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


 
               LEGISLATIVE HEARING ON H.R. 183; H.R. 2527;
                  H.R. 2661; H.R. 2974; H.R. 3180; H.R. 3387; H.R.
                  3831; H.R. 4198; AND, DRAFT LEGISLATION TO 
                  AUTHORIZE MAJOR MEDICAL FACILITY 
                  PROJECTS FOR THE DEPARTMENT OF VET-
                  ERANS AFFAIRS FOR FISCAL YEAR 2014 AND 
                  FOR OTHER PURPOSES

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

                                HEARING

                              BEFORE THE 

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

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

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                        THURSDAY, MARCH 27, 2014

                               __________

                           Serial No. 113-61

                               __________

       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, Vice-         Minority Member
    Chairman                         CORRINE BROWN, Florida
DAVID P. ROE, Tennessee              MARK TAKANO, California
BILL FLORES, Texas                   JULIA BROWNLEY, California
JEFF DENHAM, California              DINA TITUS, Nevada
JON RUNYAN, New Jersey               ANN KIRKPATRICK, Arizona
DAN BENISHEK, Michigan               RAUL RUIZ, California
TIM HUELSKAMP, Kansas                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
DAVID JOLLY, Florida
                       Jon Towers, Staff Director
                 Nancy Dolan, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

                    DAN BENISHEK, Michigan, Chairman

DAVID 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
                                     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

                              ----------                              

                        Thursday, March 27, 2014

                                                                   Page

Legislative Hearing on H.R. 183; H.R. 2527; H.R. 2661; H.R. 2974; 
  H.R. 3180; H.R. 3387; H.R. 3831; H.R. 4198; and, Draft 
  Legislation to Authorize Major Medical Facility Projects for 
  the Department of Veterans Affairs for Fiscal Year 2014 and for 
  Other Purposes.................................................     1

                           OPENING STATEMENTS

Hon. Dan Benishek, Chairman, Subcommittee on Health..............     1
    Prepared Statement...........................................    30
Hon. Julia Brownley, Ranking Member..............................     3

                               WITNESSES

Hon. Michael Grimm, U.S. House of Representatives................     3
    Prepared Statement...........................................    31
Hon. Dina Titus, U.S. House of Representatives...................    10
    Prepared Statement...........................................    31
Hon. Jackie Walorski, U.S. House of Representatives..............     4
    Prepared Statement...........................................    32
Hon. Sean Duffy, U.S. House of Representatives...................     7
    Prepared Statement...........................................    33
Hon. Marcy Kaptur, U.S. House of Representatives
    Prepared Statement...........................................    34
Hon. Kyrsten Sinema, U.S. House of Representatives...............     9
    Prepared Statement...........................................    34
Hon. David P. Roe, U.S. House of Representatives.................    11
    Prepared Statement...........................................    36
Hon. Jeff Denham, U.S. House of Representatives..................    22
    Prepared Statement...........................................    36
Joy J. Ilem, Deputy National Legislative, Director, Disabled 
  America Veterans...............................................    14
    Prepared Statement...........................................    37
Alethea Predeous, Associate Director of Health Analysis, 
  Paralyzed Veterans of America..................................    15
    Prepared Statement...........................................    46
Aleksandr Morosky, Senior Legislative Associate, National 
  Legislative Service, Veterans of Foreign Wars..................    17
    Prepared Statement...........................................    50
Madhulka Agarwal M.D., M.P.H., Deputy Under Secretary for Health 
  for Policy and Services, Veterans Health Administration, U.S. 
  Department of Veterans Affairs.................................    23
    Prepared Statement...........................................    54

    Accompanied by:

        Philip Matkovsky, Assistant Deputy Under Secretary for 
            Health for Operations and Management, Veterans Health 
            Administration, U.S. Department of Veterans Affairs

        Renee L. Szybala, Acting Assistant General Counsel, U.S. 
            Department of Veterans Affairs

                        STATEMENT FOR THE RECORD

Hon. Kevin McCarthy, U.S. House of Representatives, 23rd 
  District, California...........................................    59
American Academy of Otolaryngology-Head and Neck Surgery.........    60
Department of Veterans Affairs Office of the Inspector General...    62
International Hearing Society....................................    63
Iraq and Afghanistan Veterans of America.........................    66
National Association of State Veterans Homes.....................    68
Servicewomen's Action Network....................................    70
The American Speech-Language-Hearing Association.................    72
Warrior Canine Connection........................................    74
Wounded Warrior Project..........................................    76
VetsFirst........................................................    80
Questions For The Record.........................................    82


LEGISLATIVE HEARING ON H.R. 183; H.R. 2527; H.R. 2661; H.R. 2974; H.R. 
   3180; H.R. 3387; H.R. 3831; H.R. 4198; AND, DRAFT LEGISLATION TO 
    AUTHORIZE MAJOR MEDICAL FACILITY PROJECTS FOR THE DEPARTMENT OF 
      VETERANS AFFAIRS FOR FISCAL YEAR 2014 AND FOR OTHER PURPOSES

                        Thursday, March 27, 2014

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                            Subcommittee on Health,
                                                   Washington, D.C.
    The subcommittee met, pursuant to notice, at 9:03 a.m., in 
Room 334, Cannon House Office Building, Hon. Dan Benishek 
[chairman of the subcommittee] presiding.
    Present:  Representatives Benishek, Roe, Denham, Walorski, 
Brownley, Negrete-McLeod, Kuster, and Titus.

           OPENING STATEMENT OF CHAIRMAN DAN BENISHEK

    Mr. Benishek. The subcommittee will come to order. Before 
we begin I would like to ask unanimous consent from my friends 
and colleagues and members of the full committee to sit on the 
dais and participate in today's proceedings. Without objection, 
so ordered.
    Good morning. And thank you all for joining us today to 
discuss pending legislation regarding the health care benefits 
and services provided to our nation's veterans through the 
Department of Veterans Affairs. The ten bills we will discuss 
today are H.R. 183, the Veterans Dog Training Therapy Act; H.R. 
2527, to provide veterans with counseling and treatment for 
sexual trauma that occurred during inactive duty training; H.R. 
2661, the Veterans Access to Timely Medical Appointments Act; 
H.R. 2974, to provide beneficiary travel eligibility for 
veterans seeking treatment or care for military sexual trauma; 
H.R. 3387, the Classified Veterans Access to Care Act; H.R. 
3508, to clarify the qualifications of VA hearing aid 
specialists; H.R. 3180, to provide an exception to the 
requirement that the federal government recover a portion of 
the value or certain projects; H.R. 3881, the Veterans Dialysis 
Pilot Program Review Act; H.R. 4198, the Appropriate Care for 
Disabled Veterans Act; and draft legislation to authorize VA 
major medical facility projects for fiscal year 2014.
    By and large these ten bills aim to address two of this 
subcommittee's highest priorities: ensuring that our veterans 
have access to the care that they need, and two, ensuring that 
VA is held accountable when that care fails to meet the high 
standards that it should. Some of these bills, such as H.R. 
2527 and H.R. 2974, which aim to resolve gaps in care for 
veterans who have experienced military sexual trauma, address 
issues that have been raised through subcommittee oversight. 
Others, such as H.R. 2661, H.R. 2508, and H.R. 3831, which 
concern lengthy patient waiting times, access to care for 
hearing impaired veterans, and ongoing issues with the 
provision of dialysis care, address issues that were raised 
through external stakeholder reviews by the VA Inspector 
General and the Government Accountability Office. Still others, 
such as H.R. 183 and H.R. 4198, which concern the need for 
innovative treatment options for veterans with Post Traumatic 
Stress Disorder and the need to ensure that VA maintains 
adequate capacity to provide for the unique health care needs 
of disabled veterans, address issues that were raised by our 
veteran constituents and veterans service organizations. One 
other, the draft legislation to authorize VA major medical 
facility projects for fiscal year 2014 and of note authorize 
the construction of a new bed tower at the James A. Haley 
Veterans' Hospital in Tampa, Florida, is the department's own 
legislative request.
    I would note that VA's fiscal year 2015 budget submission 
includes five additional lease authorization requests that are 
not included in the draft bill we will discuss this morning. 
While I recognize the value of those five lease authorization 
requests, which would certainly be included in future VA major 
medical facility lease authorization packages moving through 
the committee, I thought it was important to thoroughly analyze 
and receive stakeholder views on the department's fiscal year 
2014 request.
    As you may know, last Fall the House passed H.R. 3521, the 
Department of Veterans Affairs Major Medical Facility Lease 
Authorization Act of 2013, which would authorize 27 VA major 
medical facility leases requested by the department in the 
fiscal year 2014 budget submission. It is my sincere hope that 
H.R. 3521 will be passed through the Senate and quickly signed 
into law.
    I would like to express my gratitude to my colleagues who 
have sponsored the legislation on our agenda today and who are 
joining us this morning to discuss their proposals. I would 
also like to thank our witnesses from the Disabled Veterans of 
America, the Paralyzed Veterans of America, and the Veterans of 
Foreign Wars, as well as the witness from VA for their 
leadership and advocacy on behalf of our veterans and for being 
here today to offer their views.
    It is critical that we have thorough understanding of the 
benefits and consequences of each of these bills before moving 
forward in the legislative process. And as such I look forward 
to a detailed and comprehensive conversation. With that, I now 
yield to Ranking Member Brownley for any opening statement she 
may have.

    [The prepared statement of Dan Benishek appears in the 
Appendix]

      OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

    Ms. Brownley. Thank you, Mr. Chairman. As you said the 
purpose of today's hearing will be to explore the policy 
implications of nine bills and one draft piece of legislation 
before us today which covers a wide range of topics that would 
expand and enhance VA's health ca reprograms and services.
    I am glad this committee is considering Representative 
Walorski's legislation, H.R. 2974, which I have proudly 
cosponsored. I believe there is a lot of work to be done for 
our veterans that are victims of military sexual trauma and 
providing travel benefits to those veterans is a good start. I 
look forward to hearing the views from our panelists and 
appreciate the hard work that I know their testimony will 
demonstrate. While I am disappointed in the department for not 
furnishing views on three of the bills I do understand that 
sometimes there are extenuating circumstances that preclude 
them from submitting their views in a timely manner. I hope the 
VA will be able to at least comment on some of the provisions. 
As you know, Mr. Chairman, we hold these legislative hearings 
to ensure that the committee is as fully informed as possible 
and we rely on this input to make intelligent and well-educated 
decisions on whether to advance a bill from this subcommittee.
    I look forward to a frank and open discussion on the very 
topics that are presented before us today. And thank you again, 
Mr. Chairman. And I yield back.
    Mr. Benishek. Thank you, Ms. Brownley. Joining us on the 
first panel today, and hopefully a few more members will show, 
are Representative Michael Grimm from New York; Representative 
and committee member Dina Titus from Nevada; Representative and 
committee member Jackie Walorski from Indiana; Representative 
Sean Duffy from Wisconsin; Representative Marcy Kaptur from 
Ohio; Representative Kyrsten Sinema from Arizona; 
Representative and committee member David Roe from Tennessee; 
and Representative and committee member Jeff Denham from 
California.
    It is an honor to have you all here this morning. I look 
forward to hearing your testimony. Mr. Grimm, may we begin with 
you?
    Mr. Grimm. Yes, Chairman.
    Mr. Benishek. Please proceed with your testimony.

                STATEMENT OF HON. MICHAEL GRIMM

    Mr. Grimm. Thank you very much, Chairman. I appreciate it. 
Both Chairman Benishek and Ranking Member Brownley, thank you 
for allowing me to testify today on H.R. 183, the Veterans Dog 
Training Therapy Act. This is a bill I introduced along with my 
friend the ranking member of the House Veterans' Affairs 
Committee, Congressman Michaud, in the last Congress and again 
this Congress.
    As a Marine combat veteran, it is a unique honor for me to 
address this committee. Having seen firsthand both the physical 
and mental wounds of War that the members of our nation's 
military are faced with I have a very special appreciation for 
the important work this committee does every single day. Today 
millions of Iraq and Afghanistan veterans have returned home to 
the challenge of a stagnant economy, high unemployment, and for 
many the long road to recovery for the mental and physical 
wounds sustained during their service. During my time in 
Congress I have had the honor to meet with a number of our 
nation's veterans who are now faced with the challenges of 
coping with PTSD and physical disabilities resulting from their 
service in combat. Their stories are not for the weak of heart 
and are truly moving.
    It was these personal accounts of recover, both physical 
and mental, and the important role therapy and service dogs 
played in that process, that inspired this legislation. The 
Veterans Dog Training Therapy Act would require the Department 
of Veterans Affairs to conduct a five-year pilot program in at 
least three, but not more than five, VA medical centers 
assessing the effectiveness of addressing post-deployment 
mental health and PTSD through the therapeutic medium of 
training service dogs for veterans with disabilities. These 
trained service dogs are then given to physically disabled 
veterans to help them with their daily activities. Simply put, 
this program treats veterans suffering from PTSD while at the 
same time aiding those suffering from physical disabilities.
    When I originally introduced this legislation in the 112th 
Congress both the House Veterans' Affairs Committee and the 
full House of Representatives passed it with overwhelming 
bipartisan support. Additionally, with high veteran suicide 
rats and more servicemen and women returning from deployment 
being diagnosed with PTSD, this bill meets a crucial need for 
additional treatment methods. I believe that by caring for our 
nation's veterans suffering from the hidden wounds of PTSD 
while at the same time providing assistance dogs for those with 
physical disabilities we create a win-win for everyone which I 
believe is a goal we can all be proud to accomplish.
    Working in conjunction with a number of veterans service 
organizations I have drafted updated language which mirrors 
changes made to this legislation in the 112th Congress. And I 
hope to work with the committee during mark up of H.R. 183 to 
ensure this program provides our nation's veterans with the 
highest quality care for both PTSD and physical disabilities 
while maintaining my commitment to fiscal responsibility.
    Again, I would like to thank the committee for holding 
today's hearing and I look forward to working with you to 
ensure that this program is included in your continuing efforts 
to guarantee that our nation's heroes have the best possible 
programs for treating PTSD and providing disability assistance. 
Thank you, and I yield back.

    [The prepared statement of Michael Grimm appears in the 
Appendix]

    Mr. Benishek. Thank you very much for your testimony, Mr. 
Grimm. Let me yield five minutes to Ms. Walorski for her 
statement. Thank you.

               STATEMENT OF HON. JACKIE WALORSKI

    Mrs. Walorski. Good morning. Chairman Benishek, thank you, 
Ranking Member Brownley, and members of the committee, thank 
you for the opportunity to discuss H.R. 2974, a bill making 
victims of military sexual trauma eligible for Department of 
Veterans Affairs beneficiary travel benefits. According to the 
VA, one in five women and one in 100 men screen positive for 
military sexual trauma, or MST.
    The VA provides counseling, care, and services to veterans 
and certain other servicemembers who may not have veteran 
status but who experienced MST while serving on active duty or 
active duty for training. VHA policy states, ``veterans and 
eligible individuals who report experiences of MST but were 
deemed ineligible for other VA health care benefits or 
enrollment may be provided MST-related care only. This benefit 
extends to Reservists and members of the National Guard who 
were activated to full-time duty status in the armed forces. 
Veterans and eligible individuals who received an other than 
honorable discharge may be able to receive free MST-related 
care with Veterans Benefits Administration regional office 
approval.''
    Every VA medical center offers evidence-based therapy for 
conditions related to MST and has providers who know how to 
treat the downstream effects of MST. Nationwide there are 
almost two dozen programs that offer specialized treatment in 
both residential and in patient settings. All health care for 
treatment for mental and physical health conditions related to 
MST, including medications, is provided free of charge. Fee 
basis is available when it is not appropriate to provide 
counseling in a VA facility, when VA facilities are 
geographically inaccessible or when VA facilities are unable to 
provide care in a timely manner.
    Overall while VA has taken the appropriate steps to provide 
counseling services for victims of MST, these services need to 
be more accessible. MST-related care must be provided in a 
setting that is therapeutically appropriate and takes into 
account the circumstances related in the need for such care. A 
supportive environment is essential for recovery. VA policy 
states that any veteran with MST must receive clinically 
appropriate care regardless of the location.
    Veterans being treated for conditions associated with MST 
are often admitted to programs outside their Veteran Integrated 
Service Network. VA health care in general, especially for 
women, has been characterized as fragmented. Patients with 
special needs who are unable to access the services they need 
from their local providers are referred elsewhere and 
oftentimes have to travel long distances to receive such 
services. According to a 2012 VA Inspector General report, 
obtaining authorization for travel funding was frequently cited 
as a major problem for both patients and staff.
    The beneficiary travel policy indicates that only certain 
categories of veterans are eligible for travel benefits and 
payment is only authorized to the closest facility providing a 
comparable service. The current beneficiary travel policy 
contradicts VA's MST policy, which states that patients with 
MST should be referred to programs that are clinically 
indicated regardless of geographic location. A veteran should 
never have to choose to skip treatment for conditions related 
to MST due to distance or lack of transportation.
    I applaud VA's commitment to an effective program that 
provides counseling and treatment to men and women in need of 
help in overcoming the physical and psychological stress 
associated with MST. However, VA is not doing enough to help 
veterans access these important resources and services. 
Survivors of MST should not feel re-traumatized and helpless 
because of geographic barriers to treatment. Representative 
Kuster and I introduced H.R. 2974 to make victims of MST 
eligible for VA beneficiary travel benefits. By better aligning 
the beneficiary travel policy with VA's current policy for 
responding to veterans who have experienced MST, H.R. 2974 
ensures appropriate services are more readily available to meet 
the treatment needs of our nation's veterans.
    I am grateful to work with Representative Kuster and the 
committee in addressing this critical issue for the survivors 
of military sexual trauma and I again thank you for this 
opportunity to speak today.

    [The prepared statement of Jackie Walorski appears in the 
Appendix]

    Mr. Benishek. Thank you very much for your testimony and 
for the legislation. Dr. Roe, are you ready? Well, some members 
may be late in joining us. But I think as long as we are all 
here I would ask a couple of questions of the people that are 
here with us this morning. So I will yield myself five minutes 
to begin that.
    Mr. Grimm, there is a statement from VA in their written 
testimony I would like you to respond to. It says, ``The VA 
does not support the specific provisions of H.R. 183 because 
the bill focuses on the training of the dog as opposed to what 
we believe is the goal of the legislation, which is finding 
better ways to improve the health of this veteran population.'' 
Can you respond to that?
    Mr. Grimm. Certainly. Thank you, Chairman. Simply put, they 
completely miss the mark. It is actually the veteran that may 
have Post Traumatic Stress that is actually training the dog. 
It is the actual training that is the therapy itself. Often 
veterans come back and they have had so much responsibility, 
literally life and death responsibility for multiple tours, 
years at a time. And they come back and they feel very 
minimized. They do not have that sense of responsibility. Many 
of them cannot find work. They are having trouble fitting in. 
And they feel that everyone is looking at them differently. And 
for, and I cannot tell you how it happens because it is almost 
magical. It seems almost as if it is miraculous. But what we 
have noticed is when these veterans tend to this animal, to 
this dog, to train them, one it gives them that sense of 
responsibility back again, that they are doing something that 
is important. And the way these animals just seem to know how 
to act around these veterans is simply amazing.
    So it gives them a sense of purpose. And when they know 
that the dog, if they succeed and the dog is fully trained that 
then that dog is going to be given to a fellow veterans with 
physical disabilities, it is a veteran helping another veteran. 
That is what is happening here. So it is, whether the dog 
actually gets trained fully or not is almost irrelevant. If the 
dog gets fully trained, great. We pass that dog on, it gets 
certified, and goes to another veteran. But if not what we are 
finding is many times the veteran, just that sense of being 
needed is a big step in the process of being healed. And 
sometimes they even just want to take the dog home and it 
becomes a pet. Either way, and that is why the actual training 
of the dog is very secondary. It is that sense of purpose given 
to that veteran. That is the actual therapy itself. So I think 
the Veterans Administration in this case is just completely 
missing the mark. I yield back.
    Mr. Benishek. Well I certainly know that we just did a 
field hearing in California. And that, they have veterans who 
are working with horses. I am not a horse person. But, they 
found the same thing, in that either the animal seems to be 
able to provide a measure of confidence to patients with Post 
Traumatic Stress Disorder. And I think, there is a lot of 
opportunity for this sort of alternative methods of treatment. 
Because we should be really casting a wide net to try to find 
what can help many of our veterans. So I applaud your efforts 
here.
    Let me--oh, are you waiting to talk now? Oh, okay. Well one 
other question for you, Mr. Grimm. Would you be willing to 
consider amendments to H.R. 183 that would allow VA to be 
flexible in the housing and training off campus, as the VFW 
suggested?
    Mr. Grimm. Chairman, absolutely. In fact I have proactively 
been working in conjunction with several VSOs on this issue and 
intend to suggest modified language to the committee based on a 
number of recommendations that we have already received. So 
there are VSOs that are doing this in Palo Alto and other 
places that have gotten it pretty much down to a science and we 
are willing to incorporate all of those things. So we think 
that absolutely.
    Mr. Benishek. Thank you. I will yield to Ms. Brownley for 
questions.
    Ms. Brownley. Thank you, Mr. Chairman. I am not sure that I 
have a question but I did want to make a remark with regards to 
Ms. Sinema's bill and thank you for bringing this bill forward. 
And suicide and suicide prevention is one of the number one 
goals of this committee. And as you know and the committee 
knows and the audience knows that, you know, 22 suicides a day 
in our country by our veterans and that is completely 
unacceptable. And I know that your legislation unfortunately 
will not save Daniel's life but hopefully it will save someone 
else's life. And I know today even on the Mall the Iraq and 
Afghanistan Veterans of America, whose number one priority is 
suicide prevention, is having a big occasion out on the Mall 
and will be raising flags, thousands of flags in honor of our 
veterans who have committed suicide and who have served our 
country so honorably. So I just wanted to thank you for 
bringing this legislation forward and this seems like a very, 
very simple fix that is part of the VA's policy in some sense 
and a very simple fix to potentially save future lives. So 
thank you very much for bringing it forward.
    Mr. Benishek. Thank you very much. Mr. Duffy.

                  STATEMENT OF HON. SEAN DUFFY

    Mr. Duffy. Good morning and thank you, Chairman Benishek 
and Ranking Member Brownley for holding today's very important 
hearing and for allowing me to testify on my bill 3508. I 
worked on this along with Congressman Tim Walz from Minnesota 
and I appreciate all his work and efforts to make sure this is 
a bipartisan proposal. This is a proposal that will address the 
times and backlogs that our veterans have to receive services 
from the VA.
    Currently you have the VA that hires doctors of audiology, 
which is wonderful. When our veterans receive services the 
services are wonderful. The problem is there is long wait times 
and backlogs before they are actually able to get in and see 
the doctors. Oftentimes a veteran who needs an initial exam or 
a hearing test will wait two weeks to one year for that initial 
appointment with the audiologist. And then their hearing aids 
are ordered, it is two weeks to one year before they actually 
get the hearing aid itself. And then once they get the hearing 
aid they have to go back to the VA where it is an appointment 
time of six weeks to six months before they get that 
appointment. And then if you have to have your hearing aid 
tweaked or adjusted, it is another wait time of six weeks to 
six months.
    This is unacceptable. When you have our younger veterans 
who are coming home from War and our aging veterans who have 
had hearing loss issues, you cannot hear. And they are waiting 
weeks if not months before they can get into the VA. It is 
creating real problems and I think a disservice to our 
veterans.
    This came to my attention, one of my constituents, Roger, 
he is a Vietnam Vet. He is 70 years old. He had a hearing aid, 
the hearing aid went out on him. And so he called the VA to get 
an appointment to go get a new hearing aid and they told him it 
would take six months before he got an appointment. Six months! 
He cannot hear. This is unacceptable. So he went to his local 
hearing aid specialist, bought a new hearing aid out of pocket 
and paid $5,000 for it. Now Roger could afford that. It was a 
significant dent to him. But a lot of our veterans cannot 
afford to pay $5,000 to get service on their own when they 
actually could get service from the VA.
    So what we are doing in this bill is asking that we allow 
the VA to hire hearing aid specialists. For the complex issues 
of hearing loss and hearing issues we still have the 
audiologists. But we will have hearing aid specialists who can 
do some of the more minor functions in regard to hearing loss 
like dispensing, repairing, adjusting, and fitting the aids. So 
we can eliminate that backlog and get our veterans seen right 
away. So not only will the VA be allowed to hire hearing aid 
specialists, not required, not mandated, but allowed if they 
see fit to hire hearing aid specialists, we will also allow the 
VA to contract with hearing aid specialists around our rural 
communities.
    I know, Chairman Benishek, you and I share district lines. 
We do not come from the most populated districts in the 
country. We live in rural America. And you hear stories about 
our veterans and the length of travel time they have to go to 
the VA clinics. If we allow the VA to actually contract with 
hearing aid specialists in their community, far less disruption 
for our veterans to just have the simple pleasure of hearing 
provided to them and services provided to them from the VA. So 
I hope the committee will consider our bipartisan proposal and 
I think it goes a long way to making sure we are doing justice 
by way of the men and women who have so honorably served our 
country. I yield back.

    [The prepared statement of Sean Duffy appears in the 
Appendix]

    Mr. Benishek. Thank you very much, Mr. Duffy. Now I will 
call on Representative Sinema.

                STATEMENT OF HON. KYRSTEN SINEMA

    Ms. Sinema. Thank you, Chairman Benishek and Ranking Member 
Brownley, for holding today's hearing, and thank you to my 
colleagues who have introduced important bills that improve the 
quality of care available to veterans, especially Congresswoman 
Walorski's legislation to make travel assistance available for 
veterans seeking care for military sexual trauma.
    I am here to discuss H.R. 3387, the Classified Veterans 
Access to Care Act, and thank you, Chairman Benishek, for 
cosponsoring this bill. The Classified Veterans Access to Care 
Act ensures that veterans with classified experiences can 
access appropriate mental health services at the Department of 
Veterans Affairs.
    I am working on this issue because last year a veteran in 
my district, Daniel Somers, failed to receive the mental health 
care he needed and tragically committed suicide. No veteran or 
family should have to go through the tragedy that the Somers 
family experienced. Daniel Somers was an Army veteran of two 
tours in Iraq. He served on Task Force Lightning, an 
intelligence unit. He ran over 400 combat missions as a machine 
gunner in the turret of a HUMVEE. Part of his role required him 
to interrogate dozens of terror suspects and his work was 
deemed classified.
    Like many veterans, Daniel was haunted by the War when he 
returned home. He suffered from flashbacks, nightmares, 
depression, and additional symptoms of Post Traumatic Stress 
Disorder made worse by a Traumatic Brain Injury. Daniel needed 
help and he and his family asked for help. Unfortunately the VA 
enrolled Daniel in group therapy sessions, which Daniel could 
not attend for fear of disclosing classified information. 
Despite requests for individuals counseling, or some other 
reasonable accommodation to allow Daniel to receive appropriate 
care for his PTSD, the VA delayed providing Daniel with 
appropriate support and care. Like many, Daniel's isolation got 
worse when he returned to civilian life. He tried to provide 
for his family but he was unable to work due to his disability. 
He struggled with the VA bureaucracy. His disability appeal had 
been pending for over two years in the system without 
resolution and he did not get the help he needed in time.
    On June 10, 2013, Daniel wrote a letter to his family. It 
begins, ``I am sorry that it has come to this. The fact is for 
as long as I can remember my motivation for getting up everyday 
has been so that you would not have to bury me. As things have 
continued to get worse it has become clear that this alone is 
not a sufficient reason to carry on. The fact is, I am not 
getting better. I am not going to get better. And I will most 
certainly deteriorate further as time goes on. From a logical 
standpoint it is better to simply end things quickly and let 
any repercussions from that play out in the short term than to 
drag things out in the long term.''
    He goes on to say, ``I am left with basically nothing. Too 
trapped in a War to be at peace, too damaged to be at War. 
Abandoned by those who would take the easy route, and a 
liability to those who stick it out and thus deserve better. So 
you see, not only am I better dead but the world is better off 
without me in it. This is what brought me to my actual final 
mission.''
    Daniel's parents, Howard and Jean, were devastated by the 
loss of their son. But they bravely shared Daniel's story and 
created a mission of their own. Their mission is to ensure that 
Daniel's story brings to light America's deadliest War: the 22 
veterans that we lose everyday to suicide. My office worked 
with Howard and Jean to develop this Act so that veterans can 
seek and receive comprehensive mental health care from the VA 
regardless of the classified nature of their military 
experiences. Our bill directs the Secretary of the VA to 
establish standards and procedures to ensure that a veteran who 
participated in a classified mission or served in a sensitive 
unit may access mental health care in a manner that fully 
accommodates the veteran's obligation to not improperly 
disclose classified information. It also directs the Secretary 
to disseminate guidance to employees of the Veterans Health 
Administration, including mental health professionals, on such 
standards and procedures on how to best engage veterans during 
the course of mental health treatment with respect to 
classified information. And finally, the bill directs the 
Secretary to allow veterans with classified experiences to 
self-identify so they can quickly receive care in an 
appropriate setting.
    Our legislation is supported by the Retired Enlisted 
Association, the Association of the United States Navy, and the 
Iraq and Afghanistan Veterans of America. As the IAVA states in 
its letter of support, these reforms to mental health treatment 
are necessary to provide safe and inclusive care for all 
veterans. I look forward to continuing to work with the 
committee to ensure that no veteran feels trapped, like my 
constituent Daniel did, and that all veterans have access to 
appropriate mental health care.
    Again, thank you, Chairman Benishek and Ranking Member 
Brownley, for including the Classified Veterans Access to Care 
Act in today's hearing. Thank you.

    [The prepared statement of Kyrsten Sinema appears in the 
Appendix]

    Mr. Benishek. Thank you very much for your compelling 
testimony. Ms. Titus. Are you ready to go ahead?

                  STATEMENT OF HON. DINA TITUS

    Ms. Titus. I am, Mr. Chairman. Thank you for your 
indulgence. I apologize. I am introducing H.R. 2527. I 
certainly appreciate your and the ranking member's including 
this in the hearing today.
    This is bipartisan legislation that addresses an 
unacceptable gap in current law that effectively leaves certain 
victims of sexual assault without support and treatment that 
they need and deserve. Members of the National Guard and other 
Reserve components of the armed services who have fought 
bravely for our country, and many have completed multiple tours 
in Iraq and Afghanistan, certainly that is true of the National 
Guard in Nevada. Since September 11th, more than 50,000 
Guardsmen and Guardswomen have been called to service both at 
home and abroad.
    Now we all recognize the great importance of the National 
Guard and other Reserve components and we thank them for their 
incredible service. Members of the National Guard and other 
Reserve components who are unfortunate victims of sexual 
assault while they are on active duty are like members of other 
armed forces. They are provided with all the services and 
resources they need to recover and heal physically and 
emotionally. This treatment is provided by the VA for free for 
as long as it is needed and this is the very least that we can 
do. These benefits, however, are not offered to members of the 
National Guard or other Reserve components who experience 
sexual assault while they are on active training missions. For 
example, members of the Guard are required to participate in 
training missions one weekend a month and two weeks a year. 
This oversight is simply unacceptable and it leaves many who 
have served our country so well without any assistance or 
support during a very devastating time if they are such 
victims.
    The National Guard Military Sexual Trauma Parity Act would 
fix this omission and clarify that all victims of sexual trauma 
in the National Guard or the other Reserve components would 
have access to the resources and services they need whether 
they are on active duty or they are in a required training 
mission. We should make it a priority to change the culture of 
the military and put an end to the acts of sexual trauma that 
exist within our military and that we have heard so much about 
lately. But until we do that, however, we have to provide 
victims of this kind of trauma with the care that they need. 
And certainly that would include not just the active military 
but also our National Guard in these other times.
    So I want to thank many of the VSO organizations for their 
support, the VA is supportive of this, and I thank the 
subcommittee for including this important legislation. And I 
yield back.

    [The prepared statement of Dina Titus appears in the 
Appendix]

    Mr. Benishek. I yield five minutes to Dr. Roe to present 
his testimony.

                 STATEMENT OF HON. DAVID P. ROE

    Dr. Roe. Thank you, Mr. Chairman. And it is my pleasure to 
present H.R. 3831, the Veterans Dialysis Pilot Program Review 
Act, to my colleagues on the subcommittee. This bill would 
prevent the Veterans Health Administration from rolling out a 
new in house dialysis centers until an independent review of 
the VHA dialysis pilot program has been completed.
    In 2009 the Secretary of Veterans Affairs launched a VHA 
dialysis pilot program creating four test sites at outpatient 
VA clinics to see if quality dialysis treatment could be 
delivered to veterans in house at a lower cost than contracting 
the care out to commercial dialysis treatment centers. In 2012 
a GAO report, which I ask to be inserted into the record----
    Mr. Benishek. So ordered.
    Dr. Roe. Thank you. Shows that early implementation of the 
dialysis pilot program has shown many weakness, including 
erroneous cost estimation practices and cost savings 
calculations. The Department of Veterans Affairs, however, is 
moving to expand the in house dialysis program nationally 
before review of the pilot program has been performed. In fact, 
VA is still contracting for an independent analysis of how well 
it is working.
    H.R. 3831 would simply direct the Secretary of Veterans 
Affairs to halt the establishment of any new VA dialysis 
clinics until each of the four original pilot sites has been 
operating for two years, an independent analysis of the sites 
is conducted, and a full report has been submitted to Congress. 
The intent of this bill is to ensure that we have found out if 
this pilot program is in the best interests of veterans and 
taxpayers before the VA rolls out the program nationally.
    And let me say this briefly. This does not prevent the four 
senators from continuing exactly what they are doing, and it 
does nothing to veterans receiving care that they are now from 
the private sector. It is just to see if the program works 
before we roll out another program at the VA. How many times 
have we seen this? We do not, we start a program, do not even 
analyze it, and then we are explaining and trying to figure out 
why it does not work. That is all we are doing, is just asking 
to do exactly what the VA said it would do which is to analyze 
the program before they expand it. That is all this is.
    And anecdotally, Mr. Grimm, I completely agree with what 
you are doing and I wholeheartedly support. I have seen 
veterans at home, I have met veterans and talked to them, it is 
really amazing to see what these animals can do. So I am very 
supportive of your bill. I yield back.
    Mr. Benishek. Thank you. Ms. Walorski, do you have any 
questions you would like to ask?
    Mrs. Walorski. Thank you, Mr. Chairman. I just have a 
couple of comments. To Representative Grimm, I applaud your 
efforts as well. I was just at Walter Reed's Research and 
Development Facility just a couple of weeks ago and saw a whole 
new program they are laying out with actually a whole breed of 
labs that they are using for pet therapy. And they have even 
taken it a step farther, which I think is phenomenal, because 
the therapy is for the veteran. And they are actually now 
allowing the veteran to name their therapy dog the name of 
their buddy that was left behind that was killed. And it is 
powerful. And pet therapy is a powerful tool. And just seeing 
the families there and the veterans that were involved in the 
training was incredible, and we have seen it in our district as 
well.
    And then also to Representative Sinema, I just, I applaud 
your efforts on that bill. I think, I am appalled by what we 
hear sometimes what seems to be everyday in this committee 
about how our veterans are treated. And this issue of suicide, 
I would agree with Ranking Member Brownley, is one of our top 
issues on this committee and this subcommittee. And I had a 
situation in my district where we had a Vietnam Vet that was 
not dealing with a classified issue necessarily but was 
certainly dealing with extreme depression, mental health issues 
based on chronic pain from the effects of Agent Orange. And we 
did everything we could and then some and it just was not 
enough. And they sent him home over Christmas and we got a call 
from his wife that he committed suicide. And it was one of the 
most distressing things I have dealt with being in Congress. It 
just, it is a sad, sad reality. And we have to do better. We 
just have to completely do better for the sake of our veterans 
in this country. And I yield back the rest of my time. Thank 
you, Mr. Chairman.

    [The prepared statement of David Roe appears in the 
Appendix]

    Mr. Benishek. Thanks, Ms. Walorski. Ms. Kuster.
    Ms. Kuster. Thank you, Chairman Benishek, and thank you 
Ranking Member Brownley. And I just want to speak on a couple 
of bills but I want to make a comment about our members, our 
colleagues coming forward with these bills and this committee 
being one of the few places that we can make bipartisan 
progress. So I just want to speak to the bill that I had the 
opportunity to be original cosponsor with Representative 
Walorski, and commend your work on military sexual trauma 
generally and specifically making sure that our veterans, both 
men and women, get the treatment that they need and have the 
funds for travel that they need.
    I also want to comment my colleague Representative Sinema 
for giving Daniel's live a legacy and meaning. And I think for 
all of us we each have our individual stories in our districts, 
but I have had the opportunity to meet Daniel's family with you 
and just to know that he, his life will have a purpose if we 
can do everything that we can on this committee and convince 
our colleagues that this is a priority issue for our country.
    And lastly to my colleague Representative Titus, I do a lot 
with the National Guard in New Hampshire and we have also had a 
very high level of participation in these conflicts, and I 
think it is critically important to include the National Guard. 
I have been having a series of round tables with our veterans 
and our VSOs and our National Guard on the issue of military 
sexual assault. And I completely agree with you that we need to 
eradicate this problem from our military, but in the meantime 
we need to be doing everything we can on this committee to make 
sure that people get the treatment that they need in a timely 
way.
    So I have no questions, just comments. Just thank you for 
your leadership and thank you, Representative Brownley, for 
your leadership on this committee. Thank you.
    Mr. Benishek. Thank you, Ms. Kuster. Ms. Negrete-McLeod? Do 
you have any questions? Ms. Titus, do you have any questions?
    Well I think we can excuse the first panel. Thank you very 
much for your testimony today and for taking the effort to put 
through these good efforts to improve services to our veterans. 
Thank you very much for your time.
    We will proceed with the next panel. Mr. Denham may still 
arrive to present his bill and if he does we will give him some 
time to present his case.
    Will now welcome the second panel to the witness table. 
Joining us on the second panel is Ms. Joy Ilem, Deputy National 
Legislative Director from the Disabled American Veterans; Ms. 
Alethea Predeoux, the Associate Director of Health Analysis for 
the Paralyzed Veterans of America; and Aleksandr Morosky, the 
Senior Legislative Associate for the Veterans of Foreign Wars. 
Thank you for being here this morning and for your hard work 
and advocacy on behalf of our veterans. I appreciate your being 
here to present your views and we will begin with Ms. Ilem.

                    STATEMENT OF JOY J. ILEM

    Ms. Ilem. Thank you, Mr. Chairman and members of the 
subcommittee. We appreciate your inviting DAV to testify at 
this legislative hearing. My comments will be focused primarily 
on the bills DAV supports but DAV's written testimony submitted 
for the record discusses our position on each measure in 
detail.
    H.R. 2527 seeks to expand eligibility for counseling and 
treatment for conditions related to military sexual trauma, or 
MST. Current law authorizes VA to provide such services for 
those who served on active duty, or active duty for training. 
H.R. 2527 would amend the statute to include veterans in the 
Reserve components of the armed forces during inactive duty for 
training as well so that they too will become eligible for this 
type of care. Based on DAV Resolution No. 125 we are pleased to 
support this measure and urge its enactment.
    H.R. 2974 seeks to provide eligibility for beneficiary 
travel reimbursement to veterans receiving care in one VA 
facility but based on a clinical determination they need to 
access a specialized MST program or treatment only available at 
another VA facility. According to the Inspector General, as 
noted, patients and VA mental health staff have indicated they 
are often challenged to obtain authorization for VA funded 
patient transportation to these specialized centers. DAV 
Resolution No. 125 calls on VA to ensure all MST survivors have 
access to the specialized treatment programs and services they 
need to fully recover. Therefore DAV supports this legislation 
but we also recommend the subcommittee review the VA's 
beneficiary travel policy as it relates to other groups of 
veterans' access to VA specialized care as well.
    H.R. 2661, the Veterans Access to Timely Medical 
Appointments Act, would direct VA to establish a national 
standardized scheduling policy to improve timely access to 
care. While the intent of this bill is laudable and we 
appreciate the sponsors' efforts, DAV believes the overriding 
component to solve many of VA's access challenges is a lack of 
an effective automated scheduling system. While the bill seeks 
to rectify many of the existing problems identified by GAO, 
enactment of this bill would not address what we consider the 
core issue. Specifically the implementation of a modernized 
scheduling system so that VA could begin to be based on 
reliable data, begin to assess demand versus capacity as well 
as determine associated staffing needs and resources more 
accurately. While DAV supports the intent of the legislation 
based on our Resolution No. 204, we urge the subcommittee to 
work with the bill's sponsor and VA to fully address the 
underlying issues related to this problem and determine how the 
intent of this measure could be best achieved.
    H.R. 3387 seeks to ensure that standards and procedures are 
in place for VA clinicians to provide mental health treatment 
to veterans who served in a classified military mission. We 
agree that guidance on how to best engage such veterans during 
the course of mental health treatment is critical to ensuring 
the veteran is able to access appropriate care and services 
without having to disclose sensitive information. DAV 
Resolution No. 193 supports program improvement and enhanced 
resources for VA mental health programs and we believe this 
bill is consistent with the purposes of our resolution. 
Therefore DAV offers its support of this measure.
    H.R. 4198 seeks to reinstate the requirement for an annual 
report to Congress on the capacity of VA to provide specialized 
treatment and rehabilitative needs of disabled veterans. 
Although we have no specific resolution calling to reinstate 
the report we do acknowledge the importance of having data that 
accurately reflects available capacity for these important 
services. However, due to the changes in health care delivery 
since the requirement of the original report we recommend 
amendments to the bill that would track capacity in discrete 
bed intensive units along the lines of the intent of the bill 
yet also obtain relevant information on VA program capacities 
that are no longer bed intensive, such as specialty outpatient 
mental health services, substance use disorder treatment 
services, and long term services and supports, among others. 
DAV asks the committee to consider approving the bill in its 
current form with the understanding that at a future 
legislative meeting of the committee an amendment would be 
offered by the bill's sponsor incorporating the changes we hope 
to achieve cooperatively.
    My final comments are related to the draft bill to 
authorize major VA medical facility projects for fiscal year 
2014. DAV strongly supports this draft measure on the basis of 
DAV Resolutions No. 28 and 188.
    Mr. Chairman and members of the subcommittee, thank you for 
considering the views of DAV today and I am happy to respond to 
any questions you may have related to these proposals or in any 
of DAV's testimony. Thank you.
    [The prepared statement of Joy Ilem appears in the 
Appendix]
    Mr. Benishek. Thank you very much for your testimony. Ms. 
Predeoux, you may begin.

                 STATEMENT OF ALETHEA PREDEOUX

    Ms. Predeoux. Thank you. Chairman Benishek, Ranking Member 
Brownley, and members of the subcommittee, Paralyzed Veterans 
of America, PVA, would like to thank you for the opportunity to 
present our views on the health care legislation being 
considered by the subcommittee. These important bills will help 
ensure that veterans have access to quality and timely health 
care services through the Department of Veterans Affairs.
    We are particularly pleased that H.R. 4198, which is a 
legislative priority for PVA, is among the legislation being 
reviewed today. My remarks will focus on only a few bills as 
PVA's full statement as been submitted to the subcommittee.
    H.R. 2661, the Veterans Access to Timely Medical 
Appointments Act, proposes to establish a standardized 
scheduling policy for veterans enrolled in VA health care. This 
scheduling policy would mandate that VA schedule all primary 
care appointments within seven days of the date requested by 
the veteran or the health care provider on behalf of the 
veteran, and require specialty care medical appointments to be 
scheduled within 14 days of the date requested by the veteran 
or physician. Timely access to quality care is vital to VA's 
core mission of providing primary care and specialized services 
to veterans. PVA is concerned with how to determine the best 
standardized policy for scheduling primary and speciality care 
appointments. Measuring patient access and demand is an 
extremely complex tasks. Despite VA's stated goals of providing 
primary care appointments within seven days of a veteran's 
requested date and 14 days for specialty care, wait times 
continue to exist. Legislating these goals as standardized 
policy for scheduling VA medical appointments has the potential 
to lead to unintended outcomes that could force VA into 
contracting for care with private providers too frequently. We 
encourage the VA and Congress to determine if VA has adequate 
resources to develop, implement, and support a patient 
scheduling system that will address issues involving wait time 
measures, sufficient staffing levels, and patient demand.
    PVA supports H.R. 2974, a bill to amend Title 38 to provide 
for eligibility for beneficiary travel for veterans seeking 
treatment or care for military sexual trauma in specialized 
outpatient and residential programs. Recognizing that the 
burden of cost associated with travel for health care services 
can lead to veterans foregoing much needed medical attention 
for many years, PVA has advocated for expanding beneficiary 
travel eligibility for specialized groups of veterans such as 
catastrophically disabled and severely injured ill and wounded 
veterans. PVA believes that veterans seeking treatment for MST 
should be eligible for beneficiary travel and sufficient 
resources should be provided for the costs associated with 
expanding this program.
    Lastly, PVA strongly supports H.R. 4198, the Appropriate 
Care for Disabled Veterans Act. This legislation proposes to 
amend Title 38 to reinstate the requirement for an annual 
report on the capacity of the VA to provide specialized 
treatment and rehabilitative needs for disabled veterans. Many 
of the VA's specialized systems of care and rehabilitative 
programs have established policies on the staffing requirements 
and number of beds that must be available to maintain capacity 
and provide high quality care. When VA facilities do not adhere 
to these staffing policies and requirements veterans suffer 
with prolonged wait times for medical appointments, or in the 
case of PVA members having to limit their care to an SCI clinic 
despite the need to receive more comprehensive care from an SCI 
hospital. Requiring the VA to provide Congress with an annual 
capacity report to be audited by the Office of the Inspector 
General would give VA leadership and Congress an accurate 
depiction of VA's ability to provide quality care and services 
to disabled veterans. This is particularly important for 
measuring access and bed capacity of VA's specialized services 
for blinded veterans, veterans with spinal cord injury or 
disorder, and veterans who have sustained severe traumatic 
brain injury. PVA also urges the subcommittee to not only 
reinstate the reporting requirement but also update the 
language in Title 38 to most accurately reflect specialized 
services within VA for VA long term care, mental health, and 
substance use disorders.
    We thank the subcommittee for recognizing VA's capacity to 
provide specialized services as a priority in VA health care 
deliver and look forward to working with our VSO partners and 
this subcommittee to update this report so that it reflects 
useful information that will improve care delivery for all 
veterans receiving services through VA's specialized programs.
    Again, I thank you for the opportunity to submit our views 
on the bills being reviewed today and I am happy to answer any 
questions.
    [The prepared statement of Alethea Predeoux appears in the 
Appendix]
    Mr. Benishek. Thank you very much for your testimony. Mr. 
Morosky, could you proceed?

                 STATEMENT OF ALEKSANDR MOROSKY

    Mr. Morosky. Chairman Benishek, Ranking Member Brownley, 
and members of the subcommittee, on behalf of the Veterans of 
Foreign Wars of the United States and our auxiliaries I want to 
thank you for the opportunity to present VFW's stance on 
legislation pending before this subcommittee. The bills we are 
discussing today are aimed at improving the quality of veterans 
health care and we thank you for bringing them forward.
    (The Veterans Dog Training Therapy Act)--The VFW recognizes 
the potential value of canine therapy and would not be opposed 
to a pilot program to treat veterans with PTSD by teaching them 
to train service dogs. We do however have two suggestions that 
we believe would strengthen this bill. First, we suggest the 
bill be amended to allow VA to carry out the pilot program in 
partnership with existing community resources. Second, we 
recommend the bill be amended to allow VA the flexibility to 
house the dogs at off site locations when necessary. With these 
changes, VFW fully supports this bill.
    (H.R. 2527)--The VFW supports this legislation which would 
authorize VA to provide counseling and treatment to 
servicemembers who experience MST during inactive duty 
training. The VFW strongly believes that members of the Reserve 
component who experience MST during weekend drills or other 
inactive duty deserve the same MST related services as those 
who experience sexual trauma while activated.
    (The Veterans Access to Timely Medical Appointments Act)--
Although the VFW strongly supports the intent of this 
legislation to reduce appointment wait times for veterans we do 
not support the statutory mandate of VA's seven-day primary 
care and 14-day specialty care appointment wait time goals. The 
VFW is primarily concerned that this legislation would force VA 
to overutilize purchased care. VA's new purchase care model, 
PC3, is still being implemented. Its effectiveness is still 
unknown and it may not be the best option for many veterans. 
The VFW wants to see PC3 as a secondary option to direct care, 
as it was intended. To solve this problem of long wait times VA 
must implement its plans for appointment scheduling, physician 
staffing, and purchased care, and VFW urges continued 
congressional oversight to ensure that those things happen.
    (H.R. 2974)--The VFW strongly supports this legislation. 
Under current VA policy all MST victims are eligible for 
residential rehab treatment programs and facilities that do not 
have those programs have been directed to refer veterans to 
those that do. Not all MST victims, however, meet the current 
criteria for beneficiary travel reimbursement. This legislation 
would fix that problem, fully aligning VA travel policy with 
MST treatment policy.
    (H.R. 3508)--This legislation would authorize VA to hire 
hearing specialists as full-time employees at department 
facilities to provide hearing health services alongside 
audiologists and hearing health technicians. Although we 
appreciate this bill's intent to increase hearing health 
access, the VFW believes that VA has the ability to address 
that issue under its current hiring authority. We strongly 
believe that VA must improve timeliness in issuing and 
repairing hearing aids. But adding a new class of provider 
whose scope of practice overlaps that of existing employees 
does not get to the root of the problem. To fully address the 
issue VA must determine proper staffing levels of audiologists 
and hearing health technicians necessary to provide timely care 
and increase the number of those employees accordingly.
    (H.R. 3180)--The VFW supports this legislation which would 
allow state veterans homes that receive residential care 
contracts or grants from VA to also contract with VA under the 
health care for Homeless Veterans Supported Housing Program. As 
long as there are homeless veterans who need them, beds in 
state veterans homes should not remain empty simply due to the 
unintended consequences of a federal regulation.
    (Classified Veterans Access to Care Act)--The VFW supports 
this legislation which would require VA to develop standards to 
provide care for veterans who participate in sensitive missions 
in a way that does not require them to improperly disclose 
classified information. The VFW believes that this requirement 
is reasonable and would ensure that veterans feel that they can 
access the mental health services they need without violating 
any non-disclosure responsibilities they may have.
    (The Veterans Dialysis Pilot Program Review Act)--The VFW 
supports this legislation. A May, 2012 GAO report found that VA 
was planning to expand the dialysis pilot despite not having 
developed adequate performance measures to evaluate the 
existing locations. The purpose of any pilot program should be 
to assess its strengths and weaknesses on a small scale before 
deciding whether or not it should be expanded.
    (The Appropriate Care for Disabled Veterans Act)--The VFW 
supports this legislation which would reinstate the requirement 
for VA to submit an annual report to Congress on its capacity 
to provide for the specialized treatment and rehabilitative 
needs of disabled veterans. The VFW believes that current 
accurate data on VA capacity will greatly assist Congress in 
conducting oversight on veterans access to care.
    (The draft bill to authorize major medical facility 
projects)--It is critical that VA is provided with the 
authority to enter into the 27 major medical leases. Many of 
these leases have been awaiting authorization for nearly two 
years. These facilities provide direct medical care in the 
community where veterans live and VA must enter into these new 
leases to serve their needs. The VFW supports the provision 
expanding VA's enhanced use lease authority, but VA must make 
every effort to lease these unused or underutilized properties 
for projects that directly support veterans and their families 
before considering other leasing projects.
    Mr. Chairman, this concludes my testimony and I look 
forward to any questions you or other members of the committee 
may have.
    [The prepared statement of Aleksandr Morosky appears in the 
Appendix]
    Mr. Benishek. Thank you very much, Mr. Morosky, for your 
testimony. I will begin by yielding myself five minutes for 
some questions. The question I had was about the appointment 
schedule there or the timely access. Are there any provisions 
of that legislation that you do support? I think, Mr. Morosky, 
you were the most critical of that legislation.
    Ms. Ilem. I think for DAV, I mean, we support the intent, 
wanting to have timely access. I think we did have some concern 
about legislating the seven-day and the 14-day requirements. 
But I think for DAV the biggest thing was that to really 
achieve these goals we felt that the core of the problem is the 
scheduling package that is 30 years old and VA has testified on 
that a number of times. So to achieve that things and correct 
the deficiencies that I think they really want to get at, I 
think that is the most important thing for us, that would be 
included. But, you know, there are, I think the overall intent, 
to improve access, we do not have a problem with.
    Mr. Benishek. All right, great. Go ahead, Mr. Predeoux, do 
you have a response?
    Ms. Predeoux. Just to piggyback off what Ms. Ilem just 
said. We agree with the intent. Our concern would just be 
making sure that the VA has adequate tools to ensure that the 
standards that are set are standards that are reasonable and 
positively impact patient care deliver within the VA.
    Mr. Benishek. Mr. Morosky, do you have any?
    Mr. Morosky. And Mr. Chairman, we also support the intent. 
It is mainly the seven- and 14-day requirement that we do not 
support. You know, wait times result is another way of saying 
access. And VA's plan for access right now is to develop its 
appointment scheduling policy so that the wait times are 
accurate and representative. They are not accurate and 
representative right now. So to put a day number on it when 
they are not accurately reporting what the wait times are may 
be a bit too soon. It is also their physician staffing plans 
that they are instituting across specialty care, that is part 
of access. It is hard to have access if you do not have enough 
providers. And third, they are just finishing rolling out their 
PC3 program. And so all those things put together are going to 
equal access and we certainly support the greatest level of 
access. And we support the intent of this bill, which is to 
provide that.
    Mr. Benishek. Right. Right. Well we brought up this PC3 
program, I have my own particular concerns about how that is 
going to work. Because I am not sure what the level of payment 
they are going to provide to providers and if people are 
actually going to sign up now. Talking to the VA myself on 
several occasions, they seem to think that it is all going to 
go hunky-dory. But I do not know if that is actually going to 
be the case, you know what I mean? Because I have not seen any 
actual numbers of how many people have actually signed up. So I 
am just so hesitant. And I understand your concern about 
mandating in statute, a date and a time. But I do not see, all 
the time that I have talked to VA and they say, ``well, we are 
going to have it done.'' And then it never actually happens. 
And we keep, bypassing deadlines and that. It is very 
frustrating to me.
    Let me switch topics a little bit. There was some concern 
about H.R. 183, the Veterans Dog Training Therapy Act. The 
statement for the record from the Wounded Warrior Project 
equated H.R. 183 with a directed research program and states 
that decisions to fund research initiatives, however appealing 
as they may appear, should be based on peer review evaluation 
process. Do you agree that the pilot program that would be 
mandated by H.R. 183 amounts to directed research? Does anyone 
have a comment on that?
    Ms. Predeoux. I was not able to read the statement from the 
Wounded Warriors. But as far as research, I can only imagine 
that they are likening it to the fact that the VA, this is not 
a traditional program in the area of mental health. And along 
the lines of the comments that you made earlier from the first 
panel, PVA supports this as an alternative, non-traditional 
method for mental health care and dog therapy training. I am 
not sure, we will definitely have benefits from it and it could 
be considered research in some respects. But I am not sure I 
agree with the statement that it is directed research.
    Mr. Benishek. Mr. Morosky, I think the Veterans of Foreign 
Wars in their written statement expressed concerns regarding 
the potential use of, or kenneling service dogs at a VA medical 
center could lead to some problems. Would you be supportive of 
an amendments to H.R. 183 that would allow VA flexibility to 
house and train service dogs off campus?
    Mr. Morosky. Yes, we would. That along with allowing them 
to go into community partnerships, like the Palo Alto VA 
Medical Facility does with I believe it is called the Bergen 
Canine Institute. We feel that has been very beneficial. It has 
led to positive patient and provider responses. So with those 
two things we would be supportive of this legislation.
    Mr. Benishek. I think you heard that Mr. Grimm was, willing 
to do that sort of thing. So I hope that you all can get 
together and figure that out.
    Mr. Morosky. Yes, sir. We will.
    Mr. Benishek. I am out of time, thank you. Ms. Walorski, do 
you have any questions for the panel? Or Ms. Brownley, sorry.
    Ms. Brownley. Thank you, Mr. Chairman. You have asked a lot 
of the questions that I was going to ask. But I think I will go 
back again to H.R. 2661, and I concur that I agree with the 
intent of the bill. I think I just wanted to ask, I hear what 
the concerns are with regards to, you know, strict standards 
and possibly encouraging some data manipulation and we would 
not get the, you know, the accurate data that we all are 
looking for which is a very small wait time and not a long one. 
Do you think that that is still happening, that we have not 
done enough oversight to correct it? I think that we do need an 
automated system. We are not there yet. But I mean, do you see 
this happening across the country in terms of not providing 
accurate information?
    Ms. Ilem. I think there has been, you know, continued 
concern because of the limitations of the current IT system 
that is in place, of what VA can actually do. I think the parts 
of the bill that talk about making sure people are trained 
properly and know the procedures and the policies is critical, 
I mean, that is absolute. But without a system that is nuanced 
for what they are really trying to capture today, I think 
everybody, at the end of the day everybody wants to just be 
sure we know are people waiting? They want to be sensitive in 
certain areas if there is a backlog in a certain area for 
certain procedures so that they can then transfer resources 
into that area and the proper amount of staff. We do not want 
to see VA just having to, you know, send people out of the 
system unless it is absolutely necessary because they cannot 
get a timely appointment. But to be more sensitive through 
this, you know, through that type of a scheduling package that 
they can really see do we have a wait list? Do we have a, and 
we have not seen that. I mean, it has just been very, you know, 
they have goals, they want to see people as quickly as 
possible. And you know, but if you cannot meet those goals then 
what happens? So I think, you know, the goal is to see is it a 
lack of resources? Is it a lack of management issues? You know, 
what is the problem in this particular area that we cannot get 
people seen in a timely manner?
    Ms. Brownley. Thank you. Anybody else have a comment on 
that? Or I think----
    Mr. Morosky. We mentioned the past sort of data 
misrepresentation in our testimony as well. We hope that the VA 
is not still doing that. We feel like they are trying to be 
more open and honest and transparent about it. But we would not 
want to impose such a strict standard on them that it sort of 
almost encourages not necessarily data manipulation but as we 
all know there are different ways to present data and you can 
present data in a way that is more favorable to yourself or 
that is maybe more apples to apples that everybody can 
understand. We just want to make sure that they are being as 
transparent as possible without the undue constraints of 
unreasonable standards.
    Ms. Brownley. Thank you. I did not have a chance to tell 
Representative Grimm how much I support his bill. The VA will 
state that, you know, training of dogs is sort of outside of 
their purview. I am just wondering from your perspective 
whether you agree, disagree with the VA's perspective on it?
    Ms. Ilem. I would just note that, you know, VA seems to 
have been more open in the past couple of years to the 
complementary and alternative medicine and treatment options 
for veterans and certainly that is what we are hearing. I mean, 
especially with service animals. You know, we have heard such 
great feedback from so many veterans saying, you know, this 
helped me get off, you know, so much medication. I really, you 
know, I have this connection with my service animal. It has 
allowed me to get out and do things that, you know, I was not 
able to do. So and we have also heard about, you know, the 
therapeutic training, aspects of training an animal. So I mean, 
if they are going to do it it would be nice to see if they can 
see what, you know, some outcomes of that would be for 
veterans. I mean, certainly we are hearing positive feedback 
based on the program up in Palo Alto. So we would hope that, 
and I see the problems that VA would, or challenges they would 
face with having, as the bill is currently written. But I think 
the amendments that have been suggested would be appropriate.
    Ms. Brownley. Thank you. And just, well, I might have run 
out of time but I will yield back.
    Mr. Benishek. Thank you. Ms. Negrete-McLeod, do you have 
any questions? In that case, we will excuse the second panel. 
Thank you very much for your input. We may have some written 
questions which we hope you will answer for us. So thank you 
very much for your testimony.
    At this time I will recognize the gentleman from California 
Mr. Denham to present his legislation.

                 STATEMENT OF HON. JEFF DENHAM

    Mr. Denham. Thank you, Chairman Benishek, Ranking Member 
Brownley, and thank you to the panel as supporters of H.R. 
4198, the Appropriate Care for Disabled Veterans Act. This 
legislation has the support of the Paralyzed Veterans of 
America, Veterans of Foreign Wars, and the Disabled American 
Veterans, and I look forward to working with each of those 
groups as this bill moves forward.
    Mr. Chairman, as you know the number of disabled veterans 
has been increasing at an alarming rate. The number of severely 
disabled veterans is increasing even at a quicker rate. These 
severely disabled veterans are suffering from a range of issues 
from spinal cord injury, dysfunction, blindness, Traumatic 
Brain Injury, or mental health disorders. Many require 
prosthetic or orthotic and sensory aids and all need 
specialized care in their communities.
    It is the responsibility of this committee to ensure that 
the VA is meeting the mission requirement. To ensure that the 
veterans had the care they needed Congress mandated in the 
beginning of 1996 that the VA maintain its capacity for the 
specialized treatment and rehabilitative needs of disabled 
veterans based on a number of specific measurements. For spinal 
cord injuries in particular this capacity was to be measured by 
the number of staffed beds and the number of full-time 
employees available to provide care. The VA was also required 
to report this information to Congress after it was reviewed by 
the VA's Office of the Inspector General. Unfortunately this 
report requirement has lapsed and consequently so has the VA's 
adherence to the capacity standards required by Congress. As an 
example, Paralyzed Veterans of America's testimony explains how 
issues involving VA's capacity such as staffing directly 
impacts daily bed censuses and thus creates access issues for 
veterans who need comprehensive care.
    With this bill we have the opportunity to restore and 
modernize that reporting requirement so that this committee and 
our partners in the VSO community maintain a thorough 
understanding of the VA's ability to provide specialized care 
across the Veterans Health Administration system. To that end I 
welcome the testimony that we just heard. The American people 
have provided extraordinary resources to the Department of 
Veterans Affairs. It is our job to provide oversight of those 
resources. We cannot provide the oversight necessary without 
accurate information.
    Mr. Chairman, thank you for letting me speak out of order.
    [The prepared statement of Jeff Denham appears in the 
Appendix]
    Mr. Benishek. Thank you very much, Mr. Denham. At this 
point I will call up the third panel then. Joining us from the 
Department of Veterans Affairs is Dr. Madhulka Agarwal, Deputy 
Under Secretary for Health for Policy and Services. She is 
accompanied by Mr. Philip Matkovsky, the Assistant Deputy Under 
Secretary for Health for Operations and Management, and Renee 
Szybala, the Acting Assistant General Counsel. Thank you all 
for being here this morning. Dr. Agarwal, please proceed.

   STATEMENT OF MADHULKA AGARWAL, M.D., M.P.H., DEPUTY UNDER 
 SECRETARY FOR HEALTH FOR POLICY AND SERVICES, VETERANS HEALTH 
     ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
    ACCOMPANIED BY PHILIP MATKOVSKY, ASSISTANT DEPUTY UNDER 
 SECRETARY FOR HEALTH FOR OPERATIONS AND MANAGEMENT, VETERANS 
HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND 
   RENEE L. SZYBALA, ACTING ASSISTANT GENERAL COUNSEL, U.S. 
                 DEPARTMENT OF VETERANS AFFAIRS

                 STATEMENT OF MADHULKA AGARWAL

    Dr. Agarwal. Good morning, Chairman Benishek, Ranking 
Member Brownley, and members of the subcommittee. We appreciate 
your continued efforts to support and improve veterans health 
care. Thank you for the opportunity to address the bills on 
today's agenda and to discuss the impact of these bills on 
VHA's health care operations. Joining me today are Mr. Philip 
Matkovsky, Assistant Deputy Under Secretary for Health for 
Operations and Management, and Ms. Renee Szybala, Acting 
Assistant General Counsel.
    I want to thank the subcommittee for the opportunity to 
testify concerning the bills we support, starting with H.R. 
2527. We fully support affording the same crucial benefits to 
our National Guard and Reservists as others who have suffered 
the indignity of military sexual trauma. VA is poised to begin 
delivering services to the population as soon as this bill is 
enacted.
    Let me also assure the subcommittee that while we do not 
yet have prepared views on H.R. 2974, our evaluation of the 
bill is being done within the context of recognizing the 
importance of this issue for these veterans. Likewise although 
in draft form the major medical facilities projects bill would 
authorize critically needed operations and we support it as 
well.
    With respect to the other bills on the agenda I want to 
state at the outset that we support the intent behind many of 
the provisions in these bills but have valid concerns that have 
been highlighted in our testimony, and we ask the subcommittee 
to reconsider them.
    H.R. 183 requires a five-year pilot to evaluate using 
service dog training programs to address post-deployment mental 
health and PTSD symptoms and produce specially trained service 
dogs for veterans. VA is fully committed to effective and 
proven treatment modalities as well as to alternative 
therapies, especially for veterans suffering from mental health 
disorders including PTSD. However, VA does not support H.R. 183 
as written. This Bill contains a high number of requirements 
related to selection and training of the proposed service dogs. 
The bill requires a specialized and rigorous training 
methodology for these service dogs which exceeds the competence 
and expertise in VHA.
    We have concerns about H.R. 2661. This bill seeks to 
identify specific standards with respect to appointment 
scheduling and access to VA services. VA is fully supportive of 
systems and organizational processes that promote a culture of 
excellence and accountability. However, H.R. 2661 does not 
provide the critical flexibility that is needed to manage 
clinical acuity, resources, and patient preferences for 
appointment scheduling. VA looks forward to continuing our 
ongoing and active engagement with the subcommittee and other 
members in this very important area.
    Another bill which we cannot support as written is H.R. 
3508. This bill seeks to clarify qualifications for hearing aid 
specialists within the department. We believe the clinical 
expertise that is already provided in the department by our 
audiology health technicians working under the supervision of 
our professional audiologists can provide the necessary 
services that this bill seeks to require. Should VA need to 
leverage the capabilities of hearing aid specialists the 
Secretary already has the legal authority to appoint such 
individuals.
    H.R. 3831 would prohibit VA from expanding the free 
standing dialysis pilot programs and prohibit the creation of 
any new dialysis capability provided by VA. VA plans to brief 
our congressional committees on the results of the dialysis 
pilot program before establishing any new free standing 
dialysis center. However, restricting our ability to create 
needed capacity in our super CBOCs or in our replacement 
hospitals, or the new medical centers that are planned to be 
activated soon would negatively impact our ability to deliver 
services to veterans who need dialysis at these sites.
    Finally we do not believe that H.R. 3180 as drafted has 
application in the current contracting environment for state 
homes. We also have concerns about the potential impact on our 
residential settings.
    In the time allotted to prepare for this hearing we were 
not able to complete our views and testimony on the remaining 
two bills. Thank you for the opportunity testify before you 
today. My colleagues and I will be pleased to respond to 
questions that you have, or other members may have for us. 
Thank you.
    [The prepared statement of Madhulka Agarwal appears in the 
Appendix]
    Mr. Benishek. Thank you for your testimony, Dr. Agarwal. I 
will yield myself five minutes for questions. I hope that you 
will submit answers or some comments on the other legislation 
that you say you have not had time to do that----
    Dr. Agarwal. Yes sir, we will.
    Mr. Benishek [continuing]. In the near future. So I would 
appreciate that. I understand Mr. Duffy's reason for his 
legislation about the audiology component. Have you done any 
studies about, his concern with waiting, waiting 6 months to 
get care and the timeline? Are you trying to hire more 
audiologists? What is the story with that whole problem?
    Dr. Agarwal. So thank you again for an opportunity to 
clarify certain issues related to the wait times, both for the 
hearing aids that would be delivered to our veteran patients as 
well as to be able to see an audiologist in the clinic. We have 
taken actions on both fronts. So let me just describe what had 
happened about the hearing aid delivery to our veteran patients 
that had gone in for repairs. There had been vacancies in the 
Denver Acquisition Logistics Center for a long period of time, 
which has been rectified. And the delivery times for those 
repairs are back to our standards.
    As for the hearing services wait times in the audiology 
clinics, various actions have been taken. First of all the 
number of audiologists and support staff have been increased. 
The number of sites of care where we provide audiology services 
has also been increased. We are increasingly providing 
teleaudiology services, the sites, if I can recall correctly, 
are going up from 25 sites to up to 71 sites by the end of this 
year largely in the rural communities. We are also looking to 
provide these hearing services with non-VA services, the fee 
care contracts, as well as we are looking at the overall 
systems we design of the hearing services, to see how we can 
manage our demand and capacity better.
    Mr. Benishek. It is my understanding that hearing loss and 
tinnitus is one of the largest claims for medical disability 
among returning veterans now. It definitely needs a ramp up. I 
appreciate what you said here. I did not quite analyze it in my 
brain as fast as you said it, the implications of all that. We 
would like to look at that a little bit better but I appreciate 
that.
    My other question is about the dialysis pilot program that 
Dr. Roe's talked about. I still do not understand. He, as I 
understand it, he thinks that we should analyze the results of 
the pilot program before moving along to, building more 
centers. I am sort of familiar with dialysis and that most 
dialysis in the country now is done through, local dialysis 
centers. And it just seems to me that supporting that access is 
better than VA having another access point in the same 
community, as there already may be services. So I am just a 
little concerned about that duplication there. Am I incorrect 
in that assumption? Because people who are getting dialysis now 
are getting dialysis now, it is just they are getting paid by 
different sources. I was in a situation where in my local area 
there were two dialysis centers, one at VA and one at the other 
community hospital. So that did not make much sense having two 
different dialysis centers. And I just seem to think that, VA 
supporting a local dialysis center person makes a little more 
sense than having another one in VA. Can you give me your 
thoughts on that?
    Dr. Agarwal. Sure. So sir, currently VA overall provides 
dialysis to 17,000 veteran patients. Of that, only 20 percent 
of it is done in house in our medical centers.
    Mr. Benishek. Right.
    Dr. Agarwal. We have 65 facilities that offer dialysis 
service in the, as you probably have noted, in our medical 
centers. Not everyone provides it.
    Mr. Benishek. Right.
    Dr. Agarwal. The other 80 percent is of course non-VA care 
through different contracts.
    Mr. Benishek. Right.
    Dr. Agarwal. The pilot that we were referencing earlier was 
started in 2010 and the intention here is to look at four 
aspects. First of all is the quality of care, the access to 
care, veteran satisfaction, as well if they are cost effective. 
So that component of the pilot, sir, we will be completing that 
evaluation because there was a certain delay in two of those 
centers, in the next couple of years and we will submit the 
evaluation to Congress before we will proceed with expanding 
any free standing units.
    However, we have certain medical centers that are going to 
be activated this year, Orlando being one example. And they 
have ten regular dialysis stations and one isolation. There is 
a super CBOC in Green Bay, Wisconsin that also has, it has been 
planned to have several regular dialysis stations there as well 
as a couple of replacement hospitals. So with this bill it 
would restrict our ability to expand on what has been planned 
for quite some time during the construction phase.
    Mr. Benishek. All right, thank you. I am out of time. Ms. 
Brownley, do you have any questions for the panel?
    Ms. Brownley. Just quickly, thank you, Mr. Chair. I wanted 
the panel to just if they could briefly comment on H.R. 3387, 
which is Representative Sinema's bill on Classified Veterans 
Access to Care Act. And I do not think that you commented on it 
in your testimony. And just if you could share your sort of 
initial response or feelings towards the bill? And do you 
recognize it as a problem? I would imagine hopefully there are 
not too many cases across the country where suicide was the 
ultimate outcome, but I would imagine that there are quite a 
few people who were in classified positions who may not have 
access to the appropriate mental health care. So if you could 
just comment I would appreciate it.
    Dr. Agarwal. So Ranking Member Brownley, thank you for that 
question. It was a very compelling testimony and I have heard 
of this case of Mr. Somers before. And I will sort of 
personally say that, you know, the fact that we need to provide 
services in the context of what information the veterans can 
provide to us. So that is the first goal. Our strategic goal, 
which is to be proactive to offer personalized and patient 
drive services I think also is in line with this legislation. 
But it has got to be done, within that context, that if someone 
is not ready for group therapy, then we need to offer the kind 
of services that sort of fit their needs and no one else's. So 
I do not know if I am on the right track. But clearly I think 
the intent is going to be well supported. And if we need to 
provide more education and guidance to our clinicians, we will 
do so.
    Ms. Brownley. Thank you. And I also wanted to ask briefly 
on your draft bill, I think part of the bill, the draft 
legislation to authorize the major medical facilities projects 
includes in Section 4 amendments that modify the definition of 
the medical facility. If you could comment on that? And if you 
could also explain how some of these amendments will assist the 
VA in their construction of medical facilities and why the need 
for the transfer authority that you have requested.
    Dr. Agarwal. I am going to ask my colleague Philip 
Matkovsky to answer that.
    Ms. Brownley. Thank you.
    Mr. Matkovsky. Some of them are sort of technical 
adjustments in Section 4, and then there is an element which 
allows us to use certain funds in design. In the current 
practice we have been, you know, seeking appropriation of funds 
off a prospectus and the Secretary has instituted something 
that is called the Construction Review Council. Mr. Hagstrom is 
our, sort of presides over our construction portfolio. And we 
have adjusted the practice so that we are going to a 35 percent 
design which gives us a much more accurate picture of the scope 
of the project prior to requesting appropriation of funds. But 
in order to accomplish that we need to be able to sort of 
redirect certain funds to get to the 35 percent design.
    I think it is a good idea. It is a little bit hard to have 
a perfectly accurate estimate on something that is a few-page 
prospectus. Having 35 percent designs gives us a much more 
valid estimate to bring to this committee for authorization of 
funds.
    Ms. Brownley. Can you comment on some of the technical 
adjustments?
    Mr. Matkovsky. In a couple of cases here we are looking at 
definition for a major medical facility lease as it relates to 
some of the lease issues that we have had. But some of them I 
will have to take for the record as I am not terribly 
proficient on them. Sorry.
    Ms. Brownley. Thank you. I will yield back.
    Mr. Benishek. Thanks, Ms. Brownley. Mr. Denham, five 
minutes for questions.
    Mr. Denham. Thank you, Mr. Chair. Dr. Agarwal, do you 
support the legislation that I proposed here, H.R. 4198?
    Dr. Agarwal. This is 3180, sir.
    Mr. Denham. 4198.
    Dr. Agarwal. 4198. Okay. This is the capacity?
    Mr. Denham. Reporting requirements.
    Dr. Agarwal. So we have to provide you the formal views of 
the department. But as a concept I will tell you that the 
capacity report as I have seen it from 2008 provided detailed 
information on the availability of beds, as well as services 
for many of our program areas, spinal cord injury 
rehabilitation, mental health, and so on. So in general I think 
it is very important to know what the capacity is. So in that 
of course we agree that, you know, it should be supported. 
However, health care delivery has also evolved over time and 
there are many services that were provided way back in 1996 
have sort of changed their scope. So I think it is going to be 
important to make sure that the metrics for each of these 
programs is appropriate.
    Mr. Denham. So is that an excuse on why the reporting is 
not being done today? Because they have changed?
    Dr. Agarwal. Sir, I would not say that this----
    Mr. Denham. So how long does it take you to support a bill? 
To get authorization back from the agency?
    Dr. Agarwal. Sir, I am going to defer it to my right.
    Ms. Szybala. We just got too many bills.
    Mr. Denham. Too many bills? Yes, we have too many committee 
hearings, too fast.
    Ms. Szybala. I understand.
    Mr. Denham. And even though we only get your testimony the 
night before we still find time to prepare questions and be 
prepared for the committee hearing. This bill has been in print 
for over two weeks. So we would expect a response, I think, 
that our disabled veterans would expect a response. How do you 
respond to the testimony of the PVA which states that staffing 
vacancies are creating access issues for severely disabled 
veterans?
    Dr. Agarwal. Sir, that is something that we take very 
seriously. We have regular meetings with PVA on those reports 
and PVA also does oversight of our facilities very closely.
    Mr. Denham. So do you think the VA is meeting its 
requirement, its capacity requirements for the specialized 
care?
    Dr. Agarwal. So generically I believe that we are. But if 
there are certainly instances where we are not then we would 
love to find those out and we will be having those discussions 
with PVA.
    Mr. Denham. Well, that is fantastic. We would love to find 
that out, too, which is why we want that 1996 reporting 
requirement back to Congress. That is an important reporting 
requirement that we feel that Congress not only should mandate 
but we ought to actually get that information so we know 
whether you are doing your job.
    Dr. Agarwal. Sir, as I previously stated we certainly 
support the intent. But I think we need to also have the 
appropriate metrics.
    Mr. Denham. And when can you provide what those metrics 
would be back to this committee?
    Ms. Szybala. I do not know----
    Mr. Denham. I do not know is not a good answer for us to 
take back to our constituents.
    Ms. Szybala. I do understand that. But health care has 
evolved so that beds is not a metric now for everything. We do 
telehealth. We have CBOCs----
    Mr. Denham. I understand. But the question here is there is 
a reporting requirement. Congress is going to continue to 
mandate that reporting requirement. If you are telling us that 
there needs to be new metrics in place, we would ask what do 
you think those metrics should be? And I do not know is not a 
good answer.
    Ms. Szybala. Well, I understand. I mean I think we provide 
technical assistance when asked to feed into that----
    Mr. Denham. Okay. So if you are telling us that new metrics 
needs to be in place, how long will it take you to come back to 
this committee with what those new metrics are?
    Ms. Szybala. I cannot give you a date. I cannot.
    Mr. Denham. Can you give us an estimation?
    Ms. Szybala. I really, I think that is ill-advised. It is 
too many facets of VA get involved. And it is hard to control. 
So all I can say----
    Mr. Denham. Telling a disabled veteran that has come back 
from serving in our military that they may have to wait because 
we do not know is not an acceptable answer. So this committee 
will be providing a list of questions so that we can get back 
those answers in writing on what those metrics should, what the 
timeline would be, and what the reporting requirements will be.
    Ms. Szybala. And we will get it all to you as fast as we 
can.
    Mr. Denham. Thank you. I yield back.
    Mr. Benishek. Dr. Agarwal, the subcommittee will be 
submitting additional questions for the record. I would 
appreciate your assistance in ensuring an expedient response to 
these inquiries. If there are no further questions, then the 
third panel is excused. I ask unanimous consent that all 
members have five legislative days to revise and extend their 
remarks and include extraneous material. Without objection, so 
ordered.
    I would like to thank again all of our witnesses and the 
audience members for joining us this morning. The hearing is 
now adjourned.
    [Whereupon, at 10:34 a.m., the subcommittee was adjourned.]
                                APPENDIX

              Prepared Statement of Chairman Dan Benishek

    Good morning and thank you all for joining us today to discuss 
pending legislation regarding the health care benefits and services 
provided to our nation's veterans through the Department of Veterans 
Affairs (VA).
    The ten bills we will discuss this morning are:
    H.R. 183, the Veterans Dog Training Therapy Act;
    H.R. 2527, to provide veterans with counseling and treatment for 
sexual trauma that occurred during inactive duty training;
    H.R. 2661, the Veterans Access to Timely Medical Appointments Act;
    H.R. 2974, to provide beneficiary travel eligibility for veterans 
seeking treatment or care for military sexual trauma;
    H.R. 3387, the Classified Veterans Access to Care Act;
    H.R. 3508, to clarify the qualifications of VA hearing aid 
specialists;
    H.R. 3180, to provide an exception to the requirement that the 
Federal Government recover a portion of the value of certain projects;
    H.R. 3831, the Veterans Dialysis Pilot Program Review Act;
    H.R. 4198, the Appropriate Care for Disabled Veterans Act; and,
    Draft legislation, to authorize VA major medical facility projects 
for fiscal year 2014.
    By and large, these ten bills aim to address two of this 
Subcommittee's highest priorities: (1) Ensuring that our veterans have 
access to the care that they need; and, (2) ensuring that VA is held 
accountable when that care fails to meet the high standards that it 
should.
    Some of these bills--such as H.R. 2527 and H.R. 2974, which aim to 
resolve gaps in care for veterans who have experienced military sexual 
trauma--address issues that have been raised through Subcommittee 
oversight.
    Others--such as H.R. 2661, H.R. 3508, and H.R. 3831, which concern 
lengthy patient waiting times, access to care for hearing-impaired 
veterans, and ongoing issues with the provision of dialysis care--
address issues that were raised through external stakeholder reviews by 
the VA Inspector General and the Government Accountability Office.
    Still others--such as H.R. 183 and H.R. 4198, which concern the 
need for innovative treatment options for veterans with post-traumatic 
stress disorder and the need to ensure that VA maintains adequate 
capacity to provide for the unique health care needs of disabled 
veterans--address issues that were raised by our veteran constituents 
and veterans service organizations.
    One other--the draft legislation to authorize VA major medical 
facility projects for fiscal year (FY) 2014 and, of note, authorize the 
construction of a new bed tower at the James A. Haley Veterans' 
Hospital in Tampa, Florida--is the Department's own legislative 
request.
    I would note that VA's FY 2015 budget submission includes five 
additional lease authorization requests that are not included in the 
draft bill we will discuss this morning.
    While I recognize the value of those five lease authorization 
requests--which would certainly be included in future VA major medical 
facility lease authorization packages moving through the Committee--I 
felt it was important to thoroughly analyze and receive stakeholder 
views on the Department's FY 2014 request.
    As you may know, last fall the House passed H.R. 3521, the 
Department of Veterans Affairs Major Medical Facility Lease 
Authorization Act of 2013, which would authorize 27 VA major medical 
facility leases requested by the Department in the FY 2014 budget 
submission.
    It is my sincere hope that H.R. 3521 will be passed through the 
Senate and quickly signed into law.
    I would like to express my gratitude to my colleagues who have 
sponsored the legislation on our agenda today and who are joining us 
this morning to discuss their proposals.
    I would also like to thank our witnesses from the Disabled Veterans 
of America, the Paralyzed Veterans of America, and the Veterans of 
Foreign Wars, as well as the witnesses from the VA for their leadership 
and advocacy on behalf of our veterans and for being here today to 
offer their views.
    It is critical that we have a thorough understanding of the 
benefits and consequences of each of these bills before moving forward 
in the legislative process and, as such, I look forward to a detailed 
and comprehensive conversation.

              Prepared Statement of Hon. Michael G. Grimm

    Chairman Benishek, Ranking Member Brownley, thank you for allowing 
me to testify today on H.R. 183, the ``Veterans Dog Training Therapy 
Act,'' a bill I introduced along with my friend the Ranking Member of 
the House Veterans Affairs Committee, Congressman Michaud. As a Marine 
Combat Veteran of Operation Desert Storm it is a unique honor for me to 
address this committee. Having seen firsthand both the physical and 
mental wounds of war that the members of our nation's military are 
faced with, I have a special appreciation for the important work this 
committee does every day.
    Today, millions of Iraq and Afghanistan Veterans have returned home 
to the challenge of a stagnant economy, high unemployment rate, and, 
for many, the long road to recovery from the mental and physical wounds 
sustained during their service.
    During my time in Congress I have had the honor to meet with a 
number of our nation's veterans who are now faced with the challenges 
of coping with PTSD and physical disabilities resulting from their 
service in Iraq and Afghanistan. Their stories are not for the weak of 
heart and are truly moving. It was these personal accounts of recovery, 
both physical and mental, and the important role therapy and service 
dogs played in that process, that inspired this legislation.
    The Veterans Dog Training Therapy Act would require the Department 
of Veterans Affairs to conduct a five-year pilot program in at least 
three but not more than five VA medical centers assessing the 
effectiveness of addressing post-deployment mental health and PTSD 
through the therapeutic medium of training service dogs for veterans 
with disabilities. These trained service dogs are then given to 
physically disabled veterans to help them with their daily activities. 
Simply put, this program treats veterans suffering from PTSD while at 
the same time aiding those suffering from physical disabilities. When I 
originally introduced this legislation in the 112th Congress both the 
House Veterans Affairs Committee and the full House of Representatives 
passed it with overwhelming bipartisan support.
    Additionally, with high veteran suicide rates and more servicemen 
and women returning from deployment being diagnosed with PTSD, this 
bill meets a crucial need for additional treatment methods. I believe 
that by caring for our nation's veterans suffering from the hidden 
wounds of PTSD while at the same time providing assistance dogs to 
those with physical disabilities we create a win-win for everyone, 
which I believe is a goal we can all be proud to accomplish.
    Working in conjunction with a number of Veteran Service 
Organizations, I have drafted updated language which mirrors changes 
made to this legislation in the 112th Congress, and I hope to work with 
the committee during markup of H.R. 183 to ensure this program provides 
our nations veterans with the highest quality care for both PTSD and 
physical disabilities, while maintaining my commitment to fiscal 
responsibility.
    Again, I would like to thank the committee for holding today's 
hearing and I look forward to working with you to ensure that this 
program is included in your continuing efforts to guarantee that our 
nation's heroes have the best possible programs for treating PTSD and 
providing disability assistance.

                                 

                 Prepared Statement of Hon. Dina Titus

    Chairman Benishek, Ranking Member Brownley, fellow members of the 
Committee.
    Thank you for including my bill H.R. 2527, the National Guard 
Military Sexual Trauma Parity Act on today's agenda. This bipartisan 
legislation addresses an unacceptable gap in current law that 
effectively leaves certain victims of sexual assault without the 
support and treatment that they need.
    Members of the National Guard and other reserve components of the 
armed services have fought bravely for our country, many completing 
multiple tours of duty in Iraq and Afghanistan. Since September 11th, 
more than 50,000 Guardsmen and Guardswomen have been called to service, 
both at home and abroad.
    We recognize the great importance of the National Guard and other 
reserve components, and thank them for their service. Members of the 
National Guard or other reserve components who are the unfortunate 
victims of sexual assault while on active duty are, like members of the 
other armed forces, provided all the resources and services they need 
to recover and heal, physically and emotionally. This treatment is 
provided by the VA for free for as long as is needed. This is the very 
least that we can do.
    These benefits, however, are not offered to members of the National 
Guard or other reserve components who experience sexual assault while 
on inactive training missions. For example, Members of the Guard are 
required to participate in training missions one weekend a month and 
two weeks a year. This oversight is simply unacceptable, and leaves so 
many who have served our country without assistance or support during a 
devastating time.
    The National Guard Military Sexual Trauma Parity Act would fix this 
omission and clarify that all victims of sexual trauma in the National 
Guard or other reserve components have access to the resources and 
services they need whether they are on active duty or on a required 
training mission.
    We must make it a priority to change the culture of the military 
and put an end to acts of sexual trauma within our armed services. 
Until we do, however, we must provide victims with the care that they 
need and deserve.
    I want to thank many of the Veteran Service Organizations for their 
support and appreciate that this subcommittee will consider this 
important legislation creating parity for the brave men and women in 
the National Guard and other reserve components.

                                 

               Prepared Statement of Hon. Jackie Walorski

    Good morning, Chairman Benishek, Ranking Member Brownley, and 
members of the Committee. Thank you for the opportunity to discuss H.R. 
2974, a bill making victims of military sexual trauma (MST) eligible 
for Department of Veterans Affairs (VA) beneficiary travel benefits.
    According to the Department of Veterans Affairs, 1 in 5 women, and 
1 in 100 men screen positive for military sexual trauma (MST).\1\  The 
VA provides counseling, care, and services to veterans and certain 
other servicemembers who may not have veteran status, but who 
experienced MST while serving on active duty or active duty for 
training.\2\  VHA policy \3\  states that ``veterans and eligible 
individuals who report experiences of MST, but who are deemed 
ineligible for other VA health care benefits or enrollment, may be 
provided MST-related care only. This benefit extends to Reservists and 
members of the National Guard who were activated to full-time duty 
status in the Armed Forces. Veterans and eligible individuals who 
received an `other than honorable' discharge may be able to receive 
free MST-related care with the Veterans Benefits Administration 
Regional Office approval''.
---------------------------------------------------------------------------
    \1\ Department of Veterans Affairs, National Center for PTSD, 
Military Sexual Trauma Fact Sheet, September 2013 http://
www.mentalhealth.va.gov/docs/mst-general-factsheet.pdf.
    \2\ U.S. Code, Title 38, Section 1720D, 1992.
    \3\ VHA Directive 2010-033, Military Sexual Trauma (MST) 
Programming, July 14, 2010.
---------------------------------------------------------------------------
    Every VA Medical Center (VAMC) offers evidence-based therapy for 
conditions related to MST, and has providers knowledgeable about 
treatment for the aftereffects of MST.\4\  Nationwide there are almost 
two dozen programs that offer specialized treatment in residential or 
inpatient settings. All health care for treatment of mental and 
physical health conditions related to MST, including medications, is 
provided free of charge. Fee basis is available when it is clinically 
inadvisable to provide counseling in a VA facility, when VA facilities 
are geographically inaccessible, or when VA facilities are unable to 
provide care in a timely manner.\5\  Overall, while VA has taken the 
appropriate steps to provide counseling services for victims of MST, 
these services need to be more accessible.
---------------------------------------------------------------------------
    \4\ McCutcheon, SJ and Pavao, J; Military Sexual Trauma Support 
Team, VA Office of Mental Health Services, National Training Summit on 
WomenVeterans; ``Resources for Military Sexual Trauma (MST) 
Survivors,'' PowerPoint, 2011.
    \5\ Department of Veterans Affairs Office of Inspector General. 
health care Inspection Report No. 12-03399-54, Inpatient and 
Residential Programs For Female Veterans with Mental Health Conditions 
Related to Military Sexual Trauma, December 5, 2012. Retrieved from 
http://www.va.gov/oig/pubs/VAOIG-12-03399-54.pdf.
---------------------------------------------------------------------------
    MST-related care must be provided in a setting that is 
therapeutically appropriate, taking into account the circumstances that 
resulted in the need for such care. A supportive environment is 
essential for recovery. Thus, VA policy states that any veteran with 
MST must receive clinically appropriate care regardless of location. 
Veterans being treated for conditions associated with MST are often 
admitted to programs outside their Veterans Integrated Service Network. 
VA health care in general, especially for women, has been characterized 
as fragmented.\6\ Patients with special \7\ needs who are unable to 
access the services they need from their local providers are referred 
elsewhere, and oftentimes have to travel long distances to receive such 
services. According to a 2012 VA Inspector General report, obtaining 
authorization for travel funding was frequently cited as a major 
problem for both patients and staff. \8\ The beneficiary travel policy 
indicates that only certain categories of veterans are eligible for 
travel benefits, and payment is only authorized to the closest facility 
providing a comparable service. \9\
---------------------------------------------------------------------------
    \6\ Washington DL, Yano, EM, Simon B, and Sun S. 2006. To Use or 
Not to Use: What Influences Why Women Veterans Choose VA Health Care. J 
Gen Intern Med, 21(Suppl 3): S11-S18.
    \7\ Bean-Mayberry B, Chang CC, McNeil M, Hayes P, Scholle SH. 2004. 
Comprehensive care for women veterans: indicators of dual use of VA and 
non-VA providers. J Am Med Womens Assoc, 59(3): 192-7.
    \8\ Department of Veterans Affairs Office of Inspector General. 
health care Inspection Report No. 12-03399-54, Inpatient and 
Residential Programs For Female Veterans with Mental Health Conditions 
Related to Military Sexual Trauma, December 5, 2012. Retrieved from 
http://www.va.gov/oig/pubs/VAOIG-12-03399-54.pdf.
    \9\ VHA Handbook 1601B.05, Beneficiary Travel, July 23, 2010.
---------------------------------------------------------------------------
    The current beneficiary travel policy contradicts VA's MST policy, 
which states that patients with MST should be referred to programs that 
are clinically indicated regardless of geographic location. A veteran 
should never have to choose to skip treatment for conditions related to 
MST due to distance or a lack of transportation.
    I applaud VA's commitment to an effective program that provides 
counseling and treatment to men and women in need of help in overcoming 
the physical and psychological stress associated with MST. However, VA 
is not doing enough to help veterans access these important resources 
and services. Survivors of MST should not feel re-traumatized and 
helpless because of geographic barriers to treatment.
    Representative Kuster and I introduced H.R. 2974 to make victims of 
MST eligible for VA beneficiary travel benefits. By better aligning the 
beneficiary travel policy with VA's current policy for responding to 
veterans who have experienced MST, H.R. 2974 ensures appropriate 
services are more readily available to meet the treatment needs of our 
nation's veterans. I am grateful to work with Representative Kuster and 
the committee in addressing this critical issue for the survivors of 
military sexual trauma. I thank you again for this opportunity to speak 
today.

                                 

                 Prepared Statement of Hon. Sean Duffy

    Good morning. Thank you, Chairman Benishek and Ranking Member 
Brownley for holding this hearing today. I appreciate the opportunity 
to testify on behalf of H.R. 3508, legislation I introduced to help 
address the long wait times and lack of access our Veterans are facing 
in regard to hearing health.
    Our aging and younger veterans returning from the battlefield are 
seeking help from the VA for hearing loss more than any other 
disability facing them today. The demand for audiology services is 
growing at nearly 10% per year. Because of this increased demand, the 
VA can't keep up.
    Veterans across the US are being forced to wait weeks or even 
months for an appointment, Veterans like my constituent Roger from 
Marshfield. Roger is 70 years old and a Veteran of the Vietnam War. He 
suffers from hearing loss, and when he sought help from the VA, he was 
told he could not get an appointment for six months. Unfortunately, 
Roger couldn't wait that long, so he went to his local hearing aid 
specialist--and he was seen that day. Roger was willing to pay out of 
pocket for his hearing aids because six months was just too long to 
wait.
    This situation is because today the VA is only allowed to use 
Doctors of Audiology to provide hearing services to Veterans. While 
audiology doctors are a great resource for the VA and provide adequate 
service for Veterans, there are not enough to keep up with the demand 
and needs of people like Roger.
    Hearing aid specialists have gone through a 1-2 year apprenticeship 
training period, have completed a comprehensive written exam, and are 
certified by the state to fit and sell hearing aids. They are very 
qualified to support the specialized services of Audiology doctors by 
fitting, adjusting, and making minor repairs to hearing aids, helping 
to relieve the current burden Audiologists have of performing all 
hearing services for the VA. With the provisions of my bill in place, 
VA Audiologists can turn their attention to specialized cases and 
complex conditions, and people like Roger won't be waiting six months 
for hearing aids.
    A recent Office of Inspector General report supported these 
findings: 42 percent of Veterans waited more than 30 days from the time 
the medical facility received the hearing aids to the time they were 
mailed back to the Veteran and blames the delay in repairs on staff 
vacancies and an increase in workload. My bill would also allow the VA 
to fill those staff vacancies with specialists certified for adjusting 
and repairing hearing aids.
    H.R. 3508 has the support of the Iraq and Afghanistan Veterans of 
America, the International Hearing Society, VetsFirst, Blinded Veterans 
Association, and American Veterans.
    As Americans, we can never repay our debt to Veterans like Roger, 
but Congress can pass common-sense measures like H.R. 3508 to help make 
their lives back home a little easier. I urge the Committee to pass my 
legislation quickly and appreciate your support today.
    I yield back the balance of my time.

                                 

                Prepared Statement of Hon. Marcy Kaptur

    Chairman Benishek, Ranking Member Brownley, and Members of the 
Subcommittee, I appreciate the Subcommittee's consideration today of 
H.R. 3180, and thank you for the opportunity to submit testimony on 
this important legislation.
    This bill takes a critical step to address a most unfortunate 
epidemic of homelessness among our veterans. The U.S. Department of 
Housing and Urban Development estimates that nearly 60,000 veterans are 
homeless on any given night, including more than 12,000 veterans of our 
most recent military involvements. Moreover, about 1.4 million veterans 
are considered at risk of homelessness.
    In a prosperous nation such as ours, this is simply unacceptable. 
These men and women who did so much in service to our nation deserve 
better. The U.S. Department of Veterans Affairs does provide critical 
services for our homeless veterans and indeed, all who served. Still, 
many slip through the cracks.
    H.R. 3180 would provide help to ensure that number is lower. This 
legislation is intended to remove the barriers faced by State Veterans 
Homes in running homeless veterans programs. Many State Homes operate 
with continued vacancies--beds that could be filled by homeless 
veterans. Unfortunately, federal requirements can hinder these efforts.
    By providing an exemption for State Homes that receive a contract 
or grant from VA for residential care programs, including homeless 
veterans programs, we remove disincentives to State Homes to offer 
homelessness services.
    This provision places no requirements on VA to award special 
treatment in grants and contracts. Nor does it take away from the base 
services of State Homes in favor of homelessness programs. It simply 
puts State Homes on a level playing field with other groups providing 
homeless veterans programs.
    As we wind down our military involvements overseas, we face a 
renewed need to provide the services our veterans have earned. We 
should be doing everything we can to ensure these services are provided 
efficiently and effectively. Especially in the tight fiscal constraints 
we currently face, we must ensure that we are not wasting precious 
resources. H.R. 3180 takes an important step in that direction and I 
urge continued favorable consideration of the bill.
    Thank you again Mr. Chairman and Members of the Subcommittee.

                                 

               Prepared Statement of Hon. Kyrsten Sinema

    Thank you Chairman Benishek and Ranking Member Brownley for holding 
this legislative hearing.
    Thank you to my colleagues who introduced important bills to 
improve the quality of care available to veterans, especially 
Congresswoman Walorski's legislation, H.R. 2974, to make travel 
assistance available for veterans seeking care for military sexual 
trauma.
    I am here to discuss H.R. 3387, the Classified Veterans Access to 
Care Act--thank you Chairman Benishek for helping me to introduce this 
bipartisan bill.
    The Classified Veterans Access to Care Act ensures that veterans 
with classified experiences can access appropriate mental health 
services at the Department of Veterans Affairs.
    I am working on this issue because last year a military family in 
my district--the family of Daniel Somers--was devastated when Daniel 
failed to receive the care he needed and committed suicide.
    No veteran or family should go through the same tragedy that the 
Somers family experienced.
    Daniel Somers was an Army veteran of two tours in Iraq. He served 
on Task Force Lightning, an intelligence unit. He ran over 400 combat 
missions as a machine gunner in the turret of a Humvee. Part of his 
role required him to interrogate dozens of terrorist suspects, and his 
work was deemed classified.
    Like many veterans, Daniel was haunted by the war when he returned. 
He suffered from flashbacks, nightmares, depression, and additional 
symptoms of Post-Traumatic Stress Disorder, made worse by a traumatic 
brain injury. Daniel needed help. He and his family asked for help the 
best way they knew how.
    Unfortunately, the VA enrolled Daniel in group therapy sessions, 
which Daniel would not attend for fear of disclosing classified 
information. Despite requests for individualized counseling, or some 
other reasonable accommodation to allow Daniel to fully share what gave 
him nightmares, VA delayed providing Daniel with appropriate support 
and care.
    Like many, Daniel's isolation got worse when he transitioned to 
civilian life. He tried to provide for his family, but he was unable to 
work due to his disability. Daniel struggled with the VA bureaucracy; 
his disability appeal had been pending for over two years in the system 
without any resolution. Daniel didn't get the help he needed in time.
    On June 10, 2013, Daniel wrote a letter to his family. It begins:
    I am sorry that it has come to this.
    The fact is, for as long as I can remember my motivation for 
getting up every day has been so that you would not have to bury me. As 
things have continued to get worse, it has become clear that this alone 
is not a sufficient reason to carry on. The fact is, I am not getting 
better, I am not going to get better, and I will most certainly 
deteriorate further as time goes on. From a logical standpoint, it is 
better to simply end things quickly and let any repercussions from that 
play out in the short term than to drag things out into the long term.
    He goes on to say:
    I am left with basically nothing. Too trapped in a war to be at 
peace, too damaged to be at war. Abandoned by those who would take the 
easy route, and a liability to those who stick it out--and thus deserve 
better. So you see, not only am I better off dead, but the world is 
better without me in it.
    This is what brought me to my actual final mission.
    Daniel's parents, Howard and Jean, were devastated by the loss of 
their son, but they bravely shared Daniel's story and created a mission 
of their own. Their mission is to ensure that Daniel's story brings to 
light America's deadliest war--the 22 veterans that we lose every day 
to suicide.
    My office worked closely with Howard and Jean to develop the 
Classified Veterans Access to Care Act so that veterans know they can 
seek and receive comprehensive mental health care from the VA, 
regardless of the classified nature of their military experiences.
    Our bill directs the Secretary of the VA to establish standards and 
procedures to ensure that a veteran who participated in a classified 
mission or served in a sensitive unit may access mental health care in 
a manner that fully accommodates the veteran's obligation to not 
improperly disclose classified information.
    It also directs the Secretary to disseminate guidance to employees 
of the Veterans Health Administration, including mental health 
professionals, on such standards and procedures and on how to best 
engage such veterans during the course of mental health treatment with 
respect to classified information.
    Finally, the bill directs the Secretary to allow veterans with 
classified experiences to self-identify so they can quickly receive 
care in an appropriate setting.
    Our legislation is supported by the Retired Enlisted Association, 
the Association of the United States Navy, and the Iraq and Afghanistan 
Veterans of America.
    As the Iraq and Afghanistan Veterans of America states in its 
letter of support, ``these reforms to mental health treatment are 
necessary to provide safe and inclusive care for all veterans.''
    I look forward to continuing to work with the Committee to ensure 
that no veteran feels trapped like Daniel and that all our veterans 
have access to the necessary mental health care they need and deserve.
    By working together, and using the strength that the Somers family 
shows every day, we can end the scourge of veteran suicide, and ensure 
that veterans and their families have the care they need and deserve.
    Again, thank you Chairman Benishek and Ranking Member Brownley for 
including H.R. 3387, the Classified Veterans Access to Care Act in 
today's hearing. I welcome any questions you may have.

                Prepared Statement of Hon. Phil Roe, MD

    Mr. Chairman, it is my pleasure to present H.R. 3831, the Veterans 
Dialysis Pilot Program Review Act, to my colleagues on this 
subcommittee. This bill would prevent the Veterans Health 
Administration (VHA) from rolling out new in-house dialyses centers 
until an independent review of the VHA Dialysis Pilot Program has been 
completed.
    In 2009, the Secretary of Veterans Affairs launched the VHA 
Dialysis Pilot Program, creating four test sites at outpatient VA 
clinics to see if quality dialysis treatment could be delivered to 
veterans in house at a lower cost than contracting care out to 
commercial dialysis treatment centers. A 2012 GAO report, which I ask 
to be inserted into the record, shows that the early implementation of 
the Dialysis Pilot Program has shown many weaknesses, including 
erroneous cost estimation practices and cost savings calculations. The 
Department of Veterans Affairs (VA), however, is moving to expand the 
in-house dialysis program nationally--before a review of the pilot has 
been performed. In fact, VA is still contracting for an independent 
analysis of how well it is working.
    H.R. 3831 would simply direct the Secretary of Veterans Affairs to 
halt the establishment of any new VA dialysis clinics until each of the 
four original pilot sites has been operating for two years, an 
independent analysis of the sites is conducted, and a full report has 
been submitted to Congress. The intent of this bill is to ensure that 
we find out if this pilot program is in the best interest of veterans 
and taxpayers before the VA rolls out the program nationally.
    I would like to thank the witnesses for coming before us today and 
I look forward to their testimony.

                                 

                Prepared Statement of Hon. Jeff Denham 

    Chairman Benishek, Ranking Member Brownley,
    Thank you for the opportunity to testify today on behalf of my 
legislation, H.R. 4198, the Appropriate Care for Disabled Veterans Act. 
I am pleased that this legislation has the support of the Paralyzed 
Veterans of America, Veterans of Foreign Wars and Disabled American 
Veterans and look forward to working with these groups further as we 
move this important bill through the legislative process.
    Mr. Chairman, as you know, the number of disabled veterans has been 
increasing at an alarming rate. The number of severely disabled 
veterans is increasing even more quickly. These severely disabled 
veterans are suffering from a range of issues--spinal cord injury/
dysfunction (SCI/D); blindness; traumatic brain injury (TBI); or mental 
health disorders. Many require prosthetic, orthotic and sensory aids, 
and all need specialized care in their communities. It is the 
responsibility of this committee to ensure that the VA is meeting that 
mission requirement.
    To ensure that veterans had the care they needed, Congress 
mandated, beginning in 1996, that the VA maintain its capacity for the 
specialized treatment and rehabilitative needs of disabled veterans 
based on a number of specific measurements. For spinal cord injuries in 
particular, this capacity was to be measured by the number of staffed 
beds and the number of full-time employee equivalents available to 
provide care. The VA was also required to report this information to 
Congress after it was reviewed by the VA's Office of the Inspector 
General.
    Unfortunately this reporting requirement has lapsed and 
consequently so has the VA's adherence to the capacity standards 
required by Congress. As an example, Paralyzed Veterans of America's 
testimony explains how issues involving VA's capacity such as staffing 
directly impacts daily bed censuses and thus, creates access issues for 
veterans who need comprehensive care.
    With this bill, we have the opportunity to restore and modernize 
that reporting requirement so that this committee and our partners in 
the VSO community maintain a thorough understanding of the VA's ability 
to provide specialized care across the Veterans Health Administration 
system.
    To that end I welcome the testimony provided today by Disabled 
American Veterans which points out how substantial changes in the way 
the VA provides care in such areas as substance abuse disorders, long-
term nursing care and prosthetics require new capacity measurements not 
based on standards set in 1996.
    The American people have provided extraordinary resources to the 
Department of Veterans Affairs. It is our job to provide oversight of 
those resources. We cannot provide the oversight necessary without 
accurate information.
    Chairman Benishek, Ranking Member Brownley, thank you again for the 
opportunity to speak on behalf of this legislation.

                   Prepared Statement of Joy J. Ilem

    Chairman Benishek, Ranking Member Brownley and Members of the 
Subcommittee:
    On behalf of the DAV and our 1.2 million members, all of whom are 
wartime wounded, injured and ill veterans, I am pleased to present our 
views on legislative measures that are the focus of the Subcommittee 
today, and of DAV and our members.

H.R. 183, the Veterans Dog Training Therapy Act

    This bill would require the Secretary of Veterans Affairs to 
conduct a 5-year pilot program to assess the effectiveness of a 
therapeutic medium of service dog training and handling in addressing 
post-deployment mental health and post-traumatic stress disorder (PTSD) 
symptoms in veterans.
    The pilot program would be carried out in three to five Department 
of Veterans Affairs (VA) medical centers with available resources to 
educate veterans with certain mental health conditions, in the art and 
science of service dog training and handling. The bill would require a 
facility to offer wheelchair accessibility, dedicated indoor space for 
grooming and training dogs; a classroom or lecture space for education; 
office space for staff; storage for training equipment; periodic use of 
other areas to train the dogs with wheelchair users; outdoor exercise 
and toileting space; and, transportation for weekly field trips to 
train the dogs in other environments.
    The pilot program would be administered through VA's Recreation 
Therapy Service led by a certified recreation therapist with sufficient 
experience to administer and oversee the pilot program. The measure 
also would require that, when the selection of dogs was made, a 
deference would be given to dogs from animal shelters or foster homes 
with compatible temperaments to serve as service dogs, and with health 
clearances. Each service dog in training would live at the pilot 
program site or in a volunteer foster home in close proximity to the 
training site during the period of training.
    Veterans with post-deployment mental health conditions, including 
PTSD, would be able to volunteer to participate in the pilot if the 
Secretary determined adequate resources were available and those 
selected could participate in conjunction with VA's compensated work 
therapy program. Under the bill, the Secretary would also give veterans 
preference in the hiring of certified service dog trainers to those who 
had successfully completed therapy for PTSD or other residential 
treatment.
    The goal of the pilot would be to maximize the therapeutic benefits 
to veterans participating in the program and to ultimately provide 
well-trained service dogs to veterans with certain disabilities. The 
stated purpose of the pilot program would be to determine how 
effectively trained dogs would assist veterans in reducing mental 
health stigma; improve emotional stability and patience; reintegrate 
into civilian society; and, make other positive changes that aid 
veterans' quality of life and recovery. The bill would require VA to 
study and document such efficacy, and to provide a series of reports to 
Congress.
    Although DAV has no specific resolution approved by our membership 
relating to service dogs that would authorize DAV to formally support 
this measure, we recognize that trained service animals can play an 
important role in maintaining functionality and promoting veterans' 
recovery, maximum independence and improved quality of life. We 
recognize this pilot program could be of benefit to veterans suffering 
from post-deployment mental health struggles, including PTSD. We 
understand a similar program that operates at the Palo Alto VA Medical 
Center has been beneficial for veterans--and specifically in improving 
symptoms associated with post-deployment mental health problems, 
including PTSD. DAV is supportive of non-traditional therapies and 
expanded treatment options for veterans. For these reasons we have no 
objection to this bill.

H.R. 2527, To Provide Veterans With Counseling and Treatment for Sexual 
Trauma That Occurred During Inactive Duty Training

    Unfortunately, the sexual assault and harassment scourge continues 
in the active military services, and often results in lingering 
emotional or chronic psychological symptoms or conditions in victims of 
these attacks. Currently, Title 38, United States Code, section 1720D 
authorizes VA to provide priority counseling and specialized treatment 
for eligible veterans who have experienced military sexual trauma 
(MST), but this eligibility is limited to only those who served on 
active duty or active duty for training.
    This measure would amend Section 1720D to include veterans serving 
in the reserve components of the armed forces during inactive duty for 
training so that they, too, will be eligible for VA counseling services 
for conditions related to sexual trauma that occurred during their 
training.
    DAV Resolution 125 calls on VA to ensure that all military sexual 
trauma survivors gain access to the VA specialized treatment programs 
and services they need to fully recover from sexual trauma that 
occurred during their military service. Therefore, DAV is pleased to 
support H.R. 2527 and urges its enactment.

H.R. 2661, the Veterans Access to Timely Medical Appointments Act

    This bill would direct the Secretary of Veterans Affairs to 
establish a standardized scheduling policy for veterans enrolled in the 
VA health care system. This measure would propose to improve veterans' 
timely access to health care in the VA based on an external finding of 
unreliable waiting time data, lack of local adherence to national 
scheduling policy, and ineffective oversight by VA on the scheduling 
process itself.
    If enacted, the bill would require VA to implement recent 
Government Accountability Office (GAO) recommendations (GAO-13-130, 
http://www.gao.gov/assets/660/651076.pdf) to improve the reliability 
and accuracy of appointment waiting time measures; ensure VA medical 
centers (VAMC) consistently observe and adhere to official VA 
scheduling policy; require VAMCs to allocate staffing resources based 
on actual scheduling needs; and, ensure that VAMCs provide oversight 
of, and implement best practices to improve, veterans' telephone access 
to care. The bill would also require VA to make a series of reports to 
Congress on its efforts to improve scheduling under the mandates of 
this bill.
    DAV has testified on numerous occasions before this Committee on 
the topic of timely access in general, and of a variety of individual 
VA health care scheduling challenges, such as those in outpatient 
primary care, in mental health, in prosthetics and sensory aids and in 
other specialized services. While policies made at VA's Central Office 
seek to standardize a set of goals and actions across all VA facilities 
and programs, such as for timely access, or access-to-care standards, 
the mechanisms by which these policies are implemented locally may vary 
over time for a variety of reasons.
    We also note that VA's national waiting time policies have been 
changed over the years, and were re-defined and re-interpreted as they 
encountered conflicts with realities on the ground. For example, about 
20 years ago, to respond to criticisms about long waiting times, 
particularly for specialty services, VA established its ``30/30/20'' 
goal. For outpatient care, patients were to receive initial, non-urgent 
appointments with their primary care or other appropriate providers 
within 30 days of requesting visits; receive specialty care 
appointments within 30 days when referred by primary care providers; 
and, be seen by providers within 20 minutes of scheduled appointments. 
In 2000, to replace paper waiting lists, changes were made to VHA's 
automated scheduling module, measuring actual waiting times versus VA's 
30-day standard. Over time, VA has used several different waiting time 
measures defining and refining which patients would be included in 
waiting time analysis, which outpatient and specialty clinic services 
would be counted in waiting time calculations, and when waiting times 
started and ended. VA's access goals changed again in 2010 when VA 
began measuring performance for all outpatients based on a new 14-day 
waiting time benchmark. All these shifts and amendments have 
encountered challenges when they were implemented locally.
    While the intent of the bill is laudable and we appreciate the 
sponsor's interest in this ongoing challenge at VA, DAV believes the 
overriding critical component to solving many of VA's access 
challenges, unaddressed and lingering for several years now, is lack of 
an effective, sensitive and contemporary automated VA health care 
scheduling system.
    VA's outpatient clinic scheduling module is a core component of the 
Veterans Health Information Systems and Technology Architecture 
(VistA), a landmark multi-functional computerized patient records 
system, first deployed 30 years ago. The system has been modified many 
times since, and now performs multiple interrelated functions affecting 
patients, clinicians and other VA resources. The VistA scheduling 
module captures data which enables VA to measure, manage and improve 
access, quality and efficiency of care, and monitors operating and 
capital resources used in providing care. However, as has been 
continually reported and observed by GAO, ``the VistA scheduling system 
is outdated and inefficient, which hinders the timely scheduling of 
medical appointments.'' (See GAO-13-130, page 24.) We believe when a 
new scheduling system is eventually installed, VA could reasonably 
begin to assess demand versus capacity, as well as determine associated 
staffing needs and resources more accurately for management and 
oversight purposes.
    Measuring capacity, patient access and demand is a complex issue. 
DAV believes that progress toward successful implementation of VA's 
timely access policy must be assessed to ascertain what is or is not 
being achieved and why. Valid and reliable information is crucial 
because it helps shape decisions and actions at various levels to 
ensure compliance with policy directives, reaching intermediate 
performance indicators or benchmarks, and achieving long-term policy 
goals and objectives. Many of these important objectives are hampered 
because of weaknesses and failures of VA's current IT scheduling 
infrastructure. Furthermore, trying to standardize waiting times may 
result in VA having to contract for services if staffing levels and 
appropriate resources are not identified to resolve excessive waiting 
times.
    While DAV supports the intent of this legislation based on our 
Resolution No. 204, which calls on VA and Congress to ensure timely 
access to quality VA services, to identify and correct the related 
underlying data, scheduling and reporting problems that exist, and to 
provide sufficient resources and staff to achieve this goal, we believe 
this bill may bring an opposite effect. Despite its good intentions, 
enactment of this bill would not address these issues, and may only 
further complicate VA's ongoing quest to meet its own national access 
standards. Like the author of this bill, we want veterans to gain and 
keep access to timely care in VA. Therefore, we urge the Subcommittee 
to work with VA to fully address the core issues to determine how the 
intent of this measure could be best achieved.

H.R. 2974, To Provide for the Eligibility for Beneficiary Travel for 
Veterans Seeking Treatment or Care For Military Sexual Trauma in 
Specialized Outpatient or Residential Programs at Facilities of the 
Department of Veterans Affairs

    This bill would amend Title 38, United States Code, section 111, to 
provide veterans new eligibility for VA beneficiary travel 
reimbursement if they need to travel to specialized outpatient or 
residential programs at VA facilities for treatment of mental health 
conditions related to sexual trauma that occurred during their military 
service.
    The Sexual Assault Prevention and Response Office (SAPRO) in the 
Department of Defense (DoD) reports that over 3,000 sexual assaults are 
acknowledged each year across the military branches. However, SAPRO 
estimates 87 percent of these assaults actually go unreported--meaning 
that as many as 26,000 sexual assaults are likely to occur in DoD each 
year. The VA provides specialized residential and outpatient counseling 
programs and evidence-based treatments to military sexual trauma (MST) 
survivors, and notes that nearly 800,000 MST-related patient encounters 
take place annually.
    According to VA's Office of the Inspector General (VAOIG) Report 
No. 12-03399-54, Inpatient and Residential Programs for Female Veterans 
with Mental Health Conditions Related to Military Sexual Trauma, VA 
facility and mental health services staff interviewed by the VAOIG 
consistently indicated difficulties obtaining VA authorization for 
patient transportation funding to VA's specialized centers for MST. We 
believe these difficulties arise from conflicting VA authorities and 
policies. Specifically, VHA Directive 2010-033, Military Sexual Trauma 
(MST) Programming, establishes policy that veterans and eligible 
individuals must have access to VA residential or inpatient programs 
able to provide specialized MST-related mental health care. However, 
access to such care is affected for veterans eligible and not eligible 
for beneficiary travel benefits.
    In the case of a veteran who is eligible for beneficiary travel 
benefits under current statutory authority, \1\ applying VHA Directive 
2010-033 requires clearer guidance on inter-facility referrals for 
care, consistent implementation of current policy, and oversight.
---------------------------------------------------------------------------
    \1\ Traveling for treatment or care: 1) for a service-connected 
disability; 2) for any disability of a veteran rated 30 percent or more 
for a service-connected disability; 3) for a scheduled compensation and 
pension examination; 4) of a veteran receiving pension under 38 U.S.C. 
Sec. 1521, and; 5) a veteran whose annual income (as determined under 
38 U.S.C. Sec. 1503) does not exceed the maximum annual rate of pension 
under 38 U.S.C. Sec. 1521 (as adjusted under 38 U.S.C. Sec. 5312) if 
the veteran was eligible for pension.
---------------------------------------------------------------------------
    Clearer guidance to VA facilities from VA Central Office is needed 
to help determine which VA facility would be responsible for paying 
beneficiary travel benefits when more than one VA facility is involved 
in a veteran's care, or when treating VA facilities are located in 
different Veterans Integrated Service Networks (VISN). This lack of 
guidance for beneficiary travel affects all types of care including for 
MST-related conditions. Ostensibly, the memorandum of understanding on 
inter-facility referrals required in VHA Directive 2010-033, should 
address this problem.
    Consistent implementation and oversight is required when mileage 
reimbursement is calculated to the nearest VA facility. The VAOIG 
report indicates that reimbursement is only authorized to the VA 
facility ``where the care or services could be provided.'' This 
interpretation is not wholly accurate.
    Title 38, Code of Federal Regulations, section 70.30(b)(1) and VHA 
Handbook 1601B.05 state that reimbursement for beneficiary travel to an 
eligible beneficiary ``[i]s limited to travel from a beneficiary's 
residence to the nearest VA facility where the care or services could 
be provided and from such VA facility to the beneficiary's residence.'' 
However, the Handbook also indicates that the nearest appropriate VA 
facility is subject to a clinician's determination. The ``nearest 
appropriate VA facility'' means the particular VA facility that a VA 
provider determines is capable of providing the treatment or service 
required. Thus, if a VA clinician indicates a veteran who is eligible 
for beneficiary travel requires specialized treatment for MST at a VA 
facility located in a different VISN, current policy states the amount 
of beneficiary travel payment or reimbursement shall be calculated from 
the veteran's residence to the distant facility, not the home VA 
facility.
    In the case of a veteran who is not eligible for beneficiary travel 
under current statutory authority, we believe successfully achieving 
the intentions of VHA Directive 2010-033 regarding access to 
specialized MST-related residential or inpatient MST-related care would 
require enactment of H.R. 2974.
    As you may be aware, DAV called for enactment of a similar measure 
in testifying before the Senate Veterans' Affairs Committee on October 
30, 2013, regarding a draft bill, the Survivors of Military Sexual 
Assault and Domestic Abuse Act of 2013. Thus, in accordance with DAV 
Resolution No. 125, which calls for supporting legislation to change 
beneficiary travel policies to meet the specialized clinical needs of 
veterans receiving MST-related treatment, DAV supports H.R. 2974. 
However, DAV also testified on May 21, 2013, before this Subcommittee 
on a related bill that proposed to amend Section 111 by expanding 
eligibility for beneficiary travel reimbursement benefits to another 
select group of veterans. That bill, H.R. 1284, would have given new 
eligibility for VA beneficiary travel reimbursement to veterans needing 
specialized care for vision impairment, for spinal cord injury or 
disorder, or for double or other multiple amputations. In that 
testimony, we urged this Subcommittee, as we do now, to consider a more 
equitable approach to beneficiary travel eligibility.
    Specifically, in addition to a handful of specialized MST 
residential programs targeted by H.R. 2974, VA operates 24 spinal cord 
injury/dysfunction rehabilitation centers, 13 blind rehabilitation 
centers, 7 geriatric research, education and clinical centers, 7 mental 
illness research, education and clinical centers, 3 war-related illness 
and injury study centers, and a number of other clinical centers of 
excellence. Access to these centers is important for veterans with 
conditions connected to the expertise of these centers.
    In DAV's view, the developing care delivery model for MST-related 
specialized treatment is similar to the concentrations of other 
specialized VA clinical services that often require patients to travel 
long distances to gain access to these services. Without VA's support 
for their transportation costs to reach these centers, some veterans 
encounter challenging barriers to care and do not benefit from the 
higher quality care and outcomes intended by VA and Congress in 
establishing and operating these centers of excellence. This problem 
should be addressed through the legislative process.

H.R. 3180, To Include Contracts and Grants for Residential Care for 
Veterans in the Exception to the Requirement That the Federal 
Government Recover a Portion of the Value of Certain Projects

    H.R. 3180 was introduced with the intention of allowing some state 
veterans homes to compete for existing grants to support the operation 
of homeless veterans programs using a portion of excess bed capacity in 
state home domiciliaries. The bill would amend Title 38, United States 
Code, to authorize a state veterans home to receive contracts or grants 
from VA for any residential care program, including a homeless veterans 
program, without being subjected to required federal recapture of prior 
VA construction grants to the home for the building of those beds. 
Under current statute, state veterans homes receive federal support, 
including both per diem payments for veterans' care and construction 
grants, to operate only three authorized programs: skilled nursing 
care, adult day health care, and domiciliary care. Under current law, 
were a state home to use facilities previously granted by VA to operate 
any other type of program, the federal government would seek to 
recapture a proportionate value of the construction grant funds that 
had been provided over the prior 20 years.
    The legislation as currently drafted, however, does not 
specifically reference either domiciliaries or homeless veterans 
programs, nor would it assure the intended outcome. The bill's current 
language would create a broad exception to the recapture provision that 
could be applied to any residential care program for veterans, and its 
enactment could raise the potential for other unintended consequences. 
Based on DAV Resolution 165, DAV supports the intention of H.R. 3180--
to use existing excess capacity to help homeless veterans--but 
recommends that the Subcommittee work with VA, state homes and veterans 
service organizations to craft more targeted and effective legislative 
language to achieve the goal of this bill.

H.R. 3387, the Classified Veterans Access to Care Act

    This bill would seek to amend Title 38, United States Code, to 
improve mental health treatment provided by the VA to veterans who 
served in classified military missions. If enacted, this bill would 
provide accommodation to certain veterans in VA mental health care 
treatment to not improperly disclose classified information in cases in 
which they served in ``sensitive military assignments'' or ``sensitive 
units.'' The bill would define both of these terms, as well as the term 
``classified information.'' The bill would require VA to establish 
standards and procedures to carry out its purposes.
    Given the unique nature of this relatively small group of veterans 
who have been deployed in classified missions or worked in sensitive 
units while serving, we would hope VA already acknowledges, especially 
in its mental health treatment programs, the need to be respectful of 
these veterans' particular circumstances and personal military 
histories.
    Many of VA's treatment programs are provided in group therapy 
settings. A veteran who served in a classified mission may well not be 
comfortable discussing that personal history in the presence of a 
group, and we hope that VA already has established procedures in place 
to make arrangements for individual counseling or therapy sessions in 
such cases. We understand this to already be the case in VA's 
readjustment counseling Vet Centers. We also understand that service 
members with security clearances receive training about disclosure and 
restrictions on classified information.
    We understand from VA that generally, active duty personnel are 
able to discuss their experiences without revealing classified 
information to counselors and therapists, and should be able to engage 
in treatment irrespective of whether their health care providers 
possess comparable levels (or any) security clearance. In our review of 
this issue, we have discovered that even in prolonged exposure-based 
therapy for PTSD, it is not the case that every detail of an event or 
experience must be shared by a veteran with a provider in order for 
treatment to be effective. It is reasonable to believe that VA mental 
health providers and Vet Center counselors respect and work within the 
limits of the information that veterans can share and within the 
confines of any confidentiality requirements and security clearance 
levels that may be involved.
    A reasonable approach would be to inform active duty personnel (and 
certain veterans) seeking mental health services in VA about all the 
limits of confidentiality, to include the fact that the care provider 
may not possess a security clearance. We note that mental health 
providers working in the DoD routinely inform their patients about the 
limits of confidentiality, but not security clearance limitations. 
Nevertheless, VA mental health practitioners and counselors could be at 
times impeded in aiding particular individuals because they may believe 
they are effectively ``gagged,'' and thus unable to describe in therapy 
certain military events or activities sheltered from disclosure that 
might be, or could become, keys to improved treatment. For example, in 
prolonged exposure therapy, reliving a traumatic event or incident 
repetitively has proven to be an effective treatment to reduce or 
control symptoms of post-traumatic stress disorder. In these cases, a 
talented, experienced practitioner should be able to use other 
techniques, such as cognitive behavioral therapy, to enable a service 
member or veteran to deal with his or her individual challenges, 
without disclosing classified information.
    While it may be technically unnecessary, enactment of this bill 
could reinforce a sense that these particular veterans' prior military 
duties should not become a bar to their receiving effective VA mental 
health services following their discharges, or be a reason to avoid 
seeking treatment. Thus, we believe enactment could make a positive 
contribution to care, or help persuade some veterans to actually seek 
VA mental health services who had not previously done so because of the 
nature or duties of their prior sensitive or classified military 
assignments.
    While DAV has not received a resolution from our membership 
concerning mental health services for veterans who once worked in 
classified or sensitive military activities, we did receive Resolution 
No. 193, at our most recent national convention, that supports 
``enhanced [VA] resources for VA mental health programs to achieve 
readjustment of new war veterans and continued effective mental health 
care for all enrolled veterans needing such services.'' We believe this 
bill is consistent with the purposes of our resolution; therefore, DAV 
offers its support of this measure.

H.R. 3508, To Clarify the Qualifications of Hearing Aid Specialists of 
the Veterans Health Administration of the Department of Veterans 
Affairs

    If enacted, this bill would authorize the appointment of hearing 
aid specialists in the Veterans Health Administration (VHA). The bill 
would specify that such individuals hold associate degrees in hearing 
instrument sciences, or the equivalent, from colleges or universities 
approved by the Secretary, or have successfully completed approved 
hearing aid specialist apprenticeship programs. Individuals eligible 
for appointment would need to be licensed by a state as a hearing aid 
specialist, or its equivalent.
    The Secretary would also be required to submit an annual report on 
timely access to hearing health services to include staffing levels and 
average waiting times for patients seeking appointments, a description 
of how the Secretary measured performance related to appointments and 
care in hearing health, and information on contracting policies with 
respect to providing hearing health services in non-VA facilities. Not 
later than 180 days after enactment of this bill, the Secretary would 
be required to update and reissue the VHA handbook, ``VHA Audiology and 
Speech-Language Pathology Services,'' to reflect these new 
requirements.
    On February 20, 2014, the VA's Office of the Inspector General 
(VAOIG) issued a report and findings of its audit of VA hearing aid 
services (VAOIG 12-02910-80). The purpose of the audit was to evaluate 
the effectiveness of VA's administration of hearing aid orders. 
According to the report, VA is not issuing hearing aids to veterans in 
a timely manner or meeting its own five-day goal to complete repair 
services of hearing aids issued previously. Specifically, VHA issued 30 
percent of its hearing aids to veterans more than 30 days from the 
estimated date the facility received hearing aids from vendors. 
Audiology staff attributed the delays to inadequate staffing levels and 
the large number of veterans requiring compensation and pension 
examinations, which they reported take priority over other types of 
clinic appointments. The VAOIG further noted that with the veteran 
population aging, demand for hearing aid services has increased from 
596,000 in FY 2011 to over 665,000 in FY 2012. Also, the VAOIG 
estimated that about 19,500 sealed packages of hearing aids were 
awaiting repairs at VA's Denver Acquisition and Logistics Center and 
that 17-24 days were being consumed by the center to complete the 
repair services, exceeding VA's five-day timeliness standard for such 
services.
    The VAOIG recommended VA develop a plan to implement productivity 
standards and staffing plans for audiology clinics as well as to 
determine appropriate staffing levels for its repair laboratory, and to 
establish controls to track and monitor received hearing aids pending 
repair. The VA Under Secretary for Health concurred with the audit 
recommendations and submitted corrective action plans. We understand 
these actions have been initiated and look forward to VA's report.
    DAV has no specific resolution from our membership related to the 
employment of hearing aid specialists within VA. However, the findings 
of the VAOIG report cited demonstrate that VA is now struggling to meet 
timely access for the delivery of hearing aids and for completing 
necessary repairs on malfunctioning ones. Because hearing loss 
(including tinnitus) is the most prevalent service-connected disability 
for veterans, and the demand for audiology services and hearing aid 
repairs and adjustments continues to rise, having qualified hearing aid 
specialists available for basic services (within their scope of 
practice, for necessary repairs and cleaning) may significantly reduce 
the waiting times found by VAOIG. We do, however, defer to VA to ensure 
that hearing aid specialists would meet VA's quality standards, through 
their certified scope of practice, and could contribute in reducing the 
backlog of hearing aid repairs and delivery of hearing aids to 
veterans. If this can be verified by VA we have no objection to passage 
of this measure.

H.R. 3831, the Veterans Dialysis Pilot Program Review Act of 2014

    This measure would require the Secretary to undertake an 
independent analysis of the existing dialysis program implemented by 
the VA and provide a report to Congress on the review prior to 
expanding the existing dialysis pilot program at VAMCs in Durham and 
Fayetteville, North Carolina; Philadelphia, Pennsylvania; and 
Cleveland, Ohio, or creating any new dialysis capability.
    VA estimates show that in FY 2011, approximately 35,000 veterans 
enrolled in the VA health care system were diagnosed with end-stage 
renal disease (ESRD), reflecting a higher prevalence of this condition 
in the VA population than in the general U.S. population. (Comparison 
of outcomes for veterans receiving dialysis care from VA and non-VA 
providers, Wang et al., BMC Health Services Research 2013, 13:26.) VA 
initiated several studies of this population based on the rapidly 
rising cost of VA-financed hemodialysis treatment in non-VA facilities 
and the high rates of morbidity and mortality of veteran patients with 
ESRD. (Comparing VA and private sector health care costs for end-stage 
renal disease, Hynes et al., Medical care 2012, 50(2):161-170.)
    ESRD patients are one of the most resource-intensive population 
cohorts in the VA health care system. The reality of hemodialysis is 
often overwhelming to these patients. Kidney failure is a life-altering 
disease that has a significant impact on a veteran's overall physical 
and mental health, lifestyle, and livelihood. A veteran diagnosed with 
ESRD who needs dialysis typically requires three outpatient treatments 
per week, each requiring about four hours, to be repeated for the 
remainder of his or her life, absent kidney transplant.
    In a May 2012 report, the GAO evaluated VA's dialysis pilot. GAO 
reported VA had not fully developed performance measures for assessing 
the dialysis pilot locations, even though the Department had already 
begun planning an expansion of the pilot to additional sites. Further, 
GAO concluded that such an expansion ``should not occur until after VA 
has defined clear performance measures for the existing pilot locations 
and evaluated their success.''
    DAV has no approved, specific resolution on this issue, and 
therefore takes no formal position on this bill. We do, however, offer 
some concerns that we ask the Subcommittee to consider.
    While Congress has been focused on the accuracy of VA's data, 
analysis, and plan of action to address the growing demand for dialysis 
therapies depicted in recent Committee reports (House Appropriations 
Report 112-094, page 41, May 31, 2011 and House Appropriations Reports 
112-491, pages 39-40, May 23, 2012), DAV is concerned that enactment of 
this measure would, at least through July 2015, restrict VA's capacity 
to provide life-sustaining dialysis treatment through fee-basis 
dialysis, except for those under sharing or other negotiated 
agreements.
    We note for the Subcommittee that VA testified on October 30, 2013, 
before the Senate Veterans' Affairs Committee, and indicated that 
requiring continuation of the four initial pilot sites without change 
beyond these activities for at least the next two years would prohibit 
activation of any additional free-standing VA dialysis centers until at 
least 2015. The VA also testified that a restriction of this type had 
the potential to ``. . . adversely impact VA's efforts to optimize 
Veterans' dialysis care.'' Given the brittle nature of these veterans' 
health problems and their very high morbidity and mortality rates due 
to this fatal disease, in our judgment new projects that the VA is 
currently working to activate should continue without interruption or 
further delay, and certainly should go forward without regard to the 
fate of these four pilot programs. Further, DAV would be deeply 
concerned if this bill were to halt or restrict VA from continuing to 
provide dialysis care to veterans within the system itself, or through 
private providers under contract.
    Discussions surrounding the dialysis pilot of the Department's 
purchased and provided dialysis therapy appear generally to be centered 
on cost. We find insufficient emphasis on the veteran patient; 
therefore, we appreciate this legislation's inclusion of non-cost 
factors such as access to care, quality of care, and veteran 
satisfaction in the bill's provisions related to independent analysis 
of the VA dialysis pilot program.
    As one of four Independent Budget veterans service organizations 
(IBVSOs), we note that coordinating care among the veteran, dialysis 
clinic, VA nephrologists, and VA facilities and physicians, is 
essential to improving clinical outcomes and reducing the total costs 
of care. The benefits of an integrated, collaborative approach for this 
population have been proven in several Centers for Medicare and 
Medicaid Services demonstration projects and within private-sector 
programs sponsored by health plans and the dialysis community. Such 
programs implement specific interventions that are known to avoid 
unnecessary hospitalizations, which, when they occur for these 
patients, frequently cost more than the total cost of dialysis 
treatments. These interventions include a focus on behavioral 
modification and various motivational techniques. The potential return 
on investment in better clinical outcomes, higher quality of life, and 
lower costs could be substantial for VA and veteran patients if 
integrated care coordination were emphasized.
    We understand that some community dialysis providers are piloting 
the integrated care management concept among their veteran population 
cohorts. The IBVSOs believe that VA should also provide integrated care 
management in this pilot program that can test and demonstrate the 
value of such an approach to VA and the veterans it serves.

H.R. 4198, the Appropriate Care for Disabled Veterans Act

    H.R. 4198 would amend Title 38, United States Code, to reinstate 
the requirement for an annual report to Congress on the capacity of the 
VA to provide for specialized treatment and rehabilitative needs of 
disabled veterans. The renewed report would emphasize a special--but 
not exclusive--focus on maintenance of programs of care for spinal cord 
injury/dysfunction (SCI/D); blindness; traumatic brain injury (TBI); 
prosthetic, orthotic and sensory aids; and mental health.
    We have received no national resolution approved by our membership 
to support reinstatement of this previous reporting requirement; 
however, we wish to offer some thoughts to the Subcommittee for its 
consideration in determining how to manage this proposal.
    Section 1706, Title 38, United States Code, was formulated by the 
Committee in the mid-1990's and was first authorized in Public Law 104-
262. The section was subsequently revised in three additional acts, the 
last of which was Public Law 109-461, an act that extended the 
reporting requirement through 2008. The capacity report has been 
suspended since that time, but other provisions of section 1706 are 
still applicable to VA.
    Several elements in the report that H.R. 4198 would reauthorize 
rely on the year 1996 (the year of enactment of Public Law 104-262) as 
the benchmark year for VA capacity comparisons and reporting going 
forward. Given changes in the veteran patient population, their health 
care needs, and the manner in which health care is delivered today, we 
believe reinstating the existing comparison year of 1996 for a number 
of important programs would not produce information useful for 
Congressional oversight, for review by members of our community of 
veterans service organizations, and for others with interest in VA 
capacity.
    Due to the nature and severity of veterans' contemporary war 
injuries from Iraq and Afghanistan, and the consequent massive 
investment in new and innovative prosthetics made by both VA and the 
Department of Defense since 2002, VA's prosthetic and sensory aids 
program is now more innovative, extensive and expensive today than in 
1996. Thus, 1996 would not be an appropriate benchmark in our view. In 
this light a more effective date for comparative reporting purposes in 
the prosthetics program might be 2001 or, perhaps even 2010, so that 
Congress could more closely gauge how VA capacity to provide these 
specialized services may be changing annually during a more meaningful 
interval.
    Importantly, in no small part because of this Committee's advocacy 
and the benevolence of Congressional appropriators, VA mental health 
programs including those for substance-use disorder, have been 
reformed, revised and expanded to such an extent that they barely 
resemble those of nearly twenty years ago. In staffing alone, since 
2002, VA has added over 20,000 mental health personnel to its 
employment rolls. VA already reports to Congress in its annual budget 
submissions estimated total expenditures on mental health, but 
reporting of detailed subsets is not currently required. We believe 
more detail on mental health program capacity should be made available.
    As an example of the need for public reporting, we note that 
substance-use disorder bed units were prevalent in VA and elsewhere in 
1996 when the expired reporting requirement was first established, but 
they are much rarer now. In fact over the past decade and more, VA has 
severely curtailed inpatient residential substance-use disorder 
programs. Most of these programs are now conducted on an outpatient 
basis. The expired language of section 1706 assumes inpatient 
substance-use programs are still prevalent today. Also, VA maintains a 
number of detoxification beds for acute substance-use disorder intake 
cases, but we have experienced challenges in determining the number and 
location of these beds since no publicly available inventory of them is 
maintained by VA.
    In another evolution in VA, traditional long-term, skilled nursing 
care (historically a bed-intensive program) has given way to VA's 
establishment of an array of institutional and non-institutional long-
term services and supports. The expired language is silent on VA long-
term services and supports capacity, but as an important and growing 
component of VA's clinical care mission, we believe it should be 
included. DAV is supportive of the VA's initiative to rebalance its 
long-term services and supports portfolio to care for veterans closer 
to where they live by increasing access to and creating new and 
innovative home and community-based services. However, variation in 
availability and accessibility of VA long-term services and supports 
across the 21 VA health care networks has been critiqued in multiple 
reports by the GAO. These reports collectively could offer insights 
into how a capacity report might be structured.
    In certain discrete bed units (such as VA SCI/D centers, designated 
TBI rehabilitation units, and residential blind rehabilitation centers, 
for example), year-to-year comparative bed capacities by unit, and 
full-time employee equivalents assigned to each such unit (as well as 
the distribution of those staff by health profession, compared to VA's 
``objective standards of job performance,'' as also prescribed by 
section 1706), could provide a meaningful yardstick to ascertain VA's 
true capacity to care for and rehabilitate veterans in these particular 
specialized bed-based units. Given the bill sponsor's coordination with 
Paralyzed Veterans of America in crafting this bill, DAV would support 
amendments to this bill that would require VA to report to Congress on 
discrete bed-intensive rehabilitation programs along the parameters of 
the expired section. As described in this testimony, for other VA 
specialized health care programs we believe a more nuanced report to 
gauge capacity taking into account the changes that have occurred in 
these programs would be more beneficial for oversight and monitoring 
purposes.
    Representatives of DAV and other veterans organizations recently 
have discussed these concerns and needs with the bill's sponsor, and 
have offered our assistance in crafting a possible substitute amendment 
that would accomplish our goal of reinstating a capacity-reporting 
statute that would track capacity resources in discrete bed-intensive 
units along the lines of the intent of this bill, yet also would 
provide Congress information on VA capacities that are not bed-
intensive or bed-relevant as described above.
    Taking into account these concerns, DAV asks the Subcommittee to 
consider approving the bill in its current form, with the understanding 
that at a future legislative meeting of the Committee an amendment in 
the nature of a substitute will be offered by the bill's sponsor, 
incorporating the agreed-on changes that we hope to achieve in a 
collaborative fashion.

Draft Bill, To Authorize Major Medical Facility Projects for the 
Department of Veterans Affairs for Fiscal Year 2014

    Sections 1, 2, and 3 of this bill would authorize, or amend a prior 
authorization of, 27 major medical facility leases, primarily 
outpatient clinic facilities, in fiscal year 2014, and would authorize 
appropriations of $236.6 million, an amount sufficient for VA to 
execute these leases. These are the same leases that are included in 
H.R. 3521, a bill passed by the House in 2013, and that are also 
embedded in S. 1982, now pending before the Senate.
    DAV strongly supports these sections on the basis that these new or 
expanded community-based clinics and other leased facilities would 
improve access to convenient VA primary and specialty outpatient care, 
and provide other positive health outcomes that support veterans, 
consistent with DAV Resolution No. 028. We urge the Committee to 
advance these provisions, and to deal as well with the ongoing 
stalemate between the Office of Management and Budget and the 
Congressional Budget Office on an acceptable method of treating the 
long-term costs of these facilities under the Budget Control and 
Impoundment Act of 1974, as amended.
    Section 4 of the bill would broaden the statutory definition of VA 
``medical facility'' in Title 38, United States Code, section 8101(3), 
by adding the term ``or as otherwise authorized by law'' that conveys 
jurisdiction of a capital entity to the VA Secretary. This section of 
the bill also would amend the definition of ``major medical facility 
project'' to exclude shared federal facilities constructed, altered or 
acquired, so long as the cost of VA's share did not exceed $10 million; 
the section would apply this same logic to federally shared major 
medical facility leases when VA's share did not exceed $1 million in 
annual rental costs. We have no objection to this change in definition 
that would provide VA additional flexibility to establish VA health 
care facilities in the future with other federal health partners.
    This section of the bill would create a new section 8111A in Title 
38, United States Code, to authorize the Secretary to enter into 
agreements with other federal agencies to plan, design and construct 
shared federal medical facilities for the stated purpose of improving 
access, quality and cost effectiveness of health care provided by VA to 
veterans, and by other federal agencies to their respective 
beneficiaries. The authorization would also empower the Secretary to 
transfer funds to another federal agency for these purposes, so long as 
such transfer did not exceed the applicable existing thresholds in 
Title 38, United States Code, for major medical facilities or major 
medical facility leases ($10 million, and $1 million, respectively). 
The Secretary would also be authorized to receive funds from other 
federal agencies for these same purposes, for VA construction or leases 
of shared federal facilities.
    We understand that VA has been stymied in the past in cooperating 
with the DoD on shared facilities projects due to lack of clear 
statutory authority within VA to do so. This language, if enacted, 
would provide VA this specific authority. Our only concern is that this 
policy be applied to shared VA-DoD facilities and not become the basis 
for shared activities with numerous other potential federal health 
agencies with missions unrelated to the care of veterans and military 
beneficiaries. With that understanding DAV offers no objection to this 
language.
    Section 5 of the bill would amend VA's existing authority for 
enhanced-use leases by liberalizing the purposes of such leases to two 
clear options: enhance the use of the property concerned; or, provide 
supported housing for homeless veterans. Because the enhanced-use lease 
authority has been moribund since Congress last amended it, now adding 
general language that would enhance the use of unneeded VA structures, 
in a complementary manner, in addition to their use for homeless 
veterans (the only approved use under current law) might stimulate new 
lease activity. VA anticipates this more flexible language will 
generate receipt of new funds from leaseholders of unused VA structures 
producing no income now. On that basis, DAV would not object to 
enactment of this section.
    Sections 6 and 7 of the bill would modify a prior act of Congress 
that authorized a major medical facility construction project at the 
Tampa, Florida VAMC, in effect authorizing a new bed tower at that 
facility in the amount of $231.5 million, in lieu of upgrades of the 
existing tower previously authorized by law in 2008. It is our 
understanding from VA that a determination has been made that 
constructing a new tower in lieu of renovating the existing one would 
be a more cost-effective use of these funds. Section 7 also would 
restrict the use of certain funds in carrying out the Tampa project. 
DAV takes no position on this section, but makes no objection to this 
proposed change.
    In summary, we would offer no objection to the Committee's approval 
of this bill in its current form.
    Mr. Chairman and Members of the Subcommittee, thank you for 
inviting DAV to testify before the Subcommittee on these legislative 
proposals. I stand ready to respond to any questions you wish to ask 
that are related to these proposals, DAV's positions on them, or other 
matters related to this testimony.

                                 

                 Prepared Statement of Alethea Predeoux

    Chairman Benishek, Ranking Member Brownley, and members of the 
Subcommittee, Paralyzed Veterans of American (PVA) would like to thank 
you for the opportunity to present our views on the health care 
legislation being considered by the Subcommittee. These important bills 
will help ensure that veterans have access to quality and timely health 
care services through the Department of Veterans Affairs (VA). We are 
particularly pleased that H.R. 4198, which is a legislative priority of 
PVA, is among the legislation being reviewed today.

H.R. 183, the ``Veterans Dog Training Therapy Act''

    PVA does not have an official position on H.R. 183, the ``Veterans 
Dog Training Therapy Act.'' If enacted, this legislation would direct 
the VA to conduct a pilot program on dog training therapy for veterans. 
PVA recognizes that dog training has been successfully used as a 
beneficial form of therapy for veterans dealing with Post-Traumatic 
Stress Disorder (PTSD) and other mental health issues. A model program 
for this service was created in 2008 at the Palo Alto VA Medical Center 
in conjunction with the Assistance Dog Program. This program, 
maintained by the Recreational Therapy Service at the Palo Alto VA 
medical center, was designed to create a therapeutic environment for 
veterans with post-deployment mental health issues and symptoms of PTSD 
to address their mental health needs.
    In these programs, veterans training service dogs is believed to 
help address symptoms associated with post-deployment mental health 
issues and PTSD in a number of ways. Specifically, veterans 
participating in these programs demonstrated improved emotional 
regulation, sleep patterns, and a sense of personal safety. They also 
experienced reduced levels of anxiety and social isolation. Further, 
veterans' participation in these programs has enabled them to actively 
instill or re-establish a sense of purpose and meaning while providing 
an opportunity to help fellow veterans reintegrate back into the 
community. PVA does not oppose dog training therapy as a non-
traditional form of mental health care. However, if this legislation is 
enacted as written, it would differ from the existing program at the 
Palo Alto VA medical center in that the VA would be fully responsible 
for all aspects of caring for the dogs and the training program. PVA 
does not believe that VA has the resources needed for such an 
undertaking.

H.R. 2527

    PVA strongly supports H.R. 2527, which proposes to amend Title 38 
United States Code to provide veterans with counseling and treatment 
for military sexual trauma (MST) that occurred during inactive duty 
training. As discussed in the FY 2015 Independent Budget, currently 
members of the National Guard or Reserves who experienced sexual trauma 
during drill training do not have access to VA counseling and treatment 
for sexual trauma. If a veteran is injured while in drill status, 
including transit to or from drill training, all such injuries are 
considered service-connected. The unfortunate instance of sexual trauma 
should not be treated differently. To deny veterans who serve in the 
reserve components of the military VA MST-related care for sexual 
trauma experienced during inactive duty training is not only 
inequitable, but detrimental to veterans' health and well-being.

H.R. 2661, the ``Veterans Access to Timely Medical Appointments Act''

    The ``Veterans Access to Timely Medical Appointments Act,'' 
proposes to establish a standardized scheduling policy for veterans 
enrolled in the VA health care system. This scheduling policy would 
mandate that VA schedule all primary care appointments within seven 
days of the date requested by the veteran or the health care provider 
on behalf of the veteran, and require specialty care medical 
appointments to be scheduled within 14 days of the date requested by 
the veteran or physician.
    Timely access to quality care is vital to VA's core mission of 
providing primary care and specialized services to veterans. Therefore, 
PVA believes that the VA must develop reasonable standards for 
scheduling medical appointments, and have a system that allows VA 
leadership to assess and evaluate scheduling practices as well as 
veterans' access to care. It is for this reason that we are pleased 
that H.R. 2661 addresses the Government Accountability Office's four 
main recommendations from its March 14, 2013, testimony before the 
Subcommittee on Oversight and Investigations, ``VA Health Care: 
Appointment Scheduling Oversight and Wait Time Measures Need 
Improvement.'' The four recommendations were as follows:

         Improve the reliability of [VA] medical appointment 
        wait time measures.
         Ensure VA medical centers consistently implement VHA's 
        scheduling policy.
         Require VA medical centers to allocate staffing 
        resources based on scheduling needs.
         Ensure VA medical centers provide oversight of 
        telephone access and implement best practices to improve 
        telephone access for clinical care.

    Nonetheless, PVA is concerned with how to determine the best 
standardized policy for scheduling primary and specialty care 
appointments. Measuring patient access and demand is an extremely 
complex task. Despite the VA's stated goals of providing primary care 
appointments within seven days of a veterans' requested date, and 14 
days for primary care, wait times continue to exist and fall outside of 
these seven and 14 day goals, and the definition of a veterans 
``desired'' or requested appointment date varies across VA's national 
system of care.
    Legislating these goals as standardized policy for scheduling VA 
medical appointments has the potential to lead to unintended outcomes 
that could force VA into contracting for care with private providers 
too frequently. PVA urges the Subcommittee to work with VA leadership 
to make access to VA care timelier. We encourage the VA and Congress to 
determine if VA has adequate resources to develop, implement, and 
support a patient scheduling system that will address issues involving 
wait time measures, sufficient staffing levels, and patient demand.

H.R. 2974

    PVA supports H.R. 2974, a bill to amend Title 38 United States Code 
to provide for eligibility for beneficiary travel for veterans seeking 
treatment or care for MST in specialized outpatient or residential 
programs at VA facilities. For many years, PVA has advocated for 
expanding beneficiary travel eligibility to specialized groups of 
veterans, such as catastrophically disabled, and severely injured, ill, 
and wounded veterans, recognizing that the burden of costs associated 
with travel for health care services can lead to veterans forgoing much 
needed medical attention. In fact, PVA testified before the 
Subcommittee last year in support of H.R. 1284, legislation to expand 
VA beneficiary travel benefits to catastrophically disabled veterans. 
It is for these reasons PVA believes that VA should extend the 
beneficiary travel benefit to veterans seeking treatment for MST, and 
Congress must ensure that sufficient resources will be provided for the 
costs associated with expanding eligibility of the beneficiary travel 
program.
    Additionally, it is often the case that veterans who have 
experienced sexual trauma related to their military service receive 
care from specialized programs such as specialized outpatient or 
residential programs outside of their nearest VA medical center or 
their Veteran Integrated Service Networks. When this is the case, the 
veteran is not eligible for beneficiary travel because current policy 
only allows for travel reimbursement benefits from the veteran's home 
to the nearest VA facility providing the services rendered. The VA's 
policy for beneficiary travel benefits should coincide with VA MST 
policy that veterans who have experienced MST should be referred to 
treatment that is clinically indicated regardless of geographic 
location. \1\
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    \1\ ``The FY 2015 Independent Budget,'' www.independentbudget.org.

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H.R. 3508

    PVA does not have an official position on H.R. 3508, legislation 
that proposes to amend Title 38 United States Code to clarify the 
qualifications of hearing aid specialists of the Veterans Health 
Administration of the VA.

H.R. 3180

    PVA does not have an official position on H.R. 3180, legislation 
that proposes to amend Title 38 United States Code to include contracts 
and grants for residential care for veterans as an exception to the 
requirement that the federal government recover a portion of the value 
of certain projects.

H.R. 3387, the ``Classified Veterans Access to Care Act''

    PVA supports H.R. 3387, the ``Classified Veterans Access to Care 
Act,'' which proposes to improve the mental health treatment provided 
by the VA to veterans who served on a classified mission. It is PVA's 
position that all VA mental health care should meet the specific, 
individual need of the veteran seeking medical services on a consistent 
basis. The VA should also ensure that veterans seeking mental health 
services have access to care options provided in appropriate settings. 
This is particularly important for veterans who served on classified 
missions. This particular cohort of veterans should not be compromised 
by inappropriate care settings that force them to choose between their 
duty not to improperly disclose classified information and their need 
to get much needed help. If this legislation is enacted, the VA should 
make a concerted effort to inform veterans of the option to self 
identify as a ``covered'' veteran to help provide immediate mental 
health care, and alleviate any concerns regarding veterans' military 
service records not indicating that they participated on classified 
missions.

H.R. 3831, the ``Veterans Dialysis Pilot Program Review Act of 2014''

    PVA generally supports H.R. 3831, the ``Veterans Dialysis Pilot 
Program Review Act of 2014.'' If enacted this legislation would require 
VA to review the dialysis pilot program and submit a report to Congress 
before expanding the program. Gathering and analyzing data to make the 
most informed decisions is always best when such choices involve 
veterans' health care. For this reason, PVA supports the provisions of 
this bill that require independent analysis of the pilot and a VA 
report that includes cost comparisons and non-cost factors such as 
access to care and quality of care provided to veterans. PVA believes 
that the dialysis pilot should be completed and comprehensive analysis 
should be conducted to determine the best, most cost-efficient, way to 
provide veterans with timely, quality access to dialysis care.
    On October 30, 2013, the VA testified at the Senate Committee on 
Veterans Affairs' hearing on health and benefits legislation that 
requiring implementation of each of the four initial pilot sites for at 
least two years would prohibit activation of any free-standing dialysis 
centers until 2015. The VA further testified that such a restriction 
has the potential to `` . . . adversely impact VA's efforts to optimize 
Veterans' dialysis care.'' Keeping the well-being and health care needs 
of veterans first, projects involving dialysis centers that the VA is 
currently working to activate should continue to completion without 
interruption. Additionally, PVA does not support provisions of this 
bill that would prevent VA from continuing, establishing, or providing 
dialysis care for veterans within the VA or with outside providers.

H.R. 4198, the ``Appropriate Care for Disabled Veterans Act''

    PVA strongly supports H.R. 4198, a bill to amend Title 38 United 
States Code, to reinstate the requirement for an annual report on the 
capacity of the VA to provide for specialized treatment and 
rehabilitative needs of disabled veterans. Since 1996, the VA has been 
required to collect and maintain specific information and data that is 
a reflection of its capacity to provide for the specialized treatment 
and rehabilitative needs of disabled veterans. Initially, the VA was 
also required to compile this data into a report for Congress on an 
annual basis. Unfortunately, this reporting requirement expired in 
April of 2008.
    H.R. 4198 would reinstate the annual reporting requirement, 
mandating that the VA provide an annual report to Congress that 
includes information such as utilization rates, staffing, and facility 
bed censuses. Requiring the VA to compile such data into the form of a 
report to share with Congress annually will lead to more accountability 
within the VA, help ensure more efficient allocation of VA resources, 
particularly in the area of staffing, and improve veterans' access to 
care in VA's specialized systems of care. Ultimately, the VA's capacity 
to provide specialized care and rehabilitative treatment for disabled 
veterans is directly correlated to its ability to provide veterans with 
timely, quality health care services.
    Within the VA's Spinal Cord Injury and Dysfunction (SCI/D) system 
of care, access to timely care is critical to the health and well-being 
of this population of veterans. Many of the VA's specialized systems of 
care and rehabilitative programs have established policies on the 
staffing requirements and number of beds that must be available to 
maintain capacity and provide high quality care. When VA facilities do 
not adhere to these staffing policies and requirements, veterans suffer 
with prolonged wait times for medical appointments, or in the case of 
PVA members, having to limit their care to an SCI/D clinic, despite the 
need to receive more comprehensive care from an SCI/D hospital. There 
have been instances within VA's SCI/D system of care when staffing 
positions have gone vacant for long periods at a time, and as a result, 
the facility's bed capacity is decreased, decreasing veterans' access 
to care. Requiring the VA to provide Congress with an annual capacity 
report, to be audited by the VA Office of Inspector General, will allow 
VA leadership and Congress to have an accurate depiction of VA's 
ability to provide quality care and services to disabled veterans--
blinded veterans, veterans with spinal cord injury/disorder, and 
veterans who have sustained a traumatic brain injury--as it relates to 
access and bed capacity of VA specialized services and rehabilitative 
programs.
    Recognizing that not all VA specialized services and rehabilitative 
programs for disabled veterans require inpatient care, the current 
language of Title 38 United States Code, Section 1706, does not fully 
allow for accurate evaluation of VA's current capacity to provide many 
specialized and rehabilitative health care services that cannot be 
sufficiently measured using a bed census. PVA urges the Subcommittee to 
not only reinstate the reporting requirement, but also update the 
language in Title 38 to most accurately reflect the current specialized 
services within the VA, especially in the areas of VA long-term care, 
mental health care and substance use disorders.
    We thank the Subcommittee for recognizing VA's capacity to provide 
specialized services as a priority in VA health care delivery and look 
forward to working with our VSO partners and the Subcommittee to update 
this report so that it reflects useful information that will improve 
care delivery for all veterans receiving services through VA 
specialized systems of care.

Draft Legislation to Authorize Major Medical Facility Projects for the 
Department of Veterans Affairs for Fiscal Year 2014 and for Other 
Purposes

    PVA generally supports the draft legislation to authorize major 
medical facility projects for the VA for fiscal year 2014. PVA fully 
supports provisions of this bill that authorize fiscal year 2014 major 
medical facility leases. Authorization of funding for these facilities 
is critical to the VA maintaining its ability to provide health care 
services. We urge Congress to continue to work towards the most viable 
solution for dealing with the long-term costs of VA facilities given 
the Congressional Budget Office's current scoring methodology for 
facility leases.
    Of particular importance to PVA is section 4 of this legislation 
which includes amendments to modify the definition of a medical 
facility and to authorize VA to plan, design, construct, or lease joint 
VA and federal use medical facilities. PVA is aware that while there 
are not many instances where VA shares federal medical facilities, such 
arrangements do exist. However, we have concerns regarding shared 
federal medical facility projects and leases as it has the potential to 
result in situations that diminish VA's unique mission of providing 
solely for veterans' medical health care needs. Sharing medical 
facilities with federal agencies has the potential to dilute not only 
VA's mission but the quality of care delivered to veterans. This is 
particularly the case when considering shared facilities with federal 
agencies that are not accustomed to building health care services 
around patients that are veterans and military service members like VA 
and the Department of Defense.
    This concludes my statement. PVA would like to thank the 
Subcommittee for allowing us to testify on these important issues 
involving veterans' health care services from the VA. We look forward 
to working with both the Subcommittee and the VA to improve veterans' 
access to care and the quality of services provided through the VA.

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
    National Council on Disability--Contract for Services--$35,000.
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.

    Alethea Predeoux, Senior Associate Director for Health Legislation, 
PVA

    Alethea joined Paralyzed Veterans of America in 2007 and works in 
PVA's national office in Washington, DC. As a member of PVA's 
Government Relations staff, Alethea is responsible for monitoring and 
analyzing policy within the Department of Veterans Affairs (VA) to 
determine how such policies impact the health care of disabled 
veterans, particularly veterans with Spinal Cord Injury/Dysfunction 
(SCI). Alethea also covers issues involving women veterans, VA human 
resources, prosthetics, and mental health. Alethea's professional 
experience is in the area of legislative affairs and government policy.
    In addition to her policy work, Alethea also manages the production 
of The Independent Budget, a comprehensive budget and policy document 
produced by veterans for veterans.
    Alethea earned a Master's Degree in Public Policy from George Mason 
University and completed her undergraduate studies in Political Science 
at Spelman College.

                                 

                  Prepared Statement of Aleks Morosky

    Chairman Benishek, Ranking Member Brownley 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 want to thank 
you for the opportunity to present the VFW's stance on legislation 
pending before this Subcommittee. Your hard work and dedication to 
improving the quality of veterans' health care positively impacts the 
lives of all those who have served in our nation's military. The bills 
we are discussing today are aimed at continuing that progress and we 
thank the Committee for bringing them forward.

H.R. 183, Veterans Dog Training Therapy Act

    This legislation would require the Department of Veterans Affairs 
(VA) to establish a pilot program at three to five facilities to assess 
the effectiveness of treating veterans for post-traumatic stress 
disorder (PTSD) by instructing them in the art of service dog training. 
The Palo Alto VA Medical Center (VAMC) has been operating a similar 
program since 2008 in partnership with the Bergin University of Canine 
Studies, known as Paws for Purple Hearts, which resulted in positive 
feedback from veterans and staff.
    The VFW recognizes the potential value of canine therapy and would 
not be opposed to a limited pilot program for the purpose of collecting 
data to determine its effectiveness in treating veterans for PTSD. We 
do, however, have suggestions that we believe would strengthen H.R. 
183, which we hope the subcommittee would consider, should this bill be 
advanced to markup.
    VA has been directed by Executive Order to establish community 
mental health partnerships, and numerous organizations around the 
country have expertise in the field of service dog training. We believe 
that the collaboration with the Bergin University of Canine Studies has 
benefitted the Paws for Purple Hearts program, and similar 
relationships should be encouraged going forward. For this reason, we 
suggest that the bill be amended to allow VA to carry out the pilot 
program at the selected sites in partnership with existing community 
resources.
    We also believe that it may not always be appropriate to kennel 
dogs on the grounds of VA medical facilities. The VFW is concerned that 
noise, sanitation, and available space could present problems for VA 
facilities tasked with the primary mission of delivering health care to 
veterans. We recommend the bill be amended to allow VA the flexibility 
to house and train the dogs at off-site locations when necessary. With 
the above changes, the VFW would fully support this legislation.

H.R. 2527, To Amend Title 38, United States Code to Provide Veterans 
With Counseling and Treatment for Sexual Trauma That Occurred During 
Inactive Duty Training

    The VFW supports this legislation which would authorize VA to 
provide counseling and treatment to service members who experience 
military sexual trauma (MST) during inactive duty training. VA policy 
states that veterans are entitled to treatment for all physical and 
mental health conditions determined by a VA provider to be related to 
MST, without the need for service connection or other enrollment 
qualifications. Current law, however, narrowly defines MST as having 
occurred while the service member was on active duty or active duty for 
training status. This means that many veterans who experienced MST on 
inactive duty but while still in uniform, cannot receive the care they 
need.
    VA is aware of this loophole and included proposals to expand 
eligibility for MST treatment to those who experienced MST during 
inactive duty in their FY 2014 and FY 2015 budget requests. The VFW 
agrees that members of the Reserve Component who experience sexual 
trauma during weekend drills or other inactive duty should be entitled 
to the same MST-related services as those who experience sexual trauma 
while activated, and we encourage the subcommittee to move quickly on 
this critical legislation.

H.R. 2661, Veterans Access to Timely Medical Appointments Act

    This legislation would codify the 2012 VA goal of completing all 
primary care appointments within seven days of the desired date and all 
specialty care appointments within fourteen days of the desired date. 
Additionally, it would require VA to comply with several 
recommendations of a March 2012 Government Accountability Office (GAO) 
report including: eliminating scheduler error, providing reliable 
appointment wait time data, standardizing the scheduling policy across 
all Veterans Integrated Service Networks (VISNs) and VAMCs, restricting 
the scheduling system to those who have been properly trained, 
improving veterans' phone access, and routine assessments. Although the 
VFW strongly supports the recommendations of GAO and the intent of this 
legislation to reduce appointment wait times for veterans, we do not 
support a statutory mandate of VA's appointment wait time goals at this 
time.
    In the past, VA has tried to enforce scheduling policies and wait 
time standards without proper training of staff and using flawed 
tracking programs. GAO found that this often led to data manipulation 
by staff in an effort to falsely create the appearance of short wait 
times. We are concerned that codifying the VA wait time goals would 
apply so much pressure that it would encourage further data 
manipulation in order to comply with the law. Transparency and honest 
self-assessment will be necessary to truly reduce the wait times 
experienced by veterans.
    Complicating the well-known deficiencies in VA appointment 
scheduling is the fact that VA is still in the process of establishing 
productivity standards to determine appropriate physician staffing 
levels at its facilities. Simply put, it is impossible to achieve the 
greatest level of access if too few providers are available to meet the 
demand for care. Accurate appointment scheduling and proper physician 
staffing must both be achieved in order to solve the problem of long 
appointment wait times.
    The VFW is also concerned that this legislation would force VA to 
over-utilize purchased care in order to meet its mandates. VA's new 
purchased care model, Patient-Centered Community Care (PC3), is still 
being implemented. Its effectiveness is still unknown, and it may not 
be the best option for many veterans. The VFW wants to see PC3 succeed, 
but as a secondary option to direct care, as it was intended, not as 
VA's only option to comply with the law. Suddenly sending large numbers 
of veterans out of VA for care would not solve the appointment wait 
time problem at VA facilities, only camouflaging it.
    VA should be given the opportunity to implement its plans for 
appointment scheduling, physician staffing, and purchased care before 
its self-imposed wait time goals are written into law. Furthermore, VA 
should not be discouraged from setting ambitious goals in the future 
out of fear that their announcement will be quickly followed by 
statutory mandates. In order to solve the problem of long appointment 
wait times, the VFW urges continued congressional oversight to ensure 
that VA complies with GAO and VA Office of the Inspector General (OIG) 
recommendations.

H.R. 2794, To Amend Title 38, United States Code to Provide for the 
Eligibility for Beneficiary Travel for Veterans Seeking Treatment or 
Care for Military Sexual Trauma in Specialized Outpatient or 
Residential Programs at Facilities of the Department of Veterans 
Affairs, and for Other Purposes

    The VFW supports this legislation which would extend beneficiary 
travel benefits to veterans seeking care at VA facilities for 
conditions associated with MST. VA currently provides care for all 
physical and mental health conditions determined by a VA provider to be 
related to MST, without the need for service connection. This care is 
provided with no copay charges and without any income eligibility 
requirements. Qualifying veterans are eligible for residential 
rehabilitation treatment programs, and facilities that do not have 
those programs have been directed to refer veterans to those that do in 
order to guarantee access. This means that some veterans have to travel 
significant distances to receive MST care.
    VA travel benefits are currently available to veterans who have a 
service-connected (SC) rating of 30 percent or more, are traveling for 
treatment of a SC condition, are eligible for pension, or are traveling 
for a scheduled compensation and pension examination. Not all veterans 
eligible for MST care are included in one of those categories. As a 
result, many MST victims may have to forgo the care they need and 
deserve, simply because they cannot afford the costs of traveling to 
facilities that are able to provide that care.
    OIG identified this as a problem in a December 2012 report, stating 
that VHA beneficiary travel policies are not properly aligned with MST 
policy. They recommended that the travel policy be reviewed. As of now 
the travel policy has not changed. This legislation would fix the 
problem by adding veterans who are receiving MST treatment to the list 
of eligible travel beneficiaries.

H.R. 3508, To Amend Title 38, United States Code, to Clarify the 
Qualifications of Hearing Aid Specialists of the Veterans Health 
Administration of the Department of Veterans Affairs, and for Other 
Purposes

    This legislation would authorize VA to hire hearing aid specialists 
as full time employees at department facilities to provide hearing 
health services alongside audiologists and hearing health technicians. 
Hearing aid specialists would assume the responsibilities of performing 
in-house repairs, currently performed by technicians, and fitting and 
dispensing hearing aids, currently performed by audiologists. Although 
we appreciate this bill's intent to increase hearing health access and 
reduce wait times for hearing aids and repairs, the VFW believes that 
VA has the ability to address these issues under its current hiring 
authority.
    The VFW strongly believes that VA must improve timeliness in 
issuing and repairing hearing aids. A February 20, 2014 OIG report 
revealed that 30 percent of veterans are waiting longer than 30 days to 
receive new hearing aids, and repairs take an average of 17 to 24 days 
to complete, far exceeding the VA 5-day timeliness goal for those 
services. According to the report, the long wait times can be 
attributed to a steadily increasing work load, which will likely 
continue to increase as the veteran population grows older. This 
problem is compounded by the fact that many audiology clinics are not 
fully staffed. Additionally, OIG found that the Denver Acquisition and 
Logistics Center (DALC), which performs major hearing aid repairs for 
VAMCs nationwide, lacks an adequate tracking system for the devices it 
receives.
    To address these problems, OIG recommended that VA develop and 
implement productivity standards to determine proper staffing levels in 
audiology clinics and establish tracking controls for the hearing aids 
received by the DALC. VA concurred with these recommendations and will 
include audiology in its implementation plan for productivity 
standards. In our opinion, this is the correct course of action. The 
VFW believes that adding a new class of provider whose scope of 
practice overlaps that of existing employees does not get to the root 
of the problem. To fully address the issue, VA must determine the 
proper staffing levels of audiologists and hearing health technicians 
necessary to meet timeliness standards and increase the number of those 
employees accordingly.

H.R. 3180, To Amend Title 38, United States Code, to Include Contracts 
and Grants for Residential Care for Veterans in the Exception to the 
Requirement That the Federal Government Recover a Portion of the Value 
of Certain Projects

    The VFW supports this legislation which would allow state veterans 
homes that receive residential care contracts or grants from VA to also 
contract with VA under the Health Care for Homeless Veterans (HCHV) 
supported housing program. Since state veterans homes receive VA 
funding for other programs, the recapture clause of section 8136 of 
Title 38 prohibits them from receiving HCHV funds. Only those state 
veterans homes that also run outpatient VA clinics are currently 
exempted from the recapture clause. This means that many state veterans 
homes with empty beds are unable to offer them to homeless veterans in 
their communities. Similarly exempting them from the recapture clause 
would solve this problem.
    The Secretary's ambitious five-year plan to end homelessness among 
veterans includes six strategic pillars. The sixth pillar is community 
partnerships, which certainly must include state veterans homes. The 
VFW strongly supports the Secretary's five-year plan and believes that 
state veterans homes should be utilized to the fullest extent possible 
to ensure its success. As long as there are homeless veterans who need 
them, beds in state veterans homes should not remain empty simply due 
to the unintended consequences of a federal regulation.

H.R. 3387, Classified Veterans Access to Care Act

    The VFW supports this legislation which would require VA to develop 
standards and disseminate guidance to ensure that veterans who 
participated in sensitive missions or were assigned to sensitive units 
are able to access mental health services in a way that does not 
require them to improperly disclose classified information.
    We are aware that this legislation was inspired by the case of 
Daniel Somers, a veteran of sensitive missions in Iraq, who felt that 
he was unable to participate in the group therapy sessions offered to 
him at the Phoenix VAMC, believing that he would be required to share 
classified information with other group members. Tragically, Daniel 
Somers took his own life last year. The VFW has been in contact with 
his parents, who strongly believe that had their son been offered 
individual therapy from the beginning due to the nature of his service, 
his suicide may have been prevented. The VFW believes that requiring VA 
to develop standards for those who served on sensitive missions is 
reasonable and would ensure that veterans feel that they can access the 
services they need without violating any nondisclosure responsibilities 
they may have.

H.R. 3831, Veterans Dialysis Pilot Program Review Act of 2014

    The VFW supports this legislation which would prohibit VA from 
expanding the dialysis pilot program until the program has operated at 
each initial facility for at least two years, an independent analysis 
has been conducted at each facility, and a report is submitted to 
Congress.
    A May 2012 GAO report found that VA was planning to expand the 
pilot, despite not having developed adequate performance measures to 
evaluate the existing locations. While the GAO report focused primarily 
on cost, the VFW is pleased that the report required by this 
legislation would also examine non-cost factors such as access, quality 
of care, and veteran satisfaction.
    The purpose of any pilot program should be to assess its strengths 
and weaknesses on a small scale in order to decide whether or not it 
should be expanded. If and when it is instituted on a large scale, it 
should be done based on a detailed analysis and lessons learned from 
the pilot. Therefore, we believe it is both reasonable and prudent to 
require VA to submit a detailed report on the dialysis pilot program 
before it is allowed to expand.

H.R. 4198, Appropriate Care for Disabled Veterans Act

    The VFW supports this legislation which would reinstate the 
requirement for VA to submit an annual report to Congress on its 
capacity to provide for the specialized treatment and rehabilitative 
needs of disabled veterans. This requirement expired in 2008 and since 
that time, it has become apparent that the capacity of VA specialty 
care has been inadequate to meet veteran demand. The VFW believes that 
current accurate data on VA capacity will greatly assist Congress in 
conducting oversight on veterans' access to care.
    Since the report was first mandated in 1996, many changes have been 
made in the way VA provides specialty care. We look forward to working 
with the subcommittee and our Independent Budget Veterans Service 
Organization (IBVSO) partners to identify any necessary updates to the 
original reporting requirements to ensure future reports are relevant 
and actionable.

Draft Bill, To Authorize Major Medical Facility Projects for the 
Department of Veterans Affairs for Fiscal Year 2014

    This legislation provides VA the authority to enter into 27 major 
facility leases, allows VA to construct or lease joint VA/Federal use 
medical facilities, expands VA's Enhanced-Use Lease (EUL) authority, 
and modifies the authority to build a major medical facility project in 
Tampa, Florida.
    Sections 1, 2 and 3 provide authorization for VA major facility 
leases. It is critical that VA is provided the authority to enter into 
the 27 major medical leases. Many of these leases have been awaiting 
authorization for nearly two years. Most of these facilities are 
Community-Based Outpatient Clinics (CBOC) that have provided direct 
medical care in the communities where veterans live. However, since the 
current leases have expired and there is a need to expand capacity or 
change the physical location of the CBOCs to better serve the needs of 
veterans, VA must enter into new leases.
    Congress had failed to authorize these leases because of the 
Congressional Budget Office's revised scoring model, which now requires 
VA to account for the full lease amount in the first year of the lease. 
Congress must find a workable solution to allow VA to continue its 
major capital leasing projects. Failing to pass this authorization into 
law will create greater access and timeliness issues for veterans and 
in the end cost VA more as they begin reimbursing veterans for travel 
to distant medical centers or pay for fee-based care in the community. 
The VFW fully supports these provisions and their quick passage.
    Section 4 amends VA's current medical facility construction and 
leasing authority to allow VA to enter into joint acquisitions and 
leases with other Federal agencies. Currently, when VA sees the value 
in co-locating a medical or research facility with another agency, 
either VA or the other agency must already own the property and grant 
the other agency a portion of the property through an acquisition by 
exchange. By amending the current authority, VA will be able to reduce 
construction and/or lease costs by acquiring, planning and building 
facilities jointly. The VFW sees the value in this authority and we 
fully support this provision.
    Section 5 amends VA's authority to enter into EULs. In 2012, VA was 
forced to modify its EUL authority, greatly reducing its ability to 
lease out its unused or underutilized properties. This authority will 
greatly widen VA's lease options, thereby producing revenue and 
reducing the number of unused or underutilized properties in VA's 
inventory. The VFW understands that when VA property is unused or 
underutilized, VA still incurs significant costs to maintain it, 
ultimately squandering resources that could be better used serving 
veterans. This is why the VFW supports the idea of expanding VA's 
leasing authority, but we must also point out that VA must make every 
effort to lease these unused or underutilized properties for projects 
that directly support veterans and their families before considering 
other leasing projects.
    Sections 6 and 7 authorize modification and the appropriations for 
the major medical project in Tampa, Florida. VA has requested that a 
previously authorized upgrade to the medical facility bed tower be 
reauthorized as a new bed tower at the Tampa, Florida medical center. 
The VFW supports this modification.
    Mr. Chairman, this concludes my testimony and I look forward to any 
questions you and the members of this Subcommittee may have.

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, 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 Madhulika Agarwal, M.D., M.P.H.

    Good Morning Chairman Benishek, Ranking Member Brownley, and 
Members of the Subcommittee. Thank you for inviting me here today to 
present our views on ten bills that would affect Department of Veterans 
Affairs (VA) health programs and services. Joining me today is Mr. 
Philip Matkovsky, Assistant Deputy Under Secretary for Health for 
Operations and Management and Ms. Reneee L. Szybala, Acting Assistant 
General Counsel.
    We do not yet have cleared views on H.R. 3387, H.R. 4198, and H.R. 
2974. Also, we do not yet have estimated costs associated with 
implementing several of the bills. We will forward these views and any 
estimated costs to you as soon as they are available.

H.R. 183, Veterans Dog Training Therapy Act

    H.R. 183 would require the Secretary, within 120 days of enactment, 
to commence a pilot program for a 5-year period to assess the 
effectiveness of using service dog training programs to address post-
deployment mental health and post-traumatic stress disorder (PTSD) 
symptoms and produce specially-trained service dogs for Veterans. The 
bill would require the Secretary to conduct the pilot program at a 
minimum of three and not more than five VA medical centers.
    The bill also includes provisions concerning the service dogs 
themselves and the personnel assigned to the program. The bill requires 
VA to ensure that each service dog in training have adequate 
temperament and health clearances. Dogs in animal shelters or foster 
homes are not to be overlooked as candidates. The Secretary must also 
ensure that each service dog in training is taught all essential 
commands and behaviors required of service dogs. The bill would require 
each pilot program site to have certified service dog training 
instructors with preference given to Veterans who have graduated from a 
residential treatment program and are adequately certified in service 
dog training.
    VA supports the identification of effective treatment modalities to 
address PTSD and other post-deployment mental health symptoms; however, 
VA does not support the specific provisions in H.R. 183 because the 
bill focuses on the training of the dog as opposed to what we believe 
is the goal of this legislation, which is finding better ways to 
improve the health of this Veteran population by exploring the efficacy 
and effectiveness of certain treatments, specifically Animal Assisted 
Therapy or Animal Facilitated Therapy, that will prepare dogs to become 
service dogs for Veterans.
    The restrictions that would be imposed by H.R. 183 regarding the 
criteria for the selection of dogs and the qualifications required of 
the trainers pose significant challenges to the goal of this 
legislation. Provisions requiring medical centers to ensure appropriate 
areas for the ``art and science'' of service dog training are focused 
on ensuring the quality of the rigorous training regimen required to 
produce well-trained service dogs as opposed to the therapeutic 
activities that Animal Assisted Therapy or Animal Facilitated Therapy 
may provide if appropriately administered as a component of a 
comprehensive mental health treatment program. This specialized and 
rigorous training regimen for the service dogs falls outside the 
purview and mission of VA health care and well beyond the scope of 
corporate expertise. These same concerns are extended to provisions 
related to the design of the pilot, such as the acceptance of animals 
from shelters, educating participants about service dog training 
methodologies, practical hands-on training and grooming of service 
dogs, ensuring mastery of all essential commands, and residency 
requirements for dogs.
    The VA Palo Alto Health Care System (Menlo Park Division), in 
collaboration with Bergin University of Canine Studies, established the 
Palo Alto Service Dog Training Program in July 2008. The Palo Alto 
program is not an example of VA independently and internally training 
or producing service dogs for Veterans. The dogs involved in the Palo 
Alto program were trained to become service dogs by an external 
organization, accredited by Assistance Dogs International, over an 
extended period of time and subject to standards as adopted and applied 
by that organization. The Palo Alto program, using VA facilities for 
the therapy portion but relying completely on the external 
organization's dog training program, focuses on basic obedience (e.g., 
commands such as ``sit,'' ``stay,'' and ``heel'') and public access 
skills (sensitizing dogs to different environments) to prepare the dogs 
to become service dogs for disabled persons because VA does not have 
the expertise, experience, or resources to develop independent training 
criteria or otherwise train or produce safe, high-quality service dogs 
for Veterans. Such training is highly specialized and includes the 
training of the Veteran who is to receive the service dog.
    Cost estimates for this bill were not available at the time of the 
hearing.

H.R. 2527, To Provide Veterans With Counseling and Treatment for Sexual 
Trauma That Occurred During Inactive Duty Training

    H.R. 2527 would amend 38 United States Code (U.S.C.) 1720D to 
extend VA's counseling and care benefits for treatment of sexual trauma 
to Veterans who experienced sexual trauma while serving on inactive 
duty for training. Current authority covers only sexual trauma that a 
Veteran experienced while serving on active duty or active duty for 
training.
    H.R. 2527 would also define the term ``Veteran,'' with respect to 
inactive duty training described in section 1720D(a)(1), as amended by 
the bill, to include an individual who is not eligible for VA health 
care benefits (under 38 U.S.C. chapter 17), and who, while serving in 
the reserve components of the Armed Forces, performed such inactive 
duty training but did not serve on active duty.
    VA supports this bill as it would close a gap in eligibility for 
military sexual trauma-related counseling and care. The current gap in 
eligibility arises when sexual trauma occurs during weekend drill 
trainings for members of the National Guard or Reserves. Weekend drill 
trainings are inactive duty training. Unless a Veteran who experienced 
sexual trauma while serving on inactive duty for training is eligible 
to enroll in VA's health care system and receive needed care under VA's 
medical benefits package, VA lacks current authority to treat the 
Veteran for conditions resulting from that trauma.
    VA anticipates this bill will require minimal additional funding.

H.R. 2661, The Veterans Access to Timely Medical Appointments Act

    H.R. 2661 would require the Secretary, not later than 180 days 
after enactment, to implement a standardized policy to ensure that 
enrolled Veterans are able to schedule primary care appointments within 
7 days, and specialty care appointments within 14 days, of the date 
such appointment is requested by the Veteran or the Veteran's provider. 
In addition, the Secretary would be required to ensure the policy is 
not subject to interpretation or prone to scheduling errors and is able 
to provide the Secretary with reliable data regarding the length of 
time Veterans wait for appointments. The bill would also require VHA, 
in carrying out the policy, to use uniform procedures and to issue 
detailed guidance to Directors of Veterans Integrated Service Networks 
(VISN) to ensure consistent implementation at each VA medical center 
(VAMC) and other related VA facilities. The Secretary would be required 
to ensure that only VA employees, who have completed required training, 
are allowed to schedule medical appointments and that annual 
performance reports of each VISN's performance under the policy are 
made public.
    H.R. 2661 would also require the Secretary, not later than 180 days 
after enactment and each 180-day period thereafter, to assess the 
resources of each VISN to determine the ability of the VISN to meet its 
scheduling requirements. To ensure that each VISN meets the scheduling 
requirements of its enrollees, the Secretary would be authorized to 
reprogram funds and to allocate or transfer staff and other resources 
within VHA and the VISN; however, Congress would need to be notified of 
any such reprogramming.
    The bill would further require the Secretary to direct each VAMC to 
provide oversight of telephone access and to implement the best 
practices outlined in VHA's Telephone Improvement Guide including, at a 
minimum, practices to ensure calls are answered in a timely manner and 
that patients' messages are returned with a call within 24 hours. Each 
VAMC's call center would also need to be properly staffed to meet the 
demands of its patient-population.
    Finally, H.R. 2661 would require VA's Office of Inspector General, 
in consultation with Veterans Service Organizations, to submit a 
detailed annual report to Congress on VA's progress in implementing the 
requirements of the bill.
    VA does not support H.R. 2661. VA continues to make progress in the 
reliability of measuring and reporting waiting times. This process is 
heavily dependent on the software, technology and business processes 
available at the time. Mandating the timeframe within which a patient 
must receive an appointment is ill-advised because the process of 
scheduling is multi-factorial, and flexibility is required to ensure 
that scheduling occurs in a manner that is in line with clinical 
operating standards, which can evolve over time. This also extends to 
clinical contacts made by telephone. We also are uncertain of the basis 
for the inflexible timetables that would be mandated by H.R. 2661. We 
would be interested in discussing this issue with the Committee, 
including the need for flexibility while ensuring Veterans receive 
access to high-quality health care.
    VA believes the telephone-related elements of the bill state 
valuable principles but could conflict with our ongoing efforts. The 
practices outlined in the Telephone Improvement Guide are currently 
being tested at both the VISN and facility level. In addition, three 
VISNs are investigating the use of specific communication models to 
assess the most effective approach by which to provide Veterans with 
responsive, available telephone service. It may be that these models 
will prove more efficient and preferable to what is used now or even to 
what would be required by H.R. 2661. Similar to scheduling procedures 
and other clinical operational matters, we believe codifying in law the 
details of how VA communicates with our patients is ill-advised. Once 
in statute, such terms could well end up preventing VA from identifying 
and using newer and more effective mechanisms and procedures that 
better align with clinical operational and clinical practice standards.
    VA is unable to estimate the cost of this bill.

H.R. 2974, To Provide Beneficiary Travel Eligibility for Veterans 
Seeking Treatment or Care for Military Sexual Trauma

    H.R. 2974 would amend 38 U.S.C. 111(b)(1) to ensure beneficiary 
travel eligibility for Veterans whose travel to a specialized 
outpatient or residential program at a VA facility for treatment or 
care for military sexual trauma. The bill would define the term 
``military sexual trauma'' in 38 U.S.C. 111 to mean ``psychological 
trauma, which in the judgment of a Department mental health 
professional, resulted from a physical assault of a sexual nature, 
battery of a sexual nature, or sexual harassment which occurred while 
the Veteran was serving on active duty or active duty for training;'' 
and the bill would define the term ``sexual harassment'' to mean 
``repeated, unsolicited verbal or physical contact of a sexual nature 
which is threatening in character.'' The amendments made by this 
legislation would apply with respect to travel occurring after 
enactment.
    VA is currently reviewing this bill and will provide a position 
upon completion of this review. As a technical matter, we note that the 
bill purports to add a new subsection (g) to section 111 of Title 38 
U.S.C. We believe the drafters intended to add a new subsection (h) to 
section 111 instead, as the bill makes no mention of striking the 
current subsection (g) in section 111.
    Cost estimates for this bill were not available at the time of the 
hearing.

H.R. 3180, To Provide an Exception to the Requirement That the Federal 
Government Recover a Portion of the Value of Certain Projects

    H.R. 3180 would authorize VA to contract with, or award a grant to, 
a state for residential care for Veterans in a state home without 
triggering the recapture of the state home construction grants 
previously awarded to the state for that home. The term ``residential 
care'' is not defined in Title 38 U.S.C. For purposes of the community 
residential care program, the term ``community residential care'' is 
defined in 38 CFR Sec.  17.62 to mean ``the monitoring, supervision, 
and assistance, in accordance with a statement of needed care, of the 
daily living activities of referred Veterans in an approved home in the 
community by the facility's provider.'' However, VA cannot provide 
grants or contracts for such care under that program. See 38 U.S.C. 
Sec.  1730(b)(3). Nevertheless, under another authority, 38 U.S.C. 
Sec.  1720(g), VA may contract with appropriate entities to provide 
specialized residential care and rehabilitation services to an 
Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) 
Veteran, who VA determines suffers from a traumatic brain injury, has 
an accumulation of deficits in activities of daily living and 
instrumental activities of daily living, and because of these deficits, 
would otherwise require admission to a nursing home even though such 
care would generally exceed the Veteran's nursing needs. If H.R. 3180 
is enacted, VA could contract with states to provide residential care 
in a state home under section 1720(g) without triggering the recapture 
of a grant.
    VA does not support enactment of this bill because it would 
authorize VA to contract with state homes without triggering the 
recapture of the state home construction grants previously awarded to 
the state for that home for care for which they currently receive VA 
per diem payments under the VA State Home Grant Program. State Veterans 
homes can provide any combination of three levels of care: nursing 
home, domiciliary, and adult day health care without being subject to 
the recapture of any VA construction grant. Domiciliary care is 
essentially specialized residential care that VA may contract for under 
38 U.S.C. Sec.  1720(g). State Veterans homes that provide domiciliary 
care should thus be capable of providing specialized residential care 
and rehabilitation services for OEF/OIF Veterans who suffer from a 
traumatic brain injury.
    There are no current requests from states for state Veterans homes 
to provide residential care under VA contract or grant. Thus, VA cannot 
predict future costs that would be associated with this bill.

H.R. 3508, To Clarify the Qualifications of VA Hearing Aid Specialists

    H.R. 3508 would amend 38 U.S.C. 7401(3) to include hearing aid 
specialists among personnel who may be appointed by VA as the Secretary 
may find necessary for the health care of Veterans. The bill would also 
amend 38 U.S.C. 7402(b) to specify qualifications for hearing aid 
specialists, including requiring the individual ``hold an associate's 
degree in hearing instrument sciences, or its equivalent, from a 
college or university approved by the Secretary, or have successfully 
completed a hearing aid specialist apprenticeship program approved by 
the Secretary,'' and ``be licensed as a hearing aid specialist, or its 
equivalent, in a State.'' Hearing aid specialists who do not meet these 
requirements would still be eligible for appointment to a hearing aid 
specialist position if, during the 2 years prior to enactment of the 
bill, the individual ``held an unrevoked, unsuspended hearing aid 
license, or its equivalent, in a State,'' and ``worked as a licensed 
hearing aid specialist in a State.''
    In addition, H.R. 3508 would require VA, no later than 1 year after 
enactment and each year thereafter, to report to Congress on timely 
access to hearing health services and contracting policies with respect 
to providing hearing health services in non-VA facilities. VA would be 
required to include in the report VHA staffing levels of audiologists, 
health technicians in audiology, and hearing aid specialists; a 
description of performance measures with respect to appointments and 
care related to hearing health; average wait times for specified 
appointments; percentages of patients whose wait times fell within 
specified time frames; the number of patients referred to non-VA 
audiologists for initial hearing health diagnosis appointments and to 
non-VA hearing aid specialists for follow-up hearing health care; and 
VHA policies regarding referral to non-VA hearing aid specialists and 
how such policies will be applied under the Patient-Centered Community 
Care initiative.
    Finally, H.R. 3508 would require VA, no later than 180 days after 
enactment, to update and reissue VHA Handbook 1170.02, VHA Audiology 
and Speech-Language Pathology Services, to reflect the requirements of 
this bill.
    VA values the current contribution being made by hearing aid or 
instrument specialists to hearing loss treatment and evaluation 
services, however, VA does not believe this bill is necessary as the 
Secretary already has existing authority under 38 U.S.C. Sec.  7401(3) 
to appoint such specialists if deemed necessary to support the 
recruitment and retention needs of the Department. In addition, the 
Secretary already has authority under 38 U.S.C. Sec.  7402(b) to 
establish qualification standards for health care occupations, 
including establishing technical qualifications for hearing aid 
specialists. VA believes this bill's language unduly restricts the 
Secretary's latitude to establish qualification standards under this 
authority, and that existing procedures for establishing qualifications 
standards under title 5 series 640 or hybrid Title 38 are sufficient.
    Also, VA is concerned that the lack of standardized educational or 
professional health licensure requirements could fragment hearing 
health care services and limit delivery of comprehensive hearing health 
care under the language in H.R. 3508.
    A highly trained workforce is required to deliver comprehensive 
services and coordinate care in the VA health care system, given VA's 
mission to provide comprehensive patient-centered health care. 
Utilizing occupations that are limited in training and scope for 
comprehensive hearing health services under the proposed legislation 
would fragment the current high-quality health care delivery system, 
especially because Veterans frequently exhibit hearing loss in 
combination with other co-morbidities.
    VA audiologists are doctoral-level professionals trained to 
diagnose and treat hearing loss, acoustic trauma and ear injuries, 
tinnitus, auditory processing disorders, and patients with vestibular 
complaints. VA provides comprehensive hearing health care services and 
employs both audiologists and audiology health care technicians who 
deliver care coordinated within the Patient Aligned Care Team (PACT). 
VA can appoint hearing aid specialists as audiology health technicians 
in job series 640 (health technicians) under title 5. VA currently 
employs 318 audiology health technicians (also commonly known as 
audiology assistants) who function under the supervision of 
audiologists. Some of these audiology health technicians are licensed 
as hearing aid specialists, although they are hired as health 
technicians whether or not they are licensed as hearing aid 
specialists.
    Audiology health technicians, currently employed in audiology 
clinics as valued members of the audiology team and working under the 
direction of audiologists, have a broader scope of practice than the 
typical hearing aid specialist. VA developed this job series and 
associated core competencies for health technicians to provide 
efficient support services and assist audiologists in the provision of 
comprehensive hearing care. Examples of the scope of services include 
cerumen management, aural rehabilitation, hearing conservation and 
prevention of noise-induced hearing loss, tinnitus management, hearing 
aids and other amplification technologies including implantable 
auditory devices, and management of Veterans' hearing health care with 
other health care disciplines in the context of their overarching 
patient-centered needs.
    The VA audiology health technician has duties and responsibilities 
beyond those allowed by state law for hearing aid specialists. The 
hearing instrument specialist occupation has no consistent professional 
education requirements and no standardized internships resulting in 
highly-variable skill sets. In 33 states, only a high school education 
is required for hearing instrument specialist licensure. Nine states 
have no educational requirement and eight states require an associate's 
degree. As a result, based on hybrid Title 38 grade-related education 
requirements, hearing instrument specialists are likely to be hired at 
low grades making less money working for VA than they would earn 
working in the retail business community where they are licensed to 
sell hearing aids. Hearing instrument specialists are licensed to sell 
hearing aids and are regulated primarily for their hearing aid sales 
roles. The license does not require professional education, clinical 
training, or experiential health care apprenticeships, and the 
licensure qualifications have not changed in many years. They are not 
part of any health care teams in the military, the academic or medical/
professional school environment, or the hospital environment. 
Substituting the VA audiology health technician with a hearing 
instrument specialist would fragment hearing health care services and 
limit delivery of comprehensive hearing health care.
    Finally, with respect to the treatment of ``certain current 
specialists'' in section 1(b) of the bill, we note that VHA does not 
appoint hearing aid specialists, and none are actively practicing in 
VHA as hearing aid specialists. Some audiology assistants (health 
technicians) are licensed as hearing aid specialists and may use these 
skills in performing their duties, but they were hired as health 
technicians and function under the scope of practice defined in their 
position description.
    Cost estimates for this bill were not available at the time of the 
hearing.

H.R. 3831, The Veterans Dialysis Pilot Program Review Act

    If enacted, H.R. 3831 would prohibit VA from expanding VA's 
dialysis pilot program or creating any new dialysis capability provided 
by VA in any facility other than the four participating free-standing 
dialysis facilities until three requirements have been met: VA has 
implemented the pilot program at each facility for at least 2 years; VA 
has provided for an independent analysis of the pilot program at each 
facility; and VA has submitted a report to Congress. The required 
report must include the results of the independent analysis and a 
comparison of both cost and non-cost factors (such as access to care, 
quality of care, and Veteran satisfaction) concerning the dialysis 
pilot program, and must address any recommendations from the Government 
Accountability Office with respect to the pilot. The bill would also 
require the Secretary to fully utilize VA dialysis resources in 
existence at the time this bill is enacted, including utilization of 
any community dialysis provider with whom the Secretary has entered 
into a contract or agreement for the provision of such care.
    VA fully supports using the results of our ongoing dialysis pilot 
program to inform the expansion of dialysis care by VA. However, VA is 
concerned that enactment of this bill in its current form would delay 
activating additional VA free-standing dialysis centers, which could 
adversely impact VA's efforts to optimize Veterans' dialysis care. This 
bill would have the effect of preventing VA from creating any new 
dialysis capacity until July 2015 because one of the pilot facilities 
(Cleveland, Ohio) did not activate until July 2013. Delaying expansion 
would also adversely impact VA's ability to realize potential cost 
savings associated with free-standing dialysis centers.
    VA has already developed an evaluation plan to assess performance 
of each pilot. Additionally, VA has contracted with the University of 
Michigan-Kidney Epidemiology and Cost Center (UM-KECC) to conduct an 
independent analysis of the pilot facilities. In fiscal year 2013, UM-
KECC produced five clinical quality and four cost reports analyzing the 
performance of the Raleigh and Fayetteville, North Carolina pilots. UM-
KECC will be producing these reports for all four pilot sites in fiscal 
year 2014.
    VA is ready to work with the Committee to ensure the Committee is 
briefed on the results of the pilot program before establishing any new 
free-standing dialysis centers.
    Cost estimates for this bill were not available at the time of the 
hearing.

Draft Bill To Authorize Major Medical Facility Projects for the 
Department of Veterans Affairs for Fiscal Year 2014 and for Other 
Purposes

    The draft bill represents the Administration's request for its 
fiscal year 2014 construction program and includes other measures 
useful for VA. It authorizes numerous individual medical leases 
proposed by VA, including those proposed in its fiscal year 2013 
budget, and includes provisions aimed at facilitating more streamlined 
planning, construction, and leasing for joint VA/Federal-use medical 
facilities. The bill would also enhance VA's Enhanced-Use Lease 
authority and authorize major construction funds for VHA facilities in 
Tampa, Florida. Mr. Chairman, we appreciate your inclusion of this 
Administration request on the agenda today.

Conclusion

    Mr. Chairman, this concludes my statement. Thank you for the 
opportunity to appear before you today. I am ready to respond to 
questions you or the other Members of the Subcommittee may have.

                                 

                             FOR THE RECORD

    House Committee on Veterans' Affairs, Subcommittee on Health
    Hearing on Pending Health Care Legislation
    March 27, 2014
    Rep. Kevin McCarthy
    Chairman Benishek, Ranking Member Brownley and Members of the 
Subcommittee
    Thank you for allowing me to testify on legislation I introduced, 
H.R. 2661, the Veterans Access to Timely Medical Appointments Act. This 
bill is based on the Government Accountability Office (GAO) audit on 
the Veterans Health Administration's (VHA) scheduling of timely medical 
appointments, as well as a Veterans Affairs Oversight and Investigation 
Subcommittee hearing on the audit's findings. After disappointing 
responses from leadership at the Department of Veterans Affairs (VA), I 
decided to take legislative action to implement the GAO's 
recommendations to improve the wait times our veterans face to receive 
care.
    Chairman Miller and I led 28 other members in requesting the GAO to 
conduct this audit on the VHA regarding its scheduling of medical 
appointments because I was receiving numerous complaints from veterans 
in my district who were waiting months for crucial medical appointments 
at either the local VA clinic in Bakersfield or at the VA Medical 
Center in Los Angeles. This audit was released over a year ago and to 
this day, the complaints of poor service from the VA to schedule timely 
medical appointments is still one of the most frequent by veterans in 
my district. I would also note that according to the GAO's website, 
none of its recommendations have yet to be implemented by the VA.
    H.R. 2661 would legislatively implement the GAO's recommendations 
and aid the VA in developing a better scheduling policy so veterans can 
have timely access to needed care. Specifically, it addresses the GAO-
identified factors contributing to unreliability of appointment wait 
times by mandating the VA to improve their 
medical appointment scheduling policy within 180 days of the bill's 
enactment. The bill requires the VA to schedule primary care 
appointments within seven days and specialty care appointments within 
fourteen days--goals used internally by VA supervisors and identified 
within the GAO report. It also addresses the allocation of scheduling 
resources to meet the demands of veterans, and to ensure timely medical 
appointments by improving the VA's telephone access and responsiveness. 
GAO found that the VA's positive wait time reports are far greater than 
veterans actually experience. This is due to a number of reasons, 
including unreliable data input by VA employees, the VA not requiring 
stricter adherence to scheduling policy, and a lack of over sight on 
the scheduling process as a whole.
    The VA's 2015 Budget request does not sufficiently address the wait 
times new veterans face when scheduling medical appointments and 
receiving care. It only marginally decrease times and provides no 
accountability measures. We have tens of thousands of new veterans who 
served in Iraq and Afghanistan who can't get appointments in a timely 
fashion. The VA's recent Performance Accountability Report says that 
41% of new primary care appointments are scheduled within 14 days of 
the creation date, and 40% of new specialty care appointments are 
within 14 days of the creation date. This means that over 60% of these 
veterans aren't getting appointments within two weeks. It concerns me 
that the budget submission only marginally increases scheduling goals 
to 51% and 45% respectively, and reveals a lack of urgency within the 
VA to ensure funding reduces wait times. Why should veterans and 
Congress tolerate such low targets?
    There have also been recent news stories on a supposed 
whistleblower who alleges that the VA's Greater Los Angeles Medical 
Center, which serves the health care needs of my constituents, 
``administratively closed'' about 40,000 appointments in order to 
reduce the medical appointment backlog to make its numbers look better. 
According to Dr. Petzel--who spoke briefly about this issue during a 
Subcommittee on Health Oversight Hearing last month--no patients were 
denied care and there was no attempt to destroy records in this 
instance. With an ongoing investigation, I was surprised by this 
testimony. That is why Chairman Benishek and I requested an independent 
investigation of these allegations, for which we are still waiting on 
the results. Regardless, it is still not clear to me that the needs of 
these 40,000 veterans were adequately met by the Department. This 
highlights the troubled scheduling system within the VA and that it is 
not meeting the needs of our nation's veterans.
    I am confident that H.R. 2661 will help the VA better meet the 
needs of the veterans it serves with timely access to medical 
appointments by creating a cohesive and unified scheduling policy that 
is both reliable and predictable. After a decade of war, it is our 
responsibility as Members of Congress to ensure that the department 
created to serve the men and women returning home and discharged of 
their military service have access to the care they need. I look 
forward to continuing to work with Chairman Miller, this committee, the 
Veterans Service Organizations, and my constituents to see that we 
solve the problems within the VA and help create a better system to 
serve our veterans.

                                 

       American Academy of Otolaryngology--Head and Neck Surgery

    The American Academy of Otolaryngology--Head and Neck Surgery (AAO-
HNS) thanks the Subcommittee for the opportunity to submit a statement 
for the record regarding H.R. 3508, a bill to amend Title 38, United 
States Code, to clarify the qualifications of hearing aid specialists 
of the Veterans Health Administration of the Department of Veterans 
Affairs, and for other purposes.
    The AAO-HNS, with approximately 12,000 members nationwide, is the 
medical specialty society for physicians dedicated to the care of 
patients with disorders of the ears, nose, throat (ENT), and related 
structures of the head and neck. Our members are specifically trained 
to provide hearing-impaired patients with a full medical evaluation, 
diagnosis, and treatment for their hearing disorders. Given the 
specialization of our members, the AAO-HNS closely monitors various 
pieces of legislation pertaining to the delivery of hearing health care 
services, including H.R. 3508.
    The AAO-HNS strongly supports the development and utilization of VA 
programs designed to broaden veterans' access to quality hearing health 
care services, and recognizes that in some areas, current VA programs 
are failing to meet the needs of the veteran population. However, while 
the AAO-HNS does not officially oppose H.R. 3508 at this point in the 
legislative process, we believe current Congressional action to advance 
the bill is premature and may represent an unnecessary legislative 
approach to address process failures within the VA.
    It is our understanding that the purpose of H.R. 3508 is to 
mitigate an ongoing issue within the VA regarding long wait times for 
hearing aids and hearing health care services for veterans in general. 
While this is a laudable goal, we are concerned that the bill, 
spearheaded by the national association representing hearing aid 
dispensers, would have unintended consequences. We find it necessary to 
register our concerns for the record so the members of this 
Subcommittee are fully advised of its potential impact.

Timing of Legislation

    Hearing-related issues, including hearing loss and tinnitus, are 
among the most common injuries within our nation's population of active 
and retired service men and women. The proliferation of these types of 
injuries among veterans presents a serious challenge for the VA. In 
fact, the AAO-HNS believes that the VA should explore all appropriate 
means necessary to ensure the delivery of high-quality hearing health 
care services.
    However, efforts to expand access to care must be balanced and 
include assurances that veterans are being cared for by the most 
qualified and appropriate hearing health care professionals. Hearing 
loss and tinnitus, particularly within the veteran population, are 
complex health issues, and therefore require a more comprehensive 
approach in regards to treatment.
    While the AAO-HNS contends that the underlying intent of H.R. 3508 
to ensure robust hearing-health related services are available to 
veterans is commendable, we are concerned that the course of action 
outlined in the bill attempts to legislatively correct what should, at 
least initially, be viewed as a ``process'' issue within the VA.
    Following a February 2014 audit of the VA's hearing health 
services, the VA Office of Inspector General (OIG) released a report 
outlining existing problem areas within the VA system. Specifically, 
the report recognized that inadequate staffing, coupled with 
inefficient operations/processes, at a major VA hearing aid center in 
Denver, CO (where a large percentage of hearing aids are repaired), 
accounted for much of the issue relating to long wait times. Based on 
the report's findings, the OIG recommended that the VA focus its 
immediate efforts on developing a plan for implementing more 
consistent/cohesive standards for audiology and hearing care centers in 
general.
    Given the OIG report and its recommendations for improving existing 
processes within the VA, the AAO-HNS contends that it is premature to 
pursue a legislative remedy for issues that may potentially be resolved 
via internal process changes.

Inclusion of Hearing Aid Specialists in OIG Report

    As stated, the AAO-HNS believes the VA should have the opportunity 
to conduct and implement a plan related to the productivity standards 
and staffing for audiology clinics, as recommended by the recent OIG 
audit, prior to passage of any legislation related to the provision of 
hearing health care services by the VA. We maintain that one of the 
main tenets of H.R. 3508--to allow hearing aid specialists the ability 
to directly contract with the VA--is duplicative to the current 
statutory authority of the VA. In fact, 38 U.S.C. 7401 allows the 
Secretary to appoint ``such other classes of health care occupations as 
the Secretary considers necessary for the recruitment and retention 
needs of the Department.'' Given that hearing aid specialists in some 
locations are already being contracted with by the VA to provide 
limited hearing health services, the Secretary should take hearing aid 
specialists in consideration when developing care plans and remedies as 
it implements the recommendations set forth in the OIG report.

Additional Considerations/Concerns Relating to H.R. 3508

    If after the implementation of the OIG's recommendations, 
legislation is still deemed necessary, the AAO-HNS looks forward to 
working with the bill's sponsors and this Subcommittee to address the 
below concerns with the current draft of H.R. 3508.

 Inclusion of hearing aid specialists in 38 USC 7402(b) as a 
new paragraph (14) rather than inclusion in the existing ``catch-all'' 
paragraph (14) with other health care professionals with comparable 
training [see Section (1)(a)(2)].
 Inclusion in Section (1)(c)(3)(B) of the bill the provisions 
of certain services by hearing aid specialists as described in Section 
(1)(c)(2)(C). Most notably, disability rating evaluations, primary 
hearing aid evaluations, and ordering of hearing aids are beyond the 
existing state laws governing the appropriate scope of practice of 
hearing aid dispensers.
 Inclusion of Section (1)(d) requiring the Secretary to 
``update and re-issue'' the handbook entitled ``VHA Audiology and 
Speech Language Pathology'' based upon the findings of the bill's 
required report. The AAO-HNS is concerned with this particular 
provision, especially without a requirement for stakeholder and 
Congressional input, given the VA's unilateral revisions set forth in a 
recently updated version of its nursing handbook.

    In conclusion, the AAO-HNS appreciates the opportunity to comment 
on this critical issue and to work with all interested (and impacted) 
parties to ensure our nation's veterans have timely access to and 
receive the highest quality hearing health care services. However, for 
the reasons set forth above, we respectfully urge the Subcommittee to 
not advance H.R. 3508 at this time and await the implementation of the 
OIG's recommendations.
    Thank you for your consideration. To receive additional 
information, please contact Megan Marcinko, AAO-HNS Senior Manager for 
Congressional & Political Affairs, at [email protected] or 703-535-
3796.

                                 

     Department of Veterans Affairs Office of the Inspector General

    March 25, 2014

    The Hon. Dan Benishek, MD, Chairman
    Subcommittee on Health, Committee on Veterans' Affairs,
    United States House of Representatives,
    Washington, DC 20515

    Dear Mr. Chairman:

    This is in response to your March 20, 2014, request for the views 
of the Office of Inspector General on legislation the Subcommittee will 
be considering on March 27, 2014. Specifically, we are concerned about 
the requirements for the Office of Inspector General (OIG) contained in 
Section 3(d) of H.R. 2661, The Veterans Access to Timely Medical 
Appointments Act, which would require the OIG to submit an annual 
report on the Secretary's progress in implementing the requirements 
contained in the bill. We are concerned about the following issues:

 Consultation with veteran service organizations (VSOs)--The 
bill requires the OIG to consult with Veteran Service Organizations 
(VSOs) as we prepare the report. The OIG's independence is key to 
producing reports that are a fair and balanced review of VA programs 
and operations. We believe that a statutory requirement to consult with 
and ostensibly gain the consensus of VSOs, or any other stakeholders, 
in the course of an OIG review can impinge on our independent authority 
to plan the scope and methodology of our work, and sets a troubling 
precedent.
 Annual Report--The OIG has a finite capacity to conduct and 
complete timely and relevant assessments of VA programs and operations. 
With an already substantial number of mandatory audits such as FISMA 
and the Consolidated Financial Statements, the addition of another 
annual reporting requirement on waiting times limits our flexibility to 
plan other oversight projects on current or emerging areas of concern 
on VA programs. Since 2001, the OIG has issued eight reports \1\ 
dealing with inaccurate waiting times. While we fully expect to follow 
up on this important issue as the need arises in the future, we do not 
believe an annual requirement in statute is necessary. Furthermore, an 
annual reporting requirement may not allow sufficient time to measure 
the effectiveness of actions taken by VA to implement recommended 
corrective actions from the OIG's prior year reports.

    \1\ Review of Veterans' Access to Mental Health Care (April 23, 
2012); Veterans Health Administration Review of Alleged Use of 
Unauthorized Wait Lists at the Portland VA Medical Center (August 17, 
2010); Review of Alleged Manipulation of Waiting Times, North Florida/
South Georgia Veterans Health System (December 4, 2008); Audit of 
Veterans Health Administration's Efforts to Reduce Unused Outpatient 
Appointments (December 4, 2008); Audit of Alleged Manipulation of 
Waiting Times in Veterans Integrated Service Network 3 (May 19, 2008); 
Audit of the Veterans Health Administration's Outpatient Waiting Times 
(September 10, 2007); Audit of the Veterans Health Administration's 
Outpatient Scheduling Procedures (July 7, 2005); Audit of the 
Availability of health care Services in the Florida/Puerto Rico 
Veterans Integrated Service Network (VISN) 8 (August 13, 2001).
---------------------------------------------------------------------------
    We would also like to comment on H.R. 2974, ``To amend Title 38, 
United States Code, to provide for the eligibility for beneficiary 
travel for veterans seeking treatment or care for military sexual 
trauma in specialized outpatient or residential programs at facilities 
of the Department of Veterans Affairs, and for other purposes,'' which 
would address a recommendation we made in our report, health care 
Inspection--Inpatient and Residential Programs for Female Veterans with 
Mental Health Conditions Related to Military Sexual Trauma. This 
legislation would allow VA to pay for travel for veterans being treated 
for mental health issues related to military sexual trauma at any VA 
facility regardless of the location. We support this legislation.
    Thank you for your interest in the Department of Veterans Affairs.
    Sincerely,
    Richard J. Griffin, Acting Inspector General

                                 

                     International Hearing Society

    Chairman Benishek, Ranking Member Brownley, and esteemed Members of 
the Subcommittee:
    International Hearing Society thanks you for the opportunity to 
comment on H.R. 3508. IHS stands in full support of the bill, which 
would create a new provider class for hearing aid specialists within 
the Department of Veterans Affairs (VA), thereby enabling the VA to 
hire hearing aid specialists to help deliver hearing aid services to 
Veterans. The bill would also require the VA to report annually to 
Congress on appointment wait times and the utilization of providers for 
hearing-related services, which would make the VA's efforts to address 
the backlog more transparent and provide much needed data to inform 
Congress about Veterans' experiences in accessing hearing aid services 
through the VA.
    The International Hearing Society, founded in 1951, is a 
professional membership organization that represents hearing aid 
specialists, dispensing audiologists, and dispensing physicians, 
including the approximately 9,000 hearing aid specialists who practice 
in the United States. IHS promotes and maintains the highest possible 
standards for its members in the best interests of the hearing-impaired 
population they serve by conducting programs in competency 
accreditation, testing, education and training, and encourages 
continued growth and education for its members through advanced 
certification programs.
    The VA has seen a dramatic rise in the demand for audiology 
services in the last five years. According to the VA there were 
1,617,377 outpatient audiology visits \1\ in 2012, up 36% from 2009.\2\ 
The number of hearing aids ordered per year has also dramatically 
increased with more than 665,000 ordered over the 12-month period 
ending in September 2012,\3\ up from 475,945 in FY 2009,\4\ or an 
increase of 39% in four years. With tinnitus and hearing loss being the 
two most prevalent service-connected disabilities for veterans 
receiving federal compensation, the demand will continue to rise. And 
despite audiologist-hiring following a similar growth track with a 34% 
increase in staffing between 2009 and 2013, the high demand and 
subsequent backlog continue to affect the VA's ability to deliver 
timely and high-quality hearing health care.
---------------------------------------------------------------------------
    \1\ 2013 Presentation to the Joint Defense Veterans Audiology 
Conference, ``Update on the VA Audiology Program'', Lucille B. Beck, 
PhD
    \2\  2010 Presentation to the Joint Defense Veterans Audiology 
Conference, ``21st Century Approach to VA Audiology Care'', Lucille B. 
Beck, PhD
    \3\ VA Office of Inspector General report ``Audit of VA's Hearing 
Aid Services,'' February 20, 2014
    \4\ 2010 Presentation to the Joint Defense Veterans Audiology 
Conference, ``21st Century Approach to VA Audiology Care'', Lucille B. 
Beck, PhD
---------------------------------------------------------------------------
    IHS and its membership have a great deal of respect for VA 
audiologists. They provide a wide variety of critical services to our 
Veterans, including compensation and pension exams (over 157,247 
performed in 2012 for 151,934 Veterans), programming and providing 
support for cochlear implant implantation and use, vestibular (balance) 
disorder services, tinnitus services, hearing conservation, hearing aid 
services, and advanced hearing testing. VA audiologists are also 
responsible for training and supervising audiology health technicians.
    The high demands on VA audiologists' time and expertise means that 
the VA is not currently able to meet all Veterans' needs for hearing 
health care services. To that point, in February 2014, the VA Inspector 
General released a report, ``Audit of VA Hearing Aid Services'' that 
found that ``during the 6-month period ending September 2012, VHA 
issued 30 percent of its hearing aids to veterans more than 30 days 
from the estimated date the facility received the hearing aids from its 
vendors.'' The audit also found that deliveries of repaired hearing 
aids to Veterans were subject to delay partially due to ``inadequate 
staffing to meet an increased workload, due in part to the large number 
of veterans requiring C&P audiology examinations.''
    In a practical sense, as a result of the backlog and delays, many 
Veterans are experiencing long wait times for appointments, shortened 
appointments, and limited follow-up care and counseling. And hearing 
aid specialists are observing an increase in the number of Veterans who 
seek care in their private offices as well. These Veterans request 
hearing aid specialists' help with hearing aid adjustments and repairs, 
oftentimes because they do not want to wait for the next available VA 
appointment, which may be months away, or because the distance to the 
closest VA facility that offers audiology services is too far to 
travel. We also have many Veterans who choose to purchase hearing aids 
at their own expense through a private hearing aid specialist, rather 
than using the benefits they've earned and are entitled to, because 
they want to work with someone local who they trust.
    Considering the safety risks involved as well as the impact 
untreated hearing loss can have on one's personal relationships and 
mental well-being, the VA needs an immediate solution to deal with the 
backlog and get Veterans the help they need. We also know that our 
working-age Veterans are anxious to contribute to society through 
employment, and properly fit and adjusted hearing aids are necessary 
for their success in obtaining and maintaining a job.
    H.R. 3508 provides the VA a much needed solution by creating a new 
provider class for hearing aid specialists to work within the VA. 
Hearing aid specialists can help the VA hearing health care team by 
providing hearing aid evaluations; hearing aid fittings and 
orientation; hearing aid verification and clinical outcome 
measurements; customary after care services, including repairs, 
reprogramming and modification; and the making of ear impressions for 
ear molds--just as they are currently authorized to do in the VA's fee-
for-service contract network.
    By adding hearing aid specialists to the audiology-led team to 
perform these specialized hearing aid services independently, 
audiologists will be able to focus on Veterans with complex medical and 
audiological conditions, as well as perform the disability evaluations, 
testing, and treatment services for which audiologists are uniquely 
qualified to provide--thereby creating efficiencies within the system 
and supporting the team-based approach. Adoption of the hearing aid 
specialist job classification at this juncture will also be 
advantageous given the fact that VA Audiology and Speech Pathology 
Service management will be developing staff and productivity standards 
as a result of the Inspector General's audit and recommendations,\5\ 
and would be able to consider the use of hearing aid specialists as 
they develop their model.
---------------------------------------------------------------------------
    \5\ VA Office of Inspector General report ``Audit of VA's Hearing 
Aid Services,'' February 20, 2014
---------------------------------------------------------------------------
    Also, by virtue of the report language in H.R. 3508, which would 
shine a light on the VA's utilization of hearing aid specialists in its 
contract network, it is our hope that the VA would take better 
advantage of this willing and able provider type to help address the 
need for hearing aid services.

Hearing Aid Specialist Qualifications

    Hearing aid specialists are regulated professionals in all 50 
states and in the non-VA market, hearing aid specialists perform 
hearing tests and dispense 50% of hearing aids to the public. They are 
licensed/registered to perform hearing evaluations, screen for the Food 
and Drug Administration (FDA) ``Red Flags'' indicating a possible 
medical condition requiring physician intervention, determine candidacy 
for hearing aids, provide hearing aid recommendation and selection, 
perform hearing aid fittings and adjustments, perform fitting 
verification and hearing aid repairs, take ear impressions for ear 
molds, and provide counseling and aural rehabilitation.
    Training for the profession is predominantly done through an 
apprenticeship model, which works very well given the hands-on and 
technical skill involved. And while licensure requirements vary from 
state to state, in addition to the apprenticeship experience, 
candidates generally must hold a minimum of a high school diploma, or 
they must hold an associates degree in hearing instrument sciences. 
Based on an industry study, we know that the actual level of schooling 
of a hearing aid specialist on average is an associates degree or 
higher. In nearly every state, candidates must pass both written and 
practical examinations, and in many states a distance learning course 
in hearing instrument sciences is required or recommended.
    Hearing aid specialists are already recognized by several Federal 
agencies to perform hearing health care services. The Standard 
Occupational Classification (SOC) identifies hearing aid specialists 
within the health care Practitioners and Technical Occupations category 
(29-2092), and the Federal Employee Health Benefit program and Office 
of Policy and Management support the use of hearing aid specialists for 
hearing aid and related services. And while Medicare does not cover 
hearing testing for the purpose of recommending hearing aids (a policy 
that applies to all dispensing practitioners), hearing aid specialists 
provide hearing testing, hearing aids, and related services for state 
Medicaid programs around the country. Further, many insurance companies 
contract with hearing aid specialists to provide hearing tests and 
hearing aid services for their beneficiaries.
    Finally, evidence shows that there is no comparable difference in 
the quality and outcomes of hearing aid services based on site of 
service or type of provider. A well-respected industry study found that 
instead the best determinant of patient satisfaction is whether the 
provider used best practices like fit verification, making adjustments 
beyond the manufacturer's initial settings, providing counseling, and 
selecting the appropriate device for one's loss and manual 
dexterity.\6\
---------------------------------------------------------------------------
    \6\ MarkeTrak VIII: The Impact of the Hearing Health Care 
Professional on Hearing Aid User Success, The Hearing Review, Vol 17 
(No.4), April 2010, pp. 12-34.

---------------------------------------------------------------------------
VA Strategies To Address Demand

    To address the demand for audiology and hearing aid services, the 
VA has been relying on the use of teleaudiology, audiology health 
technicians, and contract audiologists outside the VA setting. While 
IHS applauds the VA for its efforts to better serve the needs of 
Veterans, each of these strategies has its limitations. Though 
teleaudiology can make audiological services more available in remote 
settings, the cost of staffing and facilities are needlessly high, 
especially given that hearing aid specialists have fully-equipped 
offices, oftentimes operate in rural settings, and perform home and 
nursing home visits. Audiology health technicians have a very limited 
scope of duties, which does not include hearing aid tests or the 
fitting and dispensing of hearing aids, and must be supervised by 
audiologists. Finally, increased reliance solely on contract 
audiologists may also limit access as there are not enough audiologists 
to fill the current and future need for hearing care services. In order 
to fill the need, the field needs an additional 23,000 audiologists by 
2030; however only about 600 are entering the profession annually.\7\
---------------------------------------------------------------------------
    \7\ Demand for Audiology Services: 30-Year Projections and Impact 
on Academic Programs, Journal of the American Academy of Audiology, Ian 
A. Windmill and Barry A. Freeman, 24:407-416, 2013
---------------------------------------------------------------------------
    As the federal government seeks to become more efficient and cost-
effective, we urge the Subcommittee to pass H.R. 3508, which will round 
out the VA hearing health care team to mirror the private-market model, 
and increase Veterans' access to care, improve overall quality, and 
reduce cost. Now is the time to embrace hearing aid specialists to help 
meet the hearing health care needs of our Veterans, which will only 
continue to rise in the coming years.
    Thank you for your consideration and for your service to our 
Veterans. With questions, please contact government affairs director 
Alissa Parady at 571-212-8596 or [email protected].
    International Hearing Society, 6880 Middlebelt Rd., Ste. 4 Livonia, 
MI 48154, Phone: (734) 522-7200 Fax: (734) 522-0200, Web site: 
www.ihsinfo.org

          Statement of Iraq & Afghanistan Veterans of America

             Statement of Iraq & Afghanistan Veterans of America on Pending Health Care Legislation
----------------------------------------------------------------------------------------------------------------
                Bill #                        Bill Name                 Sponsor                  Position
----------------------------------------------------------------------------------------------------------------
H.R. 183                               Veterans Dog Training    Rep. Grimm               Support
                                        Therapy Act
----------------------------------------------------------------------------------------------------------------
H.R. 2527                              A bill to provide        Rep. Titus               Support
                                        counseling and
                                        treatment for MST that
                                        occurred during
                                        inactive duty training.
----------------------------------------------------------------------------------------------------------------
H.R. 2661                              Veterans Access to       Rep. McCarthy            Support
                                        Timely Medical
                                        Appointments Act.
----------------------------------------------------------------------------------------------------------------
H.R. 2974                              A bill to provide for    Rep. Walorski            Support
                                        the eligibility for
                                        beneficiary travel for
                                        veterans seeking
                                        treatment or care for
                                        military sexual trauma
                                        in specialized
                                        outpatient or
                                        residential programs
                                        at facilities of the
                                        VA.
----------------------------------------------------------------------------------------------------------------
H.R. 3508                              A bill to clarify the    Rep. Duffy               Support
                                        qualifications of
                                        hearing aid
                                        specialists within VHA.
----------------------------------------------------------------------------------------------------------------
H.R. 3180                              A bill to include        Rep. Kaptur              Support
                                        contracts & grants for
                                        residential care for
                                        veterans in the
                                        exception to the
                                        requirement that the
                                        government recover a
                                        portion of the value
                                        of certain projects.
----------------------------------------------------------------------------------------------------------------
H.R. 3387                              Classified Veterans      Rep. Sinema              Support
                                        Access to Care Act.
----------------------------------------------------------------------------------------------------------------
H.R. 3831                              A bill to review the     Rep. Roe                 No Position
                                        dialysis pilot program
                                        implemented by the VA
                                        and submit a report to
                                        Congress before
                                        expanding that program.
----------------------------------------------------------------------------------------------------------------
H.R. 4198                              A bill to reinstate an   Rep. Denham              Support
                                        annual report on the
                                        capacity of the VA to
                                        provide for
                                        specialized treatment
                                        and rehabilitative
                                        needs of disabled
                                        veterans.
----------------------------------------------------------------------------------------------------------------
Draft                                  A bill to authorize      Rep. Benishek            No Position
                                        major VA medical
                                        facility leases for
                                        Fiscal Year 2014.
----------------------------------------------------------------------------------------------------------------


    Chairman Benishek, Ranking Member Brownley, and Distinguished 
Members of the Subcommittee:
    On behalf of Iraq and Afghanistan Veterans of America (IAVA), we 
would like to extend our gratitude for being given the opportunity to 
share with you our views and recommendations regarding this important 
legislation that will impact the lives of IAVA's members and all of 
America's troops and veterans.
    As the nation's first and largest nonprofit, nonpartisan 
organization for veterans of the wars in Iraq and Afghanistan, IAVA's 
mission is critically important but simple--to improve the lives of 
Iraq and Afghanistan veterans and their families. With a steadily 
growing base of nearly 270,000 members and supporters, we aim to help 
create a society that honors and supports veterans of all generations.
    In partnership with other military and veteran service and advocacy 
organizations, IAVA has worked tirelessly to see that our members' 
needs are appropriately addressed by the Department of Veterans Affairs 
(VA) and by Congress. IAVA appreciates the efforts put forth by this 
Subcommittee to address the challenges facing our nation's veterans and 
their families, and we are proud to offer our support for the 
legislation that is the subject of this hearing today.

H.R. 183

    IAVA supports H.R. 183, the Veterans Dog Training Therapy Act, 
which would direct the VA to establish a pilot program to allow 
veterans receiving post-deployment mental health care to train service 
dogs for disabled veterans.
    The use of dog training as a therapy for post-traumatic stress 
disorder is a forward-thinking and unique option for veterans seeking 
care. Most importantly, there is a strong body of evidence supporting 
the therapeutic value of dogs, and growing evidence supporting their 
therapeutic value specifically for servicemembers and veterans with 
PTSD. Using animals as therapy or as service dogs has been a successful 
model of care already supported by the DoD and VA. This particular 
program goes a step further, to equip veterans with vocational skills. 
Such skills and abilities are instrumental in helping veterans develop 
new career opportunities.
    Additionally, the proposed program would train service dogs for 
other veterans. The use of occupational therapy to train new service 
dogs serves two populations of veterans and promotes innovative care to 
address the unique needs of every veteran.

H.R. 2527

    IAVA supports H.R. 2527, which would provide veterans with 
counseling and treatment for military sexual trauma that occurred 
during inactive training.
    The VA has a responsibility to provide the best counseling and 
treatment available to survivors of military sexual trauma. However, 
the men and women who courageously served in the National Guard or 
other reserve components of the armed services are not eligible for 
such counseling and treatment if the MST occurred during inactive 
training. IAVA supports enabling and facilitating this type of training 
in order to ensure that all survivors of MST are afforded prompt VA 
care and treatment.

H.R. 2661

    IAVA supports H.R. 2661, the Veterans Access to Timely Medical 
Appointments Act, which would require the VA to implement a 
standardized policy to ensure veterans enrolled in VA health care are 
able to schedule primary care appointments and specialty appointments 
within a certain amount of time after requesting an appointment.
    The lack of standardized appointment policies and inefficient data 
on adherence to appointment policies has been a routine issue among 
veterans seeking care at the VA. This legislation is directly 
reflective of Government Accountability Office recommendations, which 
were based on an audit stemming from veteran concerns. IAVA strongly 
supports increased access to medical care and encourages Congress and 
the VA to continue addressing ways in which increased access to care 
can be achieved.

H.R. 2974

    IAVA supports H.R. 2974, which would authorize beneficiary travel 
for veterans seeking treatment or care for military sexual trauma at 
specialized outpatient or residential programs at VA facilities.
    A 2012 survey released Pentagon report estimated nearly 26,000 
servicemembers experienced unwanted sexual contact in 2012, with just 
3,374 cases ultimately reported. Recent incidents continue to highlight 
the appalling presence of sexual assault in the U.S. military and the 
urgent need to ensure that servicemembers and veterans can access the 
appropriate assistance available to them.
    Currently, the VA is required to operate a program that provides 
counseling and the necessary care to veterans that need help in 
overcoming the physical and psychological stress of sexual assault and 
harassment. By ensuring that the travel expenses of veterans seeking 
MST-related treatment are covered, this bill would serve as a natural 
extension of the care required by the VA for survivors of military 
sexual trauma.

H.R. 3508

    IAVA supports H.R. 3508, which would clarify the qualifications of 
hearing aid specialists at the VA.
    When veterans seek VA-provided hearing aid services at a VA medical 
facility, too often they encounter facilities that are overloaded with 
appointments and/or are forced to endure long wait times, substantial 
distances to travel, and limited follow-up care. This seems to indicate 
that the number of veterans in need of adequate hearing-related 
services is quickly surpassing VA's ability to sufficiently respond.
    Since hearing impairment is one of the most common injuries faced 
by our newest generation of veterans, ensuring that these men and women 
receive the care they are entitled to is critical. IAVA supports this 
legislation because it seeks to ensure that qualified hearing aid 
specialists can work alongside the hearing professionals of the VA in 
order to better serve this nation's veterans and reduce the wait times 
and stress associated with seeking care at a VA facility.
H.R. 3180

    IAVA supports H.R. 3180, which would exempt contracts and grants 
for residential care for veterans from the requirement that the 
government recover a portion of the value of certain projects.
    The VA is authorized to provide grant money to state-run facilities 
that provide domiciliary care, medical care, or nursing home care to 
veterans. If the facility ceases to be run by the state within a 
certain amount of time, the VA is authorized to recapture up to 65 
percent of the value of the project, but not more than the original 
grant amount. This legislation would exempt residential care facilities 
from these recapture requirements. IAVA supports the VA exempting 
residential care facilities from these recapture requirements so long 
as the facilities continue to maintain high levels of care for 
veterans.

H.R. 3387

    IAVA supports H.R. 3387, the Classified Veterans Access to Care 
Act, which would improve access to mental health care for veterans who 
conducted classified missions or served in classified units.
    Currently, the VA utilizes group therapy sessions as a form of 
mental health treatment. However, these group therapy sessions do not 
consider the security clearance of the veteran, often putting veterans 
in a position to choose between compromising classified information and 
utilizing this helpful form of mental health support. However, a 
veteran should never be forced to opt out of mental health treatment 
due to a lack of feasible treatment options. The mental health needs of 
each veteran are unique, as is the nature of many military occupational 
specialties and their associated missions. Likewise, the full range of 
mental health care treatments available from the VA should reflect the 
full range of unique needs and special circumstances of military 
service.

H.R. 3831

    At this point in time, IAVA has no position on H.R. 3831, which 
would require VA to ensure that it's dialysis pilot program is not 
expanded until it has been implemented at its initial facilities, an 
independent analysis of the program has been conducted, and VA has 
provided a report to Congress detailing progress of the program.

H.R. 4198

    IAVA supports H.R. 4198, which would require the VA to reinstate an 
annual report on the capacity of the VA to provide for specialized 
treatment and rehabilitative needs of disabled veterans. This report 
has provided invaluable data on the capabilities of the VA to meet the 
needs of disabled veterans, and this bill makes a common sense change 
to require the VA to reinstate these reports.

Draft 1

    At this time, IAVA is still reviewing the draft bill to authorize 
major VA medical facility leases for Fiscal Year 2014. IAVA strongly 
encourages Congress and the VA to continue to invest in facilities to 
support the medical needs of veterans, and we therefore look forward to 
having the opportunity to evaluate this new draft legislation.
    Mr. Chairman, we at IAVA again appreciate the opportunity to offer 
our views on these important pieces of legislation, and we look forward 
to continuing to work with each of you, your staff, and this 
Subcommittee to improve the lives of veterans and their families.
    Thank you for your time and attention.

Statement on Receipt of Federal Grant or Contract Funds

    Iraq and Afghanistan Veterans of America has not received federal 
grant or contract funds relevant to the subject matter of this 
testimony during the current or two previous fiscal years.

                                 

              National Association of State Veterans Homes

                  Testimony of Brad Slagle, President

    Chairman Benishek, Ranking Member Brownley and Members of the 
Subcommittee:
    Thank you for the opportunity to submit testimony on behalf the 
National Association of State Veterans Homes (NASVH) in support of H.R. 
3180, legislation introduced by Congresswoman Marcy Kaptur of Ohio. 
H.R. 3180 was drafted to remove existing legal and financial barriers 
that effectively prevent State Veterans Homes from operating certain 
homeless veterans programs. We applaud Congresswoman Kaptur for her 
lifelong commitment to supporting veterans, including homeless 
veterans, and for her leadership in introducing this legislation. If 
properly implemented, this legislation could have the effect of 
utilizing excess existing capacity in some State Home domiciliaries to 
support new homeless veterans programs. Although there may need to be 
some language changes made to H.R. 3180 to strengthen the bill, we hope 
that the Subcommittee will work with the bill's sponsor, VA and NASVH 
to move this important, innovative and commonsense legislation.
    Mr. Chairman, as you know, NASVH is an all-volunteer, non-profit 
organization whose primary mission is to ensure that each and every 
eligible U.S. veteran receives the benefits, services, long term health 
care and respect which they have earned by their service and sacrifice. 
NASVH also ensures that no veteran is in need or distress and that the 
level of care and services provided by State Veterans Homes meets or 
exceeds the highest standards available. The membership of NASVH 
consists of the administrators and senior staffs at 146 State Veterans 
Homes in all 50 States and the Commonwealth of Puerto Rico.
    Mr. Chairman, the State Veterans Homes system is a mutually 
beneficial partnership between the States and the federal government 
that dates back more than 100 years. Today, State Homes provide over 
30,000 nursing home and domiciliary beds for veterans and their 
spouses, and for the gold-star parents of veterans. Our nursing homes 
assist the VA by providing long-term care services for approximately 53 
percent of the VA's long-term care workload at the very reasonable cost 
of only about 12 percent of the VA's long-term care budget. VA's basic 
per diem payment for skilled nursing care in State Homes is 
approximately $100, which covers about 30 percent of the cost of care, 
with States responsible for the balance, utilizing State funding and 
other sources. On average, the daily cost of care of a veteran at a 
State Home is less than 50 percent of the cost of care at a VA long-
term care facility. The VA per diem for adult day health care is 
approximately $75 and the domiciliary care rate is approximately $43 
per day.
    The bill before the Committee, H.R. 3180, is intended to address a 
problem in Title 38 that effectively prevents State Homes from 
operating certain homeless veterans programs, even when a domiciliary 
has excess capacity that could be used in other ways to help fight the 
pernicious problem of homelessness amongst veterans. According to the 
Department of Housing and Urban Development, on any given night there 
are almost 60,000 homeless veterans, and more than twice that many 
experience homelessness at some point each year. This shameful fact led 
VA Secretary Shinseki to make ending homelessness amongst veterans by 
2015 one of his highest priorities and enactment of H.R. 3180, properly 
crafted and implemented, could add State Veterans Homes to his arsenal 
of tools in that effort.
    Mr. Chairman, some State Homes currently have unused bed capacity 
in their domiciliary programs that could be used to operate specialized 
homeless veterans programs. For example, the Ohio Veterans Home in 
Sandusky, Ohio has both a 427 bed nursing home program and a separate 
300 bed domiciliary program. While the nursing home program has a 98 
percent or higher occupancy rate, the domiciliary is currently 
operating at less than 60 percent occupancy, leaving more than 125 beds 
available at any given time. The administrators at Sandusky have been 
exploring ways to use a small number of their unused domiciliary beds 
to help homeless veterans.
    However, eligibility requirements for admission to the Ohio 
Veterans Home domiciliary program limit or restrict admission for most 
homeless veterans. To be admitted to the domiciliary, a veteran must 
provide a current medical history and physical completed by a 
physician, along with detailed financial documentation demonstrating 
need for this assistance, as well as other information. Often homeless 
veterans lack the resources to obtain such information required for 
possible admission so the Ohio Veterans Home has been looking for other 
ways to use their facility to support homeless veterans.
    Learning about VA's Health Care for Homeless Veterans (HCHV) 
program, which provides grants to community homeless programs, the 
Sandusky Home drew up plans for a small homeless program using HCHV 
funding as a source of support. Under this proposed program, they would 
be able to admit homeless veterans without the tighter domiciliary 
requirements, allowing them immediate access to food, shelter, primary 
care, social services and other services. There are also a number of 
recently deployed veterans that may need a stable transition facility 
for post-acute care but who don't fall into the admissions criteria 
outlined in the VA domiciliary care program regulations. Because 
homeless veterans generally need more intense services initially to 
help them to stabilize and adjust, the Home also developed plans to 
work collaboratively with the VA Homeless Coordinators in an effort to 
help the veteran with any specific needs they may have, which could 
include education, job training and long term housing.
    After approaching VA with this proposal, the Sandusky Home was told 
that under Title 38 regulations, State Homes are only authorized to use 
their federally-supported homes to operate three programs: skilled 
nursing care, adult day health care and domiciliary care. According to 
VA's Office of General Counsel, if a State Veterans Home applied for 
and received a grant to operate a homeless veterans program, VA would 
have to recapture a portion of the construction grant funding 
previously awarded to the State Home over the past twenty years. This 
recapture of federal funds would be such a severe financial penalty 
that it would effectively prevent any State Veterans Home from even 
considering new homeless veterans programs, even though domiciliaries 
were built to provide housing for veterans without homes.
    In order to remove this obstacle, H.R. 3180 was drafted to amend 
the recapture provisions (38 USC Sec.  8136) by providing an exemption 
for State Homes that receive a contract or grant from VA for 
residential care programs, including homeless veterans programs through 
HCHV. This legislation would not require VA to award grants or 
contracts to State Homes; VA would retain the authority and discretion 
to determine when and where it might make sense for a State Home to use 
a portion of its empty beds to help homeless veterans. Nor would it 
open the door to State Homes converting domiciliary beds into new 
homeless program beds on their own; only VA's decision to provide 
funding through a grant or contract, such as HCHV, would exempt them 
from the recapture provisions. This innovative and practical proposal 
would not increase federal spending, rather it would simply allow State 
Veterans Homes to compete for existing VA grants just as private 
community organizations presently do.
    However, in further exploring how this legislation could be 
interpreted and implemented, we have become aware that the language may 
not be specific enough in terms of either the intended facilities or 
the intended programs. The broad exception in the current draft of the 
bill providing the Secretary the ability to award grants and contracts 
for resident care without triggering the recapture provision could 
theoretically be used for any number of residential programs, not just 
at domiciliaries, but at skilled nursing facilities as well. Moreover, 
there are some concerns that even though the Secretary would have broad 
new authority to award grants and contracts for additional residential 
programs, there is no guarantee VA would actually use this authority to 
support new homeless veterans programs in domiciliaries through HCHV.
    Mr. Chairman, although H.R. 3180 as currently drafted could achieve 
its intended purpose, we would recommend that the Subcommittee work 
with the bill's sponsor, VA and NASVH to tighten and strengthen the 
language in the bill. We are confident that working together we can 
refine this legislation to create new opportunities for State Homes 
with underutilized bed capacity in their domiciliary programs to help 
VA end the scourge of homelessness amongst veterans using existing 
programs, such as HCHV.

                                 

                     Servicewomen's Action Network

    Chairman Benishek, Ranking Member Brownley, and distinguished 
members of the Subcommittee:
    On behalf of the Service Women's Action Network, thank you for the 
opportunity to submit written testimony for the record and thank you 
for your continued leadership on veterans' issues and for convening 
this hearing.
    The Service Women's Action Network (SWAN) is a non-profit, non-
partisan veterans led civil rights organization. SWAN's mission is to 
transform military culture by securing equal opportunity and freedom to 
serve without discrimination, harassment or assault; and to reform 
veterans' services to ensure high quality health care and benefits for 
women veterans and their families.
    We challenge institutions and cultural norms that deny equal 
opportunities, equal protections, and equal benefits to service members 
and veterans. SWAN is not a membership organization, instead we utilize 
direct services to provide outreach and assistance to service members 
and veterans and our policy agenda is directly informed by those 
relationships and that interaction. SWAN extends opportunities to and 
promotes the voices and agency of service women and women veterans 
without regard to sex, gender, sexual orientation or gender identity or 
the context, era, or type of service.
    SWAN welcomes the opportunity to share our views on two of the 
bills before the Subcommittee today, H.R. 2527 and H.R. 2974.

H.R. 2527

    The National Guard is unique among components of the Department of 
Defense in that it has the dual state and federal mission. For example, 
while serving operationally on Title 10 active-duty status in Operation 
Iraqi Freedom or Operation Enduring Freedom, National Guard units are 
under the command and control of the president. However, upon release 
from active duty, members of the National Guard return to their states 
as serving members of the reserve component but under the command and 
control of their governors.
    A reservist can complete a full Guard or Reserve career but never 
have served on Title 10 active duty for other than training purposes. 
Drill training, annual training and Title 32 service responding to 
domestic natural disasters and defending our nation's airspace, borders 
and coastlines do not qualify for veteran status and thus any of these 
service members if sexually assaulted have the potential to fall 
through the cracks, not receiving counseling and treatment for their 
assault if that assault happened during inactive duty training. 
Compounding this conflict is the risk of becoming a victim of sexual 
violence is just as great for these service members as it is for active 
duty troops. In fact, according to the Department of Defense, nearly 
80% of reported sexual assaults occur CONUS, or stateside, in garrison-
type installations. The remainder happen at overseas installations and 
still an even smaller percentage happen in ``combat areas of 
interest.'' \1\ Serving in your community stateside does not ensure a 
service member's safety when it comes to sexual assault.
---------------------------------------------------------------------------
    \1\ http://www.sapr.mil/public/docs/reports/FY12-DoD-SAPRO-Annual-
Report-on-Sexual-Assault-VOLUME-ONE.pdf
---------------------------------------------------------------------------
    Eliminating this gap in protection for our service members is why 
the Senate unanimously passed the Victims Protection Act of 2014. Sec. 
107 of the bill requires the Department of Defense to provide for the 
availability of Sexual Assault Response Coordinators for members of the 
National Guard and the Reserve regardless of their training status. It 
only makes sense, then, that the VA close the similar gap in 
protections to veterans who need counseling and treatment for sexual 
trauma that occurred during inactive duty training. SWAN fully supports 
passage of H.R. 2527.

H.R. 2974

    As DoD continues to makes changes to policy and programming for 
sexual assault survivors, it is imperative that the VA do likewise and 
provide the men and women veterans who suffer from the invisible wounds 
of sexual assault the full range of treatment, services and disability 
benefits available to veterans who are suffering from the visible 
wounds of war.
    Since 2008, SWAN has been monitoring VA's treatment of veterans who 
carry these invisible wounds of sexual violence due to rape, sexual 
assault or sexual harassment. We have been encouraged by the progress 
that the Veterans Health Administration continues to show in the 
screening and treatment of Military Sexual Trauma and its related 
diagnoses; however, the Veterans Benefit Administration continues to 
process and award disability claims for Military Sexual Trauma 
diagnoses, specifically PTSD, inconsistently and unfairly. In spite of 
repeated requests by a chorus of military and veterans' organizations, 
individual survivors and Members of this committee, the VA continues to 
refuse to amend the language in their regulations to make evidentiary 
standards and the processing of a MST PTSD claims as consistent and 
fair as it is for the other particularized PTSD claims found in the 
regulation. \2\ Data obtained by SWAN through litigation under the 
Freedom of Information Act demonstrates that since 2010, VA approval 
rate for MST PTSD claims have lagged behind the approval rates of all 
other PTSD claims, and male survivors--who constitute the majority of 
sexual assault victims--continued to be discriminated against in the 
awarding of claims. \3\ VA's response to this has been to ignore the 
data and falsely claim that the gap between awarded MST PTSD and other 
PTSD claims is closing and their training efforts have worked. 
Unfortunately, this Jedi Mind Trick is betrayed by the facts. In 2013, 
the VA Appropriations bill included reporting language that required VA 
to submit to Congress data on MST claims. \4\ The 2013 data in this 
report shows that the VA's efforts have not worked and both the claims 
gap continues to exist and male survivors continue to face 
discrimination in the awarding of their claims. It is clear that until 
VA changes the language in the regulations so that the evidentiary 
burden for MST PTSD claims matches that of other particularized claims, 
the disability benefits process will remain broken and continue to be 
another betrayal that serves to compound the trauma of a survivor's 
initial sexual assault.
---------------------------------------------------------------------------
    \2\ 38 C.F.R. Sec.  3.304(f).
    \3\ See enclosure 1: ``The Battle for Benefits''.
    \4\ See enclosure 2: Military Sexual Trauma: FY2014 Congressional 
Report to the House and Senate Appropriations Committees 
www.servicewomen.org
---------------------------------------------------------------------------
    As SWAN and members of both the House and Senate continue to work 
for this needed regulatory reform, it is imperative that VA provide 
whatever it can to our men and women who have suffered from the impact 
of sexual violence while serving in the military. This includes common-
sense logistical support to survivors, like the support found in H.R. 
2974. This bill requires VA to provide for the eligibility for 
beneficiary travel for Military Sexual Trauma survivors seeking 
treatment in specialized outpatient or residential programs at VA 
facilities. This is a simple, common-sense benefit. The fact that today 
an MST survivor would be unable to make required appointments, 
participate in prescribed treatment programs or attend a beneficial 
resident treatment program simply because he or she cannot afford to 
travel to the facility is beyond outrageous. It is inexcusable that 
transportation costs should be a detour on a survivor's road to 
recovery. SWAN wholeheartedly supports the passage of H.R. 2974.
    Again, we appreciate the opportunity to offer our views on these 
important bills and we look forward to continuing our work together to 
improve the lives of veterans and their families. Any questions can be 
directed to Greg Jacob, Policy Director at 646-569-5216 or by mail at 
Service Women's Action Network, 1225 I St, NW., Ste 307, Washington, 
DC, 20005.

Non-Governmental Witness Declaration

    Neither the Service Women's Action Network nor I have received 
during the current or previous two fiscal years any Federal grant or 
contract relevant to the subject matter of this testimony.

                                 

            The American Speech-Language-Hearing Association

    To the House of Representatives Committee on Veterans Affairs 
Health Subcommittee Regarding H.R. 3508

Allowing for the Appointment of Hearing Aid Specialists to the Veterans 
Health Administration

    The American Speech-Language-Hearing Association (ASHA) appreciates 
the opportunity to submit a statement for the record regarding H.R. 
3508, legislation that would allow for the appointment of hearing aid 
specialists to the Veterans Health Administration. While we understand 
the desire of Congress to ensure appropriate access to hearing health 
services, we believe that this legislation will not address the 
problems associated with long wait times for hearing aids and hearing 
health care services. Additionally we believe that the legislation 
could lead to fragmented care. For these reasons, ASHA opposes the 
legislation as currently written. ASHA is the national professional, 
scientific, and credentialing association for more than 173,070 
audiologists, speech-language pathologists, speech, language, and 
hearing scientists, audiology and speech-language pathology support 
personnel, and students.
    Unfortunately, as currently written the legislation may not have 
the desired outcome of decreasing wait times for veterans either 
seeking to obtain hearing aids or repairs. Hearing health care is more 
than fitting a veteran with a device. An audiologist must do a full 
diagnostic hearing evaluation and take into consideration health 
factors, such as tinnitus and brain injury, when determining 
appropriate amplification and audiologic rehabilitation for the 
patient.
    Hearing loss and tinnitus are two of the top service-related 
disabilities of our nation's veterans, and these disabilities require 
more complex and comprehensive treatment. Although we acknowledge that 
hearing aid specialists have the knowledge and skills to dispense 
hearing aids, many of our veterans, especially those with traumatic 
brain injury or tinnitus, require the specialized care of an 
audiologist.
    The VA Office of Inspector General (OIG) recently released the 
finding of an audit of the VA's hearing health services. The audit 
found that inadequate staffing to meet increased workloads as well as 
operations and processes at the Denver Acquisition and Logistics Center 
(where hearing aids are repaired) attributed to long wait times.
    The OIG recommended that the VA develop a plan to implement 
productivity standards and staffing plans for audiology clinics. They 
also recommended that the repair center determine appropriate staffing 
levels for its rehab lab to establish controls to timely track and 
monitor hearing aid repairs.
    The VA should have the ability to review its current policies and 
develop productivity standards and staffing plans as recommended by the 
OIG prior to the adoption of any legislation that would require changes 
to the provision of hearing health care services in the VA.
    Additionally, in order to enhance hearing health care services to 
our veterans ASHA makes the following recommendations to the committee.
         Work with the VA to identify areas of the country 
        where veterans have difficulty accessing hearing health 
        services, and authorize additional funding to hire more 
        audiologists and/or contract to private audiologists to meet 
        the needs of the veterans in those areas.
         Request the VA to review data on wait times and access 
        to hearing health care services and identify best practices by 
        those facilities that have implemented ways to reduce wait 
        times for services and devices and provide this information to 
        lower performing facilities as a means to improve.
          Amend the Non-VA Purchased Care provisions of Title 
        38 to include audiologists.
         Grant the VA the authority to hire more audiologists.

Legislation Redundant Of Current VA Practices

    The VA has the authority to hire hearing aid specialists as 
technicians that work under the direction of an audiologist. According 
to the VHA handbook 1170.02, the job description of the health 
technicians for audiology is to, among other things, increase 
productivity by reducing wait times and enhancing patient satisfaction; 
and reducing costs by enabling health technicians to perform tasks that 
do not require the professional skills of a licensed audiologist. The 
role of these technicians includes performing checks on hearing aids 
and other amplification devices, performing troubleshooting and minor 
repairs to hearing aids, ear molds, and other amplification devices, 
and performing electroacoustic analysis of hearing aids, among other 
things. These responsibilities, which are already provided in the VA, 
are what hearing aid specialists are requesting to be recognized for 
under H.R. 3508.
    Additionally, Appendix A of the VA handbook specifically addresses 
the use of hearing aid specialists and allows for referrals to these 
individuals when timely referrals to private audiologists and/or other 
VHA facilities are not feasible or when the medical status of the 
veteran prevents travel to a VHA facility or a private audiologist.
    Given that hearing aid specialists are already permitted to be 
hired by the VA, we believe that H.R. 3508 adds an unnecessary mandate 
on the agency to specifically recognize hearing aid specialists for 
appointment by the Secretary.

Training and Education

    Given the complex nature of a veteran's hearing health care needs, 
veterans should have timely access to an audiologist. Audiologists are 
the primary licensed health care professionals who evaluate, diagnose, 
treat, and manage hearing loss and balance disorders. Audiologists hold 
a doctoral degree in audiology from a program accredited by the Council 
on Academic Accreditation in Audiology and Speech-Language Pathology of 
the American Speech-Language Hearing Association. Under the scope of 
practice for audiology, these individuals serve the veteran through a 
broad range of professional activities including evaluating, 
diagnosing, managing, and treating disorders of hearing, balance, 
tinnitus, and other disorders associated with the practice of 
audiology. This includes determining the appropriateness of 
amplification devices and systems as well as selecting, evaluating, 
fitting and programming hearing aids.
    Hearing aid specialists are trained in the interpretation of 
hearing assessment instrumentation, hearing aid electronics, 
specifications, analysis, modifications, and programming of hearing 
aids. While some states have gone to a college-level associate degree 
as a minimum education requirement for hearing aid dispensers, many 
states still require only a high school diploma or equivalent. There 
are no national standards or dedicated curriculum that outlines the 
core competencies of a hearing aid specialist. For example, in addition 
to the high school diploma or equivalent requirement, in the state of 
Wisconsin an individual must be 18, while in Minnesota they must be 21. 
Both licensure requirements require a test for proficiency. For more 
information and an analysis of each state's hearing aid specialist 
(dispenser) requirements for licensure, see www.asha.org/advocacy/
state/.
    Additionally, we are unaware of any nationally recognized 
accreditation body for hearing aid specialists. We are aware of the 
International Institute for Hearing Instruments Studies. This 
organization is not on the list of recognized accrediting agencies by 
the U.S. Department of Education or the Council for Higher Education 
Accreditation (CHEA). This organization is also not listed as a member 
agency of the Association of Specialized and Professional Accreditors 
(ASPA). It appears the accreditation body is limited to continuing 
education courses and programs.
    We appreciate the opportunity to express our concerns. ASHA remains 
committed to working with the Committee to address access to timely 
hearing health care services, but does not believe that H.R. 3508 is 
the solution. For additional information please contact Ingrida Lusis, 
ASHA's director of federal and political advocacy, at [email protected] 
or 202-624-5951.

                                 

                       Warrior Canine Connection,

                   Rick A. Yount, Executive Director

    Mr. Chairman and Members of the Subcommittee, as the Executive 
Director of Warrior Canine Connection, I would like to thank you for 
your invitation to submit a statement for the record in support of H.R. 
183, the Veterans Dog Training Therapy Act. I am pleased to have the 
opportunity to bring Members of the Subcommittee up to date on this 
promising therapy for symptoms of Post Traumatic Stress Disorder (PTSD) 
and Traumatic Brain Injuries (TBI) in combat Veterans, and to address 
the need for this legislation.
    Warrior Canine Connection (WCC) is a 501(c) 3 nonprofit 
organization dedicated to empowering returning combat Veterans who have 
sustained physical and psychological wounds while in service to our 
country. Based on the concept of Warriors helping Warriors, WCC's 
therapeutic service dog training program is designed to mitigate 
symptoms of PTSD and TBI, while giving injured combat Veterans a sense 
of purpose, help in reintegrating back into their families and 
communities, and a potential career path as a service dog trainer. WCC 
currently provides its program to recovering Warriors at Walter Reed 
National Military Medical Center (WRNMMC), the National Intrepid Center 
of Excellence (NICoE), Palo Alto VA Medical Center (Menlo Park), Ft. 
Belvoir Warrior Transition Brigade, the NeuroRestorative Residential 
Treatment Center in Germantown, MD, and at WCC's ``Healing Quarters'' 
in Brookeville, MD.
    Based on my experience as a licensed social worker and certified 
service dog instructor, I developed the concept of using the training 
of service dogs for fellow Warriors as a therapeutic intervention for 
the symptoms of combat trauma experienced by hundreds of thousands of 
returning Veterans. The program I designed specifically addresses the 
three symptom clusters associated with PTSD; re-experiencing, avoidance 
and numbing, and arousal. Working with Golden and Labrador Retrievers 
specially bred for health and temperament, Warrior Trainers must train 
the dogs to be comfortable and confident in all environments. In 
teaching the dogs that the world is a safe place, the Warrior Trainers 
challenge their symptoms of combat stress. By focusing on preparing the 
dogs for service as the partners of disabled Veterans, they are 
motivated and able to visit places they usually avoid, like stores, 
restaurants, and crowded public transportation stations. The program 
also emphasizes positive reinforcement, emotional affect, consistency, 
and patience--tools that make Warrior Trainers better parents and 
improve their family relationships.
    Since launching the first therapeutic service dog training program 
as a privately funded pilot at the Palo Alto VA Trauma Recovery Program 
at Menlo Park in July 2008, I have seen significant improvement in 
symptoms of PTSD and TBI in participating Veterans. In some cases, this 
safe, non-pharmaceutical intervention has benefitted patients who were 
not responding to any other treatments being offered by their medical 
providers. Based on positive feedback from wounded Warriors and their 
clinical providers, the program has expanded to several new sites and 
is being sought by other treatment facilities caring for injured combat 
Veterans. In response to these encouraging patient outcomes, the House 
Armed Services Committee included the following language in its report 
accompanying the 2014 National Defense Authorization Act:
    The committee is aware that recovering service members in treatment 
at the National Intrepid Center of Excellence (NICoE) and Walter Reed 
National Military Medical Center are reporting improvement in their 
symptoms of Post-Traumatic Stress Disorder (PTSD) and Traumatic Brain 
Injury (TBI) when participating in the service dog training programs 
currently operating in those facilities. In addition, clinical 
observations support the benefits of this animal-assisted therapy 
modality to psychologically injured service members, including: 
decreased depressive symptoms, improved emotional regulation, improved 
sleep patterns, a greater sense of purpose, better reintegration into 
their communities, pain reduction, and improved parenting skills. The 
committee urges the Secretary of Defense to consider making this 
promising new therapeutic intervention more available to service 
members suffering from the invisible wounds of PTSD and TBI. Therefore, 
the committee directs the Secretary of Defense to conduct such studies 
as may be necessary to evaluate the efficacy of service dog training as 
an adjunctive treatment for PTSD and TBI and to maximize the 
therapeutic benefits to recovering members who participate in the 
programs. The committee further directs the Secretary to provide a 
report not later than March 1, 2015 to update the congressional defense 
committees.
    WCC is currently collaborating with NICoE, WRNMMC, the Uniform 
Services University of the Health Sciences (USUHS), and civilian 
academic experts, to conduct research on the therapeutic service dog 
training programs at WRNMMC and NICoE. I look forward to obtaining the 
necessary scientific data to establish service dog training as an 
evidence-based treatment for the invisible wounds of war.
    Despite anecdotal evidence of the benefits of service dog training 
therapy on the psychological injuries of wounded Warriors, and almost 
daily news reports of Veterans who say that dogs have helped them to 
deal with symptoms of combat stress, the Department of Veterans Affairs 
(VA) presently does not support the provision of service dogs for 
psychological injuries. It is my understanding that the VA is waiting 
for the results of the VA research study mandated by the 2010 National 
Defense Authorization Act before officials will consider revising VA 
policy with regard to service dogs for psychological disabilities. 
Unfortunately, as Subcommittee Members are aware, the VA research study 
has been significantly delayed and wrought with problems. Last month, 
the VA published a solicitation for service dogs to be used in the 
study. As a clinician and a member of the Assistance Dogs International 
(ADI) Subcommittee charged with recommending tasks to be carried out by 
service dogs for psychiatric disabilities, I was alarmed to read 
through the tasks the VA is requiring the dogs to perform for the 
study. They included blocking (standing in front of the Veteran to give 
them space), sweeping rooms for intruders, barking at intruders, and 
standing behind the Veteran to give them space. In my view, these tasks 
support symptoms of PTSD by reinforcing cognitive distortions, rather 
than mitigate them and will distract Veterans from addressing their 
challenges to fully reintegrate into their communities and families. 
Clearly there is a need for mental health experts, government policy 
makers, and service dog industry representatives to come together to 
develop standards and best practices for service dogs that will support 
our Nation's Veterans with psychiatric disabilities.
    Results from the VA research study will not be available for 
several years. Meanwhile, hundreds of thousands of returning Service 
Members and Veterans with psychological injuries and their families are 
struggling to find treatments that will help heal the invisible wounds 
of war. Service dog training therapy programs at VA and DOD medical 
facilities offer combat Veterans a continuing mission to help their 
disabled brothers and sisters, as well as an innovative Animal Assisted 
Therapy for their invisible wounds. Each dog participating in the 
program touches the lives of approximately 60 wounded Warriors during 
training. The Warrior Trainers benefit from the close interactions with 
the dogs without the responsibilities of ownership. They also learn 
about the use, care, and training of service dogs. In some cases, 
Warriors may experience significant improvement in their symptoms, 
lessening their need for a service dog. When and if Warrior Trainers 
eventually decide to apply for a service dog to assist them with their 
disabilities, their experience working with service dogs in training 
sets them up for success with their new canine partners.
    Veterans seeking industry standard service dogs often wait years on 
the waiting lists of the nonprofit organizations that provide them. The 
need for well-trained service dogs to support Veterans from the recent 
conflicts will remain for many decades to come. Creating additional 
program sites will enable more recovering Warriors to benefit from this 
Animal Assisted Therapy modality, while increasing the number of 
service dogs available to be placed with disabled Veterans. In my 
testimony to the Subcommittee on similar legislation in July 2011, I 
stated that when it comes to training dogs for Veterans, no one takes 
that task more seriously than those who served by their sides in 
conflict. After working alongside wounded Warriors these past six 
years, I am more convinced of that than ever.
    Several Veterans who have participated in the training program have 
gone on to become professional service dog trainers and will continue 
to serve the needs of their fellow Warriors and other persons with 
disabilities.

Collaborative opportunities between VA and DoD

    Warrior Canine Connection is currently operating the therapeutic 
service dog training program at both VA and DoD treatment centers. Both 
Departments are individually engaged in funding and carrying out 
research studies to fully understand the efficacy of using dogs to help 
Veterans and Service Members with PTSD. Collaboration between the VA 
and DoD would enhance their individual efforts as well as offer cost 
sharing opportunities. The Bob Woodruff Foundation recently sponsored a 
convening at the National Intrepid Center of Excellence to focus on the 
use of service dogs and Animal Assisted Therapy in helping Veterans 
with the invisible wounds of war. The convening included VA and DoD 
policy makers, mental health providers, researchers and service dog 
SME's. The convening was a great first step in fostering discussion and 
future collaboration related to using dogs to support the recovery of 
returning Veterans. The therapeutic service dog training concept 
resonated with almost all who attended the convening as an innovative 
Complementary Alternative Medicine (CAM) modality.

H.R. 183

    As you are aware, legislation to create a VA pilot program on 
service dog training therapy has been approved by the U.S. House of 
Representatives in the past two Congresses. While VA officials have 
recognized the therapeutic value of the program at VA Menlo Park, and 
indicated that the Secretary does not need Congressional authorization 
to create a VA pilot program on service dog training therapy, the WCC 
program at VA Menlo Park continues to be supported exclusively by 
private donations.
    The provisions of H.R. 183 are based on the original program 
launched in 2008 at VA Menlo Park through the Recreation Therapy 
Department. Since that time, service dog training therapy has been 
incorporated into additional programs at that facility. Consequently, 
it may be more appropriate at this point to provide the Secretary with 
more discretion to tailor the pilot program on this CAM modality to the 
needs of the Veterans at individual pilot sites.
    In the past, all matters associated with service dogs have been 
delegated to the VA's Dept. of Prosthetics and Sensory Aid Services 
(PSAS). As reflected in the Congressionally mandated VA Inspector 
General's report on the VA Guide and ServiceDog Program, PSAS officials 
have been very slow to implement the VA's authority to provide service 
dogs to disabled Veterans and to provide related education and outreach 
to VA medical providers and Veterans. Since the pilot program 
established by the Veterans Dog Training Therapy Act is clearly first 
and foremost a mental health intervention and CAM modality, I would ask 
that the VA's Office of Patient Centered Care and Cultural 
Transformation be considered to take the lead on this effort, working 
closely with VA Mental Health consultants to maximize the therapeutic 
benefits to Veterans.
    I appreciate this opportunity to provide my views on this 
legislation to create a VA pilot program on service dog training 
therapy. Based on my experience working with wounded Warriors, I know 
that making this CAM modality more widely available will contribute 
significantly to the psychological healing of returning Veterans.
    Financial disclosure associated with the statement for the record 
of Rick A. Yount, Executive Director, Warrior Canine Connection
    Rick Yount serves as an individual contractor providing service dog 
training therapy and education to patients and their family members at 
the National Intrepid Center of Excellence (NICoE) in Bethesda, MD. 
Funding for his services at NICoE and associated expenses are being 
provided through a NICoE (DoD) subcontract under which he received 
$121,240 annually in calendar years 2012 and 2013.

                                 

                        WOUNDED WARRIOR PROJECT

    Chairman Benishek, Ranking Member Brownley, and Members of the 
Subcommittee: Thank you for inviting Wounded Warrior Project (WWP) to 
offer views today on legislation under consideration by the 
Subcommittee. Working closely with warriors who have sustained wounds, 
injuries, and illnesses in service since 9/11, WWP brings an important 
perspective to your deliberations regarding the VA health care system 
and the statutory framework under which it operates. Several bills on 
your agenda address issues of importance to our warriors, though we 
also want to alert the Subcommittee to concerns raised by other 
measures. For the record, however, we are concerned that today's agenda 
does not include either legislation or draft legislation to extend the 
VA's Assisted Living Pilot Program. That program has been an important 
resource for warriors who have sustained traumatic brain injuries and 
have required specialized residential rehabilitation. With veterans who 
need this level of care now ``locked out'' of the program and others at 
risk of being discharged prematurely, we renew our request that this 
Subcommittee move legislation at the earliest opportunity to lift the 
program's ``sunset.''

Expanding Access to Care for MST-Related Conditions

    WWP welcomes the Subcommittee's consideration of legislation to 
remove barriers to care and treatment for MST-related conditions. The 
importance of early access to counseling and treatment as well as 
assuring the quality and effectiveness of treatments for health 
problems associated with MST cannot be overstated. Researchers report 
that MST is an even stronger predictor of PTSD than combat \1\ and 
victims' reluctance to report these traumatic incidents can also result 
in delaying treatment for conditions relating to that experience.\2\ 
In-service sexual assaults have long-term health implications, 
including PTSD, increased suicide risk, major depression and alcohol or 
drug abuse and without outreach to engage victims of MST on needed 
care, the long-term impact may be intensified.\3\ With the VA reporting 
that some 1 in 5 women and 1 in 100 men seen in its medical system 
responded ``yes'' when screened for MST4 and the Department of Defense 
reporting that 26,000 active duty service members experienced a sexual 
assault in 2012,\4\ it is clear that there is a great need for 
resources, support, and effective treatment for those who are coping 
with health issues as a result of an in-service assault. While 
researchers cite the importance of screening for MST \5\ and associated 
referral for mental health care, many victims do not currently seek VA 
care. Indeed, researchers have noted frequent lack of knowledge on the 
part of women veterans regarding eligibility for and access to VA care, 
with many mistakenly believing eligibility is linked to establishing 
service-connection for a condition.\6\ A recent survey of WWP Alumni 
further demonstrates the great challenges in getting needed treatment 
for warriors affected by MST. Almost half of the respondents indicated 
accessing care through VA for MST related conditions was `Very 
difficult'. And of those who did not seek VA care, 41% did not know 
they were eligible for such care. In our view, there is still a lot of 
work to do to improve care and treatment for veterans with MST related 
conditions.
---------------------------------------------------------------------------
    \1\ D. Yaeger, et al.'' DSM-IV Diagnosed Posttraumatic Stress 
Disorder in Women Veterans With and Without Military Sexual Trauma,'' 
21(S3) J Gen Internal Medicine S65-S69 (2006).
    \2\ Rachel Kimerling, et al., ``Military-Related Sexual Trauma 
Among Veterans Health Administration Patients Returning From 
Afghanistan and Iraq,'' 100(8) Am. J. Public Health, 1409-1412 (2010).
    \3\ M. Murdoch, et al., ``Women and War: What Physicians Should 
Know,'' 21(S3) J. of Gen. Internal Medicine S5-S10 (2006).
    \4\ U.S. Dept. of Veterans' Affairs and the National Center for 
PTSD Fact Sheet, ``Military Sexual Trauma,'' available at http://
www.ptsd.va.gov/public/pages/military-sexual-trauma-general.asp.
    \5\  http://www.defense.gov/transcripts/
transcript.aspx?transcriptid=5233
    \6\ See Donna Washington, et al., ``Women Veterans' Perceptions and 
Decision-Making about Veterans Affairs Health Care,'' 172(8) Military 
Medicine 812-817 (2007).
---------------------------------------------------------------------------
    With these challenges in mind, WWP offers our strong support for 
H.R. 2527 and H.R. 2974, which, respectively, would expand eligibility 
to counseling and treatment for MST-related conditions for veterans 
whose sexual trauma occurred during inactive duty training and provide 
eligibility for beneficiary travel for veterans seeking treatment or 
care for MST through VA. As the Subcommittee's important oversight work 
has documented, however, the scope of the problem is not limited to 
access to care. Testimony at a recent Subcommittee hearing provided 
strong evidence that both the Department of Defense and the VA are 
failing to provide adequate mental health services for veterans who had 
been assaulted by fellow service members. Veterans at that hearing 
detailed troubling, yet similar experiences relating not only to access 
to VA care, but to inadequate screening, providers who were either 
insensitive or lacked needed expertise, and facilities ill-equipped to 
appropriately care for MST survivors. \7\
---------------------------------------------------------------------------
    \7\ http://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=101095
---------------------------------------------------------------------------
    We commend the VA for taking significant steps (described at the 
Subcommittee's February 26th oversight hearing) to improve veterans' 
screening and care for MST-related conditions. To date, however, too 
many warriors still have not received timely, effective treatment. In 
short, wide gaps remain between well-intentioned policies and on-the-
ground practice. With those concerns, we urge the Committee to continue 
to pursue these issues through oversight, to include conducting a 
searching inquiry as to whether VA has yet achieved the level of mental 
health staffing needed to meet the mental health needs of our veterans. 
Further, we urge that such oversight focus on improving access to MST-
related care and training providers, as needed, to provide effective 
screening and appropriate, sensitive care for those seeking treatment 
for MST-related conditions.

Legislation to Address Operational Challenges: H.R. 2661 and H.R. 4198

    We are unable to support two other bills, in particular, H.R. 2661 
and H.R. 4198, that propose to address operational challenges inherent 
in the administration of a health care system. H.R. 2661 would direct 
VA to implement a policy ``to ensure'' that a veteran enrolled in VA's 
health care system is able to schedule an appointment, within seven 
days in the case of primary care and within 14 days in the case of 
specialty care, of the date that the veteran or provider requests. The 
bill sets additional expectations VA is to achieve to further that 
policy.
    In testifying before the Subcommittee in the past at hearings 
examining VA mental health care, WWP expressed deep concerns with the 
long waits warriors have encountered at many facilities with regard to 
both initial and follow-up mental health care visits. Those concerns 
have not vanished. But while there are certainly systemic problems with 
VA scheduling practices and with the reliability of VA's mechanisms for 
reporting wait times, scheduling cannot be altogether divorced from an 
array of other, often complex issues. To focus solely on implementation 
of a scheduling policy, as proposed in H.R. 2661, is to fall short of 
remedying deeper problems and to risk compounding those that already 
exist.
    Repairing flaws in how VA accomplishes appointment-scheduling is 
unlikely by itself to ensure that veterans actually receive timely, 
needed treatment. To illustrate, sustained congressional oversight into 
severe timeliness problems in VA's provision of mental health care 
finally led to the Secretary's acknowledging in April 2012 a need for 
1900 additional mental health staff. Just as it is important to take 
account of the link between adequate staffing and timeliness, we urge 
the Subcommittee to work toward ensuring that VA care is not only 
timely, but effective. The establishment of rigid standards of 
timeliness (not goals, but requirements)--without regard to staffing 
levels or other limitations--can create (and has in recent experience 
in VHA led to) perverse incentives to ``game'' the system and even to 
institute practices that compromise care quality. Well-intentioned VA 
performance requirements too often lead to inappropriate practices. We 
offer the following relatively recent examples arising from VA efforts 
to set policy for mental health care:
         A VA facility at which practitioners were directed not 
        to ask veterans about their mental health problems lest it 
        become necessary to provide them treatment (as required by 
        performance measures) for which there was not adequate staff;
         VA facilities that have shifted staff to ensure that 
        veterans are ``seen'' within 14 days (to meet a metric) but 
        that, as a result, cannot begin real treatment until many weeks 
        later;
         A VA facility that has instructed staff to substitute 
        a diagnosis other than PTSD in instances where PTSD is a 
        patient's primary diagnosis to avoid having to meet performance 
        requirements relating to provision of evidence-based treatments 
        for PTSD.
         VA facilities that have prematurely placed veterans 
        who need individual therapy into group therapy that is being 
        ``counted'' inappropriately as meeting a performance metric.
    While we certainly acknowledge the importance of improving both 
VA's timeliness and systems for effective scheduling of appointments, 
we have real concern with setting rigid requirements that ignore not 
only patient acuity and differences between elective and necessary 
care, but overarching fiscal and other resource constraints. We do not 
in any way seek to minimize the importance of the issues raised by the 
Government Accountability Office in its report on the Reliability of 
Reported Outpatient Medical Appointment Wait Times and Scheduling 
Oversight. But we believe the well-intentioned prescription set in H.R. 
2661 is not the ``best medicine'' to cure the problem, and do not 
support its enactment.
    H.R. 4198 proposes to reinstitute a statutory reporting requirement 
established in 1996 that was aimed at preventing downsizing or even 
termination of certain specialized programs dedicated to the 
specialized needs of veterans with particular disabilities. A careful 
review of the impact of that well-intentioned law, and subsequent 
amendments to it, would likely call its effectiveness into question. 
The law employed 1996 as a baseline against which to gauge whether VA 
``maintained'' then-existing programs. While this bill does implicitly 
raise highly important issues, there has been too much change in the VA 
health care system to employ a 17-year old benchmark as the framework 
for judging whether VA programs and services are meeting some of our 
veterans' most critical needs. We are more than sympathetic to the 
concerns underlying the bill, but urge the Subcommittee to avoid 
missing this important mark by simply reinstating a reporting 
requirement that for a number of the programs it aims to protect is 
substantially outdated.

Mental Health Care

    H.R. 3387, the Classified Veterans Access to Care Act, would direct 
VA to establish standards and procedures to accommodate veterans' 
access to care without ``improperly disclos[ing] classified 
information.'' It is our understanding that this legislation was 
developed as a response to a disturbing instance of a patient (with 
knowledge of classified information) being prematurely placed in group 
therapy. We share a concern that veterans needing mental health care 
should be afforded that care in an appropriate and timely manner and, 
particularly, without being made to attend group therapy before they 
are offered needed individual treatment. That concern is not limited to 
situations where a patient feels unable to discuss mental health 
problems in a group setting because of an obligation not to disclose 
classified information. Congressional testimony that many VA medical 
centers have routinely placed patients in group-therapy settings rather 
than provide needed individual therapy \8\ highlights a broader problem 
than the bill addresses. As such, we recommend that the Subcommittee 
consider a more comprehensive solution than H.R. 3387 proposes. 
Providing effective care requires building a relationship of trust 
between provider and patient--a bond that is not necessarily easily 
established \9\ and setting the foundation for such trust should 
generally begin in individual treatment. We also urge more focus on the 
soundness and effectiveness of the VA's mental health performance 
measures, which currently track adherence to process requirements, but 
fail to assess whether veterans are actually improving.\10\
---------------------------------------------------------------------------
    \8\ VA Mental Health Care: Evaluating Access and Assessing Care: 
Hearing Before the S. Comm. on Veterans' Affairs, 112th Cong. (Apr. 25, 
2012) (Testimony of Nicholas Tolentino, OIF Veteran and former VA 
medical center administrative officer).
    \9\ VA Mental Health Care Staffing: Ensuring Quality and Quantity: 
Hearing Before the Subcommittee on Health of the H. Committee on 
Veterans' Affairs, 112th Cong. (May 8, 2012) (Testimony of Nicole 
Sawyer, PsyD, Licensed Clinical Psychologist).
    \10\ VA Mental Health Care Staffing: Ensuring Quality and Quantity: 
Hearing Before the Subcommittee on Health of the H. Comm. on Veterans' 
Affairs, 112th Cong. (2012) (Testimony of Ralph Ibson), supra note 21.
---------------------------------------------------------------------------
    A second measure, H.R. 183, would direct VA to carry out a five-
year pilot program to assess training service dogs as a therapeutic 
medium to treat mental health and posttraumatic stress disorder 
symptoms. In our work with Wounded Warriors, we hear from many 
individuals who have benefitted greatly from the use of a service dog 
for a mental health condition. We are also aware of reports suggesting 
incarcerated inmates have derived benefits from participating in 
programs in which they train service dogs. WWP is not able to assess 
the strength or existence of evidence that might suggest that training 
dogs offers promise as a mode of therapy for veterans with mental 
health conditions. More importantly, however, H.R. 183 is in the nature 
of a directed research program. Given many other competing claims on 
VA's budget, we believe that decisions to fund research initiatives, 
however appealing they may appear, should be based on a peer-review 
evaluation process. However meritorious this proposal may be, we would 
urge the Subcommittee to discourage the direction of VA research. While 
we do not support H.R. 183, WWP is certainly not opposed to innovation. 
To the contrary, we are supportive of finding innovative ways to engage 
more veterans in needed mental health care. In that regard, we have 
specifically supported approaches that would integrate complementary 
medicine into traditional practices as well as using complementary 
practices as a gateway to evidence-based services to engage veterans 
who, for example, might otherwise be reluctant to seek or accept mental 
health treatment.

Hearing-Related Issues

    With WWP's most recent annual survey of our wounded warriors 
showing that nearly 18% of our survey respondents report having severe 
hearing loss, evaluation, care and services for hearing-impaired 
veterans is certainly a concern. As such, we welcome the Subcommittee's 
consideration of hearing-related issues. In that regard, H.R. 3508 
would set standards for, and authorize appointment under Title 38 to, 
hearing aid specialists, and require VA to report annually on timely 
access to hearing health services and contracting policies with respect 
to providing those services.
    As discussed above, wait times for treatment and needed VA services 
is an overarching issue. And as discussed above, and in a recent IG 
audit report on VA's Hearing Aid Services,\11\ the adequacy of VA 
staffing is an important dimension of providing timely service.
---------------------------------------------------------------------------
    \11\ VA Office of Inspector General, ``Audit of VA's Hearing Aid 
Services,'' 12-02910-80 (Feb. 20, 2014).
---------------------------------------------------------------------------
    As with other VA services, there appears to be variability in the 
timeliness of VA hearing-related services. WWP field staff who reported 
very recently on their experience in several regions of the country 
advised that ``warriors still have general complaints with wait times 
for appointments, [but] not any more so for hearing assistance than any 
other service,'' and even that ``many [WWP staff and warriors] reported 
that hearing evaluations and administering of services (aids, battery 
replacements, etc.) are one of the more expedited facets of the VAMC.'' 
Another, however, cited ``lag[s in service] universally around my 
region.'' Such delays could certainly continue to grow as earlier 
generations of veterans age, and hearing impairments worsen.
    While WWP has no position on H.R. 3508, we do believe VA has much 
more work to do--across a broad range of health care services--to 
address the adequacy of health care staffing and the timeliness (as 
well as the effectiveness) of its provision of services. We would 
encourage the Subcommittee to continue to press VA on these important 
issues.
    Finally, we applaud the Subcommittee's efforts to resolve the 
longstanding difficulty associated with authorizing major medical 
facility leases, and welcome the draft authorization bill being 
considered today.
    Thank you for your consideration of our views.

                                 

                               VetsFirst

    Chairman Benishek, Ranking Member Brownley, and other distinguished 
members of the subcommittee, thank you for the opportunity to share 
VetsFirst's views on four of the bills under consideration today.
    VetsFirst, a program of United Spinal Association, represents the 
culmination of over 65 years of service to veterans and their families. 
We advocate for the programs, services, and disability rights that help 
all generations of veterans with disabilities remain independent. This 
includes access to Department of Veterans Affairs (VA) financial and 
health care benefits, housing, transportation, and employment services 
and opportunities. Today, we are not only a VA-recognized national 
veterans service organization, but also a leader in advocacy for all 
people with disabilities.

H.R. 3508, To Amend Title 38, United States Code, To Clarify the 
Qualifications of Hearing Aid Specialists of the Veterans Health 
Administration of the Department of Veterans Affairs, and for Other 
Purposes

    VetsFirst believes veterans should have timely access to 
professional hearing care services to ensure a higher quality of life.
    The VA's Office of Inspector General's February 2014 audit of 
hearing aid services found that VA was not timely in issuing new 
hearing aids to veterans and meeting its 5 day timeliness goal. The 
report indicated that VA audiology staff attributed the hearing service 
delays to inadequate staffing.\1\ In addition to providing hearing aid 
services, these staff members are also required to conduct compensation 
and pension examinations.
---------------------------------------------------------------------------
    \1\  U.S. Department of Veterans Affairs, Office of Audits and 
Evaluations, Audit of VA's Hearing Aid Services, February 20, 2014.
---------------------------------------------------------------------------
    Tinnitus and hearing loss were the most prevalent service-connected 
disabilities in FY 2012 for veterans receiving disability 
compensation.\2\ It is concerning that VA has not adequately 
anticipated the demand for hearing services, and in turn created a 
staffing model to meet the challenge. I, like many veterans of all 
eras, have experienced acoustic trauma due to my military service.
---------------------------------------------------------------------------
    \2\ Ibid.
---------------------------------------------------------------------------
    With the prevalence of explosions from artillery, and the sound of 
rifle-fire in training operations and combat operations, it is not 
surprising that many veterans have hearing loss. Audiology staff having 
to divide their time between compensation and pension exams is 
understandable. However, not adjusting current staff workloads 
appropriately to meet the timeliness delay is not acceptable.
    This legislation would allow VA to appoint hearing aid specialists 
to assist veterans in receiving quicker access to needed services. 
These professionals are licensed in their respective states and can 
provide robust services that include: hearing testing; determining 
necessity for hearing assistive devices; performing hearing aid 
adjustments; taking impressions for ear molds, and providing counseling 
and aural rehabilitation. These hearing aid specialists have received 
extensive training and hundreds of professionals are currently entering 
the industry. The legislation's reporting requirements related to wait 
times and contract referrals will also help identify remaining gaps in 
hearing care services.
    VetsFirst strongly supports H.R. 3508.

H.R. 183 Veterans Dog Training Therapy Act

    Service animals promote independence for people with disabilities 
and break down societal barriers; thus, promoting community 
reintegration. Consequently, VetsFirst supports efforts to ensure that 
properly trained service animals are available to veterans who can 
benefit from their assistance.
    This legislation would require VA to establish a pilot program to 
allow veterans with mental health needs to train service dogs for 
fellow veterans with disabilities. Specifically, this legislation 
addresses two critical needs by providing service dogs to veterans who 
are seeking the assistance of a service dog and giving veterans with 
post-deployment mental health concerns or post-traumatic stress 
disorder the opportunity to benefit from training these dogs. The dual 
nature of this approach will assist a wide range of veterans.
    Veterans who assist with training the service dogs will be required 
to follow a structured training process to ensure that the animals are 
properly trained. The legislation also requires VA to collect data 
regarding the effectiveness of the program. Lastly, veterans 
participating may even be able to use the skills they acquired as a 
trainer to successfully pursue a career in the service animal field.
    VetsFirst strongly supports H.R. 183.

H.R. 2527 To Amend Title 38, United States Code, To Provide Veterans 
With Counseling and Treatment For Sexual Trauma That Occurred During 
Inactive Duty Training

    VetsFirst knows that access to VA health care is a lifeline for 
many veterans who seek assistance for mental health conditions that may 
result from military sexual trauma (MST).
    Reservist and Guard personnel who are serving their weekend duty 
requirements are not considered to be on Active Duty under the law. 
Instead, these personnel are on Inactive Duty for Training (IADT) 
status. Title 38 currently excludes these service members from 
accessing needed VA counseling and treatment due to MST.
    This legislation would provide Reservist and Guard personnel who 
suffer an MST while on IADT status with access to related health care 
services at VA. MST assaults occurring during military service can have 
a devastating impact on a service member's mental health and well-
being. Timely access to quality VA health care is critical in assisting 
these service members with the counseling and treatment they need. This 
bill would expand those services to a greater number of our brave men 
and women.
    VetsFirst strongly supports H.R. 2527.

H.R. 2974 To Amend Title 38, United States Code, To Provide for the 
Eligibility for Beneficiary Travel for Veterans Seeking Treatment or 
Care for Military Sexual Trauma in Specialized Outpatient or 
Residential Programs at Facilities of the Department of Veterans 
Affairs, and for Other Purposes

    VetsFirst strongly supports access to beneficiary travel for 
veterans requiring treatment at VA health care facilities.
    This legislation would expand beneficiary travel to veterans who 
need specialized outpatient or residential VA health care due to MST. 
We strongly believe that expanding access to beneficiary travel to 
include MST survivors sends a message that encourages veterans to 
pursue the treatments currently available for these conditions. By 
receiving the care they need, we hope that veterans who have 
experienced MST will be able to more fully reintegrate into their 
community.
    VetsFirst strongly supports H.R. 2974.
    Thank you for the opportunity to present our supportive views on 
these important pieces of legislation. We believe that passage of these 
bills will be of great value to veterans with disabilities. This 
concludes my statement.

Information Required by Clause 2(g) of Rule XI of the House of 
Representatives

    Written testimony submitted by Christopher Neiweem, Director of 
Veterans Policy, VetsFirst, a program of United Spinal Association; 
1660 L Street, NW, Suite 504; Washington, DC 20036. (202) 556-2076, 
ext. 7702.
    This testimony is being submitted on behalf of VetsFirst, a program 
of United Spinal Association.
    In fiscal year 2012, United Spinal Association served as a 
subcontractor to Easter Seals for an amount not to exceed $5000 through 
funding Easter Seals received from the U.S. Department of 
Transportation. This is the only federal contract or grant, other than 
the routine use of office space and associated resources in VA Regional 
Offices for Veterans Service Officers that United Spinal Association 
has received in the current or previous two fiscal years.
    Christopher J. Neiweem is the Director of Veterans Policy at 
VetsFirst, which is a program of United Spinal Association.
    Mr. Neiweem began his tenure with the organization in September 
2013. His responsibilities include promoting the policy priorities of 
VetsFirst to the U.S. Congress, White House, federal agencies, and 
veteran service organization community.
    He has been advocating for veterans at the federal level since 
2011. After spending 6 years in the U.S. Army Reserve, which included a 
deployment to Iraq in 2003 to detain prisoners and support base 
security as a military police soldier, he attended college in his home 
state of Illinois. Chris completed a Bachelor's Degree in Political 
Science at Northern Illinois University, which included a summer 
internship in the Washington, DC office of Congressman Donald Manzullo. 
He went on to graduate school utilizing the Post 9-11 G.I. Bill and 
completed a Master's Degree in Political Affairs, at the University of 
Illinois at Springfield. During graduate school he completed 2 
internships. The first at Springfield-based consulting firm Cook Witter 
Inc., and the other for the U.S. Senate campaign of now Senator Mark 
Kirk.
    Since graduation Chris relocated to the Washington, DC area where 
he uses his experience in policy and military affairs to impact the 
federal benefits and services of our nation's veterans at VetsFirst.

                                 

                        QUESTION FOR THE RECORD

    Context of Inquiry: On February 26, 2014, Dr. Robert Petzel, Dr. 
Robert Jesse, Dr. Rajiv Jain, Dr. Madhulika Agarwal and Mr. Phillip 
Matkovsky testified before the HVAC-Health committee at a hearing 
titled: ``VA Accountability: Assessing Actions Taken in Response to 
Subcommittee Oversight''. There were seven deliverables from the 
hearing.

    Question 1: Please provide the complete list of specialty care 
services that have not yet implemented productivity standards.

    Response: Specialties scheduled for implementation during the 3rd 
and 4th quarters this year:

         Cardiology
         Pulmonary/Critical Care
         General Surgery
         Physical Medicine and Rehab
         Anesthesiology
         Emergency Medicine
         Laboratory/Pathology
         Geriatrics

    Question 2: Please provide an examination of the need for and 
potential incorporation of whistleblower protections for Veterans 
reporting military sexual trauma.

    Response: As noted by Committee Member Kuster, the Department of 
Defense is currently reforming policies regarding Servicemembers' 
protection against retaliation after reporting experiences of military 
sexual assault. VHA cannot conceive of a scenario where a parallel set 
of policies in VHA would be necessary.

         Disclosures of MST to a VA staff member would be 
        considered protected health information and thus subject to the 
        provisions of the Health Insurance Portability and 
        Accountability Act (HIPAA). Penalties for unauthorized use of 
        medical record information are already covered under HIPAA and 
        do not need to be duplicated by VA MST-specific whistleblower 
        protections.
         VA does provide care for some active duty 
        Servicemembers or Reservists who later return to active duty. 
        In these cases, VA medical record information may be shared 
        with the Department of Defense. If a disclosure of MST noted in 
        a Servicemember's medical record subsequently led to 
        retaliation against the Servicemember, the transgression would 
        presumably be covered under the Department of Defense's 
        whistleblower protections. Again, there is no need for a 
        parallel set of VA policies.
         Eligibility for VA care is independent of any 
        Department of Defense disciplinary or other proceedings, unless 
        the Veteran was to ultimately receive an Other Than Honorable 
        or Dishonorable discharge. If this discharge were the result of 
        retaliation, this would also presumably be covered by the 
        Department of Defense's whistleblower protections.

    Question 3: The Circumstances surrounding the six members of the 
SES who had ``serious disciplinary actions'' taken against them over 
the last two years.

    Response: The Department is currently working to provide the 
circumstances surrounding the six members of the SES who has 
disciplinary actions taken and will provide this information as soon as 
possible.

    Question 4: Provide a report on MST anonymous callers (Mystery 
Shopper).

    Response: The MST anonymous caller initiative targets a potential 
barrier to accessing MST-related care: difficulty contacting the MST 
Coordinator at a VHA health care facility. The initiative was first 
authorized in June 2010, and four rounds of review have been conducted 
since at an approximately yearly interval.
    During each round, two members of the MHS national MST Support 
Team--one female and one male--placed calls to the primary switchboard 
phone number of each facility during normal business hours. Following a 
standard script, callers asked for assistance in reaching the facility 
MST Coordinator. Calls were rated based on the ability of operators and 
other frontline staff (e.g., clinic clerks) to identify the MST 
Coordinator, the seamlessness of the transfer, and staff members' 
courtesy and sensitivity to callers' privacy concerns. Each facility 
was rated as Satisfactory, Marginal, or Unsatisfactory based on results 
from both calls. All facilities with a Marginal or Unsatisfactory 
rating received detailed feedback on the calls, and, to date, have 
submitted action plans to VA Central Office to address the identified 
issues negatively impacting MST Coordinator accessibility.
    The MST Support Team has taken several steps to assist facilities 
with preparing for the calls and with writing action plans. These 
include hosting a webinar presentation on the initiative, disseminating 
tip sheets of strategies on increasing and maintaining accessibility, 
and consulting with MST Coordinators to problem solve identified 
barriers.
    The initiative has been successful in improving nationwide MST 
Coordinator accessibility. In Round 4 (Aug-Sep 2013), 83.6% of 
facilities were judged to have Satisfactory accessibility, 13.6% 
Marginal, and 2.9% Unsatisfactory. These results represent a nearly 30 
percentage point improvement in Satisfactory accessibility and 16 
percentage point drop in Unsatisfactory accessibility since Round 1 
(Jul-Aug 2010).

    Question 5: Provide the FY 2013 Office of Productivity and 
Efficiency's staffing standard report for MST (measuring the number of 
MST patients that VA facilities are treating and the staff resources 
available to treat them).

    Response: The Annual Report on Counseling and Treatment for 
Military Sexual Trauma (MST) for Fiscal Year (FY) 2013 is currently 
being reviewed and we will provide the report to you as soon as it is 
available.

    Question 5a: Please also provide information paper on the (2) FTE 
for MST.

    Response: Please see below for the methods and results regarding 
decision to have (2) FTE for MST.

Methods

         The VA MHS MST Support Team completes an annual report 
        to determine the number of trained full time equivalent 
        employees (FTEEs) required to meet the mental health needs of 
        Veterans who have experienced MST, to fulfill the requirements 
        of 38 United States Code, Section 1720D(e). Because MST is 
        associated with a variety of mental health conditions and is 
        treated across multiple outpatient treatment settings, we could 
        not rely solely on the number of providers in a given mental 
        health service line or clinic. Therefore, we relied on methods 
        developed by the VA Office of Productivity, Efficiency, and 
        Staffing (OPES) to quantify workload associated with MST-
        related mental health care and calculate the effective number 
        of FTEEs associated with this care at each VA Health Care 
        System (HCS). From this we created a metric so that staffing 
        levels could be compared across facilities.
         Each VA HCS varies in the number of Veterans that it 
        serves who have experienced MST and therefore varies in the 
        demand for MST-related mental health care. To enable 
        comparisons across facilities, we calculated a ratio of 
        provider staffing against population size: the total FTEEs 
        providing MST-related mental health care for every 100 Veterans 
        with positive MST screens. It is important to note that not all 
        Veterans with a positive MST screen will want treatment and 
        among those that do request care, the amount of MST-related 
        care required by each Veteran will vary due to the range of 
        mental health conditions associated with MST. But in general, a 
        larger staffing ratio indicates greater staffing and 
        availability of MST-related mental health services.
         We examined the amount of MST-related mental health 
        care that each VA HCS provided and ranked facilities on two 
        indicators: (1) The proportion of Veterans with a positive MST 
        screen who received any MST-related mental health care; and (2) 
        the median number of visits among patients who received MST-
        related mental health care. We identified health care systems 
        that ranked in the top 25% for both indicators. We then used 
        staffing ratio data from these ``high volume'' VA health care 
        systems to establish the benchmark.
         The benchmark of 0.2 FTEE per 100 Veterans (or 2 FTEE 
        per 1,000 Veterans) who experienced MST is based on a 
        comparison with these ``high volume'' VA health care systems. 
        This benchmark is within two standard deviations of the average 
        staffing ratio at high volume health care systems. Even 
        staffing levels that are only a portion of a single FTEE 
        represent portions of workload from several different providers 
        due to the wide range of mental health conditions and clinic 
        settings associated with MST-related mental health care.

Results

         Knowledgeable in the treatment of MST-related mental 
        health conditions. In the most recent analysis, 99 percent of 
        VA health care systems were at or above the established 
        benchmark for MST-related mental health staffing capacity. Over 
        64,000 Veterans received MST-related mental health care from a 
        VA health care facility. These Veterans received a total of 
        over 693,000 MST-related mental health care visits from over 
        17,950 individual providers. Not all of those 17,950 individual 
        providers, however, spent all of their clinical hours 
        delivering MST-related mental health care. The care delivered 
        by those providers was equivalent to 580 FTEEs.
    Question 6: Provide the committee with information about the VA 
employees that were held accountable for patient deaths at the Augusta 
VAMC and the Atlanta VAMC.
    Response: Disciplinary actions for Atlanta and Augusta are below:

Disciplinary Actions

Atlanta VAMC

         Chief of Staff--Reprimand
         Associate Director--Reprimand
         Associate Director/Nursing and Patient Care Services--
        Reprimand
         Chief, Mental Health Service Line--Reassigned
         Mental Health Inpatient Nurse Manager--Reprimand
         Associate Nurse Executive/Mental Health and 
        Geriatrics--Reprimand
         Mental Health Inpatient Unit Medical Director--
        Admonishment
         Former Medical Center Director--Retired
         Veterans Integrated Service Network (VISN) Chief of 
        Mental Health Services--Retired

Augusta VAMC

         Chief of Staff--Received Performance Counseling 
        (Voluntarily resigned from position)

    Question 7: Please provide the timeline for VHA to contribute to 
the State Prescription Drug Monitoring Program.

    Response: VA participation with State Prescription Drug Monitoring 
Program is estimated to begin August 2014. This is predicated on a 
contract award by May 5, 2014, with a contract start shortly after 
award. The timeline includes achieving Milestone 2 (development enters 
implementation phase) by May 30, with code changes to other patches and 
Medication Order Checking Application (MOCHA 2.0) completed, 
documentation updated, and identification of additional test sites by 
the end of June. It is expected that this work would enter the national 
release process near the middle of July with testing and deployment 
leading to a mid-August completion. The State Drug Monitoring Program 
patch is dependent on MOCHA 2.0 which will deploy in waves between 
March 24, 2014 and June 16, 2014, as well as a titration management 
patch that will start simultaneously with the State Drug Monitoring 
Program patch. There are potential risks of delays to the August 2014 
start date that could arise from dependencies that include contract 
start date and unforeseen technical issues with states that are not 
part of the test site process. The VA Office of Information and 
Technology is responsible for oversight and management of software 
development and deployment for this program.

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