providing some grants and 
what the VA is doing?
    Ms. Shore. Coordination in what sense?
    Ms. Brownley. Well, coordination in terms of, you know, 
progress or the research that needs to be done before, you 
know, to pursue a clinical trial.
    Ms. Shore. Right. Well, there are scientific meetings that 
are very important that, you know, most people who do research 
in tinnitus will go to those meetings and present their 
findings and have discussions, set up collaborations.
    And that is the major source of information transfer as 
well as publication of papers. And that is going to be 
available to everybody, not just within a certain organization.
    Ms. Brownley. And of our veteran population that is 
suffering from this, do you have some percentage of our 
veterans who we just have not provided any kind of successful 
treatment for it?
    Ms. Shore. Well, I think the majority is not getting really 
successful treatment because there is no cure. And like, you 
know, I mentioned that there is a treatment program that is 
available that does help, I think, to some extent because even 
a person who comes in who has tinnitus, if they are told that 
this is not due to some life-threatening condition, that makes 
them feel better. But that does not make their tinnitus go 
away.
    Sound therapy is like masking. It sort of masks out the 
tinnitus for some people some of the time, but it is not 
actually getting rid of the tinnitus. And so currently there 
are not any standard treatments that we could say everybody 
should use this and their tinnitus will go away.
    But there are a number of tinnitus treatments that are 
being developed in research labs that are being tried out in 
animal models and that are being moved for clinical trials. And 
some of those are extremely promising because they are 
targeting the root of the disorder and trying to change brain 
circuitry.
    Ms. Brownley. Thank you.
    And thank you for the additional time. I yield back.
    Mr. Benishek. Mr. Huelskamp.
    Mr. Huelskamp. Thank you, Mr. Chairman.
    A quick question first for Mr. Drexler. You do mention a 
few of the rural areas might not have a code that you referred 
to.
    And then how are those situations handled and in your mind, 
how should they be handled in terms of these inspections? Who 
would inspect and what would be the basis for those 
inspections?
    Mr. Drexler. Essentially, the firm would hire a third-party 
inspection agency and that is becoming very common across the 
country.
    A simple example would be the State of California. We have 
all gone through, you know, the economic downturn. And 
California really took a big hit and they were forced to reduce 
numbers within their building and fire prevention staffs, 
inspection staffs, and went and began hiring third-party 
inspection agencies.
    Third-party inspection agencies would provide those 
inspections. They meet the certain qualifications that are 
established by and within the municipality and would ensure 
that----
    Mr. Huelskamp. Mr. Drexler, a quick question. If there is 
no code specified by the municipality or the county or the 
state as a mandate, what should be the code, the basis of the 
inspection then?
    Mr. Drexler. What should be the code if there is no code 
within that municipality? I think the legislation here would 
draw the need to require either the I codes or the life safety 
codes and recommend and require those codes to be in place 
within the municipalities that do not have building and fire 
prevention codes.
    Mr. Huelskamp. So the municipality would be forced to adopt 
those?
    Mr. Drexler. Yes.
    Mr. Huelskamp. Under this legislation. Okay. Well, thank 
you. One other question though. I appreciate that.
    Follow-up, a little bit more on the transportation issue. I 
did a town hall in Syracuse, Kansas one week ago or eight days 
ago. Same gentleman that was there a year ago brought up the 
same story again. I am sure you hear that from rural areas.
    In this case, he was asked to drive 524 miles to have blood 
drawn. And it is just crazy. Cannot get the VA to figure out 
that there are a dozen hospitals along the way including one in 
his hometown. And here we are talking about encouraging 
transportation, although we are encouraging to allow him to go 
a few blocks to the local hospital.
    What should I tell this veteran? What do I need to be 
doing?
    I cannot seem to get the VA to figure this out. He has 
mentioned that to them again, 524 miles to get his blood drawn. 
And it does not matter whether you have a contract issue of who 
drives him. It is himself. And as long as he drives what, three 
times a month, he can be reimbursed but not if he drives less.
    Any thoughts on that from the veteran service 
organizations? What are we supposed to be doing here? This is 
just unacceptable and I cannot get an answer for him that 
works.
    Mr. Gadd.
    Mr. Gadd. I can answer that question. We testified, The 
American Legion did in the fall last year about fee-basis and 
non-VA care coordination. And, you know, we said that the VA 
should exercise discretion based on patient-centered approach.
    And that approach is that, you know, we can understand if 
they go for a major procedure within a VISN or near an area, 
but to have multiple trips a couple days a week, you know, for 
dialysis, you know, look at other options closer to that 
veteran's community.
    And I think that that is a perfect way to--in this case, 
what was the local options? What was the closest community-
based outpatient clinic? Is there a demand for laboratory 
services there in that area? Maybe that is something that the 
gentleman from the VA could address this morning.
    But we would argue that if it is multiple trips, and it is 
inconvenient, that the VA does have that authority to allow 
that veteran to be treated there locally near his home.
    Mr. Huelskamp. Do you think that in your mind they do not 
want to allow that or it gets lost in the shuffle or they just 
generally do not want to allow that? What is your thought on 
the VA's----
    Mr. Gadd. They implemented the non-VA care coordination is 
the new rollout of that program. And they are trying to 
standardize procedures and how they formulate those decision-
making abilities.
    You know, but we have argued that the veteran should have a 
say in that process and that there should be some recourse that 
the veteran has to appeal that decision, you know, and not have 
to drive 500 miles to get a blood draw. You know, that is 
ridiculous.
    Mr. Huelskamp. Mr. Kelley or Mr. Atizado, any thoughts?
    Mr. Atizado. I am just going to echo what Mr. Gadd 
mentioned. That local VA facility, the parent facility that 
that veteran is driving to, has the authority to pay for that 
service or that lab service at the closest location to the 
veteran's residence.
    There are various reasons why a facility would choose not 
to exercise that authority. And I do not think we can discuss 
that at this point without all the information in front of us.
    But, nonetheless, that veteran should be able to speak to 
their primary care physician or social worker and hopefully 
that health care team will say, you know, 500 miles is a little 
too much.
    But, again, I cannot answer one way or the other why that 
is, just to say that VA does have the authority.
    Mr. Huelskamp. Is this a situation you hear about with 
regularity? How often does it happen? Is it just one guy in 
Syracuse, Kansas or is it something that you continue to hear 
from your constituents about as well?
    Mr. Atizado. Well, as far as getting care in the community, 
we hear it more often simply because it is an issue that is 
brought up as opposed to a veteran who does get care in the 
community and does not say, hey, I got care in the community, 
it is great. They have nothing to contact and complain to us 
about.
    So, yeah. So there are issues like that where a veteran is 
not being allowed by VA to go to a local or community service 
and have VA pay, which is not to say that the issue of 
transportation is without issues as well, but this is an issue.
    That is why VA, as Jacob mentioned, has a non-VA care 
coordination office set up to establish some semblance of 
compassion in the fee-care program to make it more patient 
centered.
    Mr. Huelskamp. Okay. Thank you, Mr. Chairman, unless Mr. 
Kelley had some thoughts. Thank you. I yield back.
    Mr. Benishek. Well, I would like to thank the Members of 
the panel for their testimony today. It was very enlightening 
and I do appreciate your comments and look forward to any 
further input you want to give to me in the future on this 
bill.
    So thank you very much for your participation and you are 
excused.
    We will now call Dr. Jesse as he is the sole member of the 
third panel.
    You can begin when you are ready, Dr. Jesse.

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. Good morning, Mr. Chairman and Ranking Member 
Brownley and Members of the Subcommittee.
    We do appreciate your continuing efforts to support and 
improve veterans' health care and we thank you for the 
opportunity to address the bills on today's agenda along with 
their impact on VHA's health care operations.
    Joining me today is Deputy Assistant General Counsel Susan 
Blauert.
    And I would also like to thank Chairman Miller for coming 
by earlier.
    VA recognizes the importance of each one of these bills and 
we are committed to work with you and the Members of the 
Subcommittee and Congress on legislation that can enhance our 
ability to provide health care to our Nation's veterans.
    I am going to address a few key points on each of the bills 
today, but the more detailed explanations are available in my 
written statement.
    Regarding the draft, Long-Term Care Veterans Choice Act, VA 
supports the concept of medical foster homes as an alternative 
to long-term institutional care as requested in VHA's fiscal 
year 2014 budget submission.
    We appreciate your interest in the concept, but we do need 
additional time to continue technical assistance to the 
Committee and particularly on details pertaining to the term 
adult foster home versus medical foster home, the payment 
methods, and cost analysis.
    VA strongly supports H.R. 1702 which would make permanent 
the authority to hire qualified drivers to expand access to VA 
health care for individuals traveling to and from VA health 
care appointments.
    In 2012, though, Veterans Transportation Service or VTS 
provided more than 199,000 one-way trips totaling more than 9.7 
million miles. The average length of a one-way trip is over 48 
miles and it is a considerable distance and often would be 
prohibitive for those with poor health were transportation not 
available.
    Veteran service organizations are invaluable in providing 
volunteers to drive veterans to their appointments. However, 
there are often not enough volunteers to meet the level of 
need. More importantly, they are often precluded from 
transporting veterans with various clinical issues such as 
portable oxygen, as you heard. We do not see VTS as 
competitive, but rather supplemental to the important role 
played by the VSOs.
    VA is in agreement with the goal of H.R. 1443, the Tinnitus 
Research and Treatment Act of 2013, which would recognize 
tinnitus as a mandatory condition for research and treatment 
and require cooperation with DoD to perform further research.
    However, the bill describes programs and operations that 
already exist within VA. Our audiology clinics already provide 
tinnitus treatment through a progressive tinnitus management 
program which includes group educational counseling treatment 
and individualized management.
    VA has active projects underway in researching the efficacy 
of this multidisciplinary tinnitus treatment, the underlying 
etiology of tinnitus, and the co-occurrence of hearing loss 
along with tinnitus.
    VA is also collaborating with DoD on the development of a 
registry of the critical information to track the diagnosis, 
surgical interventions, or medical treatments for tinnitus and 
to follow-up for each case of hearing loss and auditory system 
injury incurred by servicemembers while on active duty.
    Currently, VA has the responsibility to ensure the safety 
of veterans cared for in its grant and per diem or GPD 
facilities through on-site inspections of each facility by 
staff from the local VA medical center. Inspections are focused 
on compliance with the requirements of the life safety code of 
the National Fire Protection Association.
    The inspection team is responsible for ensuring that 
general operating requirements as noted in GPD regulations are 
met.
    VA believes these measures ensure the safety of those 
properties and recognizing that as the intent of H.R. 2065, we 
do have some concerns with the bill as written. Specifically, 
we are concerned that H.R. 2065 will shift the cost of 
certifying compliance with life safety code or other applicable 
codes to the GPD grantees.
    Currently, VA covers the cost by inspecting the GPD 
facilities for compliance with life safety code at no charge to 
the grantee. Over 96 percent of current GPD projects are 
operated by non-profit community-based providers. Any increased 
operating costs for these grantees could have a negative impact 
on the type and quality of services provided to veterans.
    We are also concerned that H.R. 2065 could have an 
inequitable impact on GPD providers in rural areas because of 
the difficulties of assessing qualified inspectors to certify 
compliance in those areas.
    We do not yet have testimony on H.R. 1612 which would 
authorize VA to transfer a 64.5 acre tract to Tuskegee 
University or as noted previously from the draft, Long-Term 
Care Veterans Choice Act.
    However, we look forward to working with the Committee in 
providing technical assistance on these and any other bills 
before the Committee today.
    This concludes my remarks. On behalf of the department, 
thank you again for the opportunity to provide our views and be 
pleased to answer questions.

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

    Mr. Benishek. Thank you, Dr. Jesse. It is a pleasure to see 
you once again before the----
    Dr. Jesse. Thank you, sir.
    Mr. Benishek. --Committee. I have a couple of questions. I 
will yield myself five minutes.
    Is there a difference in what you are saying about the 
amount of research in tinnitus?
    You said you are already doing research because I think 
this $10 million number is what keeps sticking in my mind, that 
there are so many episodes of tinnitus and you have $10 million 
for a multibillion dollar problem. It does not seem like much. 
So you seem to say something that you are already doing 
something about it.
    Is that $10 million number wrong then?
    Dr. Jesse. Well, that $10 million number, I think, was 
nationally, not just VA, nationally. VA's investment is about 
$1.2 million, so about a tenth of that is in VA, mostly in four 
projects, three of which are really focused on the clinical 
assessments, one specifically which was called for in the bill 
to look at the efficacy of this multi-step treatment program.
    Mr. Benishek. You do not dispute that number then? That 
number seems reasonable to you?
    Dr. Jesse. Oh, no. Actually, I think that is a pretty small 
number compared to what we spend on a lot of other things.
    And I think what is interesting is, as Dr. Shore noted, 
that there has really been, I think, a dramatic change in the 
past, I will just say a couple of years, through new imaging 
modalities that are really beginning to describe the functional 
changes within the brain in patients with tinnitus historically 
which has really focused on it being an ear problem.
    But those technologies are relatively new and it takes time 
to get that kind of work into the, you know, the life cycle of 
research.
    But, yeah, I think it is--I guess I do not know that I can 
say it is underfunded because there is not enough money for the 
research or it is underfunded because there has not been the 
kind of high-quality grants proposals coming through the system 
in order to get them funded.
    Mr. Benishek. So it is not like you are in favor of the 
legislation.
    Dr. Jesse. Well, we have no problems with the legislation. 
I think basically what is described in the legislation is stuff 
that we are already doing.
    I guess the one issue, and just to be very clear because of 
the dynamics of research, is remember that VA is only 
authorized to do intramural research. We cannot fund extramural 
research. That is one of the reasons why we value the research 
partnerships with DoD who can.
    Mr. Benishek. Okay.
    Dr. Jesse. And I do not have the numbers for DoD.
    Mr. Benishek. Well, that is an interesting point there.
    I have another question for you, too, and that is this 
transportation issue.
    Dr. Jesse. Uh-huh.
    Mr. Benishek. And that is something I think we may have 
talked about before, and that is the fact that it came out here 
in the earlier panel with Mr. Huelskamp pointing out the fact 
that--are we going to transport more patients, make it easier 
to transport the patient 500 miles or are we going to use, the 
local community access mode and how are we going to balance 
that.
    I have been to town hall meetings myself where veterans 
have said to me, I cannot get to the place I want to go to get 
my x-ray and the other guy said, well, I can get the x-ray 
right here. So one veteran wants to go the 100 miles to get the 
chest x-ray. The next veteran does not want to go the 100 miles 
to get the x-ray.
    So I know there is a lot of individual variability in the 
patient preference. And I do not really know the best answer to 
that myself. I think now it all happens at the VA.
    My concern is the fact that, does the patient have an 
opportunity to call back once he gets an order to come in for 
an x-ray or a blood test, he can just call the VA back and say 
can I get the test done at my local hospital without having to 
go back to the initial doctor because sometimes that can be the 
problem?
    And the person who is answering the phone cannot get a hold 
of the regular doctor, or does not have the authority to make 
that decision.
    I think in the practical terms of how that gets done, there 
may be some problem, when the patient says I would rather get 
it done in my hometown and then the person they talk to on the 
phone does not have the authority to do that and cannot get a 
hold of the person that does.
    How does that actually occur and how do we make it better 
for the patient?
    Dr. Jesse. So I think this is one of the reasons why we 
are, as Jacob Gadd mentioned, the notion of having the 
coordinator for non-VA care, so there actually is a person who 
could make these kinds of decisions without somebody getting 
into the swirl of administrative phone tag.
    I know my patients, some that live still in Richmond where 
I still have my clinic, we draw from northern, you know, down 
into Roanoke Rapids areas of North Carolina and the far south 
West Virginia, some people have to travel fair distances. I 
mean, I think that common-sense is the thing that will prevail 
here.
    And I have patients who, for instance, are on Warfarin who 
have to have their INRs checked. Most of them will get it 
checked locally and they will also get it managed locally. 
Occasionally people will get it done at the VA because they are 
coming up for a lot of other things and we can coordinate the 
visits around that.
    I think traveling 500 miles to get a blood drawn is kind of 
beyond common sense. I mean, if you are looking at a cost-
basis, what we pay for benny travel, far exceeds the cost of 
that test.
    And the other piece that comes in here and one of our real 
fears many times is that the lack of coherence of the 
information, meaning if it is done in the VA, we can track it 
through our electronic medical record. It is there for 
everybody to see. There really is the continuity of care-based 
on the information. When it is done outside and gets reported, 
it often gets lost.
    And, you know, obviously a lot of what is going on 
nationally around health IT is meant to take some of those 
things into place. But I think we really try to do what is best 
for the patient and, you know, I am sorry to hear that some 
people have problems like this. I think that we need to be 
doing better in those cases.
    Mr. Benishek. Do you think that this coordinator, this 
person is going to make the difference then? That is what you 
are telling me.
    Dr. Jesse. Well, I think the primary care, you know, as we 
move to team-based care, as we move to the idea that you now 
have actually a direct connection in and you should not be 
having these, I cannot get my provider type of things, and 
those decisions can get made and taken care of that way.
    Mr. Benishek. My time is up here. I will leave it to Ms. 
Brownley.
    Ms. Brownley. Thank you, Mr. Chair.
    I just also wanted to follow-up again on this tinnitus and 
the role of the VA in it. I mean, it seems to me that, you 
know, $1.2 million is not enough for the VA's participation.
    And it seems to me if this is something, and clearly it is, 
that our veterans are suffering from, that the VA should be 
taking a significant leadership role in trying to lead the 
research to find cures for this.
    It is clearly costing the VA a lot of money for treatment 
that does not seem to necessarily have great outcomes. And I 
think always with research, if there is a will, there is a way. 
And it seems to me that the VA should be the leader in this 
area.
    Dr. Jesse. So I think from a clinical perspective in the 
treatment of tinnitus, we are. In terms of the basic research, 
I do not know that we are not because obviously there is not a 
lot going on in the country as it is.
    But as I mentioned, I think one of the issues is it has 
been a problem because we cannot quantitate it. We do not have 
a biomarker for it. And so we do not have a cure for it because 
we do not really understand in many cases what causes it. And 
so we have had to focus on the treatment and amelioration of 
the symptoms.
    Now with newer imaging modalities and better science, I 
think we are going to get a much better handle on the basis of 
the disease. And then when one can understand that, you can 
begin to define treatments that get to the root source rather 
than treating the symptom.
    Ms. Brownley. Well, I mean, in Dr. Shore's testimony 
anyway, it seemed as though the treatments generally are not as 
successful, I guess, as we would like them to be. And if that 
is our leadership, it does not seem to me to be adequate 
because we are not necessarily treating the condition 
successfully and, yet, we also do not have a cure.
    So it just feels to me very much like we should be in a 
better leadership role around this because it is our customers, 
it is our constituents who are suffering from it and we should 
not be dependent on sort of outside research in hopes of, in 
hopes of coming up with a cure.
    I also just wanted to ask why at this moment you do not 
have a position on H.R. 1612? Is that what I heard you say, 
that you did not have a position?
    Dr. Jesse. Oh, it is for Tuskegee.
    Ms. Brownley. Yes.
    Dr. Jesse. So just to be clear, we have no issue with 
transferring the land. It is a technical issue about what is 
required before we can do that. And so my understanding without 
stepping over my knowledge-base or bounds on this is that in 
order for us to transfer land back, certain assurances have to 
be made. And those are already existent in other Federal 
statutes. And so those have to be completely vetted and 
understood and then we will work through the process.
    Our objection is not in the transferring of the property. 
It is making it happen in a way that meets all the requirements 
and we just have not fully understood all of them yet. And also 
what that is going to mean is, there is going to be some cost 
associated with it that will have to be borne by somebody. We 
just do not know what that is yet and that is why we do not 
have the views.
    Ms. Brownley. Thank you. I yield back.
    Mr. Benishek. Thank you, Ms. Brownley.
    Well, I think I have so many questions I could go on for a 
couple more hours. To tell you the truth, there was a lot of 
interesting things that came up in all the panels today. I may 
put some written questions----
    Dr. Jesse. Sure.
    Mr. Benishek. --for the record to even some of the previous 
panels because these are such an interesting subjects and I 
think deserve a little more thought.
    So I want to thank you for your testimony today, Dr. Jesse, 
and thanks to all the other people that testified today. You 
are excused, Dr. Jesse.
    I ask unanimous consent that all the Members have five 
legislative days to revise and extend their remarks and include 
extraneous material. Without objection, so ordered.
    I would like once again to thank all the witnesses and the 
audience members for joining us in today's conversation.
    The hearing is now adjourned.

    [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 this morning to discuss five pieces of 
legislation concerning the health care and services available to our 
honored veterans through the Department of Veterans Affairs' (VA's) 
health care system.
    The five bills we will discuss today are:

    - Draft legislation, the Long-Term Care Veterans Choice Act;

    - H.R. 1443, the Tinnitus Research and Treatment Act of 2013;

    - H.R. 1612, to direct the Secretary of Veterans Affairs to convey 
a parcel of land in Tuskegee, Alabama, to Tuskegee University;

    - H.R. 1702, the Veterans Transportation Service Act; and,

    - H.R. 2065, the Safe Housing for Homeless Veterans Act.

    From ensuring the safety of homeless veterans residing in VA 
Homeless Grant and Per Diem facilities to ensuring that veterans 
eligible for VA-paid nursing home care are able to receive care in 
certified medical foster homes should they choose, these five bills 
address a number of critical issues facing today's veterans and all of 
us charged with caring for them.
    I am eager to discuss each of these proposals in-depth to ensure a 
thorough understanding of their purpose, intended benefits, and 
unintended consequences.
    I am grateful to my colleagues who sponsored these bills and to our 
witnesses for being here to discuss them with us.
    I look forward our conversation.
    With that, I now yield to Ranking Member Brownley for any opening 
statement she may have.

                                 
               Prepared Statement of Hon. Julia Brownley
    Thank you, Mr. Chairman.
    The purpose of today's hearing will be to explore the policy 
implications of five bills before us today which cover a wide range of 
topics that would expand and enhance VA's health care programs and 
services. To allow maximum time for discussion, I will limit my opening 
remarks primarily to H.R. 1443 and H.R. 1702.
    H.R. 1443, Tinnitus Research and Treatment Act of 2013, is offered 
by Ranking Member Michaud.
    According to the VA, tinnitus is the number one service-connected 
disability for veterans from all periods of service, affecting over 
840,000 veterans. Since 2005, the number of veterans receiving service-
connected disability for tinnitus has increased by at least 15 percent 
each year, and VA has been paying out over $1.2 billion annually to 
veterans for tinnitus disability compensation. At the current rate of 
increase, service-connected disability payments to veterans for 
tinnitus will cost $2.26 billion annually by 2014. Nevertheless, only 
about $10 million is dedicated to researching tinnitus in the public 
and private sectors.
    H.R. 1443 will allow for appropriate research time and resources by 
directing VA to recognize tinnitus as a mandatory condition for 
research and treatment by the VA Auditory Centers of Excellence. This 
will make certain that research is conducted at VA facilities on the 
prevention and treatment of this condition, and that VA cooperates with 
the Department of Defense's Hearing Center of Excellence to further 
research on tinnitus. H.R. 1443 would ensure that we remain on the 
cutting edge for research and treatment of this issue facing veterans 
of all ages.
    Next, H.R. 1702, introduced by Mr. Barber of Arizona, would 
permanently authorize VA to operate the Veterans Transportation Service 
(or VTS), which provides transportation for individuals to and from VA 
medical facilities in connection with vocational rehabilitation, 
counseling, examination, treatment, or care. VTS was launched in 2010, 
and VA's current authority to operate the program is set to expire in 
January of next year.
    I did want to emphasize the critical need for this legislation in 
helping to increase access to care for those who would otherwise face 
challenges in getting to and from their appointments at VA. I also 
wanted to highlight that VA has estimated VTS to save up to $19.2 
million in FY14 and $102.7 million over five years, because it is less 
expensive for the VA to hire drivers through VTS than to contract with 
ambulance services or to provide mileage reimbursements. So this is 
simply a commonsense initiative.
    Thank you, Mr. Chairman, for including these bills on the agenda. I 
look forward to hearing the views of our witnesses on the legislation 
before us today.
    Thank you, and I yield back.

                                 
                 Prepared Statement of Hon. Jeff Miller
    Thank you, Dan.
    It is a pleasure to be here again with you, the Subcommittee on 
Health, and all of our witnesses, stakeholders, and audience members to 
discuss my draft bill, the Long-Term Care Veterans Choice Act.
    The Long-Term Care Veterans Choice Act would authorize the 
Department of Veterans Affairs (VA) to enter into a contract or 
agreement with a certified Medical Foster Home (MFH) to pay for the 
residential long-term care of service-connected veterans who are 
eligible for VA-paid nursing home care. As a component of such care, 
eligible veterans would also be required to receive VA home health 
services.
    Medical foster homes (M-F-Hs) are private homes in which a trained 
caregiver provides twenty four hour, around-the-clock, care to a few 
individuals. They are designed to provide a non-institutional long-term 
care alternative to those who prefer a smaller, more home-like and 
familial care setting than many traditional nursing homes are able to 
provide.
    VA has been helping to place veterans in medical foster homes for 
over a decade. VA, as part of the placement process, inspects and 
approves all MFH's, limits care to no more than three veterans at a 
time, and provides veterans living in such homes with home based 
primary care services. VA also provides safeguards to ensure veterans 
receive safe, high-quality care by requiring MFH caregivers to pass a 
Federal background check and VA screening, agree to undergo annual 
training, and allow VA adult foster home coordinators and members of a 
VA home care team to make both announced and unannounced home visits.
    Today, according to VA, over four hundred approved caregivers 
provide MFH care in their homes to over five hundred veterans daily in 
over thirty five states.
    The problem, however, is that VA does not have the authority to pay 
for the cost of the MFH. So, the veteran who chooses to live in a MFH 
must pay out of pocket with personal funds - regardless of whether or 
not such veteran is eligible for VA-paid nursing home care.
    This creates a situation where many service-connected veterans with 
limited financial resources, who would prefer to live in a medical 
foster home, go to a nursing home institution instead because VA will 
cover the cost of the nursing home, but not the MFH.
    And, while traditional nursing homes will always be a vital 
component of long-term care, medical foster homes provide a worthy 
alternative for many veterans.
    According to the Department, many more veterans would elect to 
receive care in a medical foster home should VA be granted the 
authority to pay for such care.
    I am sure we all agree that one thing we owe our veterans, 
particularly those who are service-connected and in need of long-term 
care, is the luxury of choice - the choice to decide where and how to 
receive the care they need.
    As the veteran population continues to age, the need for long-term 
care services will continue to grow. The Long-Term Care Veterans Choice 
Act would expand the long term care choices offered to veterans beyond 
traditional services. Additionally, in addition to being beneficial for 
the health and well-being of veterans, the average cost of a MFH is 
more than half the monthly cost of a nursing home, making this 
legislation a very cost effective health care option.
    This is a common-sense, veteran-centric bill that will free many 
veterans from financial turmoil, and allow them to make their own 
decisions about what kind of long-term care they want to receive.
    I look forward to working closely with all interested parties to 
resolve any issues that may arise during today's discussion.
    Thank you once again, Dan, for holding this hearing today and for 
the hard work and leadership shown by you and all of the Members of 
this Subcommittee. And, with that, I yield back the remainder of my 
time.

                                 
               Prepared Statement of Hon. Jackie Walorski
    Mr. Chairman and Ranking Member, it's an honor to serve on this 
Committee.
    I thank you for holding this legislative hearing to enable relevant 
stakeholders the opportunity to improve legislation directly impacting 
them.
    I also want to thank the veteran service organizations testifying 
today and those in attendance. The selfless work your organizations 
perform continues to inspire Members, such as me, to remain steadfast 
in our commitment to improving veteran health care.
    The Veteran Health Administration oversees an extensive integrated 
health care system. In fiscal year 2012, approximately 8.76 million 
veterans were enrolled in the VA health care system--with approximately 
6.33 million unique patients treated. \1\ While these are impressive 
numbers, we must not get buried in statistics and lose sight of what is 
most important--the veterans who have earned their right to quality and 
accessible health care.
---------------------------------------------------------------------------
    \1\ U.S. Department of Veterans Affairs, National Center for 
Veterans Analysis and Statistics, ``Department of Veterans Affairs 
Statistics at a Glance Pocket Card.'' Updated 17 April 2013. http://
www.va.gov/vetdata/docs/Quickfacts/Spring--13--sharepoint.pdf.
---------------------------------------------------------------------------
    I look forward to working with my colleagues and our panelists on 
this legislation before us.
    Thank you.

                                 
             Prepared Statement of U.S. Rep. Mike D. Rogers
                               H.R. 1612
    Thank you Chairman Benishek and Ranking Member Brownley.
    First, I would like to thank you Mr. Chairman and your staff for 
holding this hearing today. I also want to thank the Full Committee 
Chairman, Jeff Miller, for his leadership on behalf of our Nation's 
veterans.
    Mr. Chairman, H.R. 1612 will benefit the Department of Veterans 
Affairs (VA), the people of Tuskegee, Alabama and the taxpayer.
    In 1922, the board of Tuskegee University voted to donate 300 acres 
of land to the federal government for a veterans' hospital. Since that 
time, the Tuskegee VA hospital and Tuskegee University have grown into 
integral parts of the community and serve important roles for our 
nation. Now, as the VA refocuses its mission to better serve our 
veterans, some of the donated land near the University's campus no 
longer fits the VA's needs.
    My bill would transfer 64.5 acres of land at 2400 Hospital Road 
back to Tuskegee University so that the land can better serve the 
community. This transfer also creates new opportunities for the VA by 
reducing substantial overhead and maintenance costs and providing 
cooperative authority to leverage the strengths of both institutions.
    This bill has been scored at no cost to the federal government and 
is a prudent use of our federal resources. Thank you again for the 
opportunity to testify Mr. Chairman and appreciate your leadership and 
strong support for this legislation.

                                 
        Prepared Statement of Honorable David B. McKinley, P.E.
    Chairman Benishek, Ranking Member Brownley and Members of the 
Subcommittee, thank you for holding this legislative hearing today on 
important issues that affect our nation's veterans. I appreciate the 
opportunity to give remarks on my bill, H.R. 2065, the Safe Housing for 
Homeless Veterans Act. This is the same bill, with some modifications, 
that I testified for before the Subcommittee in the last Congress and 
that passed the House.
    Currently, there are over 2,100 community-based homeless veteran 
service providers across the country and many other homeless assistance 
programs that have demonstrated impressive success reaching homeless 
veterans. I have visited some of the shelters in my home district in 
West Virginia and was struck by how many seemed to not be in compliance 
with state, local or federal safety codes.
    Consequently, we began to investigate how widespread this problem 
was. It was unsettling to learn about shelter fires where lives have 
been lost. We read stories of a homeless shelter fire where occupants 
were killed because there was no sprinkler system at the facility and 
another where homeless veterans were injured because a sprinkler system 
was not working properly and the fire exits were blocked. These types 
of tragedies could have been avoided.
    This common sense legislation would ensure the wellbeing of 
veterans who have fallen on hard times and are in the most need of 
assistance. There is no current law mandating VA homeless shelters meet 
code. There is only a loosely defined policy that is not universally 
being followed. As a licensed professional engineer, I found this to be 
an egregious omission in the law governing VA homeless program funds.
    H.R. 2065 would require any organization that seeks funding from VA 
for services to homeless veterans to have documentation that their 
building meets or exceeds all building Codes. Since last Congress we 
made some modifications to the bill after meeting with stake-holder 
groups including the International Code Council. The current draft 
actually makes it easier for facilities to be certified as we open up 
the requirements beyond only Life Safety Codes to International 
Building and Fire Codes or any version of these codes that a local 
jurisdiction has adopted. Furthermore, the legislation would require 
adding a section in the VA annual report to Congress that would report 
the number of grant recipients or eligible entities who have submitted 
a certification that their facility met all building Codes.
    I understand that there is some concern over an undue burden for 
facilities to be certified that they meet or exceed the building codes. 
We welcome a continued dialogue on possible amendments to the 
legislation to make sure that this bill is simply requiring the 
facilities to follow what is already state and local law in most 
jurisdictions. I am pleased to let you know that we have already begun 
these discussions with the concerned parties and we are well on our way 
to a solution.
    After passing the House last year, this language was dropped from 
the final package that became law at the end of the year. As a nation, 
it should be unacceptable for us to allow homeless veterans be housed 
in potentially unsafe conditions. In defense of our country, these men 
and women were put in harm's way; they should not be in doubt about 
their own safety now that they are home again. These homeless veterans 
are experiencing a difficult phase of their lives and should be able to 
trust that they will be safe each night as they continue their return 
to being productive members of society.
    I appreciate the testimony in support of H.R. 2065 from other 
witnesses testifying here today and I thank you for your concern for 
the safety and living environment of our veterans.

                                 
                    Prepared Statement of Jacob Gadd
    Chairman Benishek, Ranking Member Brownley and distinguished 
Members of the Subcommittee, on behalf of Commander Koutz and the 2.4 
million members of The American Legion, I thank you and your colleagues 
for the work you do in support of our service members and veterans as 
well as their families. The hard work of this Subcommittee in 
addressing the health care needs of the veterans' community makes a 
substantial impact on the ability for veterans to receive, as they 
deserve, the best care anywhere.
         H.R. 1443: Tinnitus Research and Treatment Act of 2013
    To direct the Secretary of Veterans Affairs to recognize tinnitus 
as a mandatory condition for research and treatment by the Department 
of Veterans Affairs, and for other purposes.
    It is no secret that the men and women who serve in the armed 
forces are potentially subjected to some of the most devastating noise 
trauma in the occupational world. From noisy jet engines to gunfire and 
artillery, to say nothing of the potentially damaging shock waves from 
Improvised Explosive Devices (IEDs), the ubiquitous threat of the 
recent and ongoing wars in Iraq and Afghanistan, veterans again and 
again place their ears and hearing at risk in service to this country. 
Tinnitus, which can stem from multiple causes, is often characterized 
as a persistent ringing in the ears, ranging from the distracting to 
severely disruptive to the ability to concentrate and focus on tasks.
    The American Legion provides accreditation for over 2,600 service 
officers nationwide who work with veterans to assist with claims for 
disability benefits. As such, this dedicated network is intimately 
familiar with the types of disorders affecting the nation's veterans. 
Tinnitus represents the most prevalent service connected disability, 
with over 840,000 veterans receiving compensation for the disorder as 
of 2011 \1\. With so many veterans affected, research into the disorder 
is critical.
---------------------------------------------------------------------------
    \1\ US Department of Veterans Affairs Annual Benefits Report, FY 
2011.
---------------------------------------------------------------------------
    This bill would ensure a full spectrum of research would be 
conducted through the Department of Veterans Affairs (VA) into such 
varied topics as multidisciplinary treatment modalities, underlying 
etiological studies of the disorder, contrasting types of tinnitus with 
and without accompanying hearing loss, and other factors. The bill also 
prompts close cooperation between VA and the Department of Defense, 
perhaps a key component in preventing future incidences of the 
disorder. The American Legion ``encourages acceleration in the 
development and initiation of needed research on conditions that 
significantly affect veterans. \2\'' All hearing trauma, be it tinnitus 
or hearing loss, is a scourge veterans are quite familiar with. 
Increased research into mitigating the effects of such traumas is a 
boon not solely to today's veterans, but to generations to come.
---------------------------------------------------------------------------
    \2\ Resolution 108: Request Congress Provide the Department of 
Veterans Affairs Adequate Funding for Research and Prosthetic Research, 
- AUG 2012.

The American Legion supports the passage of H.R. 1443.
                               H.R. 1612:
    To direct the Secretary of Veterans Affairs to convey a parcel of 
land in Tuskegee, Alabama, to Tuskegee University, and for other 
purposes.
    This bill addresses land conveyance between the VA and Tuskegee 
University.
    The American Legion has no position on H.R. 1612.
             H.R. 1702: Veterans Transportation Service Act
    To amend title 38, United States Code, to make permanent the 
authority of the Secretary of Veterans Affairs to transport individuals 
to and from facilities of the Department of Veterans Affairs in 
connection with rehabilitation, counseling, examination, treatment, and 
care.
    This bill provides a technical amendment to the existing law in 38 
United States Code Sec. 111A, eliminating the provision in the current 
law which causes the authority of VA to expire and making the authority 
permanent. The authority in question allows VA to provide 
transportation services, increasing access to their facilities and 
health services.
    The American Legion believes there is a vital need for the Veterans 
Transportation System \3\ to ensure all veterans receive access to the 
care they have earned through their service and sacrifice. Through the 
conduct of our many System Worth Saving (SWS) visits to VA health care 
facilities nationwide each year, our field staff and task force members 
have seen firsthand the importance of this program in getting veterans 
to the facilities. Whether through volunteer efforts or the VTS 
program, many veterans need help to reach treatment and disruption in 
the ability to provide that help results in a loss of care. Making this 
authority permanent would help provide stability for planning purposes. 
The American Legion would further urge Congress to continue to monitor 
this program and to consider raises as appropriate for beneficiary 
travel rates \4\ as that is also a key component of getting veterans to 
the hospitals for treatment.
---------------------------------------------------------------------------
    \3\ Resolution 293: Veterans Transportation System (VTS) & Benefits 
Travel - AUG 2012.
    \4\ Ibid.
---------------------------------------------------------------------------
The American Legion supports the passage of H.R. 1702.
           H.R. 2065: Safe Housing for Homeless Veterans Act
    To amend title 38, United States Code, to require recipients of per 
diem payments from the Secretary of Veterans Affairs for the provision 
of services for homeless veterans to comply with codes relevant to 
operations and level of care provided, and for other purposes.
    This legislation requires veterans' homeless shelters to meet all 
appropriate building and fire codes. Veterans' homelessness is a 
critical problem. That veterans should have to contend with 
homelessness is a national shame. Secretary Eric Shinseki has been 
steadfast in his efforts to bring to bear the resources of VA to combat 
this issue, and great strides have been made in the last several years 
in reducing the numbers of homeless veterans on the streets every 
night.
    The American Legion supports the efforts of public and private 
sector agencies and organizations that aid homeless veterans and their 
families \5\. Additionally, the Legion supports legislative proposals 
to provide medical, rehabilitative, and employment assistance to 
homeless veterans and their families. The American Legion places 
special priority on the issue of veteran homelessness. To help our 
struggling brothers and sisters-in-arms, the Legion works on a global 
level, lobbying for legislation affecting veteran homelessness, and 
acts on a local level, directly assisting veterans who have fallen on 
tough times and are without a place to live or facing the prospect of 
it.
---------------------------------------------------------------------------
    \5\ Resolution 306: Funding for Homeless Veterans - AUG 2012
---------------------------------------------------------------------------
    This direct assistance is coordinated by the Legion's Homeless 
Veterans Task Force, which works to ensure local services and resources 
are available to homeless veterans and their families. The Task Force, 
which has chairpersons in each department, collaborates with government 
agencies, homeless service providers and veterans service organizations 
to develop and implement initiatives that will help homeless veterans.
    The Legion recognizes that aiding homeless veterans requires a 
sustained coordinated effort, which should provide secure housing and 
nutritious meals; essential physical health care, substance abuse 
aftercare and mental-health counseling, as well as personal development 
and empowerment. Homeless veterans also need job assessment, training, 
and placement assistance. The ultimate goal is total self management 
for the homeless veteran.
    Homeless veterans cannot be considered to have ``secure housing'' 
if they must contend with facilities that don't even meet basic 
building codes and place these uniquely vulnerable veterans at risk of 
serious injury or death from fires and substandard building materials. 
If these veterans have lost their homes and livelihoods, we cannot in 
good conscience place them at risk to life and limb in unsafe 
facilities.
    This legislation would ensure the facilities designated to serve 
the needs of homeless veterans comply with appropriate codes and 
regulations, and give them a stable and safe environment to help piece 
their lives together as they move forward.
The American Legion supports the passage of H.R. 2065.
         DRAFT LEGISLATION: Long Term Care Veterans Choice Act
    To amend title 38, United States Code, to authorize the Secretary 
of Veterans Affairs to enter into contracts for the transfer of 
veterans to non-Department adult foster homes for certain veterans who 
are unable to live independently.
    Adult Foster Care homes provide an alternative in some situations 
to traditional nursing home elder care. In general, these are single 
family homes which provide room, board and supervision as well as 
personal care services. These types of facilities provide for the needs 
of the elderly who, though they may require periodic or regular 
assistance with the activities of daily living, do not require full 
time nursing services.
    Individual states have a variety of rules and regulations related 
to the governance and approval of such facilities. This draft 
legislation would modify the United States Code to allow for veterans 
``for whom the Secretary is required to provide nursing care under 
section 1710A of [Title 38], the Secretary may transfer the veteran to 
an adult foster home that meets Department standards, at the expense of 
the United States, pursuant to a contract or agreement entered into 
between the Secretary and the adult foster home for such purpose.'' In 
essence, this legislation would allow VA to place veterans in these 
adult foster homes and pay for the services provided. Veterans can 
currently utilize such homes if they so choose, but they must pay out 
of their own pocket for the services, even if VA is authorized to pay 
for nursing care for the veteran.
    VA is authorized \6\ to provide a comprehensive array of medically 
necessary in-home services to enrolled veterans. This bill seeks to add 
a provision in title 38, United States Code (U.S.C.), Section 1720 that 
VA would be authorized to transfer veterans needing long-term care 
services to ``Foster Homes,'' upon the request of the veteran or 
Secretary of Veterans Affairs.
---------------------------------------------------------------------------
    \6\ Title 38, Code of Federal Regulations (CFR) Section 17.38 
(a)(1)(ix)).
---------------------------------------------------------------------------
    VA issued VHA Handbook 1141.02, Medical Foster Home Procedures, in 
November 2009, which outlined the Department's policy on definition, 
responsibilities, selection, training, quality monitoring and financial 
arrangements for this program.
    VA defines a Medical Foster Home (MFH) in VHA Handbook 1141.02 as:

    1) MFH is an adult foster home combined with a VA interdisciplinary 
home care team, such as VA Home Based Primary Care (HBPC) or Spinal 
Cord Injury - Home Care (SCI-HC), to provide non-institutional long-
term care for veterans who are unable to live independently and prefer 
a family setting.

    2) MFH is a form of Community Residential Care (CRC) for the more 
medically complex and disabled veterans, and is generally distinguished 
from other CRC homes by the following:

    (a) the home is owned or rented by the MFH caregiver;

    (b) the MFH caregiver lives in the MFH and provides personal care 
and supervision,

    (c) There are not more than three residents receiving care in the 
MFH, including both veterans and non-veterans,

    (d) veteran MFH residents are enrolled in a VA HBPC or SCI-HC 
Program.

    Each VA Medical Center facility appoints a MFH Coordinator which 
oversees the recruitment of staff, new applications for MFH in the 
community, training, quality assurance and inspections, and maintaining 
files of patients and MFH caregivers.
    While this program has been highlighted and encouraged because of 
the additional cost savings and access to care options for the veteran 
and VA, The American Legion seeks additional feedback from users of 
this MFH program about the level of patient safety and feedback on 
their quality of care that would be provided in a non-traditional care 
setting. We are continuing to study and monitor this situation to 
determine the best solution for veterans.
    The American Legion has no position on this legislation.
    For further questions or comments about this or other legislation 
affecting America's veterans please contact The American Legion through 
Ian de Planque, Deputy Legislative Director at [email protected]

                                 
                   Prepared Statement of Susan Shore
    Good morning Chairman Benishek, Ranking Member Brownley, and 
distinguished members of the Health Subcommittee. My name is Dr. Susan 
Shore, and I am the Chair of the Scientific Advisory Committee of the 
American Tinnitus Association. Thank you for holding this important 
hearing on an issue of concern to our nation's armed forces and those 
members returning from combat - Tin-night-us or tinn-it-us, most 
commonly referred to as ``ringing in the ears.'' Tinnitus has long been 
called the ``invisible injury,'' so because of this, and many other 
reasons which I will be addressing, it is extremely relevant and timely 
that tinnitus is recognized as a mandatory condition for research and 
treatment by the Department of Veterans Affairs. On behalf of the 
American Tinnitus Association and the 50 million Americans afflicted 
with tinnitus I appreciate the opportunity to speak to you today and 
respectfully urge your support for H.R. 1443, the Tinnitus Research and 
Treatment Act of 2013.
    The American Tinnitus Association focuses on curing tinnitus 
through the development of resources that advance tinnitus research. 
Founded in 1971, ATA is the only member- based and supported, national 
non-profit organization, dedicated to finding a cure for tinnitus. 
Since 1980 we have funded grants toward better understanding the 
mechanisms responsible for and underlying the genesis of tinnitus. Our 
Scientific Advisory Committee, comprised of 17 tinnitus investigators 
from multiple disciplines across the U.S., conduct peer reviews of all 
the grant proposals received at ATA. The most meritorious proposals 
with promise to help us get to that cure, are then forwarded to members 
of our Board of Directors who make the final funding decisions on these 
grants.
    The advances in tinnitus research over the past decade have been 
extraordinary. Many researchers across the country are breaking down 
barriers as I speak, in their own laboratories. One of the most 
important advances through research in recent years is the ability to 
``visualize'' tinnitus, through the use of advanced functional imaging 
technologies and through the development of animal models that can 
behaviorally assess the presence of tinnitus. These methods allow us to 
pinpoint tinnitus to certain regions of the brain. Another important 
advancement that has occurred mainly through the use of animal models 
is the discovery that tinnitus is a result of brain plasticity that 
occurs in response to outside insults such as noise damage or head and 
neck injury. In layman's terms, brain plasticity refers to the ability 
of neurons in the brain to change their responsiveness and connectivity 
in the face of environmental influences. These developments have led 
the scientific community to understand that tinnitus is a disorder of 
brain function.
    For decades, tinnitus was thought of as a disease of the ear, or 
simply a symptom of hearing loss. Because of research we now know that 
in most instances, tinnitus does not originate in the ear but rather in 
the brain. And we also know that you do not need to have a measurable 
hearing loss in order to have tinnitus. While noise overexposure is 
still the number one cause of tinnitus, it can also develop in the 
absence of hearing damage as the result of a head or neck injury. So, 
while the relationship between hearing loss and tinnitus is high, we 
still do not understand well why some people with hearing loss develop 
tinnitus and others do not. This is an important area of research for 
both human and animal models because if we understand why certain 
vulnerabilities exist, we can come up with more appropriate treatments.
    Tinnitus also does not discriminate. It can happen to anyone at any 
time. 50 million Americans experience tinnitus and of those, 16 million 
seek medical attention for recurrent or chronic tinnitus. Two to three 
million are completely debilitated from their tinnitus rendering them 
unable to work, interact with family and friends, or sometimes even 
leave their home, degrading their quality of life. In addition to 
tinnitus, these people often have feelings of anxiety, depression and 
loneliness which can be directly attributed to their condition. 
Research has uncovered that depression and anxiety are comorbid 
conditions with tinnitus and may be part of the brain circuitry that is 
misdirected in bothersome tinnitus.
    Specific groups of people are disproportionately impacted by 
tinnitus. These groups include, factory workers, police officers and 
firefighters, emergency medical technicians, musicians, and, the reason 
we are here today - our military personnel and veterans.
    Tinnitus is the number one service-connected disability for 
returning veterans from Iraq and Afghanistan. As I mentioned before, in 
addition to hearing loss, head and neck injury can also contribute to 
tinnitus. So while tinnitus in these veterans is most often the result 
of extreme noise exposure from either a single impulse noise or the 
accumulation of noise exposure, head and neck injury is also a leading 
complaint of these veterans. In fact, lumbosacral or cervical strain 
account for 23% of service-connected disabilities for Iraq and 
Afghanistan veterans as of July 2009. In addition to factors that cause 
hearing loss, such as noise over-exposure, the generation and 
maintenance of tinnitus can occur as a result of temporal-mandibular 
joint disorder, or somatic insults, including lumbosacral or cervical 
strain. Research into how these systems interact in the brain has the 
potential to lead to treatments such as tailored devices that aim to 
ameliorate aberrant brain circuitries resulting from a combination of 
hearing loss and head and neck injuries.
    Since 2006, service-connected disability payments to veterans from 
all periods of service for tinnitus, has been increasing at a rate of 
15% per year. In 2012, the VA paid out $1.5 billion in disability 
compensation to over 971,000 veterans for tinnitus alone. At the 
current rate of increase the cost will exceed $3 billion annually by 
2017. This dollar amount does not take into account the extreme 
suffering and necessary clinical care for veterans with tinnitus or the 
economic loss to society for those who are unable to work as a result 
of their tinnitus.
    When you consider that cost, in comparison to what is being spent 
on tinnitus research in the U.S., there is a severe disconnect. Up 
until very recently the amount of money being spent on tinnitus 
research has been negligible. At the end of 2012, between all public 
and private funding in the U.S., approximately $10 million was spent on 
funding research toward a tinnitus cure. Though still a small number, 
this is up from a mere $1.5 million in 2005, and that increase has been 
all due to Congressional interest in this matter.
    What have we learned as a result of recent increased research on 
tinnitus? And where do we need to go from here?

      It is now well-established that alterations in neural 
plasticity in distinct parts of the brain are changed in patient and 
animal models of tinnitus. This opens the way for stimulation 
treatments that alter the aberrant neural circuitry. Some examples of 
this are special devices that provide tailored auditory-somatosensory 
or vagal nerve stimulation with the aim of returning the circuits to a 
normal state.
      Other treatments aim to target changes in the molecular 
environment with targeted drug therapies but at present there is no 
drug treatment that is specific to tinnitus.
      The involvement of non-auditory systems in tinnitus is 
increasingly becoming apparent through animal and human tinnitus 
experimental models. Understanding these interactions in the brain is 
crucial for the development of treatments for alleviating this often 
debilitating condition.

    Several studies have been conducted by both the Department of 
Defense and the Department of Veterans Affairs as a result of the 
growing need to address tinnitus in the military. Those studies 
directly connect tinnitus as co-morbidity to both Traumatic Brain 
injury and Post Traumatic Stress Disorder as well as indicate that 
tinnitus is a larger problem than hearing loss in the blast exposed 
population. This is why our organization has advocated for the 
inclusion of tinnitus as a research condition in tandem with both TBI 
and PTSD.
    In particular, mild Traumatic Brain Injury or mTBI often includes 
tinnitus as a manifestation of injury. mTBI as defined by the 
Department of Defense Policy for Mild Traumatic Brain Injury is the 
presence of a documented head trauma or blast exposure event, followed 
by a change in mental status which could include nausea, dizziness/
balance problems, temporary headache, sensitivity to noise or lights, 
vomiting, fatigue, insomnia and sleep disturbances, drowsiness, blurred 
vision, memory problems, poor concentration and tinnitus. A recent DoD 
study on Iraq veterans exposed to blast indicated that 70% of those 
exposed to blast reported tinnitus within the first 72 hours after the 
incident. 43% of those seen one-month after exposure to blast continued 
to report tinnitus. While the rate decreases over time, tinnitus rates 
exceeded hearing loss rates at all the time points. These findings also 
demonstrate the need for more comprehensive diagnostics and broader 
range of therapeutic approaches for tinnitus which can only be achieved 
by continued and additional research on the condition.
    There have been some important bipartisan legislative steps taken 
by Congress in recent years to address the growing problem of tinnitus 
in veterans and active duty military personnel, including the addition 
of tinnitus as a researchable condition in the DoD Congressionally 
Directed Medical Research Program. The American Tinnitus Association 
applauds these efforts, and we very much appreciate the efforts of the 
Department of Veterans Affairs through the Portland VA Medical Center's 
National Center for Rehabilitative Auditory Research (NCRAR) to support 
tinnitus treatment. At the same time, we respectfully believe that 
tinnitus, which is so often associated with both TBI and PTSD deserves 
additional scrutiny. Improving tinnitus treatment with the goal of 
curing this disorder will almost assuredly impact treatment modalities 
for these other invisible wounds of war.
    Through passage of legislation such as H.R. 1443, the lives of 
veterans will be improved. And every research dollar spent, each 
discovery, and every step toward a cure for tinnitus benefits all 
Americans who suffer with this disorder.''
    I would like to close by sharing with you an email (one of hundreds 
I receive) that exemplifies the impact of research in the life of a 
veteran:

    ``Dear Dr. Shore
    Like many vets I have suffered from tinnitus ever since I was 
exposed through my line of work during the four years I served in the 
USAF servicing F-4 Phantom Jets from 1966 to 1970. They had massive 
engines running nearby and ear protection was often lacking or in need 
of repair. My ears would often ring after work but after a few years 
began to ring more often until, as now, they ring 24-7. It is now to 
the point of changing much of my life through constant use of masking 
devices, insomnia and general aggravation. The VA will sometimes allow 
a very small 10% disability for tinnitus but has made it very difficult 
and time consuming to all but those who can afford an attorney to 
represent them. That level of disability amounts to a small pittance of 
about 100 bucks a month but can be helpful with hearing aids later in 
life.
    However, I did file a claim with the VA which after many, many 
months was denied, the reason being according to their reviewing 
officer is that although I have some reduction in hearing (and had a 
reduction from my initial entrance to my discharge exam) it's not 
enough under VA standards PLUS they stand by statement quoted from and 
publication called the NOISE MANUAL (Fifth Edition, Berger, AIHA Press 
2000, P125) ``only seldom does noise cause a permanent tinnitus without 
also causing hearing loss''. Aside from the fact that ``hearing loss'' 
is an arbitrary term and by the VA standard I have none, I am living 
proof that this statement is not always true and is not a valid 
criteria for denial of claims. Thank you greatly for your time and for 
your research into what has become for me a lifelong constant 
aggravation.
    Yours sincerely, DCS''

    This patient is correct in that tinnitus does not always have to 
occur in the presence of hearing loss detectable by conventional 
clinical methods. However recent research has indicated that more 
extensive hearing tests than are performed in the clinic may unveil 
hidden abnormality in the auditory system that may contribute to the 
brain plasticity underlying tinnitus. Even conventional hearing tests 
indicate that up to 19% of adolescents in the United States show 
evidence of mild hearing impairment caused by exposure to loud 
environmental and recreational sounds. Because peripheral hearing 
damage tends to worsen over the years, tinnitus is a looming public 
health challenge for citizens of all ages as well as a major disability 
affecting thousands of veterans in our armed forces.
    Thank you again for the opportunity to be here and bring attention 
to tinnitus, a condition that has been far too long neglected. Passage 
of legislation such as H.R. 1443 will go a long way to helping us 
achieve our goals of improving tinnitus treatment and ultimately, 
finding a cure for this disorder. ATA is happy to provide any 
additional technical information on existing tinnitus research efforts 
as well as our suggestions for future activities, as embodied in the 
ATA ``Roadmap'' which is included as an addendum to my testimony.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



                                 
                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.
           Draft Bill, the Long Term Care Veterans Choice Act
    Many veterans who are disabled due to complex, chronic disease or 
traumatic injury may be unable to live safely and independently, or may 
have health care needs that exceed the capabilities of their families. 
While many of these veterans are placed in nursing homes, others can 
remain in their community of choice with proper support, delaying or 
avoiding nursing home care. Since 1951, the VA's Community Residential 
Care (CRC) Program has provided health care and sheltered supervision 
to many of these veterans. This program has evolved through the years 
to encompass Psychiatric CRC Home, Assisted Living, Personal Care Home, 
Family Care Home, and Medical Foster Home (MFH).
    Established in 2000, VA's Medical Foster Home (MFH) program 
currently operates under the same authority \1\ as the CRC program. A 
type of community residential care facility limited to no more than 
three eligible \2\ veteran residents in a private home, caregiver 
support is provided by the MFH attendant, and health care supervision 
is provided through VA's Home-Based Primary Care program or VA spinal 
cord injury home care program.
---------------------------------------------------------------------------
    \1\ 38, United States Code Sec.  1730.
    \2\ (1) The veteran is unable to live independently safely or is in 
need of nursing home level care; (2) The veteran must be enrolled in, 
or agree to be enrolled in, either a VA Home Based Primary Care or VA 
Spinal Cord Injury Homecare program, or a similar VA interdisciplinary 
program designed to assist medically complex veterans living in the 
home; and (3) The medical foster home has been approved in accordance 
with 38 C.F.R. Sec.  17.73(d).
---------------------------------------------------------------------------
    Patient participation in the MFH program is voluntary and veteran 
residents report very high satisfaction ratings. Furthermore, the 
administrative costs for VHA are less than $10 per day, and the cost of 
Home Based Primary Care, medications and supplies averages less than 
$50 per day. VA perceives this program as a cost-effective alternative 
to nursing home placement, and it is gaining popularity as evidenced by 
the program's expansion at the initiative of local VA providers with 
support from local VA facility leadership and VA Central Office.
    However, because MHF operates under the CRC authority, 
participating veterans must pay the MFH caregiver approximately $1,500 
to $4,000 per month for room and board, 24-hour supervision, assistance 
with medications, and whatever personal care may be needed. \3\ Even 
veterans, who are otherwise entitled to nursing home care fully 
reimbursed by VA under the Veterans Millennium Health Care and Benefits 
Act (Millennium Act) \4\ or under VA's policy on nursing home 
eligibility, \5\ must pay to live independently in a CRC or MFH.
---------------------------------------------------------------------------
    \3\ 38 U.S.C. Sec.  1730(a)(3).
    \4\ P.L. 106-117, 113 Stat. 1545 (1999) required that through 
December 31, 2003, VA provide nursing home care to those veterans with 
a service-connected disability rated at 70 percent or greater, those 
requiring nursing home care because of a condition related to their 
military service who do not have a service-connected disability rating 
of 70 percent or greater, and those who were admitted to VA nursing 
homes on or before the effective date of the act. Subsequent law 
extended these provisions.
    \5\ VA's policy on nursing home eligibility required that VISNs 
provide nursing home care to veterans with 60 percent service-connected 
disability ratings who are also classified as unemployable or permanent 
and total disabled.
---------------------------------------------------------------------------
    Were it not for the MFH program, veterans who meet the nursing home 
level of care standards would qualify for VA paid care to receive it at 
a significant cost to the Department. In addition, veterans who do not 
have the resources to personally pay for room, board, and caregiver 
services are not able to avail themselves of this benefit.
    DAV is pleased with VA's innovation by offering the MFH program as 
part of its long-term services and supports (LTSS) portfolio, and we 
applaud the intent of this draft legislation to give VA authority to 
enter into an agreement or contract with or a VA approved MFH and pay 
for room, board, and caregiver services of veterans already eligible 
for VA paid nursing home care.
    Accordingly, we support this draft measure based on DAV National 
Resolution No. 214, calling for legislation to expand the comprehensive 
program of LTSS for service-connected disabled veterans regardless of 
their disability ratings.
    Mr. Chairman, DAV believes favorable consideration of this draft 
bill is a good first step for this subcommittee to assist VA in its 
effort to ``rebalance'' its LTSS portfolio. VA is and will continue to 
be challenged in providing appropriate LTSS due to the diversity, 
increasing number, and medical complexity of the veteran population who 
will need these services.
    Research on consumer preferences and well-being--together with the 
1999 Olmstead decision in which the Supreme Court upheld an 
individual's right to receive services ``in the most integrated setting 
appropriate''--has motivated states to pursue rebalancing initiatives 
to shift LTSS systems away from institutional care and toward a system 
that embraces consumer choice and care in the home or community, and to 
reduce cost. The federal government's most recent commitment to 
rebalancing is found in numerous provisions in the Patient Protection 
and Affordable Care Act, where new authorities offer financial 
incentives to states to shift rebalancing efforts to the next level in 
order to continue to transform the LTSS system.
    Though concern about the financing and delivery of LTSS is a 
recurring issue among policymakers, states have utilized a variety of 
innovative programs and services to rebalance their LTSS services, and 
spending for Medicaid Home and Community-Based Services (HCBS) has 
increased, accounting for 45 percent of total Medicaid long-term care 
services in 2010, up from just 13 percent in 1995. \6\
---------------------------------------------------------------------------
    \6\ Kaiser Commission on Medicaid and the Uninsured. ``Medicaid and 
Long-Term Care Services and Supports.'' 2012. Available at http://
www.kff.org/medicaid/upload/2186-09.pdf.
---------------------------------------------------------------------------
    Today, VA lags behind States in offering and providing HCBS. The 
proportion of VA LTSS expenditures devoted to HCBS is little more than 
20 percent for FY 2012. Oversight by this Subcommittee is sorely needed 
as VA endeavors to shift resources from nursing home care to more cost 
effective HCBS in order to serve more veterans while honoring their 
preferences. We urge is subcommittee to ensure VA HCBS innovations are 
not stifled and VA LTSS encompass a broad range of assistance to 
veterans regardless of age who have lost the ability to function 
independently thus preventing them to be active participants in their 
community.
       H.R. 1443, the Tinnitus Research and Treatment Act of 2013
    If enacted this bill would require VA to recognize tinnitus as a 
``mandatory condition'' for purposes of research and treatment, led by 
VA's Auditory Centers of Excellence. The bill also would specify and 
define such research to include various assessments and studies of the 
condition of tinnitus. Finally, the bill would require cooperation 
between VA and the Department of Defense Hearing Center of Excellence 
with respect to tinnitus.
    Despite tinnitus being the top service-connected condition in the 
veteran population today, our members have not approved a DAV national 
resolution specific to research about, or treatment of, the condition. 
However, as a partner organization of the Independent Budget for Fiscal 
Year 2014, DAV believes that nothing should be permitted to interfere 
with the scientific merit review process within the VA's research 
program, whether for tinnitus or for any other particular condition, 
disease, illness or injury.
    While we are sensitive to the sponsor's expression of need for more 
research into tinnitus, as we would be for any condition endemic in the 
veteran population, as we indicated in the Independent Budget, 
``Ultimately, scientific merit based on careful peer review must be the 
determining factor in whether a [VA research] project is funded, not 
pressure from interest groups or interference in the selection of peer 
reviewers. The IBVSOs [Independent Budget veterans service 
organizations] and FOVA [Friends of VA Medical Care and Health 
Research, a 60-organization coalition] contend that between VA's 
current peer-review system and the public status of this federally 
funded activity, sufficient accountability is present and that no 
further outside interference or influence is warranted. The Independent 
Budget veterans service organizations urge Congress and VA to take 
assertive steps to preserve and protect the quality and transparency of 
VA's research funding decisions.''
    On the basis of these concerns, expressed collectively by DAV, 
AMVETS, Paralyzed Veterans of America and Veterans of Foreign Wars of 
the United States, we believe the purpose and requirements imposed by 
this bill should be reconsidered by its sponsor.
  H.R. 1612, to direct the Secretary of Veterans Affairs to convey a 
 parcel of land in Tuskegee, Alabama, to Tuskegee University, and for 
                             other purposes
    This bill would require the VA to convey 64.5 acres of the present 
VA Medical Center in Tuskegee, Alabama, comprising 20 structures, to 
the Tuskegee University, for the university's purposes.
    We have received no resolution on this specific matter from our 
members, and thus, DAV takes no position on this legislation.
             H.R. 1702, Veterans Transportation Service Act
    This bill would provide VA a renewed authority to transport 
individuals in connection with their vocational rehabilitation, 
counseling, examination, treatment, or care, and make permanent an 
important transportation program after only one year of life.
    Notably, VA has implemented the provisions of Section 202 of Public 
Law 112-260, the Dignified Burial and Other Veterans' Benefits 
Improvement Act of 2012, except for eliminating the authority granted 
under Section 111A of title 38, United States Code, to create a VA-
operated transportation program one year after enactment. That act had 
prompted VA to initiate the Veterans Transportation Service (VTS), 
supported by the Veterans Health Administration (VHA) Chief Business 
Office (CBO). The VTS was established to provide veterans with 
convenient and timely access to transportation services and to overcome 
access barriers certain veterans may have experienced, and in 
particular to increase transportation options for veterans who need 
specialized forms of transportation to VA facilities. The VTS 
transportation services to VA medical centers include the use of 
technology and mobility management training for medical center staff 
that in turn enable VTS services to better interface with other 
community transportation resources.
    VA medical centers and sites where VTS is operating can be ideal 
partners with the DAV National Transportation Network and for the 
Veterans Transportation and Community Living Initiative grant projects 
establishing One-Call/One-Click Transportation Resource Centers. Based 
on our review of this situation, were it not for the expiration of 
statutory authority from Public Law 112-260, VTS would have grown from 
its current 45 sites to all remaining VA locations by 2015.
    The DAV National Transportation Network continues to show 
tremendous growth as an indispensable resource for veterans. Across the 
nation, DAV Hospital Service Coordinators operate 200 active programs. 
They have recruited 9,249 volunteer drivers who logged over 27 million 
miles last year, providing almost 721,000 rides for veterans to and 
from VA health care facilities. These veterans rode in vans DAV 
purchased and donated to VA health care facilities for use in the DAV 
National Transportation Network. DAV Departments and Chapters, together 
with our national organization, have now donated 2,586 vans to VA 
health care centers nationwide at a cost to DAV of $56.7 million.
    DAV believes VTS serves the transportation needs of a special 
subset of the veteran patient population that the DAV National 
Transportation Network is unable to serve--veterans in need of special 
modes of transportation due to certain severe disabilities. We believe 
that with a truly collaborative relationship, the DAV National 
Transportation Network and VTS will meet the growing transportation 
needs of ill and injured veterans in a cost-effective manner.
    Currently, DAV supports enactment of this bill; however, our 
support is based on the progress gained through our collaborative 
working relationship with VHA and CBO to resolve weaknesses we have 
observed in the VTS program. As you may be aware, VTS operates with 
resources that would otherwise go to direct medical care and services 
for veterans. These resources should be used carefully for all 
extraneous programs to ensure veterans are not denied care when they 
most need it.
    We thank VHA and CBO for their commitment and continuing efforts in 
working with DAV to ensure VTS will indeed work in concert with all 
existing and emerging transportation resources for veterans who need VA 
care, and to guard against fraud, waste and abuse of these limited 
resources.
    We look forward to continuing our work with the Committee on this 
measure, and to work for its passage.
           H.R. 2065, Safe Housing for Homeless Veterans Act
    The Safe Housing for Homeless Veterans Act would amend Title 38, 
United States Code, to require entities that receive per diem payments 
through the Department of Veterans Affairs (VA), for the provision of 
services to homeless veterans, to submit an annual certification to the 
Secretary of Veterans Affairs proving that the building where the 
entity provides housing or services is in compliance with codes 
relevant to the operations and level of care provided.
    The certification would include compliance with requirements 
outlined in the recently published version of the Life Safety Code, 
International Building Code and International Fire Code, or similar 
codes that have been adopted as State or local codes in the 
jurisdiction of the project. In addition, all licensing requirements 
regarding the condition of the structure and the operation of 
supportive housing or service center, including fire and safety 
requirements, must be provided.
    For entities that receive per diem payments during the year in 
which the legislation is enacted, the recipient must submit all 
certifications required no later than two years after the date of 
enactment to the Secretary, or additional per diem payments will be 
halted until certification is received.
    DAV previously testified on a similar bill, H.R. 4079 introduced in 
the 112th Congress, that while we did not have a National Resolution 
from our membership specifically covering the state of the housing 
provided to veterans or the safety of the facilities where homeless 
services are provided, we did not oppose favorable consideration of the 
legislation. Since that hearing, it has been brought to our attention 
that the requirements outlined in H.R. 2065 may adversely impact Grant 
and Per Diem providers, which could leave many homeless veterans and 
their family without the services they need.
    While DAV agrees with the intent of the measure to provide safe 
shelters for our homeless veterans, we urge the Subcommittee work with 
VA and Homeless Grant and Per Diem providers, to mitigate any 
detrimental effects this bill may have while meeting the needs of 
homeless veterans in a safe environment.
    DAV appreciates the opportunity to submit our views on the 
legislative measures under consideration at this hearing. 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 Robert Drexler
    Good morning, Mr. Chairman, and distinguished Members of the 
Subcommittee. My name is Robert Drexler, Member of the Board of 
Directors of the International Code Council. I also serve as Fire 
Marshal for the town of Greece, New York . I am pleased to be here to 
discuss the importance of compliance with building and fire codes, 
speaking on behalf of the over fifty thousand building, fire code 
officials and other professionals across the United States who are the 
members of the Code Council.
    The Code Council was formed in 1994 as a nonprofit organization 
dedicated to developing a single set of comprehensive and coordinated 
national model construction codes. The founders of the ICC were the 
Building Officials and Code Administrators International, Inc. (BOCA), 
International Conference of Building Officials (ICBO), and Southern 
Building Code Congress International, Inc. (SBCCI). Since the early 
1900s, these nonprofit organizations developed three separate sets of 
regional model codes used throughout the United States. We joined these 
three groups together, and published a single code for the United 
States- the International Codes- beginning in 2000. In 2003, the 
International Code Council became the successor organization to the 
three legacy code groups, and so we are celebrating our tenth 
anniversary as an organization in 2013.
    Today our International Model Codes have been adopted at the state 
or local level in all 50 states and the District of Columbia. Numerous 
federal agencies, including the General Services Administration, the 
Department of Defense and the Architect of the Capitol have implemented 
the I-Codes, as have Puerto Rico and the U.S. Virgin Islands. The Code 
Council's 50,000 members and over 300 chapters include state, county 
and municipal code enforcement and fire officials, architects, 
engineers, builders, contractors, elected officials, manufacturers and 
other construction industry professionals.
    I come before you today to encourage support for HR 2065, the Safe 
Housing for Homeless Veterans Act, sponsored by Rep. David McKinley of 
West Virginia and Rep. Grace Napolitano of California. Those of us who 
work in the realm of building safety at both the state and local level 
appreciate the concern that this bill has for the welfare of our 
veterans, who are living in housing subsidized by the Department of 
Veterans Affairs.
    In the building sector, the International Residential Code, the 
International Building Code, and the International Fire Code establish 
the basic requirements for building safety at the time of construction, 
and in the case of the Fire Code, at the time of the annual inspection. 
These codes do not guarantee that a building will be safe from any and 
all hazards, as destructive forces can bring down any building if 
enough force is applied. But the codes do assure that when faced with 
the typical hazards that buildings are expected to encounter, including 
fire, windstorm, flooding, and even normal or even somewhat careless 
daily use, the building will allow for building residents and users to 
survive, and for first responders to safely rescue building occupants, 
and minimize property damage.
    In most jurisdictions around the country, either at the state 
level, or at the local jurisdictional level, both the International 
Building Code (IBC) and the International Fire Code (IFC) assure that 
buildings used for residential care and housing are safe. Our local 
code officials around the country inspect veterans' homes and assure 
that they meet currently adopted codes, just as they do other 
commercial buildings. This is true in California, as well as 42 other 
states that have adopted both the IBC and the IFC. In fact all 50 
states have adopted the IBC at either the state or local level, and 43 
states adopt the IFC, while a significant number also adopt the Life 
Safety Code(LSC), at either the state or local level.
    HR 2065 wisely does not attempt to mandate one code or the other 
for compliance by facilities approved by the Department of Veterans 
Affairs for reimbursement, but requires a certification from all homes 
that they meet either the IBC and IFC, or the LSC, which are 
functionally, and from a safety standpoint, equivalent code 
requirements.
    In addition, the bill does not impose any onerous administrative 
burden on the Department of Veterans Affairs, other than to assure that 
each facility receiving reimbursement has filed a certification, either 
from the local code official, or from a competent third party, that 
code requirements are met. This is a reasonable and very workable 
requirement that mirrors similar requirements in place for other 
medical facilities that must provide very similar assurances to the 
Centers for Medicaid and Medicare (CMS), in the Department of Health 
and Human Services.
    It is true that for veterans' homes covered by this requirement 
that are located in a jurisdiction that does not adopt and enforce 
either the IFC or LSC, there will be a small additional burden of 
obtaining an annual inspection to show compliance with the relevant 
code provisions. However, it is the clear intent of the bill sponsors, 
and a worthy goal in our opinion, that the safety of our veterans, who 
sacrificed so much for our freedoms, should be provided with safe 
housing, especially when the taxpayer is subsidizing that housing. It's 
hard to argue that our veterans should not be assured of minimal safety 
in their housing, when the cost of assuring safety is a few hundred 
dollars or less.
    In closing, the International Code Council is proud of our work in 
developing the model codes used by most jurisdictions to assure a basic 
level of safety in the built environment, and we applaud your efforts 
to use those codes to protect the safety of our veterans. We continue 
to work to update and improve the codes, issuing revised codes every 
three years, through our governmental consensus process for the 
regulation of building construction. I applaud the work of your 
Subcommittee and encourage continued collaboration between the public 
and private sectors to achieve the important goal of increased safety 
in our nation's buildings. Thank you again for the opportunity to 
appear before you today. I will gladly answer any questions.

                                 
                Prepared Statement of Raymond C. Kelley
    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. 1443, the Tinnitus Research and Treatment Act of 2013
    The VFW supports this legislation which would require the 
Department of Veterans Affairs (VA) to recognize tinnitus as a 
mandatory condition for research and treatment by the VA Auditory 
Centers of Excellence in cooperation with the Department of Defense 
Hearing Center of Excellence. Characterized by a steady or intermittent 
ringing of the ears, tinnitus can cause sleep disruption, cognitive 
impairment and employment difficulties, and can worsen the symptoms of 
depression and anxiety disorders. Tinnitus is the most frequent 
service-connected disability awarded by VA among veterans of all eras. 
The common causes of tinnitus are acoustic trauma and traumatic brain 
injury, placing Iraq and Afghanistan veterans at particularly high risk 
due to IED blast exposure. Since 2000, the number of veterans who are 
service-connected for tinnitus has increased by at least 16.5 percent 
each year.
    Although there is no known cure for tinnitus, it should not be 
assumed that the condition is untreatable. VA's Progressive Tinnitus 
Management approach, which assists tinnitus suffers through individual 
counseling and support, is helping veterans better manage their 
symptoms. Still, more research is needed in order to identify truly 
effective treatments to alleviate those symptoms. This bill represents 
a positive first step towards achieving that goal.
  H.R. 1612, to direct the Secretary of Veterans Affairs to convey a 
      parcel of land in Tuskegee, Alabama, to Tuskegee University.
    The VFW supports H.R. 1612, a bill that directs the Secretary of VA 
to convey a parcel of land in Tuskegee, Alabama, to Tuskegee 
University. More than 90 years ago, Tuskegee University, a land grant 
university, voted to donate 300 acres of land so the United States 
government could build a veterans hospital. Today, 21 of the buildings, 
accounting for nearly 280,000 square feet of space, sit vacant on that 
property. Nearly half of the buildings that would accompany the 
transfer are former quarters for employees who worked in housekeeping 
within the hospital, while several others are small 500 square feet or 
less storage buildings.
    Annually, VA spends approximately $2 per square foot to maintain 
vacant space. For the buildings that fall within this land transfer, VA 
spends more than $500,000 per year in maintenance. Reducing the 
financial burden for upkeep of these buildings and grounds will allow 
VA to better use those non-recurring maintenance funds to ensure the 
highest level of maintenance for the facilities that provide care and 
service to our veterans and not on buildings that are sitting vacant.
    With nearly 1000 vacant or underutilized buildings within their 
system, the VA must work to right-size its property inventory, 
decreasing its footprint in some areas and increasing it in others. In 
doing so, VA must ensure they can provide a full continuum of care for 
veterans. At the Tuskegee VA Campus, programs and services have been 
expanded to include homeless shelters, community living facilities and 
women veterans services. Knowing VA has utilized as much of the 
property as possible, it is a financially responsible decision to 
return 64.5 acres of the original 300 acres land and improvements back 
to Tuskegee University.
           H.R. 1702, the Veterans Transportation Service Act
    The VFW supports this legislation to permanently authorize the 
Veterans Transportation Service (VTS). This program, commissioned by 
the VHA Office of Rural Health in 2010, has greatly improved access to 
care for rural and seriously disabled veterans by allowing VA 
facilities to establish and coordinate networks of local transportation 
providers, including community and commercial transportation providers, 
and government transportation services. The VTS augments veterans 
service organizations' volunteer-based transportation services, which 
are limited to transporting ambulatory veterans, and supplements the 
existing beneficiary travel programs of mileage reimbursement, which 
does not provide assistance with the coordination of transportation for 
those who need it, and special mode travel, for which few veterans 
medically qualify.
    The VTS suffered a major setback in 2012 when it was temporarily 
suspended following a determination by the VA Office of General Counsel 
that VA lacked the statutory authority to hire paid drivers to 
transport veterans. Congress wisely passed a one-year authorization of 
the VTS program in January 2013, but a long-term fix is still needed.
    The VFW believes that unnecessary hardships associated with 
accessing VA health care should be eliminated at every opportunity. 
This legislation would guarantee the continuation and future expansion 
of VTS, which plays a critical role in minimizing the challenges many 
veterans face in traveling to their appointments due to physical 
disabilities or great distances.
         H.R. 2065, the Safe Housing for Homeless Veterans Act
    The VFW supports this legislation which would require facilities 
that house homeless veterans to meet all relevant local building codes 
in order to receive per diem payments under the VA Homeless Providers 
Grant Per Diem Program. Currently, VA is required to check housing 
certificates before awarding grants for housing services provided to 
homeless veterans. However, thorough checks of fire and safety 
requirements, as well as structural conditions of the building, are 
often overlooked. The bill requires that current recipients of per diem 
payments submit certification of compliance with local codes within two 
years of the enactment of this act, giving them ample time to make any 
necessary improvements.
    The VFW believes that VA funded transitional housing must be safe, 
secure, and sanitary. This bill would ensure that those standards are 
met, providing homeless veterans with the best chances of successful 
community reintegration.
           Draft Bill, the Long-Term Care Veterans Choice Act
    The VFW supports this legislation, which would add language to 
Section 1720 of Title 38 to allow veterans who receive VA care and 
require a protracted period of nursing home care to transfer into an 
adult foster home at their request. Under the bill, such homes must be 
``designed to provide non-institutional, long-term, supportive care for 
veterans who are unable to live independently and prefer a family 
setting.'' VA currently has the authority to reimburse institutional 
care facilities such as nursing homes for long-term domiciliary care, 
but veterans who choose to live in adult foster homes must do so at 
their own expense. To grant VA the authority to reimburse adult foster 
homes would provide veterans with an additional residency choice, 
potentially improving the quality of life for those who would prefer 
this option.
    The VFW strongly believes that all non-VA services should be 
provided in conjunction with proper care coordination. VA Handbook 
1141.02, Medical Foster Home Procedures, establishes the policies and 
standards of VA care coordination for veterans who choose to live in 
medical foster home settings. It requires an interdisciplinary VA Home 
Care Team to provide the veteran with primary care, regularly 
communicate with the foster home caregiver, and monitor the care 
provided by the foster home with frequent unannounced visits. The VFW 
feels that these would ensure adequate care coordination for veterans 
who chose to participate in a fully-funded adult foster care program. 
VA Handbook 1411.02 is scheduled for recertification in 2014, and the 
VFW recommends that the care coordination policies outlined in that 
document should be made permanent by adding them to the language of 
this legislation.
    Mr. Chairman, this concludes my statement. I am happy to answer any 
questions you or other Members of the Committee may have.
 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.

                                 
                 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.
    We do not yet have cleared views on H.R. 1612, a bill that would 
direct VA to convey a parcel of land to Tuskegee University. We will 
forward views and any estimated costs to you as soon as they are 
available.
H.R. 1443 Tinnitus Research and Treatment Act of 2013
    Section 2 of H.R. 1443 would require VA to recognize tinnitus as a 
mandatory condition for research and treatment by VA Auditory Centers 
of Excellence. Section 3 of the bill would require the Secretary to 
ensure that research on the prevention and treatment of tinnitus is 
conducted at VA facilities. Required research would include an 
assessment of the efficacy of multidisciplinary tinnitus treatment 
modalities on different subsets of patients; studies on the underlying 
etiology of tinnitus in Veteran populations that occur as a result of 
different causal factors, including blast-related tinnitus, where there 
is no measurable hearing loss, versus other forms of noise-induced 
tinnitus, where there is hearing loss; and a study of the underlying 
mechanisms between hearing loss and tinnitus, including cases in which 
one or the other condition is present, but not both. VA would be 
required to ensure VA cooperation with the Hearing Center of Excellence 
established by the Department of Defense (DoD) to perform further 
research on tinnitus.
    This bill appears to be consistent with existing programs and 
operations within the Veterans Health Administration. Therefore, we do 
not believe this legislation is necessary.
    VA Audiology Clinics currently provide tinnitus treatment through 
VA's Progressive Tinnitus Management Program, a five-level program that 
provides education and treatment services to Veterans tailored to the 
degree of the disabling effects of tinnitus. Basic tinnitus 
intervention involves group educational counseling focused on providing 
Veterans with the knowledge and skills to self-manage their tinnitus. 
This group counseling involves interdisciplinary collaboration between 
audiology and psychology. For those Veterans who do not obtain relief 
from hearing aids or group educational counseling, VA offers treatment, 
including a comprehensive assessment and individualized counseling. If 
none of the above services are beneficial, VA begins treatment 
involving individualized management including relaxation techniques, 
cognitive behavioral therapy, drug therapy, sound-based therapy, and 
combined techniques. VA has also developed patient education materials 
and clinical training materials to advise clinicians on how best to 
identify, diagnose, and treat tinnitus and other auditory conditions.
    VA's National Center for Rehabilitative Auditory Research (NCRAR), 
a VA Rehabilitation Research and Development Center of Excellence, has 
active research projects underway on the efficacy of multidisciplinary 
tinnitus treatment (e.g., Progressive Tinnitus Management) as 
referenced in Subsection (1) of Section 3 of the bill. NCRAR is also 
collaborating with the VA Audiology Program to develop and evaluate 
Progressive Tinnitus Management at VA medical centers.
    VA has active research projects underway addressing the underlying 
etiology of tinnitus, as well as the mechanisms underlying the co-
occurrence of hearing loss and tinnitus, as referenced in Subsections 
(2) and (3) of Section 3.
    VA is also collaborating with DoD on the development of the Defense 
Center of Excellence for Hearing Loss and Auditory System Injuries, as 
mandated by Congress in section 721 of Public Law 110-417. The Center 
will develop a registry of information to track the diagnosis, surgical 
intervention, or other operative procedure, or treatment, and follow up 
for each case of hearing loss and auditory system injury incurred by 
Servicemembers while on active duty. This registry will also facilitate 
an electronic data exchange with VA. The law further requires the 
Center to collaborate with NCRAR and VA to ensure coordination of 
ongoing auditory system rehabilitation benefits and services by VA.
    VA believes that implementation of H.R. 1443 would be cost-neutral, 
if enacted, because VA already complies with the provisions of the 
bill.
H.R. 1702 Veterans Transportation Service Act
    VA supports this legislation which would permanently extend the 
Secretary's authority to hire qualified drivers to transport any person 
to or from a Department facility or other place in connection with 
vocational rehabilitation or counseling required by the Secretary 
pursuant to chapter 34 or 35 of title 38, or for the purpose of 
examination, treatment, or care. The Veterans Transportation Service 
(VTS) depends on paid drivers to provide transportation services. 
Section 111A of title 38 of the United States Code (U.S.C.) currently 
provides authority for use of paid drivers until January 9, 2014.
    Through the VTS program, VA provides funding to local VA facilities 
for mobility managers, transportation coordinators, and vehicles to 
complement the existing services that volunteers already provide. The 
service provides Veterans with transportation to and from their VA 
health care appointments, improving both access to care and continuity 
of care for many who would otherwise be limited in mobility. In 2012, 
VTS provided Veterans with more than 199,000 one-way trips totaling 
more than 9.7 million miles. The average length of a one-way trip is 
over 48 miles--a considerable distance and a prohibitive one for those 
with poor health if transportation were not available. Veterans with 
prostheses or those who use wheelchairs have particularly benefited 
from the VTS program.
    Veterans Service Organizations such as Disabled American Veterans 
are invaluable in providing volunteers for VA's Volunteer 
Transportation Network. However, with increasing numbers of 
transportation-disadvantaged Veterans, there simply are not enough 
volunteers in all regions of the country to serve the level of need. 
Furthermore, volunteer drivers are generally precluded from 
transporting Veterans who are not ambulatory, require portable oxygen, 
have undergone a procedure involving sedation, or have other clinical 
issues. Some volunteers, for valid reasons, are reluctant to transport 
non-ambulatory or very ill Veterans. Without paid drivers, many 
Veterans would not have transportation to get to their medical 
appointments to receive the care they need.
    VA was grateful for enactment of the temporary authority to ensure 
we could continue to use paid drivers in the VTS program. The temporary 
nature of the authority, however, has impacted expansion of VTS, as VA 
facilities have been cautious in adding staff in light of the 
expiration that would occur early next year without legislative action. 
This has understandably dampened our ability to expand the program. 
Permanent authority will provide this beneficial program with the 
stable foundation it merits.
    VA is unable to provide an accurate estimate of the cost savings 
associated with this bill at this time. However, since VTS became 
operational, savings have resulted from the use of paid VA drivers over 
Beneficiary Travel Special Mode transportation. VA paid drivers are a 
less expensive option than Special Mode transport. VA is closely 
examining the cost data across locations where VTS is implemented and 
will provide this information for the record as soon as we are able.
H.R. 2065 Safe Housing for Homeless Veterans Act
    H.R. 2065 would amend 38 U.S.C. 2012(c)(1), which requires that 
Grant and Per Diem (GPD) grantees or eligible entities comply with 
specified fire and safety rules. In place of the current section 
2012(c)(1), H.R. 2065 would impose a new requirement that would limit 
per diem payments to grant recipients or eligible entities who submit 
an annual certification (that has been approved or verified by the 
``authority having jurisdiction or a qualified third party'') that the 
building where the entity provides housing or services is in compliance 
with codes ``relevant to the operations and level of care provided.''
    VA does not support H.R. 2065. We are concerned it would 
fundamentally shift VA's role in inspecting and overseeing GPD 
facilities and would shift some of the costs of facility inspections 
from VA to the GPD grantee. Currently, VA ensures that GPD facilities 
meet the requirements of the Life Safety Code (LSC) of the National 
Fire Protection Association through on-site inspections of each 
facility by staff from the local VA medical center. The inspection team 
includes representatives from the local VA medical center, who are 
responsible for ensuring that general operating requirements as noted 
in GPD regulations are met. The inspection team members are responsible 
for the review of the project in the following areas: clinical, 
facilities management, security/law enforcement, and nutrition and food 
services. The facilities management portion of the inspection includes 
a requirement for VA staff to evaluate compliance with the LSC. These 
projects must pass an initial inspection prior to per diem being 
awarded. Any deficiencies (e.g., nutrition, security, clinical, safety) 
noted by the inspection team must be corrected by the GPD-funded 
organization before the project can become operational. A completed 
initial inspection is signed by the VA medical center Director, 
approving the placement of Veterans within the project. The inspection 
packet is then reviewed by the Veterans Integrated Service Network 
(VISN) Homeless Coordinator for completeness and sent to the GPD 
National Program Office. GPD providers are also subject to annual re-
inspection. The annual inspections are conducted in the same manner as 
the initial inspection. VA is concerned that merely requiring a 
certification of compliance with the LSC would remove an essential 
component of VA's GPD facility inspection process making homeless 
Veteran transitional housing less safe and secure.
    Presently, the cost of inspecting a GPD facility for compliance of 
the LSC currently falls on VA. Ostensibly, section 2(a)(1) of H.R. 2065 
would shift the cost of LSC compliance to the GPD provider. Because 
section 2(a)(1) merely specifies that the annual certification must be 
``approved or verified by the authority having jurisdiction or a 
qualified third party,'' the concern is that a GPD provider would 
receive certifications of compliance from individuals or entities who 
are not truly qualified to certify compliance. Under the current 
statute and regulations, VA officials inspect and determine whether GPD 
facilities comply with the LSC. VA inspectors are directly accountable 
to the Department, and there are no concerns about the suitability or 
qualifications of third parties providing ``certifications.'' However, 
VA notes that many of the concerns addressed by section 2(a)(1) could 
be resolved through regulation.
    Furthermore, VA does not agree with the suggestion in section 
2(a)(1) that the ``International Building Code and International Fire 
Code'' are a suitable alternative to the LSC. VA is not aware of any 
single standard that is comparable to the LSC. The LSC is unique in 
that it is organized with chapters that address each occupancy type, 
has specific infrastructure requirements for existing as well as new 
facilities, and also provides operational requirements. The LSC 
accomplishes by itself what it would require multiple other codes to 
accomplish. For example, if the International Code Council (ICC) Family 
of codes was utilized, it would require use of the International 
Building Code, International Residential Code, International Fire Code, 
and International Existing Building Code in order to encompass the same 
scope as the LSC.
    While a different set of standards (other than the LSC) could be 
utilized to provide a comparable set of fire and safety requirements, 
VA believes that introducing another set of codes and standards would 
not benefit Veterans or VA in any material way. It would also not 
likely result in increasing the number of facilities that could be 
approved for the GPD program, and it could create an added burden for 
VA by potentially requiring VA staff to be trained on two sets of codes 
and standards instead of one.
    It should also be noted that VA facilities receive accreditation 
from The Joint Commission, which requires compliance with the LSC. VA 
uses the LSC for all VA facilities (including accredited facilities) to 
establish consistency across the country for minimum life safety 
requirements, code interpretation, and fire safety training for VA 
staff. Finally, section 2(b)(2) could be an extremely burdensome and 
costly reporting requirement. Although section 2(b)(2) gives little 
guidance on the extent and scope of these reporting requirements, it 
requires an evaluation of all facilities receiving per diem payments. 
Since VA has an active and robust cadre of GPD Liaisons, individuals at 
the local VA medical center who liaise with GPD grantees and ensure 
compliance with inspection findings, VA does not believe these 
potentially burdensome reporting requirements are necessary.
    If enacted, this bill would be cost neutral to VA; however the cost 
to VA's community-based providers could be substantial.
Draft bill entitled the ``Long-Term Care Veterans Choice Act''
    The draft bill would allow Veterans, for whom VA is required to 
provide nursing home care by law, to request a transfer to homes 
designed to provide non-institutional long-term supportive care for 
Veterans, who are unable to live independently and prefer to live in a 
family setting. VA would pay the expenses by a contract or agreement 
with the home. One condition upon the transfer would be the Veteran's 
agreement to accept home health care services furnished by VA.
    VA supports the Medical Foster Home (MFH) concept, where eligible 
Veterans who would otherwise need nursing home care could get, when 
clinically appropriate, long-term care in a more personal home setting. 
VA endorsed this idea in its fiscal year 2014 budget submission. Our 
experience has shown that VA-approved MFHs can offer safe, highly 
Veteran-centric care that is preferred by many Veterans at a lower cost 
than traditional nursing home care. While endorsing the MFH concept, VA 
cannot today offer a complete evaluation of the text of the draft bill. 
We have been working with the Subcommittee on technical assistance and 
look forward to further discussion.
    Mr. Chairman, thank you for the opportunity to present VA views on 
these bills, and we will be glad to answer any questions you or the 
other Members may have.

                                 
                       Statements For The Record
                          U.S. REP. RON BARBER
           H.R. 1702 the Veterans Transportation Service Act
    Mr. Chairman and Ranking Member Brownley, thank you for your 
leadership on this subcommittee, which is so vital to meeting the 
health care needs of America's veterans.
    Thank you for the opportunity to attend this hearing and to offer 
testimony on H.R. 1702, the Veterans Transportation Service Act. I 
apologize that I cannot be here in person, as I am with the Arizona 
Congressional Delegation attending the funerals of nineteen 
firefighters who perished fighting the Yarnell Hill Fire.
    Mr. Chairman, according to data provided by the Department of 
Veterans Affairs and Veterans Service Organizations, about six million 
veterans reside in rural areas of the United States.
    Of these six million veterans, more than half are enrolled in the 
Department of Veterans Affairs healthcare system.
    In my district alone, there are nearly ninety thousand veterans, 
many of whom live outside of the major cities in communities very far 
away from VA clinics or service centers. My office receives a 
significant number of calls every week from veterans who live in rural 
areas and who need medical services from the VA and for whom 
transportation is a major problem.
    The stories that I hear from rural veterans are no different, I 
imagine, from those that you are hearing from veterans in your 
districts as well.
    Those who live in rural areas are not the only veterans who need 
assistance. Thousands of veterans who live in the cities and towns 
across this nation need help with transportation as well.
    In 2010, the Department of Veterans Affairs launched a Veterans 
Transportation Service (VTS) initiative to enhance transportation 
options for veterans who were seeking health care at VA facilities.
    Through the Veterans Transportation Service, funding is provided to 
local VA facilities to hire transportation coordinators and purchase 
vehicles driven by VA-trained staff.
    Over the course of the last two years, VTS has provided veterans 
with more than 199,000 trips to medical facilities, totaling more than 
9.7 million miles in 37 states.
    As you can tell from these numbers, this is a service that plays an 
important role in supporting our veterans. I believe we need to expand 
it so that we may assist transportation-disadvantaged veterans in other 
un-served or underserved areas of the country.
    I have introduced H.R. 1702, along with my colleague and Vice 
Chairman of the House Armed Services Committee, Mac Thornberry, to 
enact a permanent reauthorization for the VTS service.
    I would be remiss if I did not also mention the leadership provided 
by Senator Jon Tester on this issue as well; he is a champion in the 
Senate where this legislation also has strong bipartisan support.
    Last year, the VA's Office of General Counsel raised questions as 
to whether the VA could hire drivers to operate the VTS without 
specific Congressional authorization. The program was discontinued as a 
direct function of the VA.
    Luckily, with Senator Tester's leadership, the Congress moved 
quickly at the end of last year to provide the authorization needed to 
get the program back in operation.
    That authorization will only run until the end of 2013.
    Questions have been raised about the possibility of volunteers 
providing transportation.
    We all appreciate the invaluable volunteer transportation 
assistance the Disabled American Veterans provide to veterans, but 
there are many veterans who need a service different from the one 
provided by the DAV. The VTS is therefore complementary, not 
competitive, to the DAV program.
    VA Mobility Managers are trained to help make transportation 
decisions that are in the best interest of the veteran, often directing 
veterans to DAV services when appropriate and available.
    VTS drivers operate Americans with Disabilities Act compliant 
wheelchair and stretcher vehicles.
    For those veterans who are not ambulatory, who require portable 
oxygen, who have undergone a procedure involving sedation, or who have 
other clinical issues, these transportation services are critical to 
ensure their safe transportation to medical appointments and 
facilities.
    One of the most important aspects of the Veterans Transportation 
Service Act is that it saves the taxpayers money.
    The Department of Veterans Affairs has projected that they will 
save 19.2 million dollars in fiscal year 2014 alone by using the VTS 
for appropriate patients.
    This legislation is estimated to save the VA over 100 million 
dollars in five years. This is money that could be well spent on other 
aspects of veteran care.
    I believe HR 1702 is critical to the care of veterans in my 
Southern Arizona district and across this nation.
    I urge the Committee to take up this needed legislation so that the 
VA can continue and expand the VTS program. Thank you again for the 
opportunity to present this testimony, and I look forward to answering 
your questions. Thank you.

                                 
              NATIONAL ASSOCIATION OF STATE FIRE MARSHALS
    Mr. Chairman and Honorable Members of the House Committee on 
Veterans' Affairs Subcommittee on Health, the National Association of 
State Fire Marshals (NASFM) is pleased to submit this statement for the 
record in support of HR 2065, the Safe Housing for Homeless Veterans 
Act. NASFM applauds Congressman McKinley's leadership on this issue.
    NASFM's mission is to protect life, property and the environment 
from fire and related hazards. NASFM's members are the senior fire 
safety officials in the United States and the District of Columbia. 
State Fire Marshals' responsibilities vary from state to state, but 
most State Fire Marshals are responsible for fire safety code adoption 
and enforcement, fire and arson investigation, fire incident data 
reporting and analysis, public education and advising Governors and 
State Legislatures on fire protection matters. Some State Fire Marshals 
are responsible for fire fighter training, hazardous materials incident 
responses, wildland fires and the regulation of natural gas and other 
pipelines.
    In connection with their code adoption and enforcement 
responsibilities, State Fire Marshals care deeply that occupancies of 
all kinds meet minimum safety code requirements--particularly those in 
which groups of individuals, at least some of whom may be challenged 
physically, gather and spend the night. We have learned from HR 2065's 
sponsor, Congressman McKinley, that more than 67,000 veterans are 
homeless on any given night, and, over the course of a year, 
approximately twice that many experience homelessness. Just as our 
veterans helped to ensure the safety of Americans during their active 
service, the United States should do no less for them now, especially 
if they are experiencing the hardship of homelessness.
    Without HR 2065, homeless veteran shelters are subject to whatever 
fire and building codes apply in their particular jurisdiction. In some 
places, the existing codes establish minimum requirements that are 
enforced. However, in some states, no minimum building or fire code 
requirements exist, except in the larger cities. And within states, 
code requirements can vary from jurisdiction to jurisdiction, as do the 
capabilities of code enforcement entities.
    This is why it is crucial to include a provision in HR 2065 that 
would require any state or local code to provide an equivalent or 
higher level of safety than is provided by the Life Safety Code. 
According to the National Fire Protection Association, the scope of the 
Life Safety Code (also known as NFPA 101) is as follows: ``The Code 
addresses those construction, protection, and occupancy features 
necessary to minimize danger to life from the effects of fire, 
including smoke, heat, and toxic gases created during a fire. The Code 
establishes minimum criteria for the design of egress facilities so as 
to allow prompt escape of occupants from buildings or, where desirable, 
into safe areas within buildings. The Code addresses other 
considerations that are essential to life safety in recognition of the 
fact that life safety is more than a matter of egress. The Code also 
addresses protective features and systems, building services, operating 
features, maintenance activities, and other provisions in recognition 
of the fact that achieving an acceptable degree of life safety depends 
on additional safeguards to provide adequate egress time or protection 
for people exposed to fire. The Code also addresses other 
considerations that, while important in fire conditions, provide an 
ongoing benefit in other conditions of use, including non-fire 
emergencies. The Code does not address . . . general fire prevention or 
building construction features that are normally a function of fire 
prevention codes and building codes.''
    NASFM believes that the Life Safety Code is an appropriate code to 
cite in HR 2065 for minimum safety criteria, because it not only 
contains both fire and building safety provisions, but it also 
addresses both new and existing buildings in the same code. Another 
Federal agency, the Centers for Medicare & Medicaid Services, requires 
compliance with the Life Safety Code by health care organizations in 
order to begin and continue participating in the Medicare and Medicaid 
programs, so there is precedence for its use in this situation. By 
referencing the most current edition of the Life Safety Code (the 2012 
edition being the most recent), HR 2065 would help ensure that homeless 
veterans are protected with a consistent fire protection code if they 
are sheltered in occupancies that receive grants from the Secretary of 
Veterans Affairs, no matter where in the United States they may be.
    Applicable provisions of the International Building Code and the 
International Fire Code - or the versions of those codes that have been 
adopted at the state or local levels by the jurisdiction in which the 
project is located - may be appropriately applied instead of the Life 
Safety Code, as long as they are demonstrated to provide equivalent or 
higher levels of safety than is provided by the Life Safety Code. We 
know from our discussions with Congressman McKinley's staff that this 
bill does not intend to preempt any state or local codes that may 
provide an equivalent or higher level of life safety than HR 2065 would 
provide. Fire and building safety codes are an intricate subject, to 
say the least. As the debate on HR 2065 continues, NASFM stands ready 
to work with the U.S. Congress and the U.S. Department of Veterans 
Affairs if questions arise regarding the implementation of the code-
related provisions of this bill.

                                 
                NATIONAL COALITION FOR HOMELESS VETERANS
    Chairman Dan Benishek, Ranking Member Julia Brownley, and 
distinguished members of the House Committee on Veterans' Affairs, 
Subcommittee on Health:

    The National Coalition for Homeless Veterans (NCHV) is honored to 
present this Statement for the Record for the legislative hearing on 
July 9, 2013. On behalf of the 2,100 community- and faith-based 
organizations NCHV represents, we thank you for your steadfast 
commitment to serving our nation's most vulnerable heroes.
    This statement will focus on Rep. David McKinley's H.R. 2065, the 
``Safe Housing for Homeless Veterans Act.'' While we are appreciative 
of any effort to protect homeless veterans from unnecessary harm as 
they work to reintegrate into society, NCHV believes that this bill as 
currently written could adversely impact organizations that seek to 
serve those veterans. Therefore, NCHV does not support H.R. 2065 at 
this time.
Evolution of ``Safe Housing'' Legislation
    The original ``Safe Housing for Homeless Veterans Act,'' introduced 
in the second session of the 112th Congress by Rep. McKinley, would 
have required entities to perform the following in order to receive 
funding under Title 38 U.S. Code Chapter 20 to house or serve homeless 
veterans:

    ``(Submit) to the Secretary a certification that the building where 
the entity proposes to provide such housing or services is in 
compliance with codes relevant to operations and level of care 
provided, including the most current Life Safety Code and all 
applicable State and local housing codes, licensing requirements, fire 
and safety requirements, and any other requirements in the jurisdiction 
in which the project is located regarding the condition of the 
structure and the operation of the supportive housing or service 
center.'' \1\
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    \1\ http://thomas.loc.gov/cgi-bin/bdquery/z?d112:h.r.004079:

    In its testimony before this Subcommittee on April 16, 2012, the 
Department of Veterans Affairs correctly noted that this legislation 
would have a very broad application, affecting such programs as the 
Supportive Services for Veteran Families (SSVF) Program, ``even when 
veterans are not cared for in these structures.'' \2\
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    \2\ http://veterans.house.gov/witness-testimony/robert-l-jesse-md-
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    NCHV appreciates that the present version of the ``Safe Housing for 
Homeless Veterans Act,'' introduced by Rep. McKinley in May 2013, would 
no longer affect programs that do not necessarily involve housing for 
homeless veterans. However, we are concerned about this bill's 
potential impact on community- and faith-based organizations.
Need to Clarify Who Bears the Burden of Certification
    The Department of Veterans Affairs is barred by law from making per 
diem payments under Title 38 U.S. Code Sec.  2012 unless an 
organization has shown that its facilities ``meet applicable fire and 
safety requirements under the Life Safety Code of the National Fire 
Protection Association or such other comparable fire and safety 
requirements as the Secretary may specify.'' \3\ VA abides by this 
statute by conducting thorough inspections before making an initial per 
diem award to a service provider.
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    \3\ http://www.law.cornell.edu/uscode/text/38/2012
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    If this initial inspection is successful and per diem funding is 
awarded, VA will continue to monitor the facility in question as well 
as provide regular re-inspections to ensure that, among other things, 
it continues to meet the applicable fire and safety requirements.
    H.R. 2065 introduces the concept of an ``annual certification'' 
that would require all per diem recipients to demonstrate the 
following:

    ``That the building where the entity provides such housing or 
services is in compliance with codes relevant to the operations and 
level of care provided, including applicable provisions of the most 
recently published version of the Life Safety Code or International 
Building Code and International Fire Code (or such versions of such 
codes that have been adopted as State or local codes by the 
jurisdiction in which the project is located), licensing requirements, 
fire and safety requirements, and any other requirements in the 
jurisdiction in which the project is located regarding the condition of 
the structure and the operation of the supportive housing or service 
center.'' \4\
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    \4\ http://www.gpo.gov/fdsys/pkg/BILLS-113hr2065ih/pdf/BILLS-
113hr2065ih.pdf

    NCHV is concerned that H.R. 2065 - as currently written - could 
discontinue VA's current practices, in which the department determines 
whether facilities are in Life Safety Code compliance during its 
regular re-inspections.
    Do these current practices constitute ``annual certification,'' as 
described in this bill? If so, H.R. 2065 should be amended to clarify 
that VA maintains responsibility for conducting all such inspections 
and providing certification. If not, this bill could place a 
significant burden on service providers to orchestrate and pay for 
these rigorous inspections out-of-pocket. This issue must be addressed 
before NCHV could consider making an endorsement.
    On the topic of whether or not International Building and Fire 
Codes should be used interchangeably with the Life Safety Code, as this 
bill would allow, NCHV defers to VA for its expertise in this area.
In Summation
    While NCHV does not support H.R. 2065 at this time, we are hopeful 
that the appropriate changes can be made to ensure that veteran service 
providers are not adversely impacted by this legislation.
    Thank you for the opportunity to submit this Statement for the 
Record. It is a privilege to work with the House Committee on Veterans' 
Affairs, Subcommittee on Health, to ensure that every veteran in crisis 
has reasonable access to the support services they have earned through 
their service to our country.

    Matt Gornick
    NCHV Policy Director

    202-546-1969
    [email protected]
                   NCHV Disclosure of Federal Grants
    Grantor: U.S. Department of Labor
    Subagency: Veterans' Employment and Training Service
    Grant/contract amount: $350,000
    Performance period: 8/13/2012 - 8/12/2013
    Indirect costs limitations or CAP limitations: 20% total award
    Grant/contract award notice provided as part of proposal: Yes

    Grantor: U.S. Department of Labor
    Subagency: Veterans' Employment and Training Service
    Grant/contract amount: $350,000
    Performance period: 8/13/2011 - 8/12/2012
    Indirect costs limitations or CAP limitations: 20% total award
    Grant/contract award notice provided as part of proposal: Yes

                                 
                     PARALYZED VETERANS OF AMERICA
    Chairman Benishek, Ranking Member Brownley, and members of the 
Subcommittee, Paralyzed Veterans of America (PVA) thanks you for the 
opportunity to submit a statement for the record regarding the five 
pieces of proposed legislation being considered today. PVA appreciates 
that you are addressing these important issues involving the health of 
our nation's veterans.
               The ``Long-Term Care Veterans Choice Act''
    PVA generally supports the ``Long-Term Care Veterans Choice Act.'' 
This bill proposes to amend title 38, United States Code to authorize 
the Department of Veterans Affairs (VA) to enter into contracts or 
agreements for the transfer of veterans to non-VA adult foster homes 
for certain veterans who are unable to live independently. PVA believes 
that VA's primary obligation involving long-term support services is to 
provide veterans with quality medical care in a healthy and safe 
environment.
    As it relates to veterans with a catastrophic injury or disability, 
it is PVA's position that adult foster homes are only appropriate for 
disabled veterans who do not require regular monitoring by licensed 
providers, but rather have a catastrophic injury or disability and are 
able to sustain a high level of independence. When these veterans are 
transferred to adult foster homes, care coordination with VA 
specialized systems of care is vital to the veterans' overall health 
and well-being. The drafted text of this bill requires the veteran to 
receive VA home health services as a condition to be transferred. As 
such, PVA believes that if a veteran with a spinal cord injury or 
disorder is eligible and willing to be transferred to an adult foster 
home, the VA must have an established system in place that requires the 
VA home based primary care team to coordinate care with the VA SCI/D 
Center and the SCI/D primary care team that is within the closest 
proximity to the adult foster home. When caring for a veteran with a 
catastrophic injury or disability this specialized expertise is 
extremely important to prevent and treat associated illnesses that can 
quickly manifest and jeopardize the health of the veteran.
    When catastrophically injured or disabled veterans who receive 
services from one of the VA's specialized systems of care are placed in 
a non-VA adult foster home they must be regularly evaluated by 
specialized providers who are trained to meet the needs of their 
specific conditions. PVA also believes that as this draft legislation 
is aptly titled the, ``Long Term Care Veterans Choice Act,'' veterans 
should only be transferred from a VA facility to a non-VA adult foster 
home with the full consent of the veteran, pursuant to title 38 U.S.C., 
Section 1710A(b)(1).
         H.R. 1443, the ``Tinnitus Research and Treatment Act''
    PVA does not have a position on H.R. 1443, the ``Tinnitus Research 
and Treatment Act of 2013,'' a bill that proposes to direct the VA to 
recognize tinnitus as a mandatory condition for research and treatment. 
PVA supports VA research efforts involving hearing loss and conditions 
such as tinnitus, however, we believe that the selection of research 
subject areas and projects should be done through the VA scientific 
peer review process.
                               H.R. 1612
    PVA does not have a position on H.R. 1612, a bill to direct the VA 
to convey a parcel of land in Tuskegee, Alabama, to Tuskegee 
University.
         H.R. 1702, the ``Veterans Transportation Service Act''
    PVA supports H.R. 1702, the ``Veterans Transportation Service 
Act,'' a bill to amend title 38 United States Code to make permanent 
the authority of the VA to transport individuals to and from VA 
facilities when it is in connection with rehabilitation, counseling, 
examination treatment, and care. Too often lack of transportation is a 
barrier to veterans' access to medical care. This is frequently the 
case for disabled veterans who do not have a personal means of 
transportation. 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. It is for this reason that PVA strongly 
supports H.R. 1702 and encourages Congress and VA to further improve 
veterans' access to care by providing accessible transportation for 
disabled veterans, specifically veterans who have incurred a spinal 
cord injury or disorder, or veterans who use a wheelchair.
       H.R. 2065, the ``Safe Housing for Homeless Veterans Act''
    PVA does not have a position on H.R. 2065, the ``Safe Housing for 
Homeless Veterans Act.'' If enacted this legislation would amend title 
38, United States Code, to require entities that provide services to 
homeless veterans and receive per diem payments from the VA to comply 
with codes relevant to operations and level of care provided to 
veterans. PVA supports Secretary Shinseki's goal of eradicating 
homelessness among America's veterans, and believes that the safety of 
facilities that offer services to homeless veterans is of extreme 
importance.
    Paralyzed Veterans of America appreciates this opportunity to 
express our views on the proposed bills being reviewed. We look forward 
to working with the Subcommittee on these and other issues in the 
future, and are happy to answer any questions.
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.

                                 
                      VIETNAM VETERANS of AMERICA
    Chairman Benishek, Ranking Member Brownley, and distinguished 
members of the House Veterans' Affairs Subcommittee on Health, Vietnam 
Veterans of America (VVA) appreciates the opportunity to offer this 
Statement for the Record on pending legislation before this 
subcommittee.
    Draft legislation: Long-Term Care Veterans Choice Act: Would 
authorize the Secretary of Veterans Affairs to enter into contracts for 
the transfer of certain veterans who are unable to live independently 
into non-Department adult foster homes.
    This seems like a good idea on the face of it, but there just isn't 
enough detail for VVA to support this bill at this juncture. For 
example, what is the meaning of the phrase ``. . . for certain veterans 
who are unable to live independently''?
    Furthermore, the proposed legislation states that ``At the request 
of a veteran for whom the Secretary is required to provide nursing home 
care under 1710A of this title, the Secretary may transfer the veteran 
to an adult foster home that meets Department standards at the expense 
of the United States . . . '' Who will decide which type of facility 
(and where) the veteran can choose to be transferred to? Currently 
there is a variety of facility options currently recognized by the VA, 
such as an adult family home, an assisted living facility, a community 
nursing home, a medical foster home, a state veterans home, or a 
community living center, and each of these options has separate 
eligibility criteria, including the veteran's income level.
    This proposed draft legislation needs far more detail before VVA 
can give further consideration of support. The issue, though, is of 
high import to us, inasmuch as Vietnam-era veterans now constitute the 
largest living cohort of elderly American veterans.
    H.R.1443: Tinnitus Research and Treatment Act of 2013; introduced 
by Congressman Michael Michaud (ME-2): would direct the Secretary of 
Veterans Affairs to: 1) recognize tinnitus as a mandatory condition for 
research and treatment by Department of Veterans Affairs Auditory 
Centers of Excellence; 2) ensure that research is conducted at VA 
facilities on the prevention and treatment of tinnitus; and 3) ensure 
VA cooperation with the Hearing Center of Excellence established by the 
Department of Defense (DoD) to further research on tinnitus. VVA 
supports H.R. 1443.
    H.R.1612: To direct the Secretary of Veterans Affairs to convey a 
specified parcel real property at 2400 Hospital Road in Tuskegee, 
Alabama, to Tuskegee University, for the purpose of permitting the 
university to use the property to further the educational and general 
welfare of its students; introduced by Congressman Mike Rogers, (AL-3).
    The Tuskegee Airmen were the most highly respected African American 
troops of World War II, the University of Alabama donated 300 acres of 
land to build a hospital solely to care for black veterans in the South 
and today that hospital is the Tuskegee Veterans Affairs Medical 
Center. In February 2013 the Tuskegee VAMC celebrated 90 years of 
service to veterans and their families. In honor of the Tuskegee 
Airmen's service and sacrifice to our nation, VVA supports H.R. 1612.
    H.R.1702: Veterans Transportation Service Act; introduced by 
Congressman Ron Barber (AZ-2); makes permanent (under current law, 
expires on January 10, 2014) the authority of the Secretary of Veterans 
Affairs to transport individuals to and from facilities of the 
Department of Veterans Affairs in connection with vocational 
rehabilitation, counseling, examination, treatment, or care. VVA 
supports making this provision of the law permanent.
    H.R.2065: Safe Housing for Homeless Veterans Act; introduced by 
Congressman David McKinley (WV-1); would require recipients of per diem 
payments for the provision of services for homeless veterans to comply 
with codes relevant to operations and level of care provided.
    The VA Homeless Providers Grant and Per Diem Program provides 
grants and per diem payment assisting public and nonprofit 
organizations in establishing and operating supportive housing and 
service centers for homeless veterans. When enacted into law, H.R 2065 
would mandate that these public and nonprofits organizations are in 
compliance with Life Safety Code of the National Fire Protection 
Association and other requirements as stated in Section 61.20 Life 
Safety Code Capital Grants in the VA Homeless Providers Grant and Per 
Diem Program regulations. VVA applauds Congressman McKinley for 
introducing this legislation and supports H.R. 2065 as written.
    Mr. Chairman and members of the House Veterans Affairs Subcommittee 
on Health VVA would like to thank you for the opportunity to submit our 
Statement for the Record on legislation that would improve the quality 
of life for veterans and their families before this subcommittee today.
                      VIETNAM VETERANS OF AMERICA
                           Funding Statement
                              July 9, 2013
    The national organization Vietnam Veterans of America (VVA) is a 
non-profit veterans' membership organization registered as a 501(c) 
(19) with the Internal Revenue Service. VVA is also appropriately 
registered with the Secretary of the Senate and the Clerk of the House 
of Representatives in compliance with the Lobbying Disclosure Act of 
1995.
    VVA is not currently in receipt of any federal grant or contract, 
other than the routine allocation of office space and associated 
resources in VA Regional Offices for outreach and direct services 
through its Veterans Benefits Program (Service Representatives).
    This is also true of the previous two fiscal years.
    For Further Information, Contact:
    Executive Director of Policy and Government Affairs
    Vietnam Veterans of America.
    (301) 585-4000, extension 127

                                 
                        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. We welcome this 
opportunity to address two of the measures before you.
                   Long Term Care Veterans Choice Act
    A draft bill under consideration is apparently intended to 
authorize VA to contract for room, board, and caregiver services in 
adult foster homes for veterans for whom VA would have an obligation to 
provide needed nursing home care. The measure would also provide for a 
participating veteran to receive VA home health services.
    Wounded Warrior Project welcomes the proposal to add medical foster 
home care to the continuum of long-term care options for wounded 
warriors. Almost without exception, our work with wounded warriors and 
their families has underscored how important it is to enable the 
individual to live in the community and avoid institutionalization. The 
comprehensive caregiver assistance program established in Public Law 
111-163 has proven enormously helpful in realizing that goal for those 
who were seriously injured on or after 9/11 and need personal care 
services. But we do encounter parents and other family members who 
worry about a time when they might no longer be able to sustain 
caregiving, as well as seriously injured warriors who have no family to 
provide care. Given wide-ranging needs and preferences among those who 
cannot live independently, \1\ there is merit to fostering new 
approaches. In sum, we applaud the effort to develop a statutory 
framework to enable VA to provide a community-based, home-like 
alternative to institutional care that includes needed home-health 
services.
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    \1\ A 2012 report on deinstitutionalized disabled individuals by 
the National Council on Disability cited studies based on the National 
Core Indicators 2009-10 Survey to assess their preferences for housing, 
dividing responses into independent living, living with family members, 
living in a community-based setting (such as a small group home or 
foster care with a host family) or living in an institution (nursing 
home or large group home). Overall, ninety percent responded that they 
liked where they lived, but those surveyed expressed the most 
satisfaction with living with family members (96%) and the least with 
institutional settings (83%). Those in individual homes (90%) and in 
community based settings (87%) were in the middle. When asked if they 
would like to live somewhere else findings were somewhat consistent. 
Only 20% of those living with parents expressed a desire to live 
elsewhere compared with 39% of institutionalized respondents. Twenty-
six percent of those in individual homes and 30% of those in community 
settings responded positively. Human Services Research Institute/ 
National Association of State Directors of Developmental Disabilities 
Services, National Core Indicators, 2011 as cited in 
Deinstitutionalization Toolkit: Community in Detail, National Council 
on Disability, 2012, Figures 2-6.
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    The legislation would vest the Department with broad authority to 
set standards for these homes. It is our understanding that adult 
medical foster homes are generally subject to state licensing 
requirements. But the draft bill sets no express expectations of VA 
with regard to those standards, which in our view should not simply 
default to a state licensure requirement, given the very vulnerable 
individuals covered under the draft bill. We do understand that VA has 
worked for some time with foster-home care providers under arrangements 
where the veteran has borne the costs of that care. It seems likely 
that the number of veterans who might choose a foster home option would 
grow were such legislation enacted. That scenario does raise questions 
as to how the program would operate, and what kind of oversight would 
be provided. What kind of training would caregivers receive? What 
precautions would be taken to ensure placements were clinically and age 
appropriate for the veteran? How would VA ensure that medical foster 
homes have appropriate oversight and that veterans and their families 
are satisfied with the services they receive there? We would encourage 
the Subcommittee to press VA to address those questions early on and 
clearly define expectations regarding standards of care, as well as 
outline how they would evaluate a potential residence's ability to 
provide for younger generations of veterans who have unique 
rehabilitative needs.
    Finally, while we welcome this initiative, we would be remiss if we 
failed to note that VA still has important work to do as it relates to 
the long term rehabilitative care for those with moderate to severe 
traumatic brain injury, and particularly with implementation of section 
107 of Public Law 112-154. Those provisions of law require that 
rehabilitative care for traumatic brain injury focus not only on 
achieving functional gains but on sustaining them, and that veterans be 
afforded community-based rehabilitative services or supports that 
contribute to maximizing an individual's independence. While Wounded 
Warrior Project, through our Independence Program, is working every day 
to help warriors with severe traumatic brain injury reach their fullest 
potential in their communities, we have not seen VA take comparable 
steps to implement a now year-old law requiring such action.
    Without ongoing rehabilitative care and community supports that 
Congress directed VA to provide, many post 9/11 Warriors with severe 
brain trauma will be relegated to lives of greater dependency, and 
without the social networks or employment options their non-disabled 
peers take for granted. VA must make significant improvements to ensure 
an adequate rehabilitative services continuum is available before 
placement of younger gravely injured veterans in residential settings 
other than their own or family homes will be acceptable.
              Tinnitus Research and Treatment Act of 2013
    H.R. 1443 would direct VA to recognize tinnitus as a mandatory 
condition for research and treatment by VA Auditory Centers of 
Excellence and for that research to include the study of treatments, 
etiology, and underlying mechanisms of the disorder. The bill also 
directs VA to work with the Department of Defense's Hearing Center of 
Excellence to advance research on tinnitus.
    With 52% of Wounded Warrior Project Alumni reporting tinnitus and 
17% experiencing severe hearing loss, we welcome the focus on exploring 
improved prevention and treatment of hearing disorders. \2\ As a very 
common health problem with limited treatment options, advancing 
research in this area could have a significant impact in improving care 
for wounded veterans. We see particular value in fostering the study 
and evaluation of prevention, assessment, and treatment of tinnitus 
through collaboration between the VA and the Department of Defense 
since it is strongly associated with service and exposure to a combat 
zone. \3\ Advancements in preventing hearing loss and tinnitus will 
have to happen within the military, so it is important to ensure gains 
in knowledge and understanding are translated into improvements on the 
battlefield and in training.
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    \2\ 2013 Wounded Warrior Project Survey Results
    \3\ Tzounopoulos, T. 2013. Mechanisms underlying Noise- Induced 
Tinnitus. Retrieved from http://cdmrp.army.mil/prmrp/research--
highlights/2013.shtml
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    We are supportive of continuing research and improvements in the 
treatment of tinnitus, as well as other forms of hearing loss. Tinnitus 
is an often very disabling problem that affects many warriors 
frustrated by the fact that there are as yet no effective treatments. 
We urge that continuing research also explore the varying impact 
tinnitus can have on different people. As a chronic condition, the 
level of disability can differ significantly and improved understanding 
could better describe the spectrum of the condition and contribute to 
scientific and medical knowledge, as well as better prevention and care 
in the future and increased accuracy in disability ratings. Tinnitus 
merits robust research efforts and WWP would support legislation to 
advance understanding in this area.
    Thank you for your consideration of WWP's views on these issues.

                                 
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