[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]










  LEGISLATIVE HEARING ON: H.R. 1319; H.R. 1603; H.R. 1904; H.R. 2639; 
   H.R. 3234; H.R. 3471; H.R. 3549; DRAFT LEGISLATION, THE PROMOTING 
RESPONSIBLE OPIOID MANAGEMENT AND INCORPORATING MEDICAL EXPERTISE ACT; 
     AND, A VA LEGISLATIVE PROPOSAL, THE VA PURCHASED HEALTH CARE 
                   STREAMLINING AND MODERNIZATION ACT

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

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

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

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                       TUESDAY, NOVEMBER 17, 2015

                               __________

                           Serial No. 114-44

                               __________

       Printed for the use of the Committee on Veterans' Affairs


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



         Available via the World Wide Web: http://www.fdsys.gov
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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               CORRINE BROWN, Florida, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         MARK TAKANO, California
DAVID P. ROE, Tennessee              JULIA BROWNLEY, California
DAN BENISHEK, Michigan               DINA TITUS, Nevada
TIM HUELSKAMP, Kansas                RAUL RUIZ, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana             KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana             TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York                 JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American 
    Samoa
MIKE BOST, Illinois
                       Jon Towers, Staff Director
                Don Phillips, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

                    DAN BENISHEK, Michigan, Chairman

GUS M. BILIRAKIS, Florida            JULIA BROWNLEY, California, 
DAVID P. ROE, Tennessee                  Ranking Member
TIM HUELSKAMP, Kansas                MARK TAKANO, California
MIKE COFFMAN, Colorado               RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio               ANN M. KUSTER, New Hampshire
RALPH ABRAHAM, Louisiana             BETO O'ROURKE, Texas

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















                            C O N T E N T S

                              ----------                              

                       Tuesday, November 17, 2015

                                                                   Page

Legislative Hearing On: H.R. 1319; H.R. 1603; H.R. 1904; H.R. 
  2639; H.R. 3234; H.R. 3471; H.R. 3549; Draft Legislation, The 
  Promoting Responsible Opioid Management And Incorporating 
  Medical Expertise Act; And, A VA Legislative Proposal, The VA 
  Purchased Health Care Streamlining And Modernization Act.......     1

                           OPENING STATEMENTS

Dan Benishek, Chairman...........................................     1
Julia Brownley, Ranking Member...................................     2
    Prepared Statement...........................................    40
Gus Bilirakis, Member............................................     3
    Prepared Statement...........................................    44
Mike Coffman, Member.............................................    28
Ron Kind, U.S. House of Representatives, 3rd Congressional 
  District; Wisconsin............................................    29
John Kline, U.S. House of Representatives, 2nd Congressional 
  District; Minnesota, Prepared Statement only...................    43

                               WITNESSES

Honorable Beto O'Rourke, U.S. House of Representatives, 16th 
  Congressional District; Texas..................................     5
Honorable Andy Barr, U.S. House of Representatives, 6th 
  Congressional District; Kentucky...............................     6
    Prepared Statement...........................................    40
Honorable Matt Cartwright, U.S. House of Representatives, 17th 
  Congressional District; Pennsylvania...........................     9
    Prepared Statement...........................................    41
Honorable Scott Peters, U.S. House of Representatives, 52nd 
  Congressional District; California.............................    10
    Prepared Statement...........................................    41
Honorable Martha Roby, U.S. House of Representatives, 2nd 
  Congressional District; Alabama................................    11
    Prepared Statement...........................................    42
Honorable Jackie Walorski, U.S. House of Representatives, 2nd 
  Congressional District; Indiana................................    13
    Prepared Statement...........................................    42
Adrian Atizado, Deputy National Legislative Director, Disabled 
  American Veterans..............................................    17
    Prepared Statement...........................................    45
LaRanda D. Holt, Assistant Director for Women and Minority 
  Veterans Outreach National Veterans Affairs and Rehabilitation 
  Division, The American Legion..................................    19
    Prepared Statement...........................................    49
Carlos Fuentes, Senior Legislative Associate, National 
  Legislative Service, Veterans of Foreign Wars of the United 
  States.........................................................    20
    Prepared Statement...........................................    54
Janet Murphy, Acting Deputy Under Secretary for Health for 
  Operations and Management, Veterans Health Administration, U.S. 
  Department of Veterans Affairs.................................    31
    Prepared Statement...........................................    58

        Accompanied by:

    Elias Hernandez, Chief Officer, Workforce Management and 
        Consulting, Veterans Health Administration, U.S. 
        Department of Veterans Affairs

    Harold Kudler, Chief Consultant for Mental Health Services, 
        Veterans Health Administration, U.S. Department of 
        Veterans Affairs

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

                       STATEMENTS FOR THE RECORD

American Counseling Association..................................    72
American Orthotic and Prosthetic Association.....................    74
AMVETS...........................................................    76
Kentucky Department of Veterans Affairs..........................    79
National Mobility Equipment Dealers Association..................    80
Paralyzed Veterans of America....................................    81
Heather Simcakoski...............................................    85
Marvin Simcakoski................................................    86
Susan Mosley, Prepard Statement only.............................    86
 
  LEGISLATIVE HEARING ON: H.R. 1319; H.R. 1603; H.R. 1904; H.R. 2639; 
   H.R. 3234; H.R. 3471; H.R. 3549; DRAFT LEGISLATION, THE PROMOTING 
RESPONSIBLE OPIOID MANAGEMENT AND INCORPORATING MEDICAL EXPERTISE ACT; 
     AND, A VA LEGISLATIVE PROPOSAL, THE VA PURCHASED HEALTH CARE 
                   STREAMLINING AND MODERNIZATION ACT

                              ----------                              


                       Tuesday, November 17, 2015

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 10:04 a.m., in 
Room 334, Cannon House Office Building, Hon. Dan Benishek 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Benishek, Bilirakis, Roe, 
Huelskamp, Coffman, Wenstrup, Abraham, Brownley, Ruiz, Kuster, 
O'Rourke.
    Also Present: Representative Walorski.

           OPENING STATEMENT OF CHAIRMAN DAN BENISHEK

    Mr. Benishek. The Subcommittee will come to order.
    Before we begin, I would like to ask unanimous consent for 
our colleagues, Congresswoman Jackie Walorski from Indiana and 
Congressman Ron Kind from Wisconsin, to sit on the dais and 
participate in today's proceeding. Without objection, so 
ordered.
    Good morning and thank you all for joining us for today's 
legislative hearing.
    There are nine bills on our agenda this morning and three 
panels of witnesses ahead of us, so I will keep my comments 
short in the interest of time.
    The bills and legislative proposal that we will discuss 
this morning address a number of critical issues facing our 
veterans and the Federal agency tasked with caring for them, 
the Department of Veterans Affairs.
    Those issues include how to help struggling VA medical 
facilities, how to increase access to care for wounded warriors 
and those who have experienced military sexual trauma, how to 
improve the quality of the adaptive equipment provided to 
disabled veterans, and how to add fairness to the VA's broken 
billing system.
    I am particularly interested in our discussion surrounding 
Vice Chairman Bilirakis' draft bill, the Promise Act, which 
would address the over-reliance of opioid medication amongst 
our veterans.
    This Subcommittee has been and will continue to be 
aggressive in our oversight of VA's pain management programs. 
To be sure, chronic pain is complex and difficult to treat and 
prescription medication overuse is a national problem that is 
not unique to the VA health care system, but far too many of 
our veterans are going to VA facilities looking for ways to 
cope with their pain and being given nothing more than multiple 
prescriptions for high-risk medications.
    Some of these same veterans come to the VA already heavily 
reliant on a cocktail of medications initiated in treatment 
while on Active duty. Tragically, some of these veterans have 
lost their lives as a result of simply taking the medication as 
prescribed or in some cases have succumbed to the dangers of 
having too many high-potency opiates readily and fatally 
available.
    One of those veterans is Jason Simcakoski who inspired the 
Promise Act and its companion bill in the Senate. We are too 
late to help Jason or to ease the anguish that his family 
including his wife, Heather, and his father, Martin, who have 
submitted statements for the record have been left with. But we 
can promise to do better for those that come after him and I 
believe the Promise Act can help get us there.
    The last bill on our agenda today is a draft legislative 
proposal from the department that would grant the VA the 
authority to enter in provider agreements. This is similar to a 
bill H.R. 1369 that the Subcommittee considered in a 
legislative hearing earlier this year.
    Provider agreement authority may, in fact, be critical to 
moving VA forward. We must be careful that we do not take a 
short-sighted approach to solving one problem that VA is facing 
and as a result create a whole host of others.
    When considering whether to allow provider agreements that 
are not subject to traditional Federal acquisition regulation 
checks and balances, I want to be sure that appropriate 
controls are in place to protect our veterans and the taxpayer 
dollars that are supporting them.
    I am grateful to the sponsors of the bills that are being 
considered today and to all of our witnesses from our veteran 
service organizations and the VA for being here to share their 
views. I look forward to hearing their testimony.
    I now yield to the Ranking Member, Ms. Brownley, for an 
opening statement.

              OPENING STATEMENT OF JULIA BROWNLEY

    Ms Brownley. Thank you, Mr. Chairman, and thanks for 
calling this hearing today.
    It is important for us to, I think, review the legislation 
that has been referred to this Subcommittee and it is important 
to hear from our colleagues on their priorities and to hear all 
views on how to best protect the health of those men and women 
who dedicate their lives to protecting this Nation.
    I wanted to just highlight three bills today that I am a 
co-author on. And the first is Mr. O'Rourke's bill which I 
believe will greatly improve and enhance the way we survey our 
veterans to get the data that we need to provide good policy 
and relationship to how well our veterans are served.
    Also, Mr. Peters' bill which I believe again will enhance 
the VA's ability to hire more marriage and family therapists to 
provide more resources and more professionals that we need for 
the mental health of our veterans.
    And, finally, Ms. Walorski's bill which would enhance 
adaptive technology in our automobiles to make sure that our 
veterans who need that will receive automobiles that are rated 
and classified.
    In support of all three of those bills, I think all the 
bills before us are worthy. And I look forward to the testimony 
from our witnesses today and their views on how to improve upon 
the many bills that we are considering.
    So thank you and I yield back the balance of my time.

    [The prepared statement of Julia Brownley appears in the 
Appendix]

    Mr. Benishek. Thanks.
    I am honored to be joined this morning by several of my 
colleagues to speak in support of their legislation. With us 
today is the Honorable Beto O'Rourke from Texas; the Honorable 
Andy Barr from Kentucky who is not quite here yet; the 
Honorable Matt Cartwright from Pennsylvania; the Honorable 
Scott Peters of California; the Honorable Martha Roby from 
Alabama; the Honorable Jackie Walorski from Indiana; the 
Honorable John Kline from Minnesota who will shortly arrive, I 
hope; and the Honorable Gus Bilirakis from Florida.
    We are also joined by a veteran constituent of Mr. Barr's, 
Ms. Susan Moseley who is apparently going to speak during 
Representative Barr's time about her personal experience 
accessing care from the VA.
    Thank you all for being here this morning and thanks to 
Mrs. Moseley for your service.
    We will begin with Representative Bilirakis. Mr. Bilirakis, 
please explain your legislation. You have five minutes.

               OPENING STATEMENT OF GUS BILIRAKIS

    Mr. Bilirakis. Thank you very much, Mr. Chairman. Thanks 
for holding this hearing and agendaing my bill.
    Chairman Benishek and Ranking Member Brownley and 
distinguished Members of the House Subcommittee and my 
colleagues, thank you for holding this legislative hearing 
today.
    Today's hearing includes many important pieces of 
legislation that will improve the services and care for our 
veterans, the care our veterans receive for their dedicated 
service to our great Nation.
    Among the bills under consideration at today's hearing is 
my bill, the Promoting Responsible Opioid Management and 
Incorporating Scientific Expertise Act or the Jason Simcakoski 
Promise Act.
    [The attachment appears in the Appendix]
    Mr. Bilirakis. I appreciate the Chairman's leadership to 
bringing this important issue before the Committee and for 
allowing me to speak today on the Promise Act.
    The tragic death of Marine Corps veteran Jason Simcakoski 
in the Tomah, Wisconsin VA medical facility prompted the need 
for Congressional action.
    In August of 2015, nearly one year from Jason's death, the 
Office of Inspector General released a report titled Unexpected 
Death of a Patient During Treatment with Multiple Medications. 
The IG report concluded that Jason's cause of death was due to 
mixed drug toxicity with the potential for respiratory 
depression and a combination of various medications was a 
plausible mechanism of action for a fatal outcome.
    Furthermore, the IG also found deficiencies in the informed 
consent process, confusion among staff when initiating 
cardiopulmonary resuscitation, and the absence of certain 
medications available in emergency situations to reverse 
effects of possible drug overdose.
    I request unanimous consent to submit this IG report, Mr. 
Chairman, for the record in today's hearing materials.
    Mr. Benishek. Without objection.
    [The attachment appears in the Appendix]
    Mr. Bilirakis. Thank you.
    As the guidelines used by the VA and DoD for opioid 
management have not been updated since 2010, it is due time to 
ensure those treating our veterans have the necessary resources 
and training to effectively treat veterans with chronic pain.
    I want to be clear. The intent of this bill is to improve 
patient safety, not to restrict access for those who truly need 
their prescriptions for their wellness plan. The Promise Act 
will increase safety for opioid therapy and pain management by 
requiring the VA and DoD to update the clinical practice 
guidelines for management of opioid therapy for chronic pain 
ensuring VA opioid prescribers have enhanced pain management 
and safe opioid prescribing education and training and 
encouraging the VA to increase information sharing with State 
licensing boards.
    We have discussed this in the past, Mr. Chairman.
    This bill also promotes needed transparency within the VA 
and will further our efforts to hold the VA accountable by 
requiring GAO to report on recommendations for improvements and 
assess the level of care veterans are receiving.
    Additionally, the Promise Act will authorize a program on 
integration of complementary and integrated health within the 
VA and encourage more outreach and awareness of the patient 
advocacy program to educate veterans on their care options.
    Our veterans have sacrificed so much for our country and we 
have a responsibility to ensure they are receiving the quality 
of care they have earned and deserve. We must hold the VA 
accountable and encourage quality care for our veterans who 
have fought for the freedoms we enjoy on a daily basis.
    I want to thank the VSOs for their support and for 
appearing today to provide their testimony in today's 
legislative hearing. I also want to thank all my colleagues on 
this Committee, of course, and the whole House for your co-
sponsorship of this bill.
    And I appreciate it very much. Thanks for agendaing the 
bill. With this strong list of bipartisan support, we can send 
a clear message to the Simcakoski family, our veterans, and 
those that have been affected by such tragedies that we are 
dedicated to ensuring similar failures will never happen again.
    In closing, I am grateful we are here discussing these 
important bills. I look forward to having substantive 
discussion on how we can improve the lives of our true American 
heroes and upholding our sacred vow and promise to our 
veterans. I urge my colleagues to support this bill and co-
sponsor the Promise Act.
    I yield back, Mr. Chairman. Thank you so much.

    [The prepared statement of Gus Bilirakis appears in the 
Appendix]

    Mr. Benishek. Thank you.
    Mr. O'Rourke, you may proceed with your testimony. Thanks.

               OPENING STATEMENT OF BETO O'ROURKE

    Mr. O'Rourke. Thank you, Mr. Chairman and Madam Ranking 
Member, for having this hearing and then allowing me the chance 
to discuss the bill that we are proposing, the Ask Veterans 
Act.
    [The attachment appears in the Appendix]
    Mr. O'Rourke. And it is essentially based on experiences 
that we have had in the district I represent, El Paso, Texas, 
that I think are applicable to all of our districts.
    When I was sworn in in 2013, I began to hold regular town 
hall meetings and I was struck by the number of veterans who 
would attend them to tell me that they could not get in to get 
a primary or specialty or mental health care appointment.
    That was at direct odds to what I was hearing when I would 
follow-up with the VA. The VA in El Paso told me that, you 
know, the vast majority of veterans seeking care were seen 
within 14 days which at the time was the established basic 
minimum wait time for a veteran and yet the complaints 
persisted.
    And the VA was almost saying, you know, what you are really 
dealing with here, Beto, are some cranky, ornery veterans. You 
know, some of these folks, you just can't make them happy, but, 
you know, you got to take our word for it and here is the data. 
We are seeing everybody within the established period of time.
    Well, something just didn't add up. And so we commissioned 
an objective scientific, third-party survey with a margin of 
error under four percent to ask veterans directly what their 
experience has been at the VA. And what we saw in the results 
confirms what we were told by the veterans which is, they were 
waiting far longer than the VA had told us they were waiting.
    To give you an idea, on average, this is an average, 
veterans in El Paso waited over 80 days for a primary care 
appointment, over 70 days for a mental health care appointment. 
And what was truly shocking and confirmed stories that I had a 
hard time believing when I was told by veterans when we first 
took office was that more than one-third of the veterans 
surveyed who tried to obtain a mental health care appointment 
could not obtain one at all, not in 14 days, not 30 days, not a 
year, just not ever.
    And that data helped us to apply targeted pressure to the 
VA on where they needed to do a better job for veterans in our 
community. And to the VA's credit, they were very responsive to 
that and they didn't resist the facts as told by the veterans. 
They have worked to try to make things better.
    We conducted this survey again this year, got similar 
results. There were some improvements, but people are waiting 
far too long and there is still a crisis in access to mental 
health care.
    I think we learned after the Phoenix wait time scandal and 
my experience in El Paso, and you may have similar experiences 
in your districts, that we cannot ask the VA how the VA is 
doing and always expect an honest answer. You know, shame on 
them the first time this happens. Shame on us if it happens 
going forward.
    For us to truly hold them accountable, there needs to be an 
independent verification of the veterans' experience at each of 
the VA medical facilities in each of our districts. And so this 
bill would simply require that the VA contract with an 
independent third-party to assess true wait times, not the 
preferred wait times which I still don't understand how that 
works.
    But from the moment you, the veteran request an appointment 
until that appointment is actually granted and you are actually 
seeing your provider, not when it was scheduled, but when you 
are seeing the provider, we want to measure that wait time. We 
want to measure wait times across primary, specialty, and 
mental health care and we want to measure veterans' 
satisfaction with the care that they received both at the VA 
and care that they received in the community.
    This bill also requires that the VA work with veteran 
service organizations in each of our communities to make sure 
that we are asking the right questions, that we are getting at 
concerns that VSOs and veterans have with the quality and 
access and timeliness of health care in a given community. And 
then the VA must publish these reports publicly on the Web for 
everyone to see and to be held accountable.
    And so that, in essence, is a very short simple bill. That, 
in essence, is what the Ask Veterans Act would do. And with 
that, I yield back.

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

    Mr. Benishek. Thanks. Nice.
    Mr. Barr, I am going to yield to you for 30 seconds and 
then to Ms. Moseley for four minutes and 30 seconds.

                 OPENING STATEMENT OF ANDY BARR

    Mr. Barr. Thank you, Chairman Benishek and Committee 
Members, for allowing me the opportunity to present my 
legislation, H.R. 1603, the Military Sexual Assault Victims 
Empowerment Act, also referred to as the Military SAVE Act.
    [The attachment appears in the Appendix]
    Mr. Barr. Two years ago, several veterans visited my 
district office to share with me their powerful and heartfelt 
stories. They told me about how they had survived military 
sexual trauma during their service but now faced with the task 
of navigating the bureaucracy at the VA. They explained that 
they were unable to access the individual care that they needed 
from the VA.
    I would like to introduce one of those veterans, Specialist 
Susan Moseley of the U.S. Army, who helped inspire me to 
introduce the Military SAVE Act. She is a courageous woman, a 
survivor of military sexual trauma and I am pleased to 
introduce her to the Committee today.
    [The statement of Andy Barr appears in the Appendix]
    Ms. Moseley. Good afternoon. I am so grateful to be in 
front of you all today.
    I entered into the military over almost 20 years ago. I 
went in like the typical youngster does not knowing what you 
want to do with your life. Going through basic training and AIT 
for your schooling, I thrived. It was the most amazing 
experience I ever had in my life.
    Then I showed up to my permanent duty station in El Paso, 
Texas at Fort Bliss where I was instructed which unit I would 
be going to. There was a female soldier that was there and she 
said I am sorry to tell you, but you are going to Foxtrot. I 
thought, huh, what does that mean. She said you need to find a 
boyfriend. Top is pretty handsy and likes girls like you. I was 
taken aback. Really? This is my future?
    I spent six months working very diligently to learn my job, 
be a good soldier, and represent the people that I was there to 
serve. I was in a patriot missile systems battery which we 
rotated in and out of Southwest Asia. And I was first assaulted 
within six months of arriving at my permanent duty station by 
the top ranking enlisted member of our unit, the first sergeant 
or Top as many enlisted people call him.
    Then I began to avoid him, tried to do everything that I 
could to do my job and stay away from him. So then he decided 
to move me into being his assistant. So I was in the CQ and my 
office was directly across from his. I spent long, long periods 
of time in trying to turn it around and instead of him 
manipulating me, me manipulate him into how, if I was going to 
be assaulted, it was going to be on my terms.
    So instead of him raping me at my desk, I would say, okay, 
I will give you a little handy J. That was the only way I could 
get to the point that I wouldn't be torn down to nothing. My 
dignity was lost and I had no idea how I was going to get 
through it.
    In the military, you are told where to go, what to do, how 
to dress, and where to be. The only thing you couldn't or the 
only thing that no one could control for me was what I ate. So 
I developed an eating disorder. And when I developed that 
eating disorder, it was the only sense of power I had.
    Once they realized that I had a problem, they sent me to 
the Army hospital which decided to send me to a treatment 
facility. My commander and Top showed up at the hospital that 
day and when I was at the lowest of low knowing that I had no 
power and no control over my life, Top whispered in my ear we 
are good, right, which meant you are not going to say anything. 
I said, yeah, we are fine.
    But I knew I had to do something. I am not the kind of 
person to sit back and allow someone to violate me and let that 
be okay. I knew that my end of service time was coming and 
after I came back from treatment, I walked into my commander's 
office and I informed him that I wanted to press charges.
    I was then sent to CID where I was given a lie detector 
test, a lie detector test as a victim. I passed that lie 
detector test. And my end of term of service came and I was 
leaving to come home to Kentucky when the major in the unit ran 
out into the parking lot when I was getting into a vehicle to 
leave and called me you lying whore and slut. How dare you say 
things to which many people which were in my unit began to join 
in with him.
    So my exit from the military was being called a whore after 
I had been in Southwest Asia and done everything I could to 
support and defend the United States of America.
    When I came back, my transition coming into out of the 
military and into the VA was quite difficult. I went into a 
reclusive state that many of us go into where we just avoid 
everything. I didn't know what had happened to me had a name to 
it. There was something that happened to me and I could go and 
I could get help.
    The VA did not help with that process for me. I eventually 
after about 16 years found a therapist who had been trained in 
Bay Pines which is at the VA there who specializes in military 
sexual trauma and knew how to treat us.
    We were given the opportunity to have great treatment, but 
we could only be seen every three weeks by her. And she, on 
every Friday gave up her lunch so we could have a group time, 
but that was all the VA could offer us. We had those groups 
until she left the VA. At that point in time, she agreed to see 
some of us at her home.
    Many of us that live out of certain areas get travel pay to 
come to the VA. But if you went to go see Karen at her home, 
you could not receive that travel pay which meant getting and 
receiving and maintaining that continuity of care was broken 
because people could not go and see her.
    The therapists that were introduced to us once Karen left 
had little to no training. And when you had been so violated, 
so violated to the core, it takes several, several visits 
before you can even begin to trust the therapist that is 
sitting in front of you.
    I was told that I could be seen once a month. How can a new 
person I had never known see me once a month and think that I 
could overcome and be a more productive member of society? It 
just doesn't happen that way. You have to have more access to 
care and be able to be treated as needed.
    Unfortunately in the not too recent, it was probably about 
six months ago, we had a member of our group who committed 
suicide. She shot herself in the stomach. She left a note to 
her son which said she did it this way so she could die slowly 
because she thought that that is what she deserved. After 
wearing a uniform, that is what she deserves? That is what she 
deserves, to die slowly?
    I had many problems at the VA where I have been required to 
take off my clothing. That is a very uncomfortable position for 
people like me. So I decided I was going to do something about 
it and I went to my State Representative who led me to 
Congressman Barr. This legislation is so important for us to be 
able to go to these specialists that can help us.
    In Lexington, Kentucky, it took fee-for-service almost six 
months to find me a female doctor to go see for one of my 
problems. There are many, many, many things that, many doctor 
positions that need to be filled by females. There needs to be 
a priority in hiring and a priority in health care for us to be 
able to walk in the door and be treated by females.
    When I went into the emergency room, I sat for seven hours 
and I was told by a female I was lucky there was a female that 
was on duty that day. Really? In a whole hospital, there is not 
any more than one female that day?
    It needs to be a priority that there is a female in every 
specialty that is available to every veteran so that no matter 
when you have a problem, you can have these problems addressed 
so that you can go out and you can do the things that you need 
to do to be a good parent.
    I can say without a doubt and it probably will choke me up, 
but I can truly say that if my daughter hadn't been born, I, 
too, probably would have been one of those statistics that 
would have not--I just wouldn't be here. And my daughter has 
given me the strength to go out.
    Still to this day, I struggle with triggers. I have to 
every day go out. I have to think about where I am going, who I 
am going to be around, what is going to happen, is there an 
entry, is there an exit. Everything in my mind is that MST 
brain that I have because I have to figure out constantly am I 
safe.
    I had to stop getting on People Finder--
    Mr. Benishek. You have very compelling testimony and I 
really appreciate you being here, but--
    Ms. Moseley. I understand.
    Mr. Benishek [continued]. unfortunately, we have a time 
situation where we want to hear from everyone. But thank you 
very much--
    Ms. Moseley. Thank you.
    Mr. Benishek [continued]. for being here, Ms. Moseley.
    Mr. Cartwright, you are recognized.

              OPENING STATEMENT OF MATT CARTWRIGHT

    Mr. Cartwright. Thank you, Mr. Chairman.
    Chairman Benishek, Ranking Member Brownley, and the Members 
of the Committee, thank you for including today H.R. 1904, the 
Wounded Warrior Workforce Enhancement Act, as part of your 
hearing today and for the opportunity to speak to the 
Subcommittee about this very important piece of legislation.
    [The attachment appears in the Appendix]
    Mr. Cartwright. I want to say it is an honor for me to 
appear before the Veterans' Affairs Committee and its Health 
Subcommittee. I also want to express my gratitude to the 
American Orthotics and Prosthetics Association as well as to 
Senator Durbin as they have been instrumental in focusing 
attention on this critical issue facing our Nation's veterans.
    The field of orthotics and prosthetics is at a critical 
tipping point in terms of the future viability of its workforce 
and the ability of those professionals to provide the best 
tailored care to our Nation's servicemembers and veterans.
    In its testimony, the American Orthotics and Prosthetics 
Association stated that there has been an approximately 300 
percent increase in the number of veterans with amputations 
served by the VA since the year 2000. Unfortunately, currently 
only 7,100 practitioners specially training in O&P nationwide 
serve more than 80,000 veterans with amputations.
    Of those trained practitioners, one in five is either past 
retirement age or is eligible to retire in the next five years, 
so we have a dwindling workforce we are working with.
    However, there are only 13 schools around the country with 
master's degree programs in this field with the largest program 
supporting fewer than 50 students. And with the growing demand 
of amputee treatment outpacing the number of new practitioners 
trained to replace an aging workforce, it is clear we must act 
now to meet our moral obligation of providing our heroes with 
the best health care available.
    The Wounded Warrior Workforce Enhancement Act is a cost-
effective approach to assisting universities in creating or 
expanding accredited master's degree programs in orthotics and 
prosthetics.
    Specifically this bill addresses these issues by 
authorizing a competitive grant program of $5 million a year 
for three years to help colleges and universities develop 
master's degree programs focusing on orthotics and prosthetics.
    The bill also requires the VA to establish a center of 
excellence in prosthetic and orthotic education to provide 
evidence-based research on the knowledge, skills, and training 
clinical professionals need to care for veterans.
    This past week, I actually ran into a professional in 
orthotics and he introduced himself as an orthotist. And I 
didn't know what that was, but all of the physicians on the 
panel already knew what that was. And then I explained this 
bill to him and he was very grateful, a gentleman from 
Nashville, Tennessee actually.
    These prosthetic and orthotic treatments serve soldiers who 
suffered limb loss injuries because they put their bodies on 
the line for our country and as a result had their lives 
forever changed. With Veterans Day just last week, it is a very 
good reminder to us all just how much we owe to our wounded 
warriors.
    Again, I want to express my gratitude, Mr. Chairman 
Benishek, Ranking Member Brownley, and Members of this 
Committee, for your consideration of this bill today and for 
bringing attention to the important issue of providing veterans 
with the very best possible prosthetic and orthotic treatment 
available.
    Thanks so much.

    [The prepared statement of Matt Cartwright appears in the 
Appendix]

    Mr. Benishek. Thank you very much.
    Representative Peters, please go ahead.

               OPENING STATEMENT OF SCOTT PETERS

    Mr. Peters. Thank you, Mr. Chairman.
    Good morning, Mr. Chairman, Ranking Member Brownley, and 
Members of the Subcommittee. Thank you for inviting me here to 
discuss the Marriage and Family Therapist for Veterans Act.
    [The attachment appears in the Appendix]
    Mr. Peters. So we all know that the veterans, and you 
mentioned this before, the VA's challenge to meet the need for 
counselors among which are marriage and family therapists or 
MFTs. In 2006, Congress enacted legislation that permits the VA 
to employ licensed MFTs.
    But the problem is that the VA takes a very restrictive 
view of which MFTs it can employ. It limits its pool to MFTs 
that graduate from a school that has been specifically 
accredited by a certain accreditation organization, the 
Commission on Accreditation for Marriage and Family Therapy 
Education or COAMFTE, a nationwide accreditation.
    What it excludes is a number of MFTs who have graduated 
from schools that have long relied on established regional 
accreditation systems. These systems existed long before the 
COAMFTE accreditation was even established.
    So, unfortunately, the VA's interpretation, their 
limitation to that one accreditation system means that MFTs who 
are qualified to practice in their home states can't walk 
across the street and apply for a job to work at the local VA 
for an MFT opening.
    So my bill would simply specify that the VA can hire State 
accredited MFTs in addition to the ones that have graduated 
from schools that are accredited by COAMFTE.
    In Florida, for instance, there is only one school that 
meets the VA's qualification standards which excludes a major 
portion of graduates from that state. Florida's situation is 
similar to California and New York.
    At this time, the California licensure and accreditation 
process has been established for 15 years with well-trained and 
qualified individuals heading into the job market, but because 
of this interpretation by the VA, they are not eligible to work 
at the VA.
    So the bill simply opens up the employment eligibility for 
those who have the proper training. It does not require 
additional work on the part of the VA. It preserves the VA's 
discretion over who they hire. It just enlarges the pool from 
which they can select applicants.
    So I appreciate the support the bill has already gotten 
from Members here and look forward to working with everyone 
here to enhance the care our veterans receive. Thank you for 
the work you do and thanks for your consideration.

    [The prepared statement of Scott Peters appears in the 
Appendix]

    Mr. Benishek. Thanks.
    Representative Roby, please go ahead.

                OPENING STATEMENT OF MARTHA ROBY

    Ms. Roby. Mr. Chairman, Ranking Member, thank you for your 
time today and the other Members of the Subcommittee for your 
consideration of H.R. 3234, the Failing VA Medical Center 
Recovery Act.
    [The attachment appears in the Appendix]
    Ms. Roby. As you recall, we have had major problems for an 
extended period of time in my district at the Central Alabama 
Veterans Healthcare System. We call it CAVHCS. The litany of 
scandals captured national headlines, including unacceptable 
wait times, the unearthing of thousands of unread x-rays, some 
of which detected cancer, I might add, a VA employee caught 
taking a drug rehab patient to a crack house and never 
disciplined until we publicly exposed it, the CAVHCS director, 
James Talton, lying directly to me, a Member of Congress, 
retaliation against whistleblowers, and, finally, the 
termination of James Talton, the first termination in the 
Nation of a director in the wake of the wait list scandal that 
has swept the Nation.
    I cannot overstate the malfeasance that took place during 
his tenure and the lasting harm that he inflicted on our 
veterans in Alabama. At the same time, his termination was well 
over a year ago. To this day, we still don't have a permanent 
director and the hiring of other key staff has been extremely 
slow.
    While progress has been made, wait times, particularly for 
outside care, remain unacceptable. Given the challenges that we 
have faced in Alabama and the bureaucratic and cultural hurdles 
to turn around a troubled medical center, I have introduced 
this bill, the Failing VA Medical Center Recovery Act.
    Today the VA lacks the organization, structure, and tools 
for swiftly addressing problems at the worst performing medical 
centers. Furthermore, there is little direct accountability at 
the very top for turning around an especially troubled medical 
center.
    This legislation focuses on the most dysfunctional medical 
centers in the Nation, ones that need major innovation and 
oversight at the highest levels of the VA.
    These two to seven medical centers are determined by 
objective criteria, a composite score derived from the VA's own 
SAIL data which measures key health metrics. Similar to how a 
State school superintendent would take over the day-to-day 
operations of a failing school, this legislation requires the 
establishment of highly specialized teams to take over the day-
to-day operations of the worst VA facilities in the Nation, 
removing the medical centers from the failed local and regional 
VA leadership.
    Rapid deployment teams are empowered with enhanced legal 
authorities so they have the tools that they need to truly make 
a difference on day one. Legal authorities in this bill include 
direct hiring authority and the ability to pay up to 125 
percent of the prevailing rate to address critical vacancies, 
enhance personnel accountability authority for termination and 
transfers, simplified contracting authority.
    Given the challenging nature of this assignment, members of 
the team are eligible for enhanced compensation and receive 
favorable consideration for promotion with a two-year tour.
    The Office of Accountability and Review is required to 
prioritize whistleblower retaliation cases at failing medical 
centers, and the Inspector General is required to prioritize 
investigations related to failing medical centers.
    Upon sustained satisfactory performance for nine months 
measured by the SAIL data, these medical centers return to the 
operational control of local and regional leadership.
    The deployment teams are managed by the Office of Failing 
Medical Center Recovery. In the legislation today, this office 
is managed by a presidentially appointed Under Secretary who 
has a direct line of access to the Secretary of the VA.
    However, I recently met with the Under Secretary of Health, 
Dr. Shulkin, and I have accepted his recommendation that this 
office fall under his direct control in VHA and I am open to 
modifying this legislation accordingly. I also welcome his 
personal commitment that these failing medical centers will 
receive his close supervision.
    There are some objections on behalf of the VA and some of 
the veterans' organizations. I am happy to address those 
objections, but due to my rapidly decreasing amount of time, I 
will save that for any questions that you may have.
    What is clear here, though, Mr. Chairman, is that the 
status quo is not going to cut it. We have to do better on 
behalf of our veterans. And I understand any of your concerns 
and I appreciate your feedback.
    I am willing to work with anyone who truly wants to improve 
the VA through this proposal and others, but let me tell you 
what I am not going to do. I am not going to wait for a broken 
bureaucracy to fix itself, so I would appreciate this 
Committee's support on this piece of legislation.
    I am happy to answer any questions. Thank you. I yield 
back.

    [The prepared statement of Martha Roby appears in the 
Appendix]

    Mr. Benishek. Thank you very much.
    Mrs. Walorski, please go ahead.

              OPENING STATEMENT OF JACKIE WALORSKI

    Mrs. Walorski. Thank you, Mr. Chairman and Ranking Member 
Brownley and Members of the Committee. I appreciate being given 
the opportunity to discuss H.R. 3471, the Veterans Mobility 
Safety Act of 2015.
    [The attachment appears in the Appendix]
    Mrs. Walorski. And first, I would like to thank Chairman 
Benishek and Ranking Member Brownley for your support of co-
sponsoring this legislation.
    Automotive mobility plays a vital part in helping our 
disabled veterans live a normal life after being wounded on the 
battlefield. This legislation ensures these veterans receive 
the best adaptive equipment installation and service by 
requiring vendors who participate in the Department of Veterans 
Affairs' VA Automotive Adaptive Equipment or AAE Program to 
meet minimum certification or accreditation standards.
    The AAE Program provides eligible disabled veterans with a 
new automobile or modification such as wheelchair lifts, 
reduced effort steering and braking to existing vehicles in 
order to improve their quality of life.
    However, the VA does not require any type of certification 
or accreditation from vendors to install or sell these 
products. Since there are no requirements, VISNs operate based 
on their own interpretations of VA procedures which has 
resulted in VISNs using inferior vendors in an attempt to 
reduce costs.
    The modifications we are talking about are highly complex 
products which means a lack of quality in service requirements 
is putting the veteran and driving public at risk. Two cases in 
my home State of Indiana illustrate this danger.
    In the first case, the VA had a company install an easy 
lock system into a veteran's vehicle. An easy lock system is a 
wheelchair docking system that secures a wheelchair to the 
vehicle floor. However, the bolt was improperly installed by 
the company and kept getting caught on things.
    The veteran complained to the VA which sent him back to the 
dealer whose solution was to cut off the bolt on the bottom of 
the chair in order to give him more room. However, doing so 
meant that the wheelchair could not lock into position, 
something the veteran didn't realize until his chair moved when 
a car cut him off and he slammed on his brakes. Thankfully the 
veteran wasn't hurt, but it is an illustration of the needless 
danger caused by the lack of standards.
    In the other case, a dealer subcontracted an individual to 
come to a veteran's home to install a wheelchair lift. However, 
that individual never tested the lift. When the wheelchair was 
on the lift, it pushed the lift down causing it to catch on and 
damage his bumper.
    The VA had another dealer take a look at the lift. Their 
solution, remove the bumper. Finally, qualified professionals 
looked at the vehicle and concluded that the lift wasn't even 
compatible with the vehicle and should never have been 
installed in the first place.
    As a point of comparison, the VA currently requires a 
certification to sell a veteran a bottle of oxygen while the 
AAE Program uses an outdated handbook that was last updated in 
2000. This inconsistency of procedures has put veterans' lives 
at risk and resulted in taxpayer dollars being wasted on shoddy 
or improperly installed equipment.
    My bill H.R. 3471 ensures disabled veterans receive the 
best quality, performance, safety, and value by establishing a 
minimum set of standards for vendors who want to participate in 
the AAE Program.
    Specifically, the vendors of adaptive equipment 
modification services must be certified by a certification 
organization or the manufacturer of the adaptive equipment and 
must adhere to the Americans With Disabilities Act of 1990 and 
the National Highway Traffic Safety Administration's federal 
motor vehicle safety standards.
    Individuals performing these modification services must 
also be certified by either a certification organization or a 
manufacturer or the State.
    Lastly, this legislation puts the veteran in charge of what 
equipment he gets by giving them the opportunity to make 
personal selections of their automobiles or adaptive equipment.
    Disabled veterans have given so much for our country and 
they deserve the highest standard of mobility services. The 
robust, enforceable set of standards that are prescribed in 
H.R. 3471 will protect our veterans and the driving public 
while responsibly spending taxpayers' funds through the AAE 
Program.
    I look forward to working with the Members of this 
Committee, veteran service organizations, and the VA in 
addressing this critical issue for disabled veterans.
    And I thank you again, Mr. Chairman and Ranking Member 
Brownley, for this opportunity to speak today.

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

    Mr. Benishek. Thanks, Mrs. Walorski.
    Mr. Kline was unable to make the hearing this morning.
    I am not going to take time right now to ask any questions. 
Does anyone have any questions for the panel?
    Go ahead.
    Mr. Roe. Just one brief question for Ms. Roby.
    One of the problems that we have seen in VA is the more 
centralized it gets, it doesn't get better. The Veterans Choice 
Program is a perfect example of one that we initiated. And the 
more you send upstream here to Washington, the worse it seems 
to get.
    I think the accountability needs to be from here down to 
make sure. That was untenable what happened and obviously a 
failure of leadership, but I am not sure making it more 
bureaucratic and putting it up to people who are in charge that 
weren't successful to begin with is going to work.
    That is my true question. I understand exactly what you are 
saying, but we have just seen something that we intended and 
you intended when everybody in this room voted for the Veterans 
Choice Act. It didn't turn out like we thought it was going to 
and I am afraid they will have the same result here.
    I think you have just got to have accountability. We have 
people now who are in charge of those VISNs. They need to be 
fired if they are not doing the job. And then they need to have 
the director fired and that is what needs to happen.
    So we look instead of making it more bureaucratic, we need 
to hold people accountable and that is what has been lacking at 
the VA is accountability.
    Ms. Roby. Right. And so I would suggest to you if you look 
closely at this bill that it cuts through the layers of 
bureaucracy and does apply direct accountability to the Under 
Secretary of Health.
    These rapid deployment teams come in and they are given the 
tools that are necessary to clean house if that is exactly what 
needs to happen so they can assess the situation on the ground.
    I do a monthly call with my acting VISN 7 director, and I 
meet with him when necessary between those calls as well 
because of the malfeasance and mismanagement.
    And what we found, James Talton, the director that was 
fired at CAVHCS, just because he was fired, we haven't seen an 
improvement in the culture. This shows that it doesn't lie at 
the feet of one person.
    Yes, Mr. Talton created a culture there and he needed to be 
removed, but there are more bad actors and they are all 
pointing fingers at one another. And they are able to hide 
behind these layers of bureaucracy that exists in the VA.
    So as I used the example of a failing school system in the 
State of Alabama and I suspect in some of your states as well, 
the school superintendent can come in and take over the day-to-
day operations of a failing system. It is an embarrassment to 
everybody involved.
    Mr. Roe. But a director can do that now. There is no--
    Ms. Roby. What we are finding is that the directors and 
others responsible are not being removed.
    Mr. Roe [continued]. And, quite frankly, we had the Under 
Secretary of Health the last time that is now gone tell us that 
everything was hunky-dory at the VA. So I am not sure. I think 
you remember that.
    So, anyway, I yield back. That was the questions I had.
    Mr. Benishek. Mrs. Walorski.
    Mrs. Walorski. Ms. Moseley, I want to take a second and I 
think many of us involved on this Committee have worked for 
years long and hard to take the horrific thing that happened to 
you and the kind of environment that you had to tolerate as a 
member of the Armed Services fighting for our Nation and we are 
working as hard as we can and as fast as we can to eradicate 
military sexual assault from this military.
    And I just wanted to thank you for what you do and let you 
know that we are behind you. And we are working every day to 
make sure that we together are going to be able to say that we 
eradicated this and it is a safe place to serve.
    So I am so sorry for what you have had to endure, but your 
bravery coming here today does make a difference and we are 
taking steps forward. And you help make that happen, so thank 
you.
    Ms. Moseley. Thank you.
    My hope is that it will help the veterans that are coming 
home from the long bouts of war that we have been in so that 
they can get better care than I have.
    Mrs. Walorski. They absolutely will. Thanks for your 
bravery.
    Mr. Benishek. Ms. Kuster, you have a question?
    Ms. Kuster. Yes. Thank you.
    I just want to add to thanking you. This is a bipartisan 
issue that we have worked very closely on and will continue to. 
And I appreciate you coming forward.
    My question for Mr. Barr, and this is just more of a 
conundrum that we have on this Committee, is if we use the 
option of outside care, which makes a great deal of sense to 
me, I am in a rural area, there are times when you can't see 
the providers you need, will we run the risk of this issue not 
being taken seriously and being front and center going forward 
within the VA?
    That is my concern. I am afraid that if we turn our 
attention away that--I mean, this is something Mrs. Walorski 
and I have been working on. We have a large group of people. We 
have passed some pieces of legislation. I hesitate to let the 
VA off the hook and that is my question.
    Mr. Barr. I appreciate my friend and the gentle lady's 
question.
    And what I have found and discovered is that the simple 
introduction of this legislation that would empower victims and 
empower survivors of MST to choose their own care, to find that 
specialized care that they need actually is the feature, the 
reform feature that holds the VA accountable and actually gets 
the VA to do those things.
    And we have seen it in our own VA right in Central 
Kentucky. The fact that we introduced this legislation has 
resulted in response from the VA in terms of some hiring 
decisions and some reforms internally that have offered new 
veterans those services that they need within the VA.
    But regardless of those reforms and those improvements that 
we have seen, we still see a need for that immediate choice to 
ultimately give the veteran the power over his or her care. And 
so they can decide the therapist, the psychologist, the care 
provider that they deem to be most suitable for their 
particular situation.
    Ms. Kuster. Great. Thank you very much. And I will look 
into working with you on that and I appreciate it.
    And then I just wanted to thank Mr. Bilirakis for his bill. 
We have an opioid crisis in New Hampshire. I started a 
bipartisan taskforce that I encourage folks to join. Mr. 
Coffman has been so kind as to schedule a hearing coming up in 
December in New Hampshire.
    And on this opioid issue within the VA, we have some folks 
working in pain management that are doing some cutting-edge 
work that I am very excited to share through this hearing 
bringing down the prescriptions of opioids and using other 
methods of pain management.
    And so I just want to thank Mr. Bilirakis. I am going to be 
an original co-sponsor of his bill and look forward to working 
in a bipartisan way on this issue.
    Thank you, Mr. Chair.
    Mr. Benishek. Thank you.
    Well, if there is no further questions, the first panel is 
excused. Thank you.
    I would like to welcome the second panel to the witness 
table. Joining us on the second panel is Adrian Atizado, the 
Deputy National Legislative Director for the Disabled American 
Veterans; LaRanda Holt, the Assistant Director for Women and 
Minority Veterans Outreach for the National Veterans Affairs 
and Rehabilitation Division of The American Legion; and Carlos 
Fuentes, the Senior Legislative Associate for the National 
Legislative Service of the Veterans of Foreign Wars of the 
United States.
    Thank you all for being here and for your hard work and 
advocacy on behalf of our veterans. So I look forward to 
hearing the views of your members.
    And let's see. Mr. Atizado, you may begin when you are 
ready.

                  STATEMENT OF ADRIAN ATIZADO

    Mr. Atizado. Thank you, Mr. Chairman, Members of the 
Subcommittee.
    First I would like to thank you for inviting DAV to testify 
at this legislative hearing. As you know, our organization is 
nearly 1.3 million members. They are wartime service-disabled 
veterans.
    As an organization, we are dedicated to a single purpose 
and that is to empower veterans to lead high-quality lives with 
respect and dignity. So DAV is pleased to be here today to 
present our views on the bills under consideration by the 
Subcommittee. So for the sake of brevity, I will limit my 
remarks to three of these bills.
    First is H.R. 3549, the VA Billing Accountability Act. As 
we mentioned earlier, this bill would provide VA the authority 
to waive a required co-payment if the veteran received a VA 
notification more than 120 days from date of VA service or more 
than 18 months after the date of a non-VA facility service and 
that the notification was delayed due to the agency's error and 
that the VA would also need to provide information to veterans 
on arranging payment plans and applying for waivers.
    We support this legislation. We have a resolution passed by 
our membership regarding co-payments and ask for swift action 
on this bill.
    With regards to the draft bill, the Promise Act, DAV 
supports this bill based on a number of resolutions adopted by 
our membership at our most recent national convention. While VA 
has made recent efforts to address over-prescribing, its 
existing pain management program appears to be not well 
organized. It is also insufficiently staffed.
    We believe enactment of this bill would call attention to 
the need for VA to better manage and staff this function at 
both the national and local levels. DAV also believes this bill 
is a good first step toward improving the patient advocacy 
program to help veterans and family caregivers better navigate 
the VA health care system.
    We support the advent of complementary and alternative care 
in substitute of VA's use of pharmacological agents and to 
better respond to the preferences of younger, mostly younger, 
but some aging veterans as well who often do not want 
traditional medical management, especially if it involves 
prescribing of pain or psychotropic medications.
    We appreciate the sponsors introducing this omnibus 
proposal and we urge Congress to proceed with its enactment 
this year.
    Now, the last measure I would like to discuss is VA's 
legislative proposal which would give the agency the authority 
to enter into agreements for purchasing medical care from 
community providers.
    Now, according to VA, this proposal will streamline and 
speed the business process for purchasing care for an 
individual veteran when necessary care cannot be purchased 
through existing mechanisms such as contracts or sharing 
agreements.
    We support the intent of this draft legislation based on 
DAV resolution 217. However, we do recommend this measure be 
amended to add certain federally recognized providers of 
service with whom VA would be able to enter into an agreement 
with under the measure.
    These providers have served over 3,400 severely ill and 
injured veterans of all ages across 31 states, the District of 
Columbia, and Puerto Rico. Under this program, veterans are 
given the opportunity to determine their own supports and 
services. They themselves control it. This allows them to live 
independently in the community and stave off having to go into 
a nursing home.
    However, as with other community providers affected by the 
current situation, their arrangement with VA remains uncertain. 
This critical program's growth to become available at every VA 
medical center has been stymied for lack of VA's authority that 
would be provided under this measure.
    We urge this Subcommittee pass this measure to relieve the 
current unsustainable and untenable situation that is adversely 
affecting the lives of ill and injured veterans and their 
families.
    This concludes my testimony, Mr. Chairman. I would be happy 
to answer any questions you or other Subcommittee Members may 
have.

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

    Mr. Benishek. Thank you very much for your testimony.
    Ms. Holt, you may begin your statement.

                  STATEMENT OF LARANDA D. HOLT

    Ms. Holt. Thank you.
    Good morning, Chairman Benishek, Ranking Member Brownley, 
and Members of the Committee. I am privileged to be here today 
and to speak on behalf of The American Legion, our National 
Commander, Dale Barnett, and more than two million members in 
over 14,000 posts across the country that make up the backbone 
of the Nation's largest wartime veteran service organization.
    There are several good bills for discussion today and our 
full remarks are with you. I would like to focus on one key 
bill, H.R. 1603, Military Sexual Assault Victim Empowerment Act 
or the Military SAVE Act.
    This bill would amend the Veterans Access Choice and 
Accountability Act of 2014 which is to improve the private 
treatment of veterans who are victims of military sexual 
trauma. This bill would make victims of military sexual trauma 
potentially eligible for non-VA health care under the Veterans 
Choice Program.
    Ultimately this is about trying to find the right 
treatments and therapies for every veteran. And in the case of 
MST, unique circumstances can shape treatment and therapy 
needs.
    VA should be flexible to ensure these veterans receive the 
appropriate care they need in an environment that is conducive 
to the veteran's unique circumstances. MST if left untreated 
for veterans is a nexus to other mental health conditions such 
as PTSD, depression, substance abuse, and suicidal ideations.
    In the case of these survivors, ensuring they get the 
appropriate therap and treatment can mean the difference 
between a survivor continuing their treatment, abandoning 
treatment, and feeling further isolated and possibly 
escalations in their symptoms.
    The American Legion is deeply concerned with the challenges 
survivors of MST face and is urging Congress to ensure MST 
survivors can receive the right health care at the right place 
and at the right time.
    In January 2011, The American Legion launched a landmark 
women veteran survey which identified challenges women veterans 
face when receiving gender-specific health care for treatment 
of MST conditions throughout the VA health care facilities.
    The American Legion has since fought for better awareness 
training in the VA for MST sensitivity, significant increases 
in outreach, and to provide more comprehensive care options for 
MST survivors to include female therapists, group therapists, 
and other options for care for MST accessible to include care 
in their community.
    As noted in our written testimony, VA is working to improve 
their MST programs. However, as we know, changes within the VA 
can take time and even the best programs can have different 
results from one VA to another. The veterans should not have to 
suffer because the health care they need is not available in 
their local health care facility.
    The American Legion recognizes that the Choice Program was 
an emergency measure to make health care accessible to veterans 
where VA was struggling to deliver such care. In recognition of 
the needs of an integrated system to deliver non-VA health care 
when needed, The American Legion believes VA needs to develop a 
well-defined and consistent non-VA coordinated program, 
policies, procedures that include a patient-centered care 
strategy which takes veterans' unique medical injuries and 
illness as well as their travel and distance into 
consideration.
    For survivors of MST who are suffering right now, The 
American Legion believes they should have immediate access to 
prompt medical treatment either within the VA health care 
system or in their local community.
    As with an outside VA, The American Legion stresses the 
importance of ensuring non-VA health care has quality of care 
standards equal to or better than VA quality care standards. 
Additionally, the care MST survivors receive must be 
coordinated effectively and efficiently to ensure veteran 
health care is not adversely impacted.
    Most importantly, non-VA health care providers must have 
access to VA health care records and to the fullest extent 
possible make use of the electronic data information exchange 
to share patient health information.
    Again, I thank the Committee for their hard work and 
consideration for this legislation as well as your dedication 
to finding solutions for problems that stand in the way of 
delivery of veterans' health care. And I am happy to answer any 
questions.

    [The prepared statement of LaRanda D. Holt appears in the 
Appendix]

    Mr. Benishek. Thank you, Ms. Holt.
    Mr. Fuentes, please begin.

                  STATEMENT OF CARLOS FUENTES

    Mr. Fuentes. Chairman Benishek, Ranking Member Brownley, 
and Members of the Committee, thank you very much for the 
opportunity to present the views of the men and women of the 
VFW and our auxiliaries. I thank you for the opportunity and 
believe that the bills that we are discussing today are aimed 
at improving the health care VA provides our Nation's veterans 
and I thank you for bringing them forward. I would limit my 
remarks to bills we support and have recommendations to 
improve.
    The VFW supports the Ask Veterans Act, which would survey 
veterans to evaluate their views and experiences seeking VA 
health care. When the VA access crisis erupted in April, 2014 
the VFW turned to our members to gauge their experiences and 
evaluate the access issues from their perspectives. The 
information we obtained through surveys was invaluable. It 
helped us shape our health care policy agenda and develop 
recommendations to improve the VA health care system.
    Currently, VA conducts a number of surveys to measure 
veterans' experiences and evaluate its progress in meeting 
strategic goals. However, frequent surveys only sample veterans 
who have recently used VA health care and surveys that sample 
all veterans are not frequent enough. That is why we urge the 
Committee to require the legislation's survey to include a 
sample of all veterans, not just recent VA patients.
    The VFW supports the Wounded Warrior Workforce Enhancement 
Act, which would expand availability of orthotic and prosthetic 
care. Orthotists and prosthetists are vital to ensuring VA 
provides the prosthetic care and services veterans have earned 
and deserved. For this reason we urge the Committee to amend 
this legislation by adding a requirement that grant recipients 
offer reduced or no cost education to students who enter into a 
service agreement with VA similar to service agreements under 
other VA health professionals education assistance programs.
    The VFW also supports the VA Billing Accountability Act, 
which would ensure veterans are promptly notified of their 
copayment obligations and would require VA to waive copayments 
if it fails to properly notify veterans. Earlier this year, 
more than 1,400 veterans were charged more than $500,000 for 
five years worth of health care received at the Minneapolis VA 
Medical Center. While disheartening, VA charging veterans for 
years of copayments is not rare. The VFW continues to hear from 
veterans that VA has sent them large bills for care they either 
had no idea they were liable for or were unaware they had not 
paid. This legislation ensures veterans are not punished for 
VA's inability to get its house in order. However, the VFW 
recommends that the Subcommittee allow VA to evaluate whether 
the 120-day and 18-month requirements for notifying veterans of 
copayments obligations are aligned with industry best 
practices.
    The VFW also supports the Promise Act, would reduce VA's 
reliance on pharmacotherapy to treat mental health and complex 
pain conditions, expand VA research, education, and delivery of 
complementary and alternative medicine, and improve VA internal 
audits. Countless veterans have experienced firsthand the 
dangerous side effects of pharmacotherapy. High dose pain 
medications if incorrectly prescribed have been proven to 
render veterans incapable of interacting with their loved ones 
and even contemplate suicide. This legislation would reform the 
way VA treats complex pain conditions to ensure VA medical 
facilities comply with VA's critical practice guidelines for 
pain management.
    The VFW has consistently heard from veterans that their 
patient advocates are ineffective or seek to protect the 
medical facility's leadership instead of addressing their 
concerns. For this reason we strongly recommend that the 
Subcommittee amend this legislation to codify VA's Veterans 
Experience Office, established to collect and disseminate best 
practices for improving customer service, coordinate community 
outreach efforts, and serve as the subject matter experts on 
the benefits and services VA provides veterans. The Veterans 
Experience Officers should replace patient advocates currently 
located at VA medical facilities. That requires that the duties 
of Veterans Experience Officers be amended to include ensuring 
protections under Title 38 are fully applied and complied with 
by VA medical facilities and contracted community care 
providers.
    Mr. Chairman, this concludes my remarks and I am ready to 
answer any questions you and your Members of the Subcommittee 
may have. Thank you.

    [The prepared statement of Carlos Fuentas appears in the 
Appendix]

    Mr. Benishek. Thank you, Mr. Fuentes. I appreciate all of 
your comments. They are very helpful. I yield myself five 
minutes for a few questions that I have. And I guess really 
what I want to talk about a little bit is the VA is going to 
talk about their VA purchased health care streamlining and 
modernization proposal. And I would like to talk to you about 
that a little bit before they actually testify and I get to ask 
them questions about it. Because you know, we passed this 
Choice Act last year which we thought would make it easier for 
veterans to get care in the private sector. And basically the 
implementation of that was left to the VA and they decided they 
cannot do it, we are going to get these third party providers 
to do it, and it is going to be so much easier for veterans to 
get care in the local community. And yet that really has not 
worked as far as I can tell. It has been a difficult 
implementation. So now they want to have a unified plan to 
getting care in the community instead of different programs and 
one community outreach plan, so it is uniform and easier for 
everybody. So I was hoping to ask you all if you had any ideas 
as to the best way to do that. Because we left it to the VA, 
they came up with a plan that has not been that good. So with 
that thought in mind, Mr. Atizado, what do you think of a way 
to improve patients' access to community care? Do you have any 
ideas in that regard? Or what has your group been thinking 
about?
    Mr. Atizado. I guess I will tackle that question from two 
fronts. With regards to this bill that VA has proposed, my 
understanding is, and I am sure VA will mention this as well, 
provider agreements are a staple when purchasing care in the 
communities. At least for VA's side of the house, they have 
used this type of arrangement rather than a more cumbersome 
contract vehicle, which is what the Choice program actually 
requires is a contract as a vehicle to establish the business 
arrangements.
    With a contract there are a lot more requirements that some 
smaller service providers may find not appealing to enter in 
with VA. They just, the volume just would not make any business 
sense for them to enter into that kind of an agreement, hence a 
provider agreement.
    But with respect to the Choice program, you know, this was 
a pretty rapid response to a burgeoning issue, a crisis. And as 
we have noticed, Congress has acted to change the Choice 
program at least a couple of times because once it was 
implemented we realized, everybody realized, that there were 
problems with operationalizing this concept. So with regards to 
your central question about what do we have to do to get VA to 
be able to purchase care in the community the way we would 
like? Well, I can tell you as a patient and as members of our 
organization have requested, there are four main areas that 
need to be addressed. I do not want to take up all your time. 
But I can certainly send you a written response to that.
    Mr. Benishek. Well, I appreciate that. You know, I have 
been a provider at the VA myself. And I understand lots of 
those things that you mentioned here. I just thought I would 
try to reach out because this is a problem that we tried to 
solve, improving care, but we just have not got the VA to do it 
right. And we are just hoping to get continued input as we 
struggle to find a way to get community care for our veterans 
in a timely fashion. And I would welcome input from all your 
groups as we work toward that struggle here and now. So Mr. 
Fuentes?
    Mr. Fuentes. Mr. Chairman, if I may, I just wanted to kind 
of follow-up on what my colleague said here. And also to say 
that the Choice program, although it has made a lot of 
progress, was intended to be essentially a pilot program to see 
what works and what does not. Through our surveys, working with 
VA and working with the contractors, we have been able to 
identify a lot of issues, right? And I think you have all seen 
it through your constituents. And really the next step really 
is to reform the delivery model, right? And take the lessons 
learned and really take a holistic approach to delivering 
health care to veterans that incorporates the best qualities 
and capabilities of the private sector and VA and other public 
health care providers, right? And making that analysis at the 
local level to see what VA is able to provide, what the demand 
is, and I think that is what has been lacking for a long period 
of time. Is having that demand capacity analysis to really take 
a look at what the demand is and who can provide that care, who 
is best to provide that care with the most quality and also 
accessible. And, you know, we are happy to follow-up. And we 
are looking forward to the hearing tomorrow to discuss the plan 
and we are hoping to maybe comment on some of the VA's plan in 
more detail.
    Mr. Benishek. Right. Thank you. Ms. Brownley?
    Ms. Brownley. Thank you, Mr. Chairman. I wanted to ask 
quickly about Mr. O'Rourke's bill, the Ask Veterans Act. And I 
know that the DAV and the American Legion both either do not 
have a position or feel, agree, I guess, with the VA that it is 
duplicative. And you know, I just wanted to hear why you think 
that. From my perspective, it is not because of the surveying 
that the VA is doing now, it is sort of comprehensive, it is 
sort of national. It does not, I do not think, we have not 
really been able to trust the data and it does not drill down I 
think deep enough to get the data that we really need on a 
regional basis to understand what some of those issues are. So 
I am just curious to hear from both of you about it.
    Ms. Holt. Yes. The American Legion, as you mentioned we do 
not have a position at this time for that. And it is because 
they do have this process in place. Now what we can do we can 
take that into consideration and maybe bring that back to our 
members. Because we do not want to do anything without our over 
two million members agreeing. And we really want to know what 
it is that their needs are. So I think we just need to do 
further research on that. And we can get back with you and 
provide you a written, a more written, conductive statement to 
provide for you on that topic.
    Ms. Brownley. Thank you.
    Mr. Atizado. Ms. Brownley, I appreciate you having read our 
testimony on it. Our positions on legislation really come from 
mandates from our membership. Since we do not have one 
specifically on surveys, taking a position on Mr. O'Rourke's 
bill would just, it would not be the place based on our 
constitution and bylaws. But having said that, we understand 
Mr. O'Rourke's situation. We hear it everyday. I hear it 
everyday. I see the numbers that VA puts out and I hear those 
thousands, there are literally thousands of veterans, or I 
should say as VA measures them, appointments that are well 
outside what we would think to be timely. Now the concern that 
we have with surveying members, or surveying patients, is that 
what happens after that? Our testimony talks about getting all 
this information and what happens after? What is the action to 
be taken? So our recommendation with the bill is if this 
Subcommittee passes this bill in its form, notwithstanding what 
VA has been trying to do recently. I think they came out with 
some, a couple of additional surveys that look to more specific 
points of service within a hospital as well as outside in the 
community. But what action will be taken after that?
    I have looked at the numbers for El Paso, Mr. O'Rourke. And 
I can tell you the wait times are higher than average. We are 
talking thousands of veterans, not only in completed 
appointments, but waiting to have scheduled over 30 days. There 
are certain areas of the country that are just far worse off 
than others. And as any medical center director or any facility 
director can tell you, it is far more complicated than surveys. 
But that is a key question to ask. I think one of the 
prevailing themes that we have been, that we have come across 
throughout this discussion about access to care is where is the 
patient's voice in all of this? Where does VA put veterans when 
they develop their initiatives or their policies? Where is the 
patient in that? Oftentimes we are consulted. They take our 
ideas into consideration. But being part of the development I 
think would be key. It would go a long way.
    Ms. Brownley. Thank you. I wanted to ask quickly another 
question on the military sexual assault. So Mr. Fuentes, I 
understand that VFW is opposing the bill. They feel as though 
MST is better treated within the VA, generally, roughly. So, 
you know, if you could respond to that? And what I am really 
curious to know for all three organizations on something like 
military sexual assault, how do you survey your membership? Do 
you, is it a broad brush survey that everybody responds to? Or 
are you surveying just, well not necessarily, it is not always, 
always women. Sometimes men are assaulted too. But, you know, 
how do you get that information from your organization?
    Mr. Fuentes. And just to clarify, we do not believe that 
MST is best delivered at VA at all times, right? I think our 
opposition is that the Choice program, as I said, is going to 
end soon. And really what you need to do is take a look at how 
to solve the access issue as a whole, and I think MST is also 
included in there. And how to, ultimately our belief is that VA 
is accountable for the care that is provided to veterans, 
regardless if it is a non-VA care provider or VA. It is 
providing that holistic approach to medicine that has made VA 
the best, one of the best providers in the world, actually.
    Now--
    Ms. Brownley. My time is running out. So I think we are 
going to have to follow-up.
    Mr. Fuentes [continued]. Yes. I can follow-up with that.
    Ms. Brownley. Okay. Very good. Thank you. I yield back.
    Mr. Benishek. Dr. Roe? You are recognized.
    Mr. Roe. Thank you, Dr. Benishek. Just a couple of things 
that seem simple to me. One is, what is the purpose of the VA? 
It is to provide health care for veterans, real simple. I have 
literally made thousands of appointments, medical appointments, 
to see other specialists. The VA is one of the only 
organizations in the world that can make that complicated. It 
is really simple to do. The patient comes in and sees Dr. Roe. 
They need to see a dermatologist. I know who the dermatologists 
are in my community who are quality. I write it. It goes out 
front. I send them a note either electronically or by, oh 
heaven forbid somebody types it. They make an appointment. They 
go see the dermatologist, and I get information back. That 
happens millions of times. But only the VA can take something 
as simple as an appointment and send it out front, to 
Washington, to a third party, to my Lord, and it could make 
your head, you could send it up to the space shuttle easier 
than getting an appointment.
    And so I think we have got to back up and empower veterans. 
And I think veterans are going to be able to vote with their 
feet. I think if they want, if they feel like they get the best 
care somewhere else they should be getting that care wherever 
they can get the best care. And I am so frustrated with this 
because it should not be that hard, I can tell you having done 
it for 30-plus years, to get a patient an appointment. We know 
if you cannot get a cardiology appointment you recruit 
cardiologists. We know if you cannot get primary care, I am not 
saying it is easy, but you know what those things are and this 
is not difficult to do. Dr. Benishek has done it, and Dr. 
Abraham has done it. Others of us. And Dr. Ruiz, he is not here 
now, he has done the same thing. We know how to get those 
appointments. And we know there are places, like in treating 
PTSD, there is a shortage of providers. We know that. So we 
need to concentrate on providing those resources for people. 
But I just share my frustration with how the VA has gotten so 
bogged down about it being about the VA and not about the 
patient. It ought to be about the veteran and how to quickly, 
the best way to get that veteran care. Look, if it is to do 
with the loss of a limb, probably some of the best in the world 
is certainly at Walter Reed. I have been there many times and 
looked at that, translated down to the VA. For others it may be 
something else. It may be out in the non-VA care. It should be 
about getting the quality, quick care for the veteran. We ought 
to be figuring, not making the bureaucracy bigger and harder to 
do.
    But anyway, I just wanted to make those statements. And 
certainly I disagree. And you cleared it up, Mr. Fuentes, that 
Military Sexual Trauma may be best treated outside the VA for 
that particular, it should be where it is best, as this young 
woman provided her testimony, what is best for her. It should 
not be about the VA, it should be about where is the best care.
    Mr. Fuentes. And if I may, Dr. Roe, you know, I completely 
agree in terms of, you know, it needs to be where it is best. 
Ultimately, what I think has been lost in a lot of this 
conversation is that first and foremost it needs to be high 
quality care, and accessible is also a part of that. And I 
think it is secondary to quality, however. But when it comes to 
reformed ideas we are strongly opposed to just simply giving a 
veteran a card and going off to the community and fending for 
themselves. That is because if you do that what you are doing 
is underfunding VA and then giving them an option, or putting 
them out there in the private sector that is not prepared or 
does not have the actual capacity in all aspects, in every 
state and every place.
    Mr. Roe. Mr. Fuentes, I disagree with you on that. And we 
will just respectfully disagree. Look, I was prepared to see 
veterans. I am a veteran. I was prepared to see veterans, 
although I did not work at the VA. I could clearly see those 
patients. That is what I did for a living, took great care of 
people, but put the quality up with anybody. I think you are 
going to have the VA compete for those patients to keep them in 
there and not trap them in there. I had an old GP tell me one 
time that there are three A's of practicing medicine before I 
started my practice. It is accessibility, affability, and 
ability. People have got to like you. They have got to be able 
to get to you. If you cannot get there, the quality does not 
count if you cannot get an appointment. And just because the VA 
practices medicine does not mean that that quality does not 
exist because it does outside the VA and yet we are making it 
hard when the patient, the veteran, cannot get in to get the 
care in the VA, we are making it almost impossible to get care 
outside the VA and we are going to hear more about that 
tomorrow.
    Mr. Fuentes. And if I may, Dr. Roe, I completely agree with 
you that VA is not the best every single place, right? What 
needs to happen is analyze who has the best care in what market 
and determine what--
    Mr. Roe. Yes, I agree with that.
    Mr. Fuentes [continued]. where that veteran needs to go to 
receive high quality, accessible care.
    Mr. Roe. And in a timely--
    Mr. Fuentes [continued]. And most of the times we think it 
will be VA. But in plenty of times, in a lot of times, 
depending on MST, depending on what the service is, it could be 
in the private sector. Because there are providers, such as 
yourself, in the private sector who are ready and able to care 
for veterans and we need to empower them to be able to do so as 
well.
    Mr. Roe. I yield back.
    Mr. Benishek. Thanks. Mr. O'Rourke, you are recognized. 
Good? Mr. Takano?
    Mr. Takano. Ms. Kuster was in before me.
    Mr. Benishek. Oh, okay.
    Mr. Takano. I just had one question. Regarding the Failing 
VA Medical Center Recovery Act, do you think a new office is 
necessary to oversee whether a VA medical facility is doing its 
job of treating veterans? And what are your concerns regarding 
the medical treatment of veterans should this new office be 
created? And it is generally to whoever wants to answer the 
question.
    Mr. Atizado. I will step in. Thank you for the question, 
Congressman Takano. We, as you probably surmised from our 
testimony, we do not have a resolution to support the bill, but 
we have a number of concerns on the bill. I think one first and 
foremost is creating a new bureaucracy within the VA health 
care system where the responsibilities for that one new office 
really rest with those parts within VA that have the expertise 
that deal with that domain. A health care hospital is a very 
complex institution. And I understand that the bill wants to 
centralize all those under one office. But I hesitate to 
consider what would happen if you were to create that, and what 
happens to the other parts of VA whose responsibility is right 
now to make sure that hospitals that need help, are 
underperforming, are actually incentivized to raise up to the 
standard that VA expects its facilities to be.
    But having said that, there is one part of the bill that I 
want to make sure this Committee is aware of and I am thinking 
you already are. And it is this dearth of leadership. There 
seems to be an environment right now within the VA health care 
system that people who would otherwise step forward to take 
leadership positions in the VA just are not. I cannot explain 
to you why that it is not. VA has had statements before about 
how many are acting, how many are vacant, not only in the 
facilities at the local level but also at central office, who 
we need to make sure that there is a minimum standard that 
every facility must meet, whether it is MST or access. Whether 
it is recruiting appropriately or having a center of 
excellence. That I could not tell you how to possibly address 
that situation, but it is hurting facilities which means it is 
hurting VA employees, which means it is hurting veterans.
    Ms. Holt. And on behalf of the American Legion, the reason 
why at this moment or at this time that we are not supporting 
this is because we feel that we do not need to establish 
another bureaucracy to monitor and track the VA facilities for 
poor performance. We believe that that responsibility should 
lie solely under the Under Secretary for Health. Now should 
Congress make amendments to this we can bring that back to our 
members and we would be more than happy to provide a statement 
in a later time if that is okay with you.
    Mr. Fuentes. Congressman, we agree with the intent of 
identifying facilities that need assistance. However, what we 
believe is necessary is a compliance mechanism, right? And our 
opinion is that the Patient Advocacy Program is supposed to be 
that compliance mechanism to ensure that veterans are receiving 
the care that they have earned and deserved. However, due to 
the fact that they are under the chain of command of their 
local medical facility leadership, it prevents them from really 
being that advocate for veterans. And we feel that if you 
strengthen that program, and like we said, like we recommend 
codifying the Veterans Experience Office and having that be a 
part of the chain of command--not, I am sorry, separate from 
the chain of command will enable VA to really implement that 
compliance mechanism that is necessary.
    Mr. Takano. Thank you. Mr. Chairman, I yield back.
    Mr. Benishek. Thanks, Mr. Takano. Mr. Coffman, you are 
recognized.

               OPENING STATEMENT OF MIKE COFFMAN

    Mr. Coffman. Thank you, Mr. Chairman. As a member of both 
the American Legion and the VFW, thank you for being here 
today. And certainly in talking about Military Sexual Trauma I 
really appreciate the position of the American Legion. I think 
that those victims of Military Sexual Trauma ought to be able 
to choose the best treatment options available in their 
specific case rather than having it dictated to them. And I 
would expand that to all mental health care. Because the 
biggest cost-driver, I think that we are confronted in 
disability care, I mean in disability, is Post-Traumatic Stress 
Disorder, or mental health. And so I think it is a very 
personal thing, that interaction between a therapist and a 
patient. And I really think that individuals ought to be able 
to select what is best for them. And I am disappointed with the 
VA in terms of having a drug-centric approach in terms of a 
modality of treatment. And I think we have had testimony to the 
effect in this Committee where in fact we have related suicides 
to, say, I think we had one instance where a veteran had moved 
and was given a cocktail of psychiatric drugs to counter 
symptoms of PTSD, and then moved and could not navigate the 
system for a refill. And that is a fairly dramatic thing to 
happen, when somebody is suddenly off of these drugs. And at 
the end they are given a drug to wake up in the morning, and a 
drug to go to sleep at night, and a drug for this and a drug 
for that. In my view, that is not a good therapy but I 
understand that it is, probably from the VA's point of view it 
is more cost effective to do that than the laborious sort of 
treatment where psychotherapy is given as an exchange between 
two individuals, the therapist and the patient. And so I think 
the more options, the better? If a patient is feeling better as 
a result of a certain modality of treatment that they are going 
through, whatever that modality of treatment is, I just think 
it ought to be available. And again, I think it is a very 
personal, interpersonal thing. And so I would ask for the VFW 
to go back and take a second look at this issue. Because I just 
think it is so important for individuals to have options and to 
make it their decision when it comes to something so 
interpersonal as therapy for MST, for Military Sexual Trauma, 
or for Post-Traumatic Stress Disorder. Sure.
    Mr. Fuentes. If I may, Congressman? We completely agree 
that veterans need to be presented with options. But I think 
high quality and accessible options. And ultimately what it 
comes down to is providing them the ability to go to providers 
that, one, knows how to care for veterans, right? But also 
knows the other aspects of comorbidities that are associated 
with mental health conditions, right? But ultimately what it 
comes down to is reforming the VA culture and the deliver care 
model. One of the things that is most frustrating about VA is 
that we often, as a patient we also find that a lot of VA 
employees are quick to justify why they can say no instead of 
getting to yes, right? That is something that needs to change. 
But also the delivery of care model, to be able to provide them 
those options instead of just sending them off to the private 
sector to fend for themselves.
    Mr. Coffman. All right, let me tell you, I do not think our 
veterans that have returned from war can wait for the VA to 
reform itself. There was one veteran, Iraq War veteran, in my 
Congressional district who committed suicide. He, the only 
thing, what we were able to trace was the fact that he called 
VA for an appointment and had not received a response for two 
weeks before his death. And so I can tell you as an Army Marine 
Corps veteran, our veterans deserve better. And they cannot 
wait for this system to improve. They have to have choices and 
they deserve to have those choices now. With that, Mr. 
Chairman, I yield back.
    Mr. Benishek. Thanks, Mr. Coffman. Mr. Kind?

                 OPENING STATEMENT OF RON KIND

    Mr. Kind. Thank you, Mr. Chairman. I want to first of all 
think you and Ranking Member Brownley and all the Members of 
the Committee for the courtesy for me to be in the dais. I am 
not a normal Member of the Veterans Committee, but I do 
appreciate the oversight, the work, the attention, the concern 
that you have shown with many of the challenges that we face 
within the VA system itself, but the VA medical centers.
    I am here specifically in regards to legislation that Mr. 
Atizado and the DAV has endorsed, the Jason Simcakoski Promise 
Act. I have been working very closely with Chairman Bilirakis 
as well as Representative Rice of this Committee to introduce 
this bill this week. And Mr. Coffman, I could not agree with 
you more. I think we have got a major opiate problem within the 
VA system, but not limited to the VA system. I think it is 
health care systemwide, that is going to require a lot more 
care and focus and attention by this Congress in order to make 
the changes that are necessary. And that is exactly what the 
Promise Act was meant to do.
    It is named after a constituent of mine, Jason Simcakoski, 
who lost his life under the care and the treatment of the VA 
medical center in the center of my Congressional district in 
Tomah, Wisconsin. And I have been working very closely with his 
wife and his father, Heather and Marvin Simcakoski, to get the 
story out. But that family has one concern on their mind, and 
that is to work with this Congress, to work with the VA to make 
sure that the tragedy that befell their loved one does not 
happen again. And that is the whole intent behind the Promise 
Act. We have companion legislation already in the Senate on 
this. And again, with Chairman Bilirakis' leadership we are 
hoping to be able to introduce something. And we appreciate the 
DAV's level of input and support that you have given this 
legislation.
    In a moment I am going to ask you whether the DAV in 
looking at the legislation has any further recommendations in 
working with us and what you would make. There is one aspect of 
it I have been especially focused on. It is based on 
legislation I have introduced earlier called the Veterans Pain 
Management Improvement Act, that I have introduced with Mr. 
Zeldin and Mr. Ribble, which would establish pain management 
boards. It comes out of the recommendations that the OIG has 
made on a nationwide survey withing the VA system, but also the 
particular investigations that came out of Tomah in light of 
what took place there. And what it does do is it changes the 
delivery of care model, the culture. But probably most 
importantly it gives the patients and the family members 
themselves a greater say and a greater input in regards to the 
treatment regimen. I am convinced that the family members are 
the first line of defense when it comes to our veterans. They 
are going to know what is working and what is not working, and 
we have to make it easier for them to provide that input in 
regards to the care and the treatment that the loved one, the 
veteran in their family, is receiving. And unfortunately we 
have not seen that in many instances.
    That Pain Management Board Act is included in the Senate 
version. We are still working on whether or not it makes sense 
or what type of changes have to be made in regards to the 
Promise Act when we introduce it this week. But Mr. Atizado, if 
you have anything you want to share in regards to the DAV's 
insight on this matter it would be appreciated.
    Mr. Atizado. Congressman Kind, thank you for your kind 
words, your effort in this area. This is a very sensitive 
issue. Most of our members, if not all, are severely injured 
with some kind of chronic pain. It is prevalent in our 
membership. Our members are quite, feel very strongly about 
pain management in the VA. Yes, they are worried, as Mr. 
Coffman had mentioned, about overprescribing. But there is also 
a growing voice that is worried that they are being 
underprescribed. And if they are in fact being underprescribed 
they are trying to seek relief with alternative types of care 
which while they would like to receive are not, are having a 
hard time trying to get for a number of reasons.
    I would love to work with you and your staff on that.
    Mr. Kind. Yes, I am glad you mentioned that aspect because 
it is so important. There are so many more alternative and 
complementary forms of care that we ought to be exploring in 
much greater detail rather than just loading them up on a 
cocktail of drugs all the time. And I have been aghast with the 
number of veterans and families who have come into my 
Congressional office with literally grocery bags full of 
prescription drugs that they are getting from the VA system. 
And they cannot in their lifetime take all of that, yet it 
keeps being sent to them almost on a weekly basis and they are 
overwhelmed with it. So I think we have to be a little 
creative.
    And one other piece of legislation, if you may, Mr. 
Chairman, is I have introduced a Veterans Access to Care Act to 
try to deal with the access and waiting line issue that we have 
out there. And what this does is expands the definition of 
health professional shortage areas for qualified VA medical 
centers around the country. It is loan forgiveness, it is 
scholarships, it is other incentives in order to get the highly 
qualified and trained health care professionals in the VA 
system in order to address the shortages. And I know speaking 
to Tomah, they have got a critical shortage of primary care, 
nurse practitioners. They cannot find a dermatologist. I mean, 
all that has to be farmed out if they are lucky enough to do 
that. But we are seeing this across the board, these shortage 
areas and that. And this legislation that I have introduced 
with my colleague Mr. Ribble might be a part of the answer of 
creating further incentives to get the trained professionals in 
where we need them the most. But I thank you again for your 
courtesy in allowing me to participate here today for this 
important hearing. I yield back.
    Mr. Benishek. Well thanks for being here. I appreciate it. 
Are there any other questions? If not, then the panel is 
excused. Thank you very much for being here. I very much 
appreciate your input.
    I would like to now welcome our third and final panel to 
the witness table. Joining us from the Department of Veterans 
Affairs is Janet Murphy, the Acting Deputy Under Secretary for 
Health for Operations and Management. She is joined by Elias 
Hernandez, the Chief Officer of Workforce Management and 
Consulting; Harold Kudler, the Chief Consultant for Mental 
Health Services; and Susan Blauert, the Deputy Assistant 
General Counsel. Thank you for being here. Ms. Murphy, you may 
begin when you are ready. Thanks.

                   STATEMENT OF JANET MURPHY

    Ms. Murphy. Good morning, Mr. Chairman and Ranking Member 
Brownley. Thank you for inviting me here today to present our 
views on several bills that would affect the Department of 
Veterans Affairs. Joining me today is Dr. Harold Kudler, Chief 
Mental Health Consultant; Elias Hernandez, Chief Officer, 
Workforce Management and Consulting; and Susan Blauert, 
Attorney in the Officer of General Counsel.
    First let me begin by thanking the Committee for including 
the VA legislative proposal to establish certain agreements for 
purchasing medical care for veterans when care within VA 
facilities or through contracts or sharing agreements is not 
feasibly available. As many of you know, this is VA's top 
legislative priority and we certainly appreciate the full 
Committee's support and passage of this bill.
    H.R. 1319 would require VA to enter into a contract to 
conduct annual surveys of veterans at each facility. However, 
VHA is already conducting ongoing surveys of over one million 
veterans annually through our survey of health experiences of 
patients per our SHEP program. VA uses a scientifically 
designed survey instrument, the consumer assessment of health 
providers and systems, in developing our SHEP survey which 
allows us to compare our performance with non-VA hospitals and 
health care systems.
    H.R. 1603 would allow veterans seeking care for Military 
Sexual Trauma to elect to use the Veterans Choice Program and 
waive Choice eligibility requirements. While VA fully supports 
veterans seeking care for MST where they choose in the 
community, if they choose, we are currently able to offer that 
option through Choice at this time and the new changes that 
Congress has made to the Choice Act make that even more 
available for those veterans. I would also say that VA 
providers have received evidence-based training and education 
about MST related issues which may not be commonly found in the 
community.
    H.R. 1904 calls for enhancing existing prosthetic orthotic 
graduate programs, as well as developing a prosthetic orthotic 
research center of excellence. VA currently operates five 
research centers of excellence which incorporate our interns 
and residents as well as graduate students from affiliated 
academic institutions.
    VA does not support revising the VA Marriage and Family 
Therapy Qualification standards as proposed by H.R. 2639. VA's 
current qualification standards for all mental health 
professionals require an individual to have graduated from a 
program accredited by an approved accrediting body that also 
certifies the training program within that specific discipline.
    With H.R. 3234 we recognize the intent of the bill is to 
improve performance. VA already conducts many of the activities 
and requirements outlined in the bill. We utilize strategic 
analytics improvement and learning, or SAIL data, to measure, 
evaluate, and benchmark quality and efficiency at VAMCs. Based 
on SAIL, VA also sends teams of subject matter experts to local 
facilities to provide consultative training and to help 
facilities and provide follow-up consultation. We continuously 
monitor facility performance and provide additional resources 
as necessary.
    VA is extremely concerned with establishing a new Under 
Secretary position to manage and lead this office as it removes 
authority currently vested in the Under Secretary for Health. 
We believe such an organization would be costly and duplicative 
and would not be successful in achieving improved outcomes in 
care.
    With H.R. 3471, VA does not believe this bill is necessary. 
VA does not manufacture nor install adaptive equipment on a 
beneficiary's vehicle. Instead VA's role is to prescribe and 
pay for adaptive equipment. All safety and compliance issues 
are addressed by the National Highway Traffic and Safety 
Administration.
    VA supports the intent of 3549 to provide the authority to 
the Secretary to waive copayment bills generated in error to 
prevent undue burden to veterans. However, VA wants to ensure 
that any statutory changes do not remove authority to generate 
copayment bills that are rightfully owed, but are delayed due 
to normal businesses processes. VA estimates a ten-year revenue 
loss of about $700 million if copayments are waived after 120 
days from the date of service.
    We do not have cleared views or costs for Section 103, 
Title 3, and Section 501 of the Promise discussion draft. 
However we would be glad to provide these views at a later 
time.
    Thank you, Mr. Chairman and Ranking Member, for the 
opportunity to testify before you today. My colleagues and I 
would be pleased to respond to any questions that you may have.

    [The prepared statement of Janet Murphy appears in the 
Appendix]

    Mr. Benishek. Thanks for your testimony, Ms. Murphy. I 
really appreciate it. How do you explain the difference in the 
results of Mr. O'Rourke's survey and the VA survey? I mean, 
that is basically the reason here. Is that, you know, we have 
sort of come to not trust the VA and the results. So when you 
say that you are doing things in a scientific fashion, you 
know, that is all well and good. But you are opposed to a third 
party doing it? I do not get that.
    Ms. Murphy. So currently we do have a third party that does 
our survey. So it is directly between the third party under 
contract directly with the veterans and we are simply given the 
results. So there is no interaction with that survey between us 
and the veterans. The contractor does it all.
    But I would just say that our results actually are the same 
as the Congressman's results. The veterans are not very happy. 
And so our results actually align.
    I think also we want, in measuring access what we really 
want to know is what the veterans think, which is what the 
Congressman's survey tells us, and which is what our survey 
tells us too. And so in many ways they are very aligned. And I 
guess what I would really welcome is the opportunity to sit 
down with the Congressman and see where we could, where we 
feels we have deficits in our process and where we could align 
our process more with what he has in mind. We are always 
looking for input. The VSOs and veterans have input on our 
current survey. In 2016, we are actually going to expand it to 
be able to drill down more to certain specialties, particularly 
high volume specialties in mental health and other areas. So 
you know, we are constantly improving it. And you know, I would 
welcome having a conversation with the Congressman or his staff 
on how we could do better.
    Mr. Benishek. I guess I have, you heard my question to Mr. 
Atizado there, obtaining third party or outside the VA care. 
And really it was up to the VA to develop the plan for how to 
implement Choice. And they said that they could not do it 
internally, and so they got these third party payers. And now 
it does not seem to be working too good. So why did we not do 
that in the first place? I mean, why did we not do what we are 
talking about here in the first place? And I know that somebody 
mentioned that, oh, it was a pilot program and we found out 
this does not work. Give me your thoughts as to how we can make 
this work better, getting care in the community.
    Ms. Murphy. So it is true, sir, that we had a pretty short 
timeline to get that program up and running. It was really our 
first time out of the shoe with a program like that, of that 
magnitude and with those requirements. I think as the program 
has evolved and as Congress has given us additional authorities 
and flexibilities with the program it is getting better.
    I would say that I am probably as unhappy with the TPAs as 
the veterans are. We are working hard to hold them accountable 
to their contractual obligations. We have sent some of them 
letters of correction, so that they are required to correct 
some of the deficiencies. So I would say it is a work in 
progress.
    But let me give you an example of something that Congress 
has done recently that is going to help us really tremendously. 
So the provider agreements that we are asking for legislative 
authority for, we already have that under the Choice 
legislation. So currently our Choice providers do not provide 
home and community care, for example. But with our provider 
agreement authority we are now going to be able to set up our 
own agreements with those home and community care providers and 
we are going to be able to use Choice funding to pay for that 
care. That is a terrific opportunity for us to really open up 
access to care.
    Mr. Benishek. Well I guess I understand that. It is just 
that you guys set up this third party administration of the 
Choice program providers. Now you are saying that is not 
working out, right? I mean, I do not get why we did not do it 
right the first time.
    Ms. Murphy. I think we tried the best we could, and I think 
we are trying to make it work and it is getting better.
    Mr. Benishek. Well, I mean I agree that we should have one 
way of doing it, and a coordinated way rather than having six 
different techniques of getting people into the private sector.
    Ms. Murphy. And you have now legislated us and you have 
told us that we must find a way to do that, which is going to 
be coming forward to you, I think later this month to tell you 
what our plan is to do that.
    Mr. Benishek. Yes, we are going to do another hearing 
tomorrow. All right. Ms. Brownley?
    Ms. Brownley. Thank you, Mr. Chairman. I just have two 
quick questions. On Ms. Walorski's bill on Veteran Mobility 
Safety Act, so you stated that the VA simply pays for the 
adaptive equipment, that you are not, you know, building or 
constructing the adaptive equipment. So when, you know, she 
cited a couple of different examples that veterans have 
incurred. And so when something happens to a, you know, it is 
adapted improperly, the lift does not work, then what does the 
VA do then? The veteran comes back to you and says it is not 
working, I paid for it but my car is still not working for me? 
Do you just pay again?
    Ms. Murphy. No.
    Ms. Brownley. That is it?
    Ms. Murphy. No, we do not pay again. So I am not familiar 
with those two cases. But theoretically, you know, that could 
happen anywhere. It could happen under a certification program 
or a state certified program as well.
    Ms. Brownley. Understood. But what do you do at that point?
    Ms. Murphy. Well we would go back and try to help the 
veteran get the problem remedied. If it were really serious, I 
presume we would report that vendor to the Transportation 
Safety folks. You know, I think, you know, we do not have 
regulatory authority. You know, we, but we try to resolve the 
problem for the veteran if we can. And you know, if we see a 
pattern of unsafe installments, I am sure we would be really 
quick to report that to the appropriate Federal authorities.
    Ms. Brownley. So do you have success in rectifying this for 
veterans who have these experiences?
    Ms. Murphy. I believe so. And I personally was involved in 
a case where we went back to the vendor several times to get 
the modification corrected and it was eventually corrected.
    Ms. Brownley. So do you have data on that?
    Ms. Murphy. I can ask and if we do we can provide that to 
you.
    Ms. Brownley. Okay. Very good. And on the marriage and 
family therapists, so does the, what are the amount of openings 
across the country for mental health professionals and 
counselors? I do not have the data in front of me but I know 
that we struggle with filling all of those positions. I know in 
my district, you know, the turnover of that is very, very high. 
So you know, it is, I am still struggling with your opposition 
to this because I feel like we should be doing everything 
possible. We obviously want highly qualified people. But you 
know I think that we need to do as much as we possibly can to 
make professionals available so that we can fill these 
positions. Because it is, I know in my own district it is a big 
problem.
    Ms. Murphy. So I am going to defer the question to Mr. 
Hernandez here. But I would say that marriage and family 
therapist is not a classification of employees that we find 
difficulty filling. So I think we really feel that the 
standards that we have are high standards and we have some 
concern about going in a different direction with the 
standards. But to your question about openings and vacancies, I 
will defer to Mr. Hernandez.
    Mr. Hernandez. Thank you, Ms. Murphy. Ranking Member 
Brownley, currently we have a total of 51 vacancies, of which 
40 of them are already in the recruitment process. So we do not 
have a high number of vacancies for--
    Ms. Brownley. This is specifically for your definition of 
marriage and family therapist. And so what about, you know, 
across the board in terms of other counselors and other mental 
health professionals?
    Mr. Hernandez [continued]. I do not have those numbers in 
front of me, Ranking Member. But I do know that for the family 
and marriage therapist, you know, we have seven of those 
vacancies and for the licensed professional mental health 
counselors we have 34 vacancies.
    Ms. Brownley. Thank you. I yield back.
    Mr. Benishek. Mr. Coffman, you are recognized.
    Mr. Coffman. Thank you, Mr. Chairman. And Ms. Murphy, you 
characterized the legislation before us today, or being 
discussed before us today, on Military Sexual Trauma as that 
you already have the authority to do that under the Choice Act 
so the issue is already taken care of. That is simply not true. 
The way this legislation is written is that it is not 
contingent upon distance from a VA facility, nor is it 
contingent upon wait time. It makes one eligible from day one 
who has an incident of Military Sexual Trauma. So I am just 
surprised at your testimony before this Committee. Can you 
explain that?
    Ms. Murphy. Thank you, sir. Yes, and with the new 
authorities that you gave us we no longer have to wait the 30 
days if there is a clinically indicated need for the service. 
So basically, if a clinician or a physician or a patient feels 
they need it today, and that becomes a clinically indicated 
date in that service, they are eligible for Choice today. There 
is no longer any enrollment constraint. So anybody enrolled at 
any time can take advantage of Choice. We also have the undue 
burden criteria, where if it is an undue burden for a veteran 
to travel a certain distance or to get to a VA facility, they 
are also eligible under Choice.
    Mr. Coffman. Here is the problem with that. They have to 
navigate your bureaucracy to get there, which is so hard to do. 
I mean, it is unfriendly to veterans, it is unfair to veterans. 
And so what this legislation does is it automatically places 
them as eligible. And so despite your testimony, I would 
strongly urge my colleagues today to support that legislation. 
With that, Mr. Chairman, I yield back.
    Mr. Benishek. Thank you, Mr. Coffman. Ms. Kuster? Do you 
have any questions? Oh, okay. Mr. Takano?
    Mr. Takano. Yes. Ms. Murphy, in his testimony, Mr. Fuentes 
mentioned that veterans in extended care facilities are in 
danger of losing access to their homes because VA cannot extend 
the contract. Can you explain the situation? Would the VA's 
proposed legislation help? Or would the bill text need to be 
revised to impact those veterans?
    Ms. Murphy. So thank you, sir. Are you referring to the 
provider agreement legislation?
    Mr. Takano. I think so. That is right.
    Ms. Murphy. Right. So the way we have used those vehicles 
is there are often small nursing homes or community living 
centers or home board and care facilities--not board and care. 
Sorry, that does not qualify. But home health agencies, aid and 
attendance, where we are able to use a vehicle called a 
provider agreement rather than a FAR-based contract to procure 
those services.
    What we have learned as we began to try to find ways to 
continue those agreements that we really are being pressed to 
use FAR-based contracts. And some of those providers are 
dropping out. Because if you are a small family run agency or a 
small business, it is very difficult to comply with FAR-based 
requirements. Our provider agreements give us another vehicle 
that has protections, such as those that are provided to 
Medicare providers, and has constraints, but does not have all 
the requirements of a FAR-based contract. And thus some of our 
smaller providers, our community providers, our one doc shops 
we hope will be more willing to stick with us and continue to 
serve veterans.
    Mr. Takano. Okay. Thank you. You mentioned briefly that the 
VA would like to make additional improvements on the draft bill 
on care in the community that we are discussing today. Could 
you go into a little bit more detail on that?
    Ms. Murphy. So I am sorry sir, which bill are you referring 
to?
    Mr. Takano. The provider agreement.
    Ms. Murphy. I am going to turn it over to Susan as our 
legal eagle here.
    Ms. Blauert. Yes. So Senator Blumenthal introduced S. 2179 
and we noted that it more clearly articulated some of the 
protections for employment opportunities more so than the draft 
bill that the administration introduced in May. So that is, it 
is really clarifying those portions.
    Mr. Takano. Okay. Great. Well I agree with the intent of 
the VA Billing Accountability Act. Veterans deserve to know 
what they are expected to pay in a timely manner. I understand 
the VA puts a 90-day hold on bills to veterans when other 
health insurance is involved. This is to allow VA to collect 
from third party payers before billing the veteran. But how 
does that compare to the industry standard? Would that initial 
hold period make the 120-day timeline unworkable? Would that 
period need to also be revised? What billing and processing 
improvements would make, would VA need to do to meet the 120-
day limit? If 120 days is not feasible, what limit would be 
acceptable to the VA?
    Ms. Murphy. So sir, I would point out that you are giving 
the private sector 18 months and you are giving us 120 days. So 
there is a little bit of imbalance there. I think we would 
just, the 120 days is just too fast for normal business 
processes. You know, we are relying on the other health 
insurance to actually accept our bill, accept it as a clean 
claim, pay it timely. We rely on them to have their bill 
processing in order. Claims sometimes go back and forth because 
they disagree with what we have got on there or they want 
additional information. So sometimes it just takes more time.
    The other thing that happens is that sometimes our copay 
bills are delayed because we have a process of verifying a 
veterans' income. And we use the IRS database for that. So 
sometimes veterans will appear based on the income that they 
have declared not to owe a copay, but when we go through the 
IRS verification process which is sometimes out in the future 
after people file their taxes, we sometimes find that the IRS 
tells us that the income that the veteran has declared is not 
accurate and in fact they are now liable for copays. And so we 
want to be able to bill those copays for which the veterans are 
liable, even though that is well beyond the 120 days. So I 
guess what I am saying is that that is too limited a timeframe 
for us to work in. It is too small a box for us to be able to 
manage this appropriately. And I mean the opportunity for us to 
lose revenue that, you know, veterans actually owe. I mean, 
obviously if we made a mistake we need to own that. But we also 
need a little bit more time to work in.
    Mr. Takano. Thank you, Mr. Chairman, I yield back.
    Mr. Benishek. Mr. O'Rourke, you are recognized.
    Mr. O'Rourke. Thank you, Mr. Chairman. And Ms. Murphy, 
first of all thanks for the offer to work with us. Because if 
you are already tracking some of this then I agree, or we want 
to look at this, but I agree we do not want to duplicate 
efforts and spend more money. And we just want to get to an 
accurate measure and understanding of veterans' experiences in 
their own words or by their own measure. I think that is 
important. Where can I find the SHEP survey that you 
referenced?
    Ms. Murphy. We will send it to you.
    Mr. O'Rourke. Where could a veteran in my district find the 
SHEP survey?
    Ms. Murphy. I think it is on a link. I think the link, I 
will send you the link.
    Mr. O'Rourke. So I spent the last, and David who is behind 
me spent the last 20 minutes searching for SHEP VA survey, 
survey of health care experiences of patients, which is what 
SHEP stands for, El Paso VA survey, we cannot find it online. 
So I do not doubt that it exists. It is not accessible. And I 
think that lack of accessibility is connected to a lack of 
accountability. Part of the reason we want to do this is we 
want the VA, and frankly my office, to be accountable for the 
performance of the VA. And I am a big believer in that which is 
accurately measured tends to improve. And when people do not 
know what those measures are it makes it harder for us to 
direct resources or prioritize accordingly. How did you measure 
wait times? How were wait times measured or asked for in the 
SHEP survey?
    Ms. Murphy. They do not ask specifically for wait times. 
They ask questions like when you called, did you get an 
appointment when you wanted it? Did you have to wait more than 
15 minutes past your appointment time? When you called, when 
you needed an urgent care appointment, did you get it when you 
wanted it?
    Mr. O'Rourke. So the SHEP survey does not ask for wait 
times? So we have no independent check on what the VA has been 
telling us, which was wrong in Phoenix, it was wrong in El 
Paso. I think it is actually still wrong today because you do 
preferred appointment, which is a concoction that I do not 
understand. I understand the veterans requests an appointment 
on day one, and I understand he or she is seen at a certain 
date thereafter. That, the period between, you know, one and 
whenever that date is is the wait time. I do not know why you 
do not measure it that way, but our survey does.
    So does the SHEP survey measure access to mental health 
care?
    Ms. Murphy. It asks veterans if they felt they got an 
appointment when they needed it or wanted it?
    Mr. O'Rourke. Specific to mental health care?
    Ms. Murphy. I would have to check. I think it does.
    Mr. O'Rourke. Okay. So our survey found that, as I 
mentioned earlier, more than one-third of veterans in El Paso 
did not have access to mental health care. Could not make an 
appointment despite their best efforts to do so. When we 
brought that to the VA's attention, and when we hammered the VA 
frankly on this huge gap in service, that helped the VA to 
prioritize resources where they were most needed. It is not too 
hard to connect care denied, frankly, absolutely denied, to the 
high rate of veteran suicides. And we have those in El Paso. So 
that is where I found this survey to be incredibly useful to 
us.
    If I understand you correctly, the SHEP survey says were 
you happy with your service, were you seen when you wanted to 
be seen? It does not give us an independent check or 
verification on numbers and data that you give us, which is 
what we need and what I think veterans would be far happier 
with, and what I as a Member of Congress with oversight 
responsibility would be far happier with, than just trusting 
you that you are seeing veterans within a certain period of 
time that you say they are.
    So if the SHEP survey does not do all those things, then I 
do not think you have a compelling case against the Ask 
Veterans Act. Now I am very happy to take you up on your offer. 
I will meet with you. If in fact the SHEP survey does all those 
things that today we are not sure about, then let us just 
publish it, make sure everybody can see it, and let us hold 
everyone responsible accountable. But if not, then I think we 
need to have, I would love to have your support on the Ask 
Veterans Act.
    And lastly, Mr. Chairman and Madam Ranking Member, this is 
not rocket science to design these surveys. It is not 
incredibly expensive. We spent about $6,000 of our office's 
resources to conduct these surveys to get it within a margin of 
error under four percent. If we do not pass this legislation, 
if the VA does not want to implement it on its own, I would be 
very happy to show any office how to do this or at least how we 
did it. And it could certainly be improved upon. So with that, 
I yield back.
    Mr. Benishek. Thank you. Any other questions? Well, thank 
you for being here this morning. I appreciate that. The 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 once again thank all of our witnesses and the audience 
members for joining us this morning. The hearing is now 
adjourned.

    [Whereupon, at 12:10 p.m., the Subcommittee was adjourned.]




                            A P P E N D I X

                              ----------                              

          Prepared Statement of Ranking Member Julia Brownley
    Thank you, Mr. Chairman, for calling this hearing today. It is 
important for us to review the legislation that has been referred to 
this subcommittee. It is important to hear from our colleagues on their 
priorities and to hear all views on how to best protect the health of 
those men and women who dedicate their lives to protecting this nation.
    I am pleased so many of our colleagues are attending the hearing 
today in support of their legislation. Thank you so much for your 
interest in the well-being of the veteran community.
    Mr. Chairman, while there are many worthy bills on the agenda 
today, I will focus on just a few being considered today.
    I am pleased to be a cosponsor of Congressman O'Rourke's bill, H.R. 
1319, the Ask Veterans Act. This bill requires the VA to conduct an 
annual survey over the next five years to find out if
    Veterans are obtaining hospital care and medical services at the 
facility in a timely manner; how long it is between the time a veteran 
requests an appointment and the date the appointment is scheduled, the 
frequency with which scheduled appointments are cancelled, and the 
quality of hospital care or medical services received. These reports 
will then be posted on the VA's website.
    I am also a cosponsor of Congressman Peters' bill, H.R. 2639, the 
Marriage and Family Therapists for Veterans Act. This bill revises the 
eligibility criteria for appointment to a marriage and family therapist 
position with the Veterans Health Administration to require a person to 
hold a master's degree in marriage and family therapy, or a comparable 
degree in mental health, from an appropriately accredited institution 
and to have passed the Association of Marital and Family Therapy 
regulatory board examination in marital and family therapy or have a 
marriage and family therapy license given by a state board that 
oversees this issue. We need to know that our men and women coming to 
the VA are getting the proper therapy when they come to the VA for 
treatment.
    I am also delighted that we are considering H.R. 3471, the Veterans 
Mobility Safety Act of 2015. This bill directs the VA to ensure that an 
eligible disabled veteran provided an automobile or other conveyance is 
given the opportunity to make personal selections relating to the 
automobile or other conveyance. It also included the minimum standards 
of safety and quality for adaptive equipment. I am pleased to be a 
cosponsor of this legislation.
    Mr. Chairman, I look forward to the testimony from our witnesses 
today and their views on how to improve upon the many bills that we are 
considering.
    Thank you and I yield back the balance of my time.

                                 
               Prepared Statement of Honorable Andy Barr
      Thank you Chairman Benishek and Committee Members for 
allowing me the opportunity to present my legislation, H.R. 1603, the 
Military Sexual Assault Victims Empowerment Act also referred to as the 
Military SAVE Act.
      Two years ago, several veterans who were survivors of 
military sexual trauma but were not receiving the proper individual 
care they needed from the VA, visited my district office to share with 
me their powerful and heartfelt stories.
      I would like to introduce one of those individuals who 
helped inspire the creation of the Military SAVE Act - a courageous 
woman and survivor of military sexual assault, Ms. Susan Moseley.
      I would like to yield the balance of my time to Ms. 
Mosley.

                                 
            Prepared Statement of Honorable Matt Cartwright
    Chairman Benishek, Ranking Member Brownlee, and Members of the 
Committee, thank you for including H.R. 1904, the Wounded Warrior 
Workforce Enhancement Act, as part of the hearing today and for the 
opportunity to speak to the Committee about this very important piece 
of legislation.
    Additionally, I would like to thank the American Orthotics and 
Prosthetics Association as well as Senator Durbin as they have been 
instrumental in focusing attention on this critical issue facing our 
nation's veterans.
    The field of orthotics and prosthetics is at a critical tipping 
point in terms of the future viability of its workforce and the ability 
of those professionals to provide the best-tailored care to our 
nation's service members and veterans.
    In its testimony, the American Orthotics and Prosthetics 
Association stated that there has an approximately 300% increase in the 
number of veterans with amputations served by the VA since the year 
2000.
    Unfortunately currently only 7100 practitioners specially trained 
in O&P nationwide serve more than 80,000 vets with amputations. Of 
those trained practitioners, one in five is either past retirement age 
or eligible to retire in the next five years.
    However, there are only 13 schools around the country with master's 
degree programs in this field with the largest program supporting less 
than 50 students.
    With the growing demand of amputee treatment outpacing the number 
of new practitioners trained to replace an aging workforce, it is clear 
that we must act now to meet our moral obligation of providing our 
heroes with the best health care available.
    The Wounded Warrior Workforce Enhancement Act is a cost-effective 
approach to assisting universities in creating or expanding accredited 
master's degree programs in orthotics and prosthetics.
    Specifically, the bill addresses these issues by authorizing a 
competitive grant of program of $5 million per year for 3 years to help 
colleges and universities develop master's degree programs focusing on 
orthotics and prosthetics.
    The bill also requires the VA to establish a Center of Excellence 
in Prosthetic and Orthotic Education to provide evidence-based research 
on the knowledge, skills, and training clinical professionals need to 
care for veterans.
    These prosthetic and orthotic treatments serve soldiers who 
suffered limb loss injuries because they put their bodies on the line 
for our country, and as a result, have their lives forever changed. 
With Veterans Day just last week, it is a very good reminder just how 
much we owe our wounded warriors.
    Thank you again Chairman Benishek, Ranking Member Brownlee, and 
Members of the Committee for your consideration of this bill today and 
for bringing attention to the important issue of providing veterans 
with the best possible prosthetic and orthotic treatment possible.

                                 
              Prepared Statement of Honorable Scott Peters
    Thank you to Chairman Benishek, Ranking Member Brownley and members 
of the subcommittee, for agreeing to hear H.R. 2639, the Marriage and 
Family Therapists for Veterans Act. This subcommittee works tirelessly 
to provide veterans the care they deserve, and this bill can help 
achieve that goal for which we all strive.
    My bill is short and simple. It will modify the current US Code to 
allow well trained Marriage and Family Therapists (MFTs) the 
opportunity to provide mental health services to veterans, and their 
families, through the VA.
    The current standards make it impossible for many MFTs to work at 
the VA despite being licensed in the state they operate, due to non-
alignment with federal hiring requirements. Some of the most affected 
applicants are those in California, Florida, and New York. My bill will 
open the VA application process to those who are qualified through 
regionally accredited programs and established regulatory board 
examinations. Furthermore, this bill allows the VA to maintain its 
authority to make the final decisions on who is hired. Fixing this 
problem will help foster competition in hiring practices at the VA and 
America's veterans will be the greatest benefactor.
    My intent is that the VA will recognize MFT's who have the 
qualifications outlined in this bill are able to apply for jobs and be 
hired at the VA to increase the mental health care that is available. I 
look forward to working with the committee to enhance the care our 
veterans receive and appreciate the consideration.

                                 
              Prepared Statement of Honorable Martha Roby
    Mr. Chairman,
    Thank you for your time today and consideration of HR 3234, the 
Failing VA Medical Center Recovery Act.
    As you recall, we have had major problems for an extended period of 
time in my district at the Central Alabama Veterans Healthcare System 
(CAVHCS). The litany of scandals captured national headlines:
      unacceptable wait times
      the unearthing of thousands of unread Xrays (some of 
which detected cancer I might add)
      an employee of the VA taking a patient to a crack house
      CAVHCS Director James Talton lying directly to me, a 
Member of Congress
      retaliation against whistleblowers
      and finally the termination of James Talton, the first 
termination in the nation of a Director in the wake of the wait list 
scandal that swept the nation
    I cannot understate the malfeasance that took place during the 
tenure of James Talton and the lasting harm he inflicted on Veterans in 
Alabama. At the same time, his termination was well over a year ago. To 
this day, we still do not have a permanent Director, and the hiring of 
other key staff has been extremely slow. While progress has been made - 
wait times, particularly for outside care - remain unacceptable. Given 
the challenges we have faced in Alabama and the bureaucratic and 
cultural hurdles to turn around a troubled medical center, I have 
introduced the Failing VA Medical Center Recovery Act.
    Today the VA lacks the organization structure and systemic tools 
for swiftly addressing problems at the worst performing medical 
centers. Furthermore, there is little direct accountability at the very 
top for turning around an especially troubled medical center. The 
legislation focuses on the medical centers facing the most 
dysfunctional medical centers in the nation, ones that need major 
intervention and oversight at the highest levels of the VA. These 2-7 
medical centers are determined by objective criteria, a composite score 
derived from the VA's own SAIL data which measures key healthcare 
metrics.
    Similar to how a state may takeover the day to day operations of a 
failing school, this legislation requires the establishment of highly 
specialized teams to takeover the day to day operations of these worst 
VA facilities in the nation, removing the medical centers from the 
failed local and regional VA leadership.
    Rapid deployment teams are empowered with enhanced legal 
authorities so they have the tools necessary to truly make a difference 
on day one. Legal authorities include:
      Direct Hiring Authority and the ability to pay up to 125% 
of the prevailing rate to address critical vacancies
      Enhanced Personnel Accountability Authority (Terminations 
and Transfers)
      Simplified Contracting Authority
    Given the challenging nature of this assignment, members of the 
team are eligible for enhanced compensation and receive favorable 
consideration for promotion with a two year tour.
    The Office of Accountability and Review is required to prioritize 
whistleblower retaliation cases at failing medical centers, and the 
Inspector General is required to prioritize investigations related to 
failing medical centers.
    Upon sustained satisfactory performance (9 months) measured by 
SAIL, these medical centers return to the operational control of local 
and regional leadership.
    The deployment teams are managed by the Office of Failing Medical 
Center Recovery. In the legislation, this office is managed by a 
presidentially-appointed Under Secretary who has a direct line of 
access to the Secretary of the VA. However, I have recently met with 
Undersecretary of Health Dr. Shulkin. I have accepted his 
recommendation that this office fall under his direct control, and I am 
amenable to modifying this legislation accordingly. I also welcome his 
personal commitment that these failing medical centers will receive his 
close supervision.
    The legislation does impose statutory reporting requirements so 
that Congress, the President, and the public have a clear report card 
on the office's progress.
    I welcome your questions and comments.

                                 
            Prepared Statement of Honorable Jackie Walorski
    Good morning Chairman Benishek, Ranking Member Brownley and members 
of the Committee. I appreciate being given the opportunity to discuss 
H.R. 3471, the Veterans Mobility Safety Act of 2015.
    First, I would like to thank Chairman Benishek for holding this 
hearing and Ranking Member Brownley for cosponsoring this important 
legislation. Automotive mobility plays a vital part in helping our 
disabled veterans live a normal life after being wounded on the 
battlefield. This legislation ensures these veterans receive the best 
equipment by requiring vendors who participate in the Department of 
Veteran Affairs (VA) Automobile Adaptive Equipment, or AAE, program to 
meet minimum certification or accreditation standards.
    The AAE program provides eligible disabled veterans with a new 
automobile or modification, such as wheelchair lifts and reduced-effort 
steering and braking, to existing vehicles in order to improve their 
quality of life. However, the VA does not require any type of 
certification or accreditation from vendors to install or sell these 
products. Since there are no requirements, VISNs operate based on their 
own interpretations of VA procedures, which has resulted in VISNs using 
inferior vendors in an attempt to reduce costs. The modifications we 
are talking about are highly complex products, which means a lack of 
quality and safety requirements is putting the veteran and driving 
public at risk.
    Two cases in my home state of Indiana illustrate this danger. In 
the first case, the VA had a company install an EZ Lock system into a 
veteran's vehicle. An EZ Lock system is a wheelchair docking system 
that secures a wheelchair to the vehicle floor. However, the bolt was 
improperly installed by the company and kept getting caught on things. 
The veteran complained to the VA, which sent him back to the dealer, 
whose solution was to cut off the bolt on the bottom of the chair in 
order to give him more room. However, doing so meant that the 
wheelchair could not lock into position - something the veteran didn't 
realize it until his chair moved when a car cut him off and he had to 
slam on his brakes. Thankfully, the veteran wasn't hurt, but it is an 
illustration of the needless danger caused by this lack of standards.
    In the other case, a dealer subcontracted an individual to come to 
a veteran's home to install a wheelchair lift. However, that individual 
never tested the lift. When the wheelchair was on the lift, it pushed 
the lift down causing it to catch on and damage his bumper. The VA had 
another dealer take a look at the lift. Their solution? Remove the 
bumper. Finally, qualified professionals looked at the vehicle and 
concluded that the lift wasn't even compatible with the vehicle and 
shouldn't have been installed in the first place.
    As a point of comparison, the VA currently requires a certification 
to sell a veteran a bottle of oxygen, while the AAE program uses an 
outdated handbook that was last updated in 2000. This inconsistency of 
procedures has put veterans' lives at risk and resulted in taxpayer 
dollars being wasted on shoddy or improperly-installed equipment.
    My bill, H.R. 3471, Veterans Mobility Safety Act, ensures disabled 
veterans receive the best quality, performance, safety, and value by 
establishing a set of minimum standards for vendors who want to 
participate in the AAE program. Specifically, vendors of adaptive 
equipment modification services must be certified by a certification 
organization or the manufacturer of the adaptive equipment, and must 
adhere to the Americans with Disabilities Act of 1990 and the National 
Highway Safety Administration's Federal Motor Vehicle Safety Standards. 
Individuals performing these modification services must also be 
certified by either a certification organization, manufacturer, or the 
state. Lastly, this legislation puts the veteran in charge of what 
equipment he gets by giving them the opportunity to make personal 
sections of their automobiles or adaptive equipment.
    Disabled veterans have given so much for our country and they 
deserve the highest standard of mobility services. The robust, 
enforceable set of standards that are prescribed in H.R. 3471 will 
protect our veterans and the driving public while responsibly spending 
taxpayer funds through the AAE program. I look forward working with the 
members of this Committee, Veteran Services Organizations, and the VA 
in addressing this critical issue for disabled veterans. I thank you 
again for this opportunity to speak today.

                                 
               Prepared Statement of Honorable John Kline
    Chairman Benishek, Ranking Member Brownley, and members of the 
Health Subcommittee, thank you for the opportunity to testify this 
morning in support of H.R. 3549, the VA Billing Accountability Act, my 
legislation that will keep faith with our veterans by protecting them 
from flawed billing practices at the Department of Veterans Affairs.
    Mr. Chairman, last week, we, as a nation, paused on Veterans Day to 
honor those men and women who bravely wore our country's uniform. One 
of the reasons I first came to Congress was to ensure promises made to 
our veterans, troops, and their families were promises kept. While 
Washington has made some strides to do more to keep those promises, we 
can always do better.
    Mr. Chairman, this summer I was notified the VA discovered unbilled 
co-pay amounts for impatient care provided to Minnesota and Wisconsin 
veterans over a five-year period. Most concerning, our veterans were 
going to be immediately assessed co-pays after the VA erred in not 
charging veterans at the time of care. To be clear: through no fault of 
their own, Minnesota and Wisconsin veterans were set to receive on 
their monthly statements unexpected charges for thousands of dollars 
for care received, in some cases, several years ago.
    Many of our veterans live on fixed incomes or may not have the 
resources available to cover the unexpected costs caused by the VA's 
erroneous and untimely billing procedures. These billing blunders can 
unnecessarily cause confusion, frustration, and stress for many of the 
veterans in Minnesota, Wisconsin, and across the nation who seek care 
at the VA.
    We owe a great deal to those who have proudly served our nation. 
They should never be suddenly saddled with bills years later due to the 
VA's inability to properly track, record, and bill for services.
    That is why I am urging members to support my eight-page bill, the 
VA Billing Accountability Act, which keeps our promise of a fair 
billing process to veterans by giving the Secretary of Veterans Affairs 
the authority to waive a required co-payment if the VA erred in not 
sending the bill in a timely manner - timely being within 120 days.
    The bill also requires the VA to inform veterans of their rights to 
payment plans and waivers if the VA does not meet billing timelines 
based on how and where a veteran received care. If a veteran received 
care at a VA facility, the VA has up to 120 days to send a bill. If the 
care is at a non-VA community facility, where the VA must sometimes 
wait for a final bill to be completed beyond inpatient care times, the 
VA has up to 18 months to send a bill. The legislation's billing 
standards are modeled on VA's own stated timelines. If the VA fails to 
meet their standard timelines shared with me in a letter, the VA must 
notify the veteran of how to get a waiver and establish a payment plan 
before they can collect a payment. To be clear, nothing in this section 
stops the VA from billing a veteran after they inform the veteran of 
their rights.
    I want to thank my colleagues for their support, including 
bipartisan cosponsors from Minnesota: Collin Peterson, Erik Paulsen, 
Tom Emmer, and VA Committee member Tim Walz, along with Health 
Subcommittee member Phil Roe of Tennessee. We worked hard to make this 
bipartisan legislation, and I also am grateful to Senator Amy Klobuchar 
for her leadership on this bill in the Senate.
    Mr. Chairman, the federal government is expected to keep the 
public's trust and meet our commitments - especially to those who have 
sacrificed for our nation. We must work tirelessly to change the 
culture of bungled bureaucracy and mismanagement at the VA, and restore 
faith that our veterans will receive the health care they deserve.
    I urge members of the committee to support the VA Billing 
Accountability Act to ensure a promise made is a promise kept. Thank 
you, and I am happy to answer your questions.

                                 
            Prepared Statement of Honorable Gus M. Bilirakis
    House Veterans Affairs Committee Subcommittee on Health Legislative 
Hearing
    Statement of the Honorable Gus M. Bilirakis on the ``PROMISE Act''
    November 17, 2015
    Chairman Benishek, Ranking Member Brownley and distinguished 
Members of the Health Subcommittee,
    Thank you for holding this legislative hearing today. Today's 
hearing includes many important pieces of legislation that will improve 
the services and care our Veterans receive for their dedicated service 
to our great nation.
    Among the bills under consideration in today's hearing, is my bill 
the Promoting Responsible Opioid Management and Incorporating 
Scientific Expertise Act or the ``Jason Simcakoski PROMISE Act.'' I 
appreciate the Chairman's leadership in bringing this important issue 
before the Committee and for allowing me to speak today on the PROMISE 
Act.
    The tragic death of Marine Corp. Veteran Jason Simcakoski in the 
Tomah, Wisconsin VA Medical Facility prompted the need for 
Congressional action. On August 2015, nearly one year from Jason's 
death, the Office of Inspector General released their report titled: 
``Unexpected Death of a Patient During Treatment with Multiple 
Medications.''
    The IG report concluded that Jason's cause of death was due to 
mixed drug toxicity with the potential for respiratory depression and 
the combination of various medications was the plausible mechanism of 
action for a fatal outcome. Furthermore, the IG also found deficiencies 
in the ``informed consent'' process, confusion among staff when 
initiating cardiopulmonary resuscitation, and the absence of certain 
medications available in emergency situations to reverse effects of 
possible drug overdose. I request unanimous consent to submit this IG 
report for the record in today's hearing materials.
    As the guidelines used by the VA and DOD for opioid management have 
not been updated since 2010, it is due time to ensure those treating 
our Veterans have the necessary resources and training to effectively 
treat Veterans with chronic pain. I want to be clear; the intent of 
this bill is to improve patient safety, not to restrict access for 
those who truly need these prescriptions for their wellness plan.
    The PROMISE Act will increase safety for opioid therapy and pain 
management by requiring the VA and DOD to update their Clinical 
Practice Guidelines for Management of Opioid Therapy for Chronic Pain, 
VA opioid prescribers to have enhanced pain management and safe opioid 
prescribing education and training, and the VA to increase information 
sharing with state licensing boards.
    This bill also promotes needed transparency within the VA and will 
further our efforts to hold the VA accountable by requiring GAO to 
report on recommendations for improvement and assess the level of care 
Veterans are receiving.
    Additionally, the PROMISE Act will authorize a program on 
integration of complementary and integrative health within the VA and 
encourage more outreach and awareness of the Patient Advocacy Program 
to educate Veterans on their care options.
    Our Veterans have sacrificed so much for our country, and we have a 
responsibility to ensure they are receiving the quality of care they 
have earned and deserve. We must hold the VA accountable and encourage 
quality care for all Veterans who have fought for the freedoms we enjoy 
on a daily basis.
    I want to thank all the VSOs for their support and for appearing 
today to provide their testimony in today's legislative hearing. I also 
want to thank all my colleagues on this Committee and in the House for 
your support in signing on as an original cosponsor prior to this 
hearing. With this strong list of bipartisan support, we send a clear 
message to the Simcakoski family, our Veterans and those that have been 
affected by such tragedies that we are dedicated in ensuring similar 
failures will never happen again.
    In closing, I am grateful we are here discussing these important 
bills. I look forward to having a substantive discussion on how we can 
improve the lives of our true American heroes. In upholding our sacred 
vow and promise to our Veterans, I urge my colleagues to support this 
bill and cosponsor the PROMISE Act.
    Thank you Mr. Chairman and I yield back.

                                 
                Prepared Statement of Adrian M. Atizado
    Mr. Chairman and Members of the Subcommittee:
    Thank you for inviting the DAV (Disabled American Veterans) to 
testify at this legislative hearing of the House Veterans' Affairs 
Subcommittee on Health. As you know, DAV is a non-profit veterans 
service organization comprised of nearly 1.3 million wartime service-
disabled veterans that is dedicated to a single purpose: empowering 
veterans to lead high-quality lives with respect and dignity.
    DAV is pleased to be here today to present our views on the bills 
under consideration by the Subcommittee.
                    H.R. 1319, the Ask Veterans Act
    This bill would require the Department of Veterans Affairs (VA) to 
contract with an experienced non-government entity to conduct an annual 
survey, over a five-year period, to determine the experiences of 
veterans in obtaining hospital care and medical services at each VA 
medical facility. Survey questions would include but are not limited to 
those relating to a veteran's ability to obtain hospital care and 
medical services at the facility in a timely manner, the time between 
the date the veteran requests an appointment and the date the 
appointment is scheduled, the frequency with which scheduled 
appointments are cancelled, and the quality of hospital care or medical 
services received. Under the bill, the results of the surveys would be 
made publicly available on the VA's website.
    We understand the intent of this legislation is to better describe 
the veterans experience in accessing and receiving VA medical care, as 
a standard of comparison to VA's reported data. Wounded, injured and 
ill members of DAV report they do experience delays in receiving timely 
access to medically necessary services from the VA health care system. 
Arguably, this kind of patient experience can be illustrated by various 
VA reports such as its access reports (http://www.va.gov/health/access-
audit.asp) and the VHA Facility Quality and Safety Report (system 
level: www.va.gov/health/hospitalReportCard.asp, and for local 
facilities: www.va.gov/HEALTH/docs/QandS--Report--2013--data--tables--
fy12--data.pdf).
    If this legislation is to be favorably considered, we urge the 
Subcommittee to amend the legislation to require that surveys results 
be acted upon in consonance with the continuous improvement philosophy 
of the VA health care system. Perhaps also such information could be 
used to require analyzing and/or revising existing policy or used as a 
basis for developing new policy to ensure the VA health care system and 
all its points of care meet the goal of consistently providing high 
quality care that is safe, effective, efficient, timely, patient 
centered, and equitable.
     H.R. 1603, the Military Sexual Assault Victims Empowerment Act
    This bill would amend the Veterans Access, Choice, and 
Accountability Act of 2014 VACAA) to make eligible a veteran who was 
the victim of a military sexual trauma (MST) which occurred on active 
duty, active duty for training, or inactive duty training, for 
treatment by a non-VA provider.
    This bill would exempt such MST survivors from mileage and waiting-
time standards otherwise applicable to veterans to receive contract 
care under the provisions of VACAA, and would remove the eligibility 
date of enrollment before August 1, 2014, for survivors of MST.
    DAV has not received a resolution from our membership in support of 
the specific matter of contracting out counseling and care on demand 
for victims of MST; therefore, DAV takes no formal position on this 
bill. However, our resolution on treatment for MST recognizes VA as a 
provider of specialized residential and outpatient counseling programs 
and evidence-based treatments for MST survivors. Accordingly, enactment 
of this bill would engender a number of questions that we ask the 
Subcommittee to consider before advancing this measure.
    This bill would provide access to the Veterans Choice Program for 
survivors of MST by exempting them from certain qualifying or 
eligibility aspects, but it leaves other patients with other 
disabilities to comply with VACAA. Moreover, current law and VA 
national mental health policy are positioned to honor the preferences 
of MST survivors, such as meeting their designated preferences for a 
female or male provider, or to be referred to private care and 
counseling services when necessary.
    We do not believe the failure of one facility is justification for 
enacting this legislation - a bill that would do little to improve 
every VA facility's ability to care for MST survivors. To refer MST 
care and counseling to community providers would increase the risk of 
fragmenting the holistic approach employed by VA using all available 
resources, benefits and services across the Department that are 
critical to optimal treatment outcomes for these patients.
    Over the past decade, given the growing incidence of MST, VA has 
made major strides to elevate this program, employ additional resources 
and personnel, and ensure that treatment staff in every locale are 
trained to deal with the sequalae of MST in the most effective manner. 
Nationally, VA is now treating over 100,000 veterans for their needs 
associated with MST. Over 800,000 annual outpatient visits are being 
made by these individuals, and we believe the vast majority are well 
satisfied with the services they are receiving.
    We believe VA is the right choice for most if not all veterans who 
have experienced MST and need specialized counseling and care in its 
aftermath. Mental health is one of VA's most significant and successful 
programs, and VA offers integrated and coordinated care to millions of 
veterans. Accordingly, we urge this Subcommittee to exercise its 
oversight responsibilities, and for VA to take action when local 
facilities fail to comply with these policies to the detriment of 
veterans' health and well-being.
        H.R. 1904, the Wounded Warrior Workforce Enhancement Act
    This bill would establish two VA grant programs. One would be made 
to educational institutions to establish or enhance orthotic and 
prosthetic masters and doctoral education programs, with an 
appropriations limitation of $15 million; and the other to establish a 
private ``center of excellence in orthotic and prosthetic education,'' 
with an appropriations limitation of $5 million.
    DAV has no resolution from our membership that would support the 
establishment of these specific activities. Nevertheless, prosthetic 
and orthotic aids and services are important to injured and ill 
veterans, and constitute a specialized medical program within the VA. 
However, absent a defined shortage of individuals who possess related 
skills and knowledge in these fields, justification for enactment of 
this bill seems questionable. Also, assuming the grant programs that 
would be established by this bill were to take form, graduating 
students who benefitted from them would not be required to provide 
obligated employment in VA to repay the government's investment in 
their education such as is required in VA's existing health 
professional scholarship programs under Chapters 75 and 76 of title 38, 
United States Code. We believe this existing and highly successful 
mandate for students in other health fields be considered in adopting 
the concept embedded in this bill, to ensure that VA regains at least 
some of the value of the work of these students following their VA-
subsidized education and training.
    Finally, assuming the establishment of a center of excellence in 
this particular field is warranted, DAV questions whether the center 
should be outside VA, rather than become a new VA in-house center of 
excellence along the lines of those centers already established in law 
in Chapter 73 of title 38. We ask that the sponsor of this bill 
reconsider and restructure this proposal in light of our testimony.
     H.R. 2639, the Marriage and Family Therapists for Veterans Act
    This bill would amend VA policy to require marriage and family 
therapist candidates to pass examination by the Association of Marital 
and Family Therapy, or pass an examination by a state board of 
behavioral sciences or an equivalent activity of a state, as a 
precondition to employment within the VA.
    VA's various authorities under title 38, United States Code, 
section 7402 (which would be modified by this bill) generally require 
licensure in a state, or registration in the cases of nurses and 
pharmacists, as a condition of clinical professional employment in VA. 
Generally, any other requirements for VA employment of patient care 
professionals are left to the discretion of the VA Secretary. In the 
case of marriage and family therapists, current law requires a certain 
level of educational achievement and a valid state license, unless the 
Under Secretary for Health recommends to the Secretary a waiver of 
licensure requirement for a reasonable period of time following initial 
appointment.
    On this basis, we cannot identify a valid reason that this one 
particular category of patient care provider would need to undergo 
additional qualification testing as a pre-condition to employment in VA 
health care.
    DAV has received no national resolution from our membership 
specific to the matters proposed in this bill, and thus takes no 
official position, but hopes the Subcommittee would take our views into 
consideration.
    We also would take this opportunity to remind the Subcommittee of 
DAV's and VA's prior testimonies dealing with the topic of marriage and 
family counselors and licensed mental health counselors, and their 
potential employment in VA. DAV has long agreed with VA's position that 
these individuals from these professions could be employed in the 
Department's mental health programs without further acts of Congress. 
We maintain that view with respect to this bill.
         H.R. 3234, the Failing VA Medical Center Recovery Act
    If enacted this bill would establish within the VA a new Office of 
Failing Medical Center Recovery, led by an Under Secretary-level 
official.
    Under this bill, the Secretary would be required to establish a set 
of key measurements against which to evaluate each VA medical center, 
and the bill would specify the measurements to be used. If a medical 
center were ranked and certified by the Secretary as ``failing'' under 
this measurement scheme, operational control of the medical center 
would be transferred to the new office. The office would be required to 
dispatch a ``rapid deployment team'' to each such failing medical 
center to examine and report on its resources, practices, health care 
programs. The Under Secretary for Failing Medical Center Recovery would 
be empowered to take a number of personnel actions, execute contracts, 
and carry out other actions to improve the performance of failing 
medical centers.
    Both the VA Inspector General and the VA Office of Accountability 
Review would be required by the bill to give priority to whistleblower 
retaliation investigations emanating from failing medical centers.
    The bill would define a number of terms associated with these new 
authorities, and would specify qualifications of the individual 
appointed to the position of Under Secretary for Failing Medical Center 
Recovery.
    A number of the authorities this bill would prescribe to the new 
office are currently embedded in VA's existing organizational table, or 
are parts of the functions of existing staff offices, including the 
Office of Medical Inspector, the Office of Research Oversight and 
Compliance, the Office of the Inspector General, as well as the 
Governmental Accountability Office in its continuing reviews of VA 
health care, most of which are directed by Congress. Numerous offices 
within the Veterans Health Administration are responsible for ensuring 
medical centers do not fail in their work. In our view, collectivizing 
these responsibilities into one new office, while attractive on its 
face, could create a number of unintended consequences and conflicts 
with similar and preexisting VA functions. Also, we believe 
establishing a single set of measurements to apply to every medical 
center in the system could be very challenging, given the wide variety 
of missions and histories of individual centers, producing distorted 
results. Some are clearly academic health centers with major 
affiliations with educational institutions; others are secondary-level 
facilities, many in rural areas or small cities; and still others are 
primarily long-term care oriented.
    Finally, it should be noted that the bill is silent on addressing 
the disposition of a failing medical center once it improves its 
performance such that it is no longer ``failing.''
    DAV has received no national resolution from our membership that 
could be applied to this legislative proposal; therefore, DAV takes no 
position on this bill.
          H.R. 3471, the Veterans Mobility Safety Act of 2015
    The intent of this legislation would be to ensure disabled veterans 
receive the best quality, performance, and safety by establishing a set 
of minimum standards for vendors who want to participate in the VA 
Automobile and Adaptive Equipment (AAE) program. Specifically, under 
the bill an AAE vendor would need to be certified by a qualified 
organization or by the equipment's manufacturer. The vendor could also 
be licensed or certified by the state where the modification services 
are performed.
    DAV recognizes that the intent of this legislation could be 
beneficial to wounded, injured and ill veterans, but we urge the 
Subcommittee consider addressing certain possible unintended 
consequences. For example, a new provision may need to be added to this 
bill in cases where a veteran who requires AAE repair, maintenance, or 
replacement services resides beyond a reasonable distance from a 
certified AAE provider or requires emergency repairs when the closest 
provider is not certified as required by the bill. A strict requirement 
without flexibility, such as a waiver or approved exception, could be 
particularly troublesome for veterans residing in rural areas or when 
traveling across a vast distance when the need for these services 
arises.
              H.R. 3549, the VA Billing Accountability Act
    This bill would provide VA the authority to waive an otherwise 
required co-payment if the veteran received a VA notification more than 
120 days after the date the veteran received services or medication 
from the VA, or more than 18 months later for services from a non-
Department facility, and that the notification delay was caused by an 
error on the part of the agency. VA would also need to provide 
information to veterans on arranging payment plans and applying for 
waivers.
    Based on Resolution Nos. 114 and 231, passed by our membership 
regarding VA copayments, we support this legislation.
     Draft Bill - the Promoting Responsible Opioid Management and 
           Incorporating Scientific Expertise ``PROMISE'' Act
    Title I of this bill would establish a far-reaching and ambitious 
new program to deal with, protect against, control, and report any 
over-prescribing of benzodiazepines and opioid substances in the care 
of veterans enrolled in health programs of VA. While VA has made recent 
efforts to address overprescribing, its existing pain management 
program is not well organized, and is insufficiently staffed in our 
view, so enactment of this bill would call attention to the need for VA 
to better manage and staff this function at both the national and local 
levels.
    DAV strongly supports Title II of the bill, which would establish a 
formalized national patient advocacy program in VA. As a co-author of 
the Independent Budget, DAV has called for improvements in patient 
advocacy and ombudsman programs in VA for several years. We believe 
this bill would give this program the weight and importance it deserves 
to help veterans to better navigate the VA health care system.
    Title III of the bill would enhance complementary and alternative 
health care programs in VA. We support the advent of complementary and 
alternative care, both in substitute to VA's use of pharmacological 
agents, and to better respond to the needs and demands of a younger 
generation of veterans, who often do not want traditional medical 
management - especially if it involves the prescribing of pain and 
psychotropic medications.
    Title IV of this bill would require VA to strengthen its scrutiny 
in hiring practices for physicians and other providers by validating 
that such candidates for employment in VA carry no blemishes on their 
state licenses. If a VA provider were to violate a requirement of 
medical licensure, VA would be required by the bill to report such 
violation to the state medical board(s) of the state(s) that had 
granted licensure. Also, if the VA provider were to resign from VA, or 
transfer from one VA facility to another, your bill would require VA to 
determine whether there were any ``concerns, complaints, or allegations 
related to the medical practice'' of the individual during VA 
employment, and to take appropriate action in response. In respect to 
these requirements, the sponsor or the Subcommittee staff may wish to 
consider amending the bill to more clearly define the term 
``provider,'' and whether the intention is to include all or only some 
of the individuals identified as direct care providers in section 7401 
of title 38, United States Code.
    Title V of the bill would require the establishment and reporting 
to Congress of a series of internal audits of VA administrations and 
key offices.
    In summary, based on Resolution Nos. 103, 116, 228, and 126 adopted 
by our membership in our most recent National Convention, DAV supports 
this bill. We appreciate the sponsor's introducing this omnibus 
proposal, and we urge Congress to proceed with its enactment this year.
     A VA legislative proposal to establish certain agreements for 
purchasing medical care for veterans when care within VA facilities or 
   through contracts or sharing agreements is not feasibly available.
    This draft bill would establish authority for VA to execute 
purchase agreements for medical care for veterans when the VA and 
contracts or sharing agreements are not feasibly available. According 
to VA, this proposed language will streamline and speed the business 
process for purchasing care for an individual veteran when necessary 
care cannot be purchased through existing contracts or sharing 
agreements.
    The continuing problem harming disabled veterans and their families 
was discussed in prior testimony from DAV on H.R. 1369, the Veterans 
Access to Extended Care Act of 2015. Like VA's draft bill, which would 
give VA the authority to enter into provider agreements, H.R. 1369 
focuses on selected extended care facilities.
    We support the intent of this draft legislation based on DAV 
Resolution 217. However, as with H.R. 1369, we recommend this measure 
be amended under subsection (e) to add federally recognized providers 
of service--Aging and Disability Resource Centers, area agencies on 
aging, State agencies (as defined in section 102 of the Older Americans 
Act of 1965 (42 U.S.C. 3002)), and centers for independent living (as 
defined in section 702 of the Rehabilitation Act of 1973 (29 U.S.C. 
796a)). These entities serve on the front lines of a partnership 
between the VA and the Department of Health and Human Services that has 
served over 3,400 Veterans across 31 States and the District of 
Columbia and Puerto Rico. These agencies provide severely ill and 
injured veterans of all ages the opportunity to determine their own 
supports and services to live independently at home.
    This concludes my testimony, Mr. Chairman. DAV would be pleased to 
respond for the record to any questions from you or the Subcommittee 
Members concerning our views on these bills.

                                 
                 Prepared Statement of Laranda D. Holt
    Chairman Benishek, Ranking Member Brownley, and distinguished 
members of the subcommittee, on behalf of our National Commander, Dale 
Barnett, and the over 2 million members of The American Legion, we 
thank you for this opportunity to testify regarding The American 
Legion's positions on the following pending legislation.
                      H.R. 1319: Ask Veterans Act
 To direct the Secretary of Veterans Affairs to conduct annual surveys 
of veterans on experiences obtaining hospital care and medical services 
from medical facilities of the Department of Veterans Affairs, and for 
                            other purposes.
    This bill would require the VA Secretary to enter into a contract 
with a non-government entity to conduct an annual survey to determine 
the nature of the experiences of such veterans in obtaining hospital 
care and medical services furnished at each medical facility. The 
survey would look at the veteran's ability to obtain care in a timely 
manner, the period of time between the requested appointment and the 
scheduled appointment, the frequency in which scheduled appointments 
are cancelled by the facility, and the quality of care the veteran 
received at the facility.
    The Veterans Health A7dministration (VHA) currently has a process 
of conducting surveys to measure veterans health care experiences 
through the Survey of Health Experiences of Patients (SHEP) process. 
This process serves both quality improvement and performance 
measurement functions. When a given standard falls substantially below 
national benchmarks in a particular medical unit or clinic, process 
action teams can examine the question scores to identify specific 
barriers that addresses the overall patient experience.
    Through The American Legion's System Worth Saving (SWS) Program, 
which assesses the quality and timeliness of how VA delivers benefits 
to our nation's veterans, The American Legion has helped educate our 
federal government and our veterans as to the strengths and weaknesses 
of the Department of Veterans Affairs (VA) health care system and all 
of the services that VA is responsible for delivering to veterans. \1\ 
In 2012, The American Legion SWS Task Force Report specifically focused 
on Veterans Health Administration's (VHA) Quality of Care and Patient 
Satisfaction. In our report, we made the following recommendations: \2\
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    \1\ American Legion No. 105: Reiteration of the System Worth Saving 
Program: SEPT. 2015
    \2\ American Legion System Worth Saving Report: Quality of Care and 
Patient Satisfaction: 2012
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      The SHEP scores data need to be sent to VA medical 
facilities in a timely manner, rather than a three to six-month wait, 
in order to adequately evaluate and measure ``real-time'' quality of 
care and patient satisfaction.
      VHA needs to adopt a single and consistent patient-
satisfaction survey tool such as Truth Point or Press Ganey to utilize 
as the main tracking tool in order to make it more efficient and 
effective to gather results.
      Representatives from the veterans' community should be 
involved and serve as a member of the facility's Customer Service Board 
and Patient Satisfaction Committee meetings. The Veterans 
Administration Voluntary Service (VAVS) National Advisory Committee 
(NAC) has brought forward this recommendation to senior VA officials. 
Following this recommendation, VHA has stood up a new Veterans 
Experience Office and this office will be working with community 
leaders nationwide to gain feedback on veterans' experiences at their 
local VA medical centers.

    The American Legion has no position on H.R. 1319 due to the fact 
that VHA currently has a process of conducting surveys to measure 
veterans health care experiences through the SHEP process.

  H.R. 1603: Military Sexual Assault Victims Empowerment Act/Military 
                                SAVE Act
    To amend the Veterans Access, Choice, and Accountability Act of 
2014 to improve the private treatment of veterans who are victims of 
military sexual assault.
    This bill would amend the Veterans Access, Choice, and 
Accountability Act (VACAA) of 2014 to improve the private treatment of 
veterans who are victims of military sexual assault. H.R. 1603 would 
make a victim of a military sexual trauma potentially eligible for non-
VA care under the Veterans Choice Program.
    Ultimately, this is about trying to find the right treatment for 
every patient, and in the case of Military Sexual Trauma (MST), unique 
challenges can shape treatment needs, and VA should be flexible to 
ensure these veterans receive the care they need. The American Legion 
is deeply concerned with the plight of survivors of MST and has urged 
Congress to ensure the VA properly resources all VA medical centers, 
vet centers, and community-based outpatient clinics so that they employ 
a MST counselor to oversee the screening and treatment referral 
process, and continue universal screening of all veterans for a history 
of MST. \3\ A January 2011 landmark survey of women veterans conducted 
by The American Legion found challenges for women veterans receiving 
gender specific care sensitive to their needs, particularly with regard 
to MST, and The American Legion has since fought for better awareness 
training in VA for MST sensitivity, significant increases in outreach, 
and more comprehensive care options for MST survivors including better 
availability of female therapists, female group therapy and other 
options to make MST care more accessible. \4\
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    \3\ Resolution No. 67: Military Sexual Trauma AUG 2014
    \4\ Resolution No. 18: Women Veterans OCT 2015

    VA is working to improve in these areas, as is evidenced by VA 
---------------------------------------------------------------------------
publications that note:

      VA knows that MST survivors may have special treatment 
needs and concerns. For example, a Veteran can ask to meet with a 
clinician of a particular gender if it would make him or her feel more 
comfortable. Similarly, to accommodate Veterans who do not feel 
comfortable in mixed-gender treatment settings, many facilities 
throughout VA have separate programs for men and women. All residential 
and inpatient programs have separate sleeping areas for men and women.
      VA has specialized treatment programming available for 
MST survivors. VA facilities have providers knowledgeable about 
evidence-based mental health care for the aftereffects of MST. Many 
have specialized outpatient mental health services focusing on sexual 
trauma. Vet Centers also have specially trained sexual trauma 
counselors. For Veterans who need more intensive treatment and support, 
there are programs nationwide that offer specialized sexual trauma 
treatment in residential and inpatient settings.
      In VA, treatment for all mental and physical health 
conditions related to MST is free and unlimited in duration. Veterans 
do not need to have a disability rating (that is, be ``service-
connected''), to have reported the incident(s) at the time, or to have 
other documentation that MST occurred in order to receive free MST-
related care. There are no time limits on eligibility for this care, 
meaning that Veterans can seek out treatment even many years after 
discharge.
      Veterans may be eligible for free MST-related care even 
if they are not eligible for other VA services. There are special 
eligibility rules associated with MST-related care and many of the 
standard requirements related to length of service or financial means 
do not apply. \5\
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    \5\ Top Ten Things All Healthcare & Service Professionals Should 
Know About VA Services for Survivors of Military Sexual Trauma

    However, implementation of change within VA can take time, and even 
the best of programs can have irregular results from facility to 
facility. Veterans should not have to suffer because the care they need 
is not well implemented at their local VA facility.
    The American Legion recognized that the Choice program was an 
emergency measure to get care to veterans where VA was struggling to 
deliver care. At the time of its passage in 2014, The American Legion 
hoped lessons could be learned about how VA implements non-VA care and 
how better systems could be devised to ensure veterans can use that 
care seamlessly when needed, but still benefit from the healthcare 
system specifically designed to meet their needs, the VA.
    In recognition of the needs of an integrated system to deliver non-
VA care when need, The American Legion believes VA need to develop 
``develop a well-defined and consistent non-VA care coordination 
program, policy and procedure that includes a patient-centered care 
strategy which takes veterans' unique medical injuries and illnesses 
[emphasis added] as well as their travel and distance into account.'' 
\6\
---------------------------------------------------------------------------
    \6\ Resolution No. 46: Department of Veterans Affairs (VA) Non-VA 
Care Programs OCT 2014
---------------------------------------------------------------------------
    One of the unique problems that survivors of MST face is that the 
treatment environment at VA is not always conducive to their comfort 
level, and comfort is critical in particular when dealing with issues 
such as psychiatric care for Posttraumatic Stress Disorder (PTSD) which 
is frequently a major side effect of MST. In the case of these 
survivors, getting them to a treatment program within their comfort 
level can mean the difference between a survivor continuing treatment, 
or abandoning treatment and feeling further isolation and possibly 
escalation of their symptoms.
    For veterans who are suffering right now, they need to get the 
treatment they need, but we should also be mindful this is not a 
panacea for the problems faced by MST survivors, and ensuring 
integration with the VA system is also beneficial to their overall 
health picture. As with any care outside VA, The American Legion 
stresses the importance of ensuring non-VA care has quality of care 
standards equal to or better than they receive within VA, that the care 
is coordinated effectively to ensure veterans are not stuck with 
billing problems with outside providers that can adversely affect their 
credit, and perhaps most importantly, that the providers have access to 
VA healthcare records for the patient and vice versa. \7\ One of the 
best assets of VA healthcare for veterans is the ability for providers 
within the system to have a total picture of the veteran's health. By 
seeing all interconnected conditions, and being aware of the unique 
health challenges of veterans, providers can spot patterns leading to 
early screening for conditions such as PTSD, health conditions related 
to environmental exposures like Gulf War Illness and Agent Orange, and 
other things an average civilian provider would miss. While sometimes 
it's necessary for veterans to get the care they need outside the 
system, it's important to make sure when that's done, they do not lose 
out on the real and tangible benefits to care they get as part of the 
integrated care network that is VA.
---------------------------------------------------------------------------
    \7\ Resolution No. 46: Department of Veterans Affairs (VA) Non-VA 
Care Programs OCT 2014
---------------------------------------------------------------------------
    But first, for veteran survivors of Military Sexual Trauma, we have 
to make sure they get the care they need in the environment that's 
going to maximize the effects of treatment.

    The American Legion supports H.R. 1603.

        H.R. 1904: The Wounded Warrior Workforce Enhancement Act
    To require the Secretary of Veterans Affairs to award grants to 
establish, or expand upon, master's degree or doctoral degree programs 
         in orthotics and prosthetics, and for other purposes.
    This bill would require the Secretary of the Department of Veterans 
Affairs to award grants to establish, or expand upon, master's degree 
programs in orthotics and prosthetics, and for other purposes. The 
American Legion believes due to the shortage of physicians in certain 
specialized areas, such as orthotics and prosthetics, Congress must 
ensure resources and funding are available to support continuing 
education and training of such physicians. \8\ Through this continuing 
education program, VA would benefit from providers of these professions 
being available to treat VA patients through their continuing education 
program, and upon completion of the program becoming gainfully employed 
by the VA.
---------------------------------------------------------------------------
    \8\ American Legion Resolution No. 311: The American Legion Policy 
on VA Physicians and Medical Specialists Staffing Guidelines: SEPT. 
1998

---------------------------------------------------------------------------
    The American Legion supports H.R. 1904.

       H.R. 2639: Marriage and Family Therapists for Veterans Act
   To amend title 38, United States Code, to provide for additional 
 qualification requirements for individuals appointed to marriage and 
family therapist positions in the Veterans Health Administration of the 
                    Department of Veterans Affairs.

    Marriage and Family Therapists (MFTs) are mental health 
professionals that are trained in psychotherapy and family systems. 
These professionals are licensed and trained to treat mental and 
emotional disorders within the environment of marriage, couples, and 
family systems. H.R. 2639, would revise the eligibility criteria for a 
marriage and family therapists to be employed by the Department of 
Veterans Affairs by requiring those individuals to have a graduate 
level degree in marriage and family therapy and/or mental health. The 
additional requirements set forth in the bill will ensure Marriage and 
Family Therapists that are employed by the VA are certified to be the 
best in their field.
    The American Legion has no position on H.R. 2639.
           H.R. 3234: Failing VA Medical Center Recovery Act
    To amend title 38, United States Code, to establish within the 
  Department of Veterans Affairs an Office of Failing Medical Center 
                    Recovery, and for other purposes
    This bill would add a new subsection Sec.  323 to 38 United States 
Code (U.S.C.) Chapter 3- Department of Veterans Affairs \9\ entitled 
``Office of Failing Medical Center Recovery''. This section would 
establish the new Office of Failing Medical Center Recovery headed by a 
new Under Secretary for Failing Medical Center Recovery within VHA. The 
purpose of this office would be to carry out the managerial and day-to-
day operational control of each medical center of the Department that 
the Secretary certifies as a failing medical center.
---------------------------------------------------------------------------
    \9\  https://www.law.cornell.edu/uscode/text/38/part-I/chapter-3
---------------------------------------------------------------------------
    The American Legion currently has no position on the creation of 
such an entity and is researching the potential impact - both positive 
and negative - of such a change on the ability to deliver health care 
so that the membership of The American Legion will have a chance to 
consider a resolution on the issue and solidify a formal position.

    The American Legion has no position on H.R. 3234 at this time.
            H.R. 3471: Veterans Mobility Safety Act of 2015
    To amend title 38, United States Code, to make certain improvements 
in the provision of automobiles and adaptive equipment by the 
Department of Veterans Affairs.
    This bill requires a vendor of automotive adaptive equipment to be 
certified by a qualified organization or the manufacturer of the 
adaptive equipment. Through the VA Automotive Adaptive Equipment (AAE) 
program, VA provides physically challenged persons the necessary 
equipment to safely operate their vehicle on the country's roadways. 
Through the Department of Rehabilitation and Prosthetic Services VA 
provides the necessary equipment such as: platform wheelchair lifts, 
under vehicle lifts, power door openers, lowered floors/raised roofs, 
raised doors, hand controls, left foot gas pedals, reduced effort and 
zero effort steering and braking, and digital driving systems. Based on 
our research, The American Legion has not found any issues with 
veterans obtaining automobile adaptive equipment or automobile grants 
and does not feel that there is a need at this time for additional 
policy. The American Legion is continuing to research this issue and 
should information change would consider working to develop a 
resolution with our membership to provide specific policy guidance.

    The American Legion does have a position on H.R. 3471 at this time.

                H.R. 3549: VA Billing Accountability Act
 To amend title 38, United States Code, to authorize the Secretary of 
 Veterans Affairs to waive the requirement of certain veterans to make 
  copayments for hospital care and medical services in the case of an 
  error by the Department of Veterans Affairs, and for other purposes.
    No veteran should have to wait 30, 60, 90 or 120 days or more to 
receive a copay bill immediately following VA hospital care or medical 
services. The American Legion's National Commander Dale Barnett has 
spoken to many veterans recently about the troubles caused with their 
finances and credit due to discrepancies and problems with third party 
billing. VA is required to provide timely health care to our nation's 
veterans and should be held to similar standards for third party 
billing. The American Legion thanks Congress for taking the leadership 
steps necessary to require VA to establish regulations for first party 
billing which conform with the time standard outlined in the bill and 
to provide the Secretary the authority to waive the veterans first 
party copayments.

    The American Legion supports H.R. 3549.

                     Discussion Draft: Promise Act
To improve the use by the Department of Veterans Affairs of opioids in 
 treating Veterans, to improve patient advocacy by the Department, and 
to expand availability of complementary and integrative health, and for 
                            other purposes.
    In the wake of serious concerns about over prescription of 
medications at the Tomah Veterans Affairs Medical Center, the nation 
has become more focused on ensuring veterans and service members are 
treated properly with opioid medications and do not unduly suffer due 
to mixed drug toxicity. The American Legion has been concerned about 
increasing reports of overmedication with pain management even before 
the stories began to circulate out of Tomah.
    This legislation would work to improve pain management policies 
between the Departments of Defense (DOD) and Veterans Affairs (VA) 
through establishing better clinical guidelines, countering overdoses, 
encouraging more collaboration between VA and DOD, and establishing 
pain management boards across VA to ensure better compliance. The 
legislation would also strengthen communication between VA and the 
veterans' community, enhance patient advocacy, and improve research and 
education on complementary and alternative care.
    The American Legion firmly believes in increasing federal funding 
throughout the Department of Defense, Department of Veterans Affairs 
and the National Institutes of Health for pain management research, 
treatment and therapies. Furthermore, The American Legion urges these 
institutions to increase investment in pain management clinical 
research by accelerating clinical trials at military and VA treatment 
facilities, as well as at affiliated university medical centers and 
research programs \10\. The increased use of complementary and 
alternative medicine is directly in line with policies of The American 
Legion regarding treatment for veterans with mental health and brain 
injuries, and represents a welcome expansion of care in these areas. 
\11\
---------------------------------------------------------------------------
    \10\ Resolution No. 190: Support for Pain Management Research, 
Treatments and Therapies at DOD, VA and NIH - AUG 2015
    \11\ Resolution No. 292: Traumatic Brain Injury and Post Traumatic 
Stress Disorder Programs - AUG 2014

---------------------------------------------------------------------------
    The American Legion supports this discussion draft.

Discussion Draft: Department of Veterans Affairs Purchased Health Care 
                   Streamlining and Modernization Act
To amend title 38, United States Code, to establish certain agreements 
for purchasing medical care for veterans when care within facilities of 
  the Department of Veterans Affairs or through contracts or sharing 
                  agreements is not feasibly available
    Under title 38 U.S.C. Sec.  1703, entitled ``Contracts for hospital 
care and medical services in non-Department facilities'', when 
Department facilities are not capable of furnishing economical hospital 
care or medical services because of geographical inaccessibility or are 
not capable of VA furnishing the care or services required, the 
Secretary, as authorized in section 1710 of this title, may contract 
with non-Department facilities. Contracts between VA and non-VA 
facilities are currently negotiated under Federal contract statutes and 
regulations (including the Federal Acquisition Regulation (FAR), which 
is set forth at 48 Code Federal Regulations (CFR) Chapter 1; and the 
Department of Veterans Affairs Acquisition Regulations, which are set 
forth at 48 Code Federal Regulations (CFR) Chapter 8.
    Federal contract laws and regulations are not always the best 
method for procuring individual services, which is why for many years 
VA issued individual authorizations to providers, without following 
contracting laws and regulations. VA General Counsel has informed VA 
that they must comply with contracting laws and regulations, which will 
make it more difficult for VA to procure individual services from non-
VA providers. Provider agreements would allow the Veterans Health 
Administration (VHA) to procure non-VA health care services on an 
individual basis in accordance with the terms and agreements set forth 
in the law. The American Legion supports legislation that would allow 
the Department of Veterans Affairs (VA) to enter into provider 
agreements with eligible non-VA providers to obtain needed health care 
services for the care and treatment of eligible veterans. \12\
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    \12\ American Legion Resolution No. 32: Department of Veterans 
Affairs Provider Agreements with Non-VA Providers: SEPT. 2015

---------------------------------------------------------------------------
    The American Legion supports this discussion draft.

                               Conclusion
    As always, The American Legion thanks this subcommittee for the 
opportunity to explain the position of the over 2 million veteran 
members of this organization. For additional information regarding this 
testimony, please contact Mr. Warren J. Goldstein at The American 
Legion's Legislative Division at (202) 861-2700 or 
[email protected].

                                 
                  Prepared Statement of Carlos Fuentes
    MR. CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE:
    On behalf of the men and women of the Veterans of Foreign Wars of 
the United States (VFW) and our Auxiliaries, thank you for the 
opportunity to offer our thoughts on today's pending legislation.

    H.R. 1319, Ask Veterans Act

    This legislation would require the Department of Veterans Affairs 
(VA) to survey veterans to evaluate their views and experiences when 
seeking VA health care. The VFW supports this legislation and has a 
recommendation to improve it.
    When the VA health care access crisis erupted in April 2014, the 
VFW turned to our members to gauge the issues from their perspective. 
We launched a series of surveys, held town halls, and provided a 
mechanism for veterans to share their experiences and seek help 
obtaining VA health care. What we heard from veterans was not 
surprising to us, but it did provide a holistic view of the VA health 
care system from the perspective of those it was designed to serve.
    The VFW's first survey only included quantitative questions. While 
these questions provided a clear picture of the health care access 
crisis, they did not provide an empirical mechanism for us to determine 
the reasons for certain outcomes. For example, we were able to 
determine that 50 percent of veterans chose to keep receiving VA health 
care when given the opportunity to receive community care. However, the 
survey did not ask why veterans chose to stay with VA care. The VFW's 
subsequent surveys included qualitative questions to close the loop. 
That is why we urge the Subcommittee to amend this legislation by 
requiring that the annual survey of veterans include both qualitative 
and quantitative questions.
    Currently, VA conducts a number of surveys to measure veterans' 
experiences and evaluate its progress in meeting strategic goals. VA's 
most notable survey is the Survey of Healthcare Experiences of 
Patients, which surveys a random sample of veterans who have received 
VA health care within a month. The problem, however, is that VA mainly 
surveys VA patients or veterans who utilize VA benefits and programs. 
The last time VA conducted a survey of non-VA users was in 2010 as part 
of its National Survey of Veterans. That is why we recommend that this 
legislation be amended to include veterans who may be eligible for VA 
health care instead of only sampling veterans who have received VA 
health care in the proposed survey.

    H.R. 1603, Military Sexual Assault Victims Empowerment (SAVE) Act

    This legislation would expand eligibility for the Veterans Choice 
Program to any veteran who is the victim of military sexual trauma. The 
VFW opposes this bill.
    The VFW strongly believes that veterans who struggle with 
psychological effects of military sexual trauma deserve timely access 
to high quality care. With the extraordinarily high incidence of sexual 
trauma in the military and the failure of many victims to report the 
trauma to medical or police authorities, it is important to ensure 
veterans who seek assistance are given the opportunity to receive 
timely access to mental health care.
    VA has made a concerted effort in recent years to increase its 
capacity to deliver mental health care by hiring additional mental 
health providers and integrating mental health into primary care 
clinics. The VFW agrees that VA lacks the resources and capacity to 
provide timely mental health care to all the veterans it serves. 
However, veterans who have used the Veterans Choice Program also report 
having long wait-times for care or not being able to find a private 
health care provider willing to see them. While the VFW supports the 
use of private sector care and has worked to improve the Veterans 
Choice Program, we do not believe that expanding eligibility for the 
Veterans Choice Program is the correct solution.
    Instead of shifting the workload to the private sector, the VFW 
recommends reforming the way we deliver health care to veterans by 
seamlessly combining the capabilities of the VA health care system with 
public and private health care providers in each community. Doing so 
would ensure veterans receive high quality mental health care and give 
private sector providers the cultural competency training needed to 
deliver veteran-centric care.

    H.R. 1904, Wounded Warrior Workforce Enhancement Act

    This legislation would require VA to expand the availability of 
training programs for orthotists and prosthetists. The VFW supports 
this legislation and has a recommendation to improve it.
    Orthotists and prosthetists are vital to ensuring VA provides the 
prosthetics care and services veterans need and deserve. In 2014, VA 
provided 17.5 million prosthetic items and services to more than three 
million veterans and estimates a growing demand in future years. The 
VFW strongly supports expanding the availability of orthotic and 
prosthetic care for veterans. For this reason, we believe the 
Subcommittee should amend this legislation by adding a requirement that 
grant recipients offer reduced or no-cost education to any admitted 
student who agrees to work at a VA medical facility for a period of 
time specified by the Secretary, similar to service requirements under 
other health professional educational assistance programs.

    H.R. 2639, Marriage and Family Therapists for Veterans Act

    This legislation would amend VA's hiring requirements to increase 
VA's capacity to provide marriage and family therapy. The VFW agrees 
with the intent of this legislation, but we defer to VA to determine 
and justify the educational requirements of its therapists.
    Suicide among military personnel and veterans presents a serious 
challenge to VA, the Department of Defense and the nation. A recent 
study of veterans from the Iraq and Afghanistan wars found that 
recently discharged veterans are up to 61 percent more likely to commit 
suicide compared to the United States general population. The study 
also found that more than 9,300 recently discharged veterans committed 
suicide between 2001 and 2007.
    Without access to mental health care, those suffering from the 
invisible wounds of war are forced to deal with their mental health 
symptoms on their own, which makes recovery nearly impossible. This 
legislation would expand access to VA mental health care by requiring 
VA to accept regionally accredited master's degrees when hiring 
marriage and family therapists. While the VFW strongly supports 
expanding access to mental health care, we believe such expansion must 
not diminish the quality of care veterans receive from VA. Ultimately, 
VA is responsible for assuring the quality of care veterans receive. 
That is why the VFW believes VA is best suited to determine and justify 
the education requirements of its health care providers.

    H.R. 3234, Failing VA Medical Center Recovery Act

    This legislation would establish an undersecretary level office to 
identify and take over failing VA medical facilities. The VFW cannot 
support the legislation as written.
    This past year VA deployed a rapid response team to the Phoenix VA 
Health Care System to address the issues that drew national attention 
to the VA health care access crisis. However, the problems the team 
were asked to address were largely systemic issues with outdated 
systems and processes that were not unique to Phoenix. The VFW has said 
many times that Phoenix was not Ground Zero because the nationwide 
access crisis could have started at any VA facility. The breakdown was 
caused by a systematic failure at every level. These failures included 
congressional and VA Central Office oversight that was too trusting of 
people and the information they presented; a decentralized management 
system that creates internal fiefdoms and breeds an employee culture of 
indifference towards politically-appointed leadership; and the lack of 
proper resources, both in human and fiscal capital.
    The VFW supports efforts to identify and address facility specific 
issues that negatively affect VA's ability to deliver timely and high-
quality health care. However, requiring the VA central office to take 
over underperforming facilities would further degrade the relationship 
between politically-appointed leadership and medical center staff. 
Instead of establishing a new undersecretary position, Congress should 
strengthen VA's Veterans Experience Office to ensure every VA medical 
facility provides the timely and high quality health care veterans have 
earned and deserve.

    H.R. 3471, Veterans Mobility Safety Act of 2015

    This legislation would establish minimum safety standards for the 
Automobile Adaptive Equipment Program. The VFW supports the intent of 
this legislation and has a recommendation to improve it.
    The Automobile Adaptive Equipment Program was established to enable 
severely disabled veterans to drive without the assistance of others by 
making modifications to their existing vehicles or purchasing a new 
vehicle with the specific accommodations they need. Because the VA 
automobile grant is a one-time benefit, it is important that 
modifications made to vehicles are safe and function properly the first 
time.
    Currently, VA prosthetic representatives are required to assist 
veterans in locating an approved vendor and inspecting the workmanship 
of vehicle modification. VA encourages veterans to verify that a vendor 
is registered with the National Highway Traffic Safety Administration 
(NHTSA), which is responsible for developing motor vehicle safety 
standards. However, NHTSA does not conduct thorough compliance 
evaluations to ensure registered adaptive equipment installers comply 
with the established standards. The VFW recommends that any 
certification organization used by VA to accredit installers conduct 
thorough site visits to inspect installers and verify compliance with 
safety standards. VA must also ensure that requiring certification does 
not impede its ability to administer the Automobile Adaptive Equipment 
Program.

    H.R. 3549, VA Billing Accountability Act

    The VFW supports this legislation, which would ensure veterans are 
properly notified of their copayment obligations and would require VA 
to waive copayment if it fails to properly notify veterans.
    Earlier this year, more than 1,400 veterans where charged more than 
$500,000 for five-years' worth of health care received from the 
Minneapolis VA Medical Center. While disheartening, VA charging 
veterans for years of copayments all at once is not rare. The VFW 
continues to hear from veterans that VA has sent them large bills for 
care they either had no idea they were liable for or were unaware they 
had not paid. In most instances, veterans do not have the ability to 
pay such debts and are not offered any other recourse but to have their 
monthly disability benefits garnished until the debt is repaid. That is 
why the VFW supports waiving medical debt when VA fails to properly 
notify veterans. Veterans must not be punished for VA's inability to 
get its house in order.
    However, the VFW recommends that the Subcommittee amend this 
legislation by authorizing VA to evaluate whether the 120-day and 18-
month requirements for notifying veterans of copayment obligations are 
aligned with industry best practices.

    Draft Legislation, Promoting Responsible Opioid Management and 
Incorporating Medical Expertise Act

    This legislation would reduce VA's reliance on pharmacotherapy to 
treat mental health and complex pain conditions; expand VA research, 
education, and delivery of complementary and alternative medicine (CAM) 
treatments; and improve VA hiring and internal audits. The VFW supports 
this legislation and has a recommendation to strengthen it.
    Too often, the VFW hears stories of veterans who have been 
prescribed high doses of pain medication to treat their mental health 
conditions. Countless veterans have experienced first-hand the 
dangerous side effects of pharmacotherapy. Many of these medications, 
if incorrectly prescribed, have been proven to render veterans 
incapable of interacting with their loved ones and even contemplate 
suicide. With the expanding evidence of the efficacy of non-
pharmacotherapy modalities, such as psychotherapy and CAM, VA must 
ensure it affords veterans the opportunity to access effective 
treatments that minimize adverse outcomes.
    Timely and accessible mental health care is crucial to ensuring 
veterans have the opportunity to successfully integrate back into 
civilian life. With more than 1.4 million veterans receiving 
specialized VA mental health treatment each year, VA must ensure such 
services are safe and effective. VA has made a concerted effort to 
change its health care providers' dependence on pharmacotherapy to 
treat mental health conditions and manage pain. In 2011, the 
Minneapolis VA Medical Center launched its Opioid Safety Initiative. 
Aimed at changing the prescribing habits of providers, the Opioid 
Safety Initiative educates providers on the use of opioids, serves as a 
tool to taper veterans off high-dose opioids, and offers them 
alternative, non-pharmacotherapy modalities for pain management. 
Unfortunately, VA has failed to produce a notable change since 
implementing the Opioid Safety Initiative systemwide. This legislation 
includes much needed reforms to ensure VA's clinical practice 
guidelines for pain management are appropriate and includes the proper 
compliance mechanisms, such as the pain management boards, to ensure 
such guidelines are carried out.
    The VFW has consistently heard from veterans that their patient 
advocates are ineffective or seek to protect the medical facility's 
leadership instead of addressing their concerns. For this reason, we 
strongly recommend the Subcommittee amend this legislation to codify 
VA's Veterans Experience Office. Established to collect and disseminate 
best practices for improving customer service, coordinate community 
outreach efforts, and serve as the subject matter experts on the 
benefits and services VA provides to veterans, veteran experience 
officers should replace patient advocates currently located in VA 
medical facilities.
    Patient advocates cannot effectively meet their obligations to 
veterans if their chain of command includes VA medical facility staff 
who are responsible for the actions and policies they are required to 
address. In the markup of this bill, the VFW recommends that the 
Subcommittee codify the Veterans Experience Office and expand the 
duties of veteran experience officers to include: ensuring the health 
care protections afforded under Title 38, U.S.C., a veteran's right to 
seek redress through clinical appeals; claims under Section 1151 of 
Title 38 U.S.C. and the Federal Tort Claims Act; and the right to free 
representation by accredited veteran service organizations are fully 
applied and complied with by VA medical facilities and contracted non-
VA health care providers.
    With the growing body of research on the efficacy of CAM therapies, 
such as biofeedback, mindfulness meditation, and other non-
pharmacologic approaches to treating mental health conditions and 
managing pain, the VFW believes that more work must be done to ensure 
veterans are afforded the opportunity to receive these safe and 
effective alternatives to pharmacotherapy. This legislation would make 
significant strides toward ensuring veterans who are tapered off high-
dose medications have effective alternatives.

    Legislative Proposal, VA Purchased Health Care Streamlining and 
Modernization Act

    The VFW strongly supports this legislation, which would streamline 
VA's ability to purchase health care from private sector health care 
providers when VA health care is not readily available.
    VA must have the ability to quickly provide non-VA health care when 
it is unable to provide direct care to the veterans it serves. The VFW 
is glad to see this legislation includes best practices, such as 
requiring non-VA medical providers to return medical documentation, and 
quality and safety mechanisms to ensure veterans receive high quality 
care from non-VA providers.
    The VFW has heard from veterans who live in contracted extended 
care facilities that they may be required to leave the place they have 
called home for years because VA does not have the authority to renew 
provider agreements. The VFW urges this Subcommittee to quickly 
consider and pass this important legislation to ensure severely 
disabled veterans are not harmed by VA's inability to enter into 
provider agreements.
 Information Required by Rule XI2(g)(4) of the House of Representatives
    Pursuant to Rule XI2(g)(4) of the House of Representatives, the VFW 
has not received any federal grants in Fiscal Year 2015, nor has it 
received any federal grants in the two previous Fiscal Years.
    The VFW has not received payments or contracts from any foreign 
governments in the current year or preceding two calendar years.

                                 
                   Prepared Statement of Janet Murphy
    Good morning Chairman Benishek, Ranking Member Brownley, and 
Members of the Committee. Thank you for inviting us here today to 
present our views on several bills that would affect VA health programs 
and services. Joining me today is Elias Hernandez, Chief Officer, 
Workforce Management and Consulting; Harold Kudler, Chief Consultant 
for Mental Health Services; and Susan Blauert, Deputy Assistant General 
Counsel.
    The Department of Veterans Affairs (VA) provided views on the 
majority of bills on the agenda, but we are unable to provide cleared 
views on sections 103, 501, and Title 3 of the draft legislation, the 
Promoting Responsible Opioid Management and Incorporating Medical 
Expertise Act, at this time. We will forward these views to you as soon 
as they are available.

    H.R. 1319 Ask Veterans Act

    The proposed bill would require VA to enter into a 5-year contract 
with a
    non-government entity to conduct an annual survey of a 
statistically significant sample of Veterans who reside in the 
geographic area served by each of VA's medical facilities to determine 
the nature of the experiences of such Veterans in obtaining hospital 
care and medical services at each such medical facility. In developing 
the survey, the contractor would be required to consult with Veterans 
Service Organizations. The contractor would also be required to submit 
each of its proposed surveys to the Comptroller General for review and 
certification before conducting them. Furthermore, VA would be required 
to make the results of such surveys publicly available on its website 
within 30 days after their completion.
    VA does not support H.R. 1319, as such activities would be 
duplicative of current efforts already in place and, therefore, the 
minimal benefit of such additional surveys would be substantially 
outweighed by their significant costs. The provision that requires 
contractors to obtain a certification from the Comptroller General 
prior to a survey also contravenes the separation of powers. In its 
Survey of Health Experiences of Patient (SHEP) Program, the Veterans 
Health Administration (VHA) is already conducting ongoing surveys of 
Veterans' experiences with hospital care.
    VA uses a scientifically designed survey instrument, the Consumer 
Assessment of Health Providers and Systems (CAHPS), and an external 
contractor IPSOS. The CAHPS surveys are designed by a scientific 
community that is sponsored by the Agency for Health Research and 
Quality. CAHPS surveys are an integral part of the Centers for Medicare 
and Medicaid Services efforts to improve healthcare in the U.S. For 
example, some CAHPS surveys are used in quality ratings for Medicare 
and Medicaid health plans, as well as other CMS initiatives such as 
Value-Based Purchasing. The surveys have also been endorsed by the 
National Quality Forum and the National Commission for Quality 
Assurance . Furthermore, the surveys are widely used by commercial 
health plans. The scientific properties of CAHPS surveys were examined 
in peer-reviewed scientific literature, examples of which VA can 
provide upon request. \1\ Because VA utilizes the same scientific 
survey approach as the private sector, we are also able to compare our 
performance to non-VA hospitals.
---------------------------------------------------------------------------
    \1\ For a summary of the scientific evidence, see Price et al, 
``Should health care providers be accountable for patients' care 
experiences'' Journal of General Internal Medicine 2015 (Feb); vol 30: 
pp 253-256. Additional information about CAHPS is available at 
www.cahps.ahrq.gov
---------------------------------------------------------------------------
    VA utilizes CAHPS surveys in its SHEP program, which currently 
assesses over one million Veterans annually to obtain valid and precise 
estimates of performance for each VA medical facility. Our survey 
provider, IPSOS, has been certified by Medicare as meeting scientific 
standards for sampling, survey administration, and data validation. 
Furthermore, our SHEP protocols are approved by the Office of 
Information and Regulatory Affairs.
    VA regularly obtains input from Veterans Service Organizations 
regarding our SHEP program, and we provide SHEP results annually to 
them upon request. We also post updated facility-level SHEP results 
quarterly on our public website. \2\ The SHEP program's surveys are 
completed anonymously, and all of VA's posted results are fully de-
identified, aggregate data. VHA's Office of Analytics and Business 
Intelligence enthusiastically welcomes the opportunity to provide a 
more detailed briefing of our SHEP program to Congressional staff.
---------------------------------------------------------------------------
    \2\  http://www.va.gov/qualityofcare/apps/shep/barchart.asp

---------------------------------------------------------------------------
    H.R. 1603 Military Sexual Assault Victims Empowerment Act

    H.R. 1603 would amend subsection (b) of section 101 of the Veterans 
Access, Choice, and Accountability Act of 2014 (the Choice Act) to add 
a provision specifically addressing eligibility for the Veterans Choice 
Program (Choice Program) for victims of military sexual trauma (MST) 
described in section 1720D(a)(1) of title 38, United States Code 
(U.S.C.). The intent of this bill appears to make such victims eligible 
for the Choice Program regardless of the date they enroll for VA health 
care and without the need to satisfy the wait-time or residence 
eligibility criteria.
    New legislation is not needed to exempt MST victims from the Choice 
Act enrollment date restrictions. The bill does not take into account 
recent legislative changes to the eligibility provisions for the Choice 
Act. Specifically, section 4005 of the Surface Transportation and 
Veterans Health Care Choice Improvement Act of 2015, Public Law 114-41, 
amended section 101 to remove the August 1, 2014, enrollment date 
restriction, thereby making all Veterans enrolled in the VA health care 
system under 38 Code of Federal Regulations (C.F.R.) Sec.  17.36 
eligible for the Choice Program if they meet its other eligibility 
criteria. If the intent of the bill is to make Veterans who meet the 
requirements of 38 U.S.C. Sec.  1720D eligible for the Choice Program 
without having to enroll in VA health care, that is not clear, and the 
bill language would need to be clarified. The proposed amendment would 
also make Veterans who are victims of MST as described in 38 U.S.C. 
Sec.  1720D(a)(1) eligible for the Choice Program without regard to the 
wait-time or place of residence eligibility criteria that apply to 
other Veterans. VA does not support this provision for a number of 
reasons.
    VA supports the Choice Program, which creates a mechanism for 
providing timely, local care to eligible Veterans for whom such care 
would otherwise be inaccessible. The Choice Program provides this same 
access to otherwise eligible Veterans who experienced MST; under 
existing authorities, MST survivors already have the option to seek 
Choice Program care based on the wait-time or place of residence 
eligibility criteria.
    There is, however, no clearly identifiable clinical advantage or 
benefit to MST survivors, in terms of quality of care or patient 
outcomes, to allow MST survivors to elect Choice Program care as a 
first-option preference, rather than as a secondary-option based on 
need under existing non-VA care authorities. As noted in VA's annual 
report to Congress, required by 38 U.S.C. Sec.  1720D(e), care for MST-
related conditions is available through every VA medical facility and 
Vet Center, and all VA health care facilities have sufficient staffing 
capacity to meet the MST-related care needs of their local Veteran 
populations. As such, there is no clear need to create an exception to 
the existing Choice Program eligibility criteria on the basis of the 
availability of MST-related care in VA facilities.
    There are also some advantages to viewing VA as the first-option 
provider of MST-related care whenever wait-time and place of residence 
are not an issue. VA has the authority and infrastructure to ensure 
that its providers have received training on evidence-based 
psychotherapies for trauma-related disorders, and specifically on 
provision of care to MST survivors. Currently all VA mental health and 
primary care providers must complete mandatory training on MST as 
specified by VHA Directive 2012-004. VA also offers a range of 
continuing education opportunities for staff interested in furthering 
their level of MST expertise. There are few checks to ensure that 
private providers have the specialized training to offer a standard of 
evidence-based care to match care available in a VA facility.
    Further, it is not uncommon for Veterans who experienced MST to 
have multiple health concerns and comorbidities and, within VA, to 
receive care from a range of medical and mental health clinics. As a 
single umbrella provider, VA is well positioned to provide this type of 
coordinated, tailored care that ensures the Veteran's history of MST is 
considered in all treatment provided. VA providers are familiar with 
internal resources available to address new or emergent treatment 
needs, and can provide timely internal referrals as needed. Every VA 
health care system has a designated MST Coordinator whose role includes 
assisting MST survivors with accessing needed services and facilitating 
coordination of care. Given the considerable clinical benefit to MST 
survivors of coordinated, trauma-sensitive, evidence-based care, and 
the need to direct Choice Program resources towards addressing 
accessibility gaps where they exist, VA maintains that VA MST-related 
care should be considered the first-option treatment standard whenever 
wait-time and place of residence are not an issue.
    It is not possible to estimate costs for this bill without further 
study to determine how many Veterans would choose to seek Choice 
Program care under this new authority.

    H.R. 1904 Wounded Warrior Workforce Enhancement Act

    H.R. 1904, the Wounded Warrior Workforce Enhancement Act, would 
direct VA to establish two grant award programs. Section 2 of the bill 
would require VA to award grants to institutions to: (1) establish a 
master's or doctoral degree program in orthotics and prosthetics, or 
(2) expand upon an existing master's degree program in those areas. 
This section would require VA to give a priority in the award of grants 
to institutions that have a partnership with a VA medical center or 
clinic or a Depatment of Defense (DoD) facility. Grant awards under 
this provision must be at least $1 million and not more than $1.5 
million. Grant recipients must either be accredited by the National 
Commission on Orthotic and Prosthetic Education in cooperation with the 
Commission on Accreditation of Allied Health Education Programs, or 
demonstrate an ability to meet such accreditation requirements if 
receiving a grant. VA would be required to issue a request for 
proposals for grants not later than 90 days after the date of enactment 
of this provision.
    In addition to the two purposes noted above, grantees would be 
authorized to use grants under this provision to train doctoral 
candidates and faculty to permit them to instruct in orthotics and 
prosthetics programs, supplement the salary of faculty, provide 
financial aid to students, fund research projects, renovate buildings, 
and purchase equipment. Not more than half of a grant award may be used 
for renovating buildings. Grantees would be required to give a 
preference to Veterans who apply for admission in their programs.
    VA does not support the enactment of section 2 of this bill. We 
believe VHA has adequate training capacity to meet the requirements of 
its health care system for recruitment and retention of orthotists and 
prosthetists. VA offers one of the largest orthotic and prosthetic 
residency programs in the Nation. In fiscal year (FY) 2015, VA 
allocated $877,621 to support 20 Orthotics/Prosthetics residents at 10 
VA medical centers. The training consists of a year-long post masters 
residency, with an average salary of $44,000 per trainee. In recent 
years, VA has expanded the number of training sites and the number of 
trainees. Moreover, recruitment and retention of orthotists and 
prosthetists has not been a challenge for VA. Nationally, VA has 
approximately 312 clinical orthotic and prosthetic staff.
    VA offers in-house orthotic and prosthetic services at 79 locations 
across VA; however, much of the specialized orthotic and prosthetic 
capacity of VA is met through contract mechanisms. VA contracts with 
more than 600 vendors for specialized orthotic and prosthetic services. 
Through both in-house staffing and contractual arrangements, VA is able 
to provide state-of-the-art, commercially-available items ranging from 
advanced myoelectric prosthetic arms to specific custom fitted 
orthoses.
    We also note certain aspects of the bill that would make its 
implementation problematic. First, the bill would not require grant 
funded programs to affiliate with VA or send their trainees to VA as 
part of a service obligation. Also, section 2, subsection (e) would 
authorize appropriations ($15 million) in only one fiscal year, FY 2014 
- which we presume the drafters intended to be FY 2016, consistent with 
the language in section 3(e) - and specify that the funding would 
expire as of September 30, 2016. This subsection contemplates that 
unobligated funds would be returned to the General Fund of the Treasury 
immediately upon expiration. Under 31 U.S.C. Sec.  1552(a), expired 
accounts are generally available for 5 fiscal years following 
expiration for the purpose of paying obligations incurred prior to the 
account's expiration and adjusting obligations that were previously 
unrecorded or under recorded. If the unobligated balance of these funds 
were required to be returned to the Treasury immediately upon 
expiration, then VA would be unable to make obligation adjustments to 
reflect unrecorded or under recorded obligations. A bookkeeping error 
could result in an Antideficiency Act violation. Lastly, we also note 
that 90 days after the date of enactment of this provision would not be 
enough time for VA to promulgate regulations and a request for 
proposals (RFP) for these grants.
    Section 3 of H.R. 1904 would require VA to award a $5 million grant 
to an institution to: (1) establish the Center of Excellence in 
Orthotic and Prosthetic Education (the Center); and (2) improve 
orthotic and prosthetic outcomes by conducting evidence-based research 
on orthotic and prosthetic education. Under the bill, grant recipients 
would be required to have a robust research program; offer an education 
program that is accredited by the National Commission on Orthotic and 
Prosthetic Education in cooperation with the Commission on 
Accreditation of Allied Health Education Programs; be well recognized 
in the field of orthotics and prosthetics education; and have an 
established association with a VA medical center or clinic and a local 
rehabilitation hospital. This section would require VA to give priority 
in the grant award to an institution that has, or is willing and able 
to enter into: (1) a memorandum of understanding with VA, DoD, or other 
appropriate government agency; or (2) a cooperative agreement with an 
appropriate private sector entity. The memorandum of agreement would 
provide resources to the Center and/or assist with the Center's 
research. VA would be required to issue a request for proposals for 
grants not later than 90 days after the date of enactment of this 
provision.
    VA does not support section 3 because VA would not have oversight 
of the Center and there would be no guarantee of any benefit to VA or 
Veterans. Further, we believe that a new Center is unnecessary. DoD has 
an Extremity Trauma and Amputation Center of Excellence, and VA and DoD 
work closely to provide care and conduct scientific research to 
minimize the effect of traumatic injuries and improve outcomes of 
wounded Veterans suffering from traumatic injury. VA also has five 
Research Centers of Excellence that conduct research related to 
prosthetic and orthotic interventions, amputation, and restoration of 
function following trauma:
    1. Center of Excellence for Limb Loss Prevention and Prosthetic 
Engineering in Seattle, WA.
    2. Center of Excellence in Wheelchairs and Associated 
Rehabilitation Engineering in Pittsburgh, PA.
    3. Center for Functional Electrical Stimulation in Cleveland, OH.
    4. Center for Advanced Platform Technology in Cleveland, OH.
    5. Center for Neurorestoration and Neurotechnology in Providence, 
RI.
    These centers provide a rich scientific environment in which 
clinicians work closely with researchers to improve and enhance care. 
They are not positioned to confer terminal degrees for prosthetic and 
orthotic care/research but they are engaged in training and mentoring 
clinicians and engineers to develop lines of inquiry that will have a 
positive impact on amputee care. Finally, the requirement to issue a 
request for proposals within 90 days of enactment would be very 
difficult to meet as VA would first need to promulgate regulations 
prior to being able to issue the RFP.
    VA estimates that, if section 2(e)(1) referred to FY 2016, instead 
of FY 2014, sections 2 and 3 of H.R. 1904 would cost $150,000 in FY 
2016 and $21.6 million over 5 years.

    H.R. 2639 Marriage and Family Therapists for Veterans Act

    H.R. 2639, the ``Marriage and Family Therapists for Veterans Act,'' 
would amend the qualification standards for Marriage and Family 
Therapists (MFT), prescribed under 38 U.S.C. Sec.  7402(b)(10).
    Under current qualification standards, MFTs must meet two 
requirements: (1) hold a master's degree in marriage and family 
therapy, or a comparable degree in mental health, from a college or 
university approved by the Secretary; and (2) be licensed or certified 
to independently practice marriage and family therapy in a state.
    H.R. 2639 would add a third prerequisite to the qualification 
standards for MFTs, which would require that an MFT have passed a 
marital and family therapy examination administered by the Association 
of Marital and Family Therapy or an examination for a marriage and 
family therapy license given by a state board of behavioral sciences or 
its equivalent.
    H.R. 2639 would also amend the first requirement in the 
qualification standards to allow an MFT to fulfill that prerequisite if 
he or she obtained a master's degree in marriage and family therapy, or 
a comparable degree in mental health, from a regionally accredited 
college or university. VA has a number of policy concerns about the 
amendment to this requirement and consequently cannot support the bill.
    Under current law, the Secretary has discretion to approve colleges 
and universities that have master's degree programs in marriage and 
family therapy. This discretion allows VA to require that MFTs graduate 
from schools with programs accredited by the national accrediting body 
for MFTs, the Commission on Accreditation for Marriage and Family 
Therapy Education (COAMFTE). COAMFTE is a specialized accrediting body 
that accredits master's degree, doctoral degree, and post-graduate 
degree clinical training programs in Marriage and Family Therapy 
throughout the United States and Canada and, since 1978, has been 
recognized by the U.S. Department of Education as the national 
accrediting body for the field of Marriage and Family Therapy.
    Requiring a Marriage and Family Therapist to have a COAMFTE 
accredited degree ensures that the MFT has completed a course of 
professional preparation that meets specific standards established by 
the discipline's accrediting body and that the individual has been 
trained in the appropriate knowledge and skill areas required of the 
profession. The requirement that MFTs graduate from a program 
accredited by COAMFTE is similar to the requirements imposed on other 
core mental health disciplines (e.g., Psychology, Psychiatry, Social 
Work, Nursing, Licensed Professional Mental Health Counseling, and 
Marriage and Family Therapy), in that individuals in these disciplines 
must also graduate from programs that are accredited by a recognized 
body.
    Requiring that an MFT graduate with a master's degree in marriage 
and family therapy or a comparable degree in mental health, from a 
college or university that is regionally accredited, is problematic 
because regional accrediting bodies accredit academic institutions but 
do not examine the quality of education provided in a specific program. 
In 2013, the American Association of Marriage and Family Therapy and 
COAMFTE identified a number of regionally accredited universities with 
marriage and family therapy programs. However, after reviewing the 
academic curricula for the programs, COAMFTE staff determined that many 
of these programs would not be eligible for COAMFTE accreditation since 
the programs were unable to demonstrate they actually trained their 
students in marriage and family therapy.

    H.R. 3234 Failing VA Medical Center Recovery Act

    H.R. 3234, the ``Failing VA Medical Center Recovery Act,'' would 
establish an Office of Failing Medical Center Recovery (OFMCR) within 
VA. Under the bill, OFMCR would manage day-to-day operations for VA 
medical centers (VAMC) that are ranked as ``failing'' key health 
metrics. VA has legal and policy concerns about H.R. 3234 as outlined 
below.

    Determining a VAMC's ranking

    H.R. 3234 would require the Secretary to publish a quarterly list 
of key health metrics for each VAMC. This quarterly list would also 
include rankings for each VAMC as either ``excellent,'' 
``satisfactory,'' ``poor,'' or ``failing,'' based on Strategic 
Analytics Improvement and Learning (SAIL) data. SAIL data is a web-
based balanced scorecard model that VA developed to measure, evaluate, 
and benchmark quality and efficiency at VAMCs. VA designed SAIL for 
internal benchmarking within VHA to spotlight the successful strategies 
of VA's top performers to promote high-quality, safety, and value-based 
health care across all of its VAMCs. SAIL is available on the VHA 
Intranet website and accessible to all VA staff members who have 
network access. In support of VA Transparency Program, VA published 
SAIL benchmark tables for each medical facility on the Internet in 
October 2014 to ensure public accountability and spur continuous 
improvements in health care delivery.

    Overlap of OFMCR with activities performed by VHA

    The bill would require that VAMCs ranked as ``failing'' be 
transferred by the Secretary from VHA to the newly established OFMCR. 
OFMCR would then manage the day-to-day operation of the ``failing'' 
VAMC until the VAMC can achieve a ranking of ``satisfactory'' or better 
under the key health metrics for three consecutive quarters, at which 
time the VAMC would be restored back to VHA. Once the Secretary ranks a 
VAMC as ``failing,'' the head of OFMCR, the Under Secretary for Failing 
Medical Center Recovery (the Under Secretary), would assume all the 
duties, responsibilities, and authority held by the director of the 
``failing'' VAMC. Once the ``failing'' VAMC is under the control of the 
OFMCR Under Secretary, he or she would retain the use of all resources 
and services that would otherwise be made available to the covered 
``failing'' medical cenver and would operate the center independently 
from its respective Veterans Integrated Service Network (VISN).
    A number of OFMCR activities are already performed by VHA. For 
example, VHA already monitors performance in VHA facilities based on 
SAIL data which encompasses 28 measures - 27 quality measures, which 
are organized into 9 domains: acute care mortality; avoidable adverse 
events; cause mortality register 30-Day mortality and readmission rate; 
length of stay; performance measures; customer satisfaction; ambulatory 
care sensitive condition hospitalizations; access; and mental health - 
and an additional measure to assess overall efficiency. Based on the 
SAIL data, VA facilities are benchmarked on individual measures and 
domains, and using 10th, 30th, 70th, 90th percentile cut-offs of 
overall quality score, each facility is designated a 1- to 5-star 
rating for overall quality.
    We are deeply concerned that this bill proposes to use percentile-
based ranking to identify ``failing'' medical centers. Applying a 
percentile-based ranking schema ensures that there will always be a 
certain number of medical centers that are certified as ``failing'' 
irrespective of how high their scores might be on the SAIL metrics. 
This would perpetuate a continuous need for the OFMCR to sieze control 
of various medical centers even if SAIL scores were to collectively 
improve across all medical centers. We therefore propose that a 
specific SAIL score threshold be established and used to identify 
``failing'' VAMCs.
    Based on SAIL data, VHA sends teams of subject matter experts out 
to facilities to provide on-site consultative training to help 
facilities in areas specific to their needs. In FY 2014, there were a 
total of 62 consultative trainings that were provided. In
    FY 2015, VHA provided at least 133 trainings. During these 
trainings, facilities were provided with areas where they have 
improvement opportunities, recommendations for improvement strategies, 
and points of contact from VA medical centers where there are strong 
practices they can borrow from. VHA provides follow-up consultation to 
facilities within 30-60 days of the training. In FY2015, nearly 45% of 
VA medical centers improved their overall performance from one year 
ago. For VHA as a whole, significant improvements were found on patient 
outcome measures such as mortality, length of stay, hospital 
readmission rate, ambulatory care sensitive condition hospitalizations, 
are healthcare acquired infections. All of these measures are 
considered significant quality indicators that are publically reported 
by agencies such as Centers for Medicare and Medicaid Services.

    Authority of the Under Secretary for Failing Medical Center 
Recovery

    The Under Secretary would be directly responsible for the operation 
of OFMCR. Under the bill, the Under Secretary can appoint individuals 
in OFMCR using direct-hire authority in 5 U.S.C. Sec.  3304(a)(3) and 
can pay these individuals at a prevailing rate that is 125 percent of 
the rate of pay for the employee's position. OFMCR employees who serve 
for 2 or more years with that office would also be entitled to receive 
preferential treatment for promotion and advancement within VA. VA is 
extremely concerned with establishing a new Under Secretary position to 
manage and lead this office as it removes authority vested in the Under 
Secretary for Health and moves it to what appears to be a non-medical 
position. This would make it harder for the Under Secretary for Health 
to manage Veteran medical care when his authorities are being shifted 
out of the administration. A realignment of VHA functions for failing 
medical centers under a new Under Secretary position would create 
costly and duplicative functions at the national, regional and local 
levels. Furthermore, VA does not believe a separate Under Secretary and 
organization would be successful in achieving improved outcomes and 
care.
    The bill does not address funding for OFMCR or whether the 
preferential treatment for OFMCR employees in applying for promotions 
and advancement within VA trumps Veterans' preference.
    The bill allows the Under Secretary to hire individuals as 
employees of VHA at ``failing'' VAMCs; pay an employee at a ``failing'' 
VAMC at a prevailing rate that is 125 percent of the rate of the 
employee's position; and carry out adverse actions, including transfers 
or reassignments for all employees at a ``failing'' VAMC.
    By allowing the Under Secretary to appoint individuals at 
``failing'' VAMCs as employees of VHA, the bill fails to consider the 
possible repercussions such appointments would have on VHA's budget, 
which is typically managed by the Under Secretary for Health. Indeed, 
the possible budgetary impact on VHA would be significant as the Under 
Secretary can pay these employees or other employees at ``failing'' 
VAMCs at a prevailing rate that is 125 percent of the rate of the 
employee's position.
    With regard to paying an employee at a ``failing'' VAMC or OFMCR at 
125 percent of the employee's rate of pay, the bill does not address 
statutory limits on employee pay linked to the Executive Schedule, 
which would, for example, cap a Registered Nurse at Level IV of the 
Executive Schedule. The bill also does not consider pay retention for 
employees paid at 125 percent of their pay rate. That is, whether an 
employee who has been paid at 125 percent of their rate of pay would be 
allowed to retain that pay increase if they leave the ``failing'' VAMC 
or OFMCR, or, if the employee continues to work at the ``failing'' 
VAMC, once the VAMC is no longer designated as ``failing'' by the 
Secretary. VA is also concerned that this flexibility to pay an 
employee at the 125 percent rate would be limited to hospitals that are 
deemed ``failing'' and not all facilities that face hiring challenges 
and other difficulties.
    The bill also would allow the Under Secretary to designate any 
employee of a ``failing'' VAMC as an employee covered by 38 U.S.C. 
Sec.  713, for purposes of removal, even if that employee is not a 
senior executive. This provision would have broad implications on VA's 
personnel system as any employee of a ``failing'' VAMC, regardless of 
grade, pay level, or direct patient-care responsibilities, could be 
removed under a section intentionally limited to VA senior executives.
    Limiting the appeal rights for employees who are removed at these 
``failing'' VAMCs would also create a two-tier system of employment in 
VA. That is, employees at ``failing'' VAMCs would have fewer appeal 
rights if they are terminated under 38 U.S.C. Sec.  713 than their 
counterparts at other VAMCs and the rest of the Federal Government. To 
that extent, high-performing employees at VAMCs, who through no fault 
of their own, are employed at VAMCs that the Secretary has designated 
as ``failing,'' may be reluctant to remain employed at those 
facilities, when they can have better removal appeal rights at other 
VAMCs or Federal agencies, or greater pay by joining the private 
sector. Because VA is already hard-pressed to compete with the private 
sector, especially in positions involving health care, the inclusion of 
a provision curtailing employee removal appeal rights would be 
detrimental to Veteran care and the operation of the impacted VAMCs.
    Ultimately, the inclusion of this provision would make conditions 
of employment in VA significantly less attractive than in other Federal 
agencies or in the private sector, and as a result, would discourage 
outstanding VA employees from remaining in VA and dramatically impair 
VA's ability to recruit top talent, including Veterans. In addition, we 
understand that the Department of Justice believes that the political 
affiliation restriction for the Under Secretary raises Appointments 
Clause concerns.
    The Office of Personnel Management (OPM) may also have views on 
H.R. 3234, as the bill would adversely impact the treatment of VA 
employees under Title 5 personnel authorities administered by OPM.
    VA is unable to determine the costs of H.R. 3234 at this time.

    H.R. 3471 Veterans Mobility Safety Act of 2015

    H.R. 3471 would amend 38 U.S.C. Sec.  3903 to require the Secretary 
to ensure that, to the extent practicable, eligible individuals are 
given the opportunity to make personal selections related to 
automobiles or other conveyances provided under chapter 39 of title 38, 
U.S.C. The bill would also set forth minimum standards for adaptive 
equipment modification services - requiring the providers of such 
services to be certified by a certification organization or the 
manufacturer of the adaptive equipment. Individuals performing adaptive 
equipment modification services on an automobile would also be required 
to meet these certification requirements or be licensed or certified by 
the state in which the modification service is performed if the service 
is within the scope of practice. Under the bill, providers of 
automobiles, adaptive equipment, or modification services would be 
required to adhere to chapter 126 of title 42 (the Americans with 
Disabilities Act of 1990), and to the ``make inoperative mandates'' of 
the Department of Transportation National Highway Traffic Safety 
Administration (NHTSA) Federal Motor Vehicle Safety Standards 
prescribed pursuant to section 30122 of title 49. The bill would define 
the terms ``certification organization'' and ``modification services.''
    H.R. 3471 would also amend 38 U.S.C. Sec. Sec.  1718 and 3104 to 
specify that if the Secretary provides adaptive equipment in providing 
rehabilitative services or a rehabilitation program under chapters 17 
or 31 of title 38, U.S.C., respectively, the equipment must meet the 
minimum standards prescribed under 38 U.S.C. Sec.  3903(d)(2), as 
amended by the bill. No later than 1 year after enactment, VA would be 
required to prescribe regulations to carry out these amendments.
    VA does not support H.R. 3471, as VA defers to the NHTSA on safety 
compliance issues. NHTSA prescribes safety standards for adaptive 
equipment and develops criteria to assist not just Veterans, but all 
citizens, when selecting a modifier and/or alterer to modify their 
vehicles (49 U.S.C. Sec.  30111; 49 C.F.R. Parts 571 and 567). VA does 
not manufacture or install adaptive equipment on a beneficiary's 
vehicle. Rather, VA pays for automobile adaptive equipment that 
accommodates beneficiaries' driving and/or passenger needs as 
identified by a VHA certified Drivers Rehabilitation Specialist.
    We note that H.R. 3471 may be too restrictive and cause undue 
hardship for small businesses that are not members of a certified 
organization and/or certified by the state in which the modification 
service is performed. This, in turn, may restrict the access and choice 
Veterans have when selecting a modifier or alterer for adapting their 
personal vehicles. Further, we note that there are no systematic issues 
regarding automobile adaptive equipment safety (as authorized in 
chapter 39 of title 38, U.S.C.) being reported across VA. Therefore, 
the amendments in H.R. 3471 would provide no added value to support 
Veterans and Servicemembers who are eligible to receive automobile 
adaptive equipment under chapter 39 of title 38, U.S.C.
    We do not expect H.R. 3471 to directly impact the provision of 
benefits to Veterans by VA. Therefore, no benefit costs or savings 
would be associated with this bill. Any administrative costs associated 
with this bill would be minimal.
    As a technical matter, we would read 38 U.S.C. Sec.  1718(h), as 
added by section 2(b) of the bill, as applying only to automobile 
adaptive equipment, and note that this amendment would tend to clarify 
VA's authority to provide automobile adaptive equipment under chapter 
17.

    H.R. 3549 VA Billing Accountability Act

    H.R. 3549 would add a new section 1709C to title 38, U.S.C., that 
would require VA to notify Veterans of their copayment requirements no 
later than 120 days after the date of care or services provided at VA 
medical facilities, and no later than 18 months after the date of care 
or services provided at non-VA facilities. If VA does not provide such 
notice, VA could not collect the copayment, including through a third-
party entity, unless VA provides the Veteran: (1) information on 
applying for a waiver and establishing a payment plan, and (2) an 
opportunity to make a waiver or establish a payment plan. The Secretary 
would be authorized to waive the copayment requirement in cases where 
notification to the Veteran was delayed because of an error committed 
by VA, a VA employee, or a non-VA facility (if applicable), and the 
Veteran received notification beyond the specified timeframes. H.R. 
3549 would also require VA, no later than 180 days after enactment, to 
review and improve its copayment billing internal controls and 
notification procedures, including pursuant to the provisions of the 
bill.
    VA supports the intent of H.R. 3549 to prevent delays in the 
release of copayment charges due to operational error, avoid undue 
burden to Veterans, and improve VA's copayment billing procedures. 
However, the 120-day time period proposed in the bill is not reflective 
of the timeline of normal business operations. Further, it is not clear 
what specific copayment billing issues the bill would address.
    We note that copayments are automatically generated by VA's 
integrated billing system. Moreover, VA ensures that every Veteran is 
given the notice of rights and the opportunity to request a waiver or 
compromise, and to establish a repayment plan for copayment charges. 
This information is included with every copayment billing statement 
that VA sends to a Veteran. As a service to Veterans, VA holds 
copayment bills until a Veteran's other health insurance (OHI) is 
billed and either pays or denies the claim. This allows VA to 
potentially offset the Veteran's copayment charges with payment 
received from the OHI, reducing the Veteran's liability. When a Veteran 
has OHI, the copayment charge is placed on hold for 90 days while the 
OHI is billed. If no payment is received within 90 days, the charges 
will automatically be released and a statement generated to the 
Veteran. If a balance remains after an OHI payment is applied to the 
copayment debt, the bill for the remaining balance is released to the 
Veteran and he or she receives it within a variable timeframe that 
ranges from 70 to 150 days depending on when the OHI payment is made - 
a timeframe that can exceed the proposed 120-day standard in H.R. 3549. 
VA financial policy for medical care debts specifies that Veterans who 
do not have OHI should have the opportunity to satisfy copayment 
obligations at the Agent Cashier's office prior to leaving the medical 
facility. Otherwise, the record of service is prepared and the 
copayment is released for billing on the Veteran's next scheduled 
monthly billing statement, which is normally received anywhere from 14 
to 42 days after the date of service.
    Copayment bills may also be generated following income verification 
under 38 U.S.C. Sec.  5317, which authorizes VA to validate certain 
Veterans' reported income with the Internal Revenue Service (IRS) and 
Social Security Administration information. This validation begins 18 
months after the calendar year in which that income is reported due to 
receipt of data, upon completion of tax processing, from the IRS. If VA 
identifies unreported income, VA has authority to generate copayment 
billings as a result of this verification process. VA also refunds 
copayments, when appropriate, as a result of this income verification 
process. The timeframe associated with this process exceeds the 120-day 
standard proposed in H.R. 3549. We also note that private sector 
billing industry standards allow for billing up to 12 to 18 months 
after services are rendered - also exceeding the proposed 120-day 
timeframe.
    H.R. 3549 does not specify what constitutes an error, what would 
justify a waiver, and whether the waivers and payment plans authorized 
under the bill would differ from those currently authorized in 
applicable statutes and regulations. VA has existing procedures under 
38 U.S.C. Sec.  5302 to waive collection in cases where the Secretary 
determines that recovery would be against equity and good conscience. 
In these instances, an application for relief must generally be made 
180 days from the date of notification of the indebtedness.
    As a technical matter, we note that the bill does not define the 
term ``third-party entity'' or specify how this language would be 
applied. Further, we note that VA copayment requirements under 38 
U.S.C. Sec.  1710(f)-(g), 38 U.S.C. Sec.  1722A, and 38 U.S.C. Sec.  
1710B (which is not referenced in H.R. 3549, but requires copayments of 
certain Veterans for extended care services) apply regardless of 
whether the care or services was provided in a VA facility or 
authorized by VA in a non-VA facility. Therefore, the 120-day timeframe 
that would be added in section 1710(f)(3)(G)(ii) and section 
1722A(c)(2) by the bill may be read as applying to care or services in 
both VA and non-VA facilities. If copayments billings delayed beyond 
120 days from date of service are waived, VA estimates a 5-year revenue 
loss of $365.6 million and a 10-year revenue loss of $695.2 million 
from the First Party Inpatient/Outpatient and Pharmacy Medical Care 
Collection Fund.

    Draft Bill Promoting Responsible Opioid Management and 
Incorporating Scientific Expertise (PROMISE Act)

    In general, this draft bill contains some very appropriate 
requirements for opioid safety, many of which are already underway in 
VA. We note, however, that Servicemembers' opioid use is often 
initiated by DoD prescribers, and a major shortcoming of this bill is 
that it lacks requirements for DoD to address opioid use at the 
beginning of the process and instead focuses on VA interventions after 
opioid use has been initiated. This problem cannot be resolved in 
isolation; DoD and VA must both be accountable for opioid use by 
Servicemembers and Veterans, respectively. To be more effective, this 
bill should be strengthened so that VA's requirements are mirrored by 
requirements for DoD.
    Section 101 would require, within 1 year of the date of the 
enactment of the Act, VA and DoD to jointly update the VA/DoD Clinical 
Practice Guideline for Management of Opioid Therapy for Chronic Pain. 
The guideline would have to include common recommended guidelines for 
safely prescribing opioids for the treatment of chronic, non-cancer 
pain in outpatient settings as compiled by the Centers for Disease 
Control and Prevention (CDC); enhanced guidance in certain specified 
areas; enhanced guidance with respect to the treatment of patients with 
behaviors or comorbidities such as posttraumatic stress disorder, 
psychiatric disorders, or a history of substance abuse or addiction, 
that require consultation or co-management of opioid therapy with one 
or more specialists; enhanced guidance with respect to the conduct by 
health care providers of an effective assessment for patients receiving 
opioid therapy; guidance that each VA and DoD provider, before 
initiating opioid therapy, use VA's Opioid Therapy Risk Report tool to 
assess the risk for adverse outcomes; guidelines to govern the 
methodologies used by VA and DoD providers to taper opioid therapy when 
adjusting or discriminating opioid therapy; guidelines with respect to 
appropriate case management for patients receiving opioid therapy who 
transition between inpatient and outpatient settings; guidelines on 
appropriate hand-off of case management responsibility for patients 
receiving opioid therapy who transition from receiving care during 
active duty and post-military health care networks; enhanced standards 
on the use of routine and random urine drug tests for all patients 
before and during opioid therapy; and guidance that health care 
providers discuss with patients before initiating opioid therapy, other 
options for pain management therapies. Before updating these 
guidelines, VA and DoD would be required to jointly consult with the 
Pain Management Working Group of the VA/DoD Health Executive Council.
    VA appreciates the intent of this thoughtful and comprehensive bill 
and agrees that more needs to be done to support clinicians with 
clearer guidance and training on prescribing medications for pain 
management. This bill will, in effect, codify the spirit of the 
recently released Presidential Memorandum requiring education for all 
Federal prescribers. \3\ VA, because of its central role in training 
physicians across the country, can provide leadership by training 
clinicians in pain management and supporting a team approach to care. 
There are cases where the use of opioids is clinically indicated, 
albeit closely controlled and monitored, to control pain when nothing 
else does. VA should have the flexibility to develop its own evidence-
based prescribing guidelines in partnership with DoD.
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    \3\ Presidential Memorandum-Addressing Prescription Drug Abuse and 
Heroin Use. White House Office of the Press Secretary. October 21, 
2015. Available at https://www.whitehouse.gov/the-press-office/2015/10/
21/presidential-memorandum-addressing-prescription-drug-abuse-and-
heroin. Downloaded 11/13/2015
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    In addition, the bill's requirement that VA and DoD health care 
providers, before initiating opioid therapy to treat a patient, use the 
VA Opioid Therapy Risk Report tool, including information from the 
prescription drug monitoring program of each State, is problematic 
because not every state has a functioning program and not every state 
allows access by health care providers not licensed in that state. VA 
has many providers who are not licensed in the state where they work.
    Section 102(a) would require VA, within 180 days of enactment, to 
expand the Opioid Safety Initiative to include all VA medical 
facilities.
    Section 102(b) would require VA to ensure that all providers 
responsible for prescribing opioids to receive education and training 
on pain management and safe opioid prescribing practices. The education 
and training would have to cover a number of identified areas, and in 
providing the training, VA would be required to use the 
Interdisciplinary Chronic Pain Management Training Team Program.
    Section 102(c) would require each VA medical facility to identify 
and designate a pain management team of health care professionals 
responsible for coordinating and overseeing therapy at the facility for 
patients experiencing acute and chronic pain that is not related to 
cancer. In consultation with VISN Directors, a consensus on established 
protocols would have to be adhered to for the designation of a pain 
management teams at each VA medical facility, and the protocols would 
need to ensure that any health care provider without expertise in 
prescribing analgesics or who has not completed required training does 
not prescribe opioids, with limited exceptions. Within 1 year of 
enactment of this Act, each VA medical facility would be required to 
submit to the Deputy Under Secretary for Health and VISN Director a 
report identifying the health care professionals that have been 
designated as members of the pain management team at the facility, and 
other specified information.
    Section 102(d) would require, within 18 months of the date of the 
enactment of the Act, that VA submit an acquisition and budget plan to 
create a system that allows for real-time tracking and access to data 
on the use of opioids and prescribing practices. VA also would be 
required to ensure access by VA health care providers to information on 
controlled substances prescribed by community providers through State 
prescription drug monitoring programs (PDMPs). Within 18 months of the 
enactment of this Act, VA would be required to submit to Congress a 
report on the implementation of these improvements. As noted above, we 
recommend that any such requirements also involve DoD. Also, we note 
that VA already has trending reports available to monitor the key 
clinical indicators of the Opioid Safety Initiative. In addition, VA 
health care providers receive real-time order checks on all 
prescriptions, including opioids. VA likely could not develop the 
proposed system within 18 months, and the system would offer little 
value to existing trending reports. Further, it is unclear what the 
benefit or desired outcome would be to tracking mail-order 
prescriptions of opioids prescribed to Veterans in real-time.
    Section 102(e) would require VA to maximize the availability of 
opioid receptor antagonists, such as naloxone, to Veterans and ensure 
their availability for use by VA health care providers treating 
Veterans. Within 90 days of enactment of this Act, VA would be required 
to equip each VA medical facility with opioid receptor antagonists 
approved by the Food and Drug Administration (FDA). VA notes that other 
opioid receptor antagonists approved by FDA exist, but only one type 
(naloxone) is approved for overdose reversal. This section would also 
direct VA to enhance training of providers on distributing such 
antagonists and to expand the Overdose Education and Naloxone 
Distribution program to ensure all Veterans in receipt of health care 
who are at risk of opioid overdose (as defined by the bill) have access 
to opioid receptor antagonists and training on their proper 
administration. Within 120 days of the date of the enactment of this 
Act, VA would be required to submit to the Committees on Veterans' 
Affairs a report on compliance with these requirements.
    Section 102(f) would require that VA include in the Opioid Therapy 
Risk Report tool information on the most recent time the tool was 
accessed by a VA health care provider with respect to each Veteran and 
information on the results of the most recent urine drug test for each 
Veteran. VA would also be required to determine if a provider 
prescribed opioids without checking the information in this tool first.
    Section 102(g) would require VA to modify VA's Computerized Patient 
Record System (CPRS) to ensure that any health care provider that 
accesses the record of a Veteran will be immediately notified whether 
the Veteran is receiving opioid therapy and has a history of substance 
use disorder or prior instances of overdose, has a history of opioid 
abuse, or is at risk of becoming an opioid abuser.
    VA agrees that additional training for providers is necessary, and 
will be compliant with the Presidential Memorandum. Clinicians want to 
help Veterans and Servicemembers, but often do not have the skills and 
resources to do so. A well-trained physician and clinical team will 
know how to evaluate comprehensively a patient with pain, including 
making clinical diagnoses and how to develop a goal oriented management 
plan for pain, as well as how to engage the particular resource needs 
of each patient. Regarding other parts of section 102, VA is currently 
taking steps to fulfill the intent of many of these provisions. For 
example, section 102(e) would require VA to maximize the availability 
of opioid receptor antagonists approved by the FDA, and VA is currently 
exploring ways to increase the availability of these life-saving 
medications. Similarly, section 102(g) would require VA to modify the 
CPRS to ensure that providers will be immediately notified about opioid 
risks for each patient. VA's electronic health record already has real-
time mechanisms in place to alert VA health care providers of existing 
opioid prescriptions to prevent prescribing of additional opioids to 
Veterans who receive all their healthcare and prescriptions through the 
VA system. These mechanisms include real-time order checks that alert 
providers of prescriptions with potential problems with duplication, 
drug interactions, and doses in excess of the maximum recommended 
amount. We note that the Veterans Choice Program also allows VA 
patients, in certain circumstances, to receive medicines outside of the 
VA system.
    Subparagraphs (A) and (C) of Section 102(d)(2) are duplicative of 
existing Federal law and regulations, but their general language could 
cause confusion as to the responsibilities of the Department and its 
individual providers. More specifically, 38 U.S.C. Sec.  5701(l) 
required VA to issue regulations authorizing the disclosure of 
information about Veterans and their dependents to state PDMPs. 
Accordingly, those regulations were published in 38 C.F.R. Sec.  1.515, 
which sets forth the specific categories of information that may be 
disclosed to state PDMPs. Some VA facilities already have policies in 
place that mandate the querying of state PDMPs regarding patients who 
are prescribed certain kinds of drugs. If Congress desires to make the 
disclosure of information to state PDMPs mandatory, rather than 
permissive, it should consider making that change within 38 U.S.C. 
Sec.  5701(l), rather than in a separate law.
    Section 104 would require VA to conduct a study on the feasibility 
and advisability of carrying out a pharmacy lock-in program under which 
Veterans at risk for abuse of prescription drugs would be permitted to 
receive prescription drugs only from certain specified VA pharmacies. 
VA would be required to report to the Committees on Veterans' Affairs 
within 1 year of enactment on this study.
    VA has numerous concerns with section 104. We believe a pharmacy 
lock-in program, under which Veterans at risk for abuse of prescription 
drugs are permitted to receive prescription drugs only from certain 
specified VA pharmacies, would lead to negative patient outcomes. For 
example, Veterans who are travelling or require emergent/urgent medical 
care from a VA facility may need to receive a prescription from another 
VA facility's pharmacy to treat the Veteran's emergent/urgent 
condition. The pharmacy lock-in program would prevent medically-
necessary drugs from being dispensed to Veterans. VA health care 
providers receive duplicate order checks from other VA facilities at 
the point of prescribing. These duplicate order checks would notify the 
provider and pharmacist in real-time that the Veteran is receiving 
similar medications at another VA facility. Therefore we do not believe 
a study on a pharmacy lock-in program would yield useful information.
    Section 105(a) would require the Comptroller General, within 2 
years of enactment of this Act, to submit to the Committees on 
Veterans' Affairs a report on the Opioid Safety Initiative and the 
opioid prescribing practices of VA health care providers. The report 
would include recommendations for improvement, and under section 105(b) 
VA would be required to report to the Committees on Veterans' Affairs 
on a quarterly basis on the actions taken by VA to address any 
outstanding findings and recommendations from the Comptroller General.
    We defer to the Government Accountability Office (GAO) on this 
provision. However, we note that we would construe the provision not to 
require VA to implement the Comptroller General's recommendations, due 
to the separation of powers concerns that would otherwise be presented. 
See Bowsher v. Synar, 478 U.S. 714, 726-27 (1986). We would construe 
section 105(b) as merely requiring VA to report the actions taken to 
implement those recommendations, if any.
    Section 105(c) would also require VA to conduct an annual report on 
opioid therapy, and to submit this report to the Committees on 
Veterans' Affairs. This report would include specified information on 
patient populations and prescribing patterns for opioids. VA has a 
number of technical concerns with section 105, and we would be glad to 
meet with Subcommittee staff to discuss these further.
    VA supports section 201, which would require VAMCs and community-
based outpatient clinics to host community meetings, open to the 
public, on improving VA health care. This section is consistent with 
current practices of hosting Town Hall meetings to hear from Veterans, 
families, and other stakeholders.
    Section 202 would require VA display at each VA medical facility 
the purposes of the Patient Advocacy Program, contact information for 
the patient advocate, and the rights and responsibilities of patients 
and family members. VA supports increasing the awareness of the Patient 
Advocacy Program and the rights and responsibilities of Veterans and 
family members. This section is consistent with current practices of 
posting this information in medical facilities and would only require 
the addition of posting the Patient Advocacy Program's purpose.
    Section 203 would require the Comptroller General to submit to the 
Committees on Veterans' Affairs a report on VA's Patient Advocacy 
Program, including recommendations and proposals for modifying the 
program and other information the Comptroller General considers 
appropriate.

    We defer to GAO on this provision.

    Section 204 would require VA, in consultation with DoD, to submit 
to the Committees on Veterans' Affairs, within 180 days of the date of 
the enactment of this Act, a report on the transition from DoD to VA 
health care settings undergone by Veterans in receiving health care. 
The report would have to include an evaluation of VA's standards for 
facilitating and managing the transition undergone by Veterans in 
receiving health care in VA and DoD health care settings, an assessment 
of the case management services that are available, an assessment of 
the coordination in coverage of and consistent access to medications, 
and a study of the sufficiency of VA resources to ensure delivery of 
quality health care relating to mental health issues among Veterans 
seeking VA treatment.
    VA does not support section 204 because its requirements would 
duplicate multiple GAO investigations regarding the health care 
transition of Servicemembers and Veterans, most notably a November 2012 
report, Recovering Servicemembers and Veterans: Sustained Leadership 
Attention and Systematic Oversight Needed to Resolve Persistent 
Problems Affecting Care and Benefits. In response, DoD and VA are 
enhancing care coordination and case management to improve transitions 
across health care settings, including the development of an 
Interagency Comprehensive Plan for Servicemembers and Veterans 
requiring complex care coordination as well as a Lead Coordinator to 
align and standardize care coordination processes, roles, and 
responsibilities and to reduce confusion, duplication, and frustration.
    In addition, GAO is currently conducting a study, Engagement on 
Care Transitions and Medication Management for Post-Traumatic Stress 
Disorder and Traumatic Brain Injury (GAO code 291282). GAO is 
interviewing DoD and VA officials, as well as staff in the field. Thus 
far, GAO has conducted interviews at the Washington, DC VAMC; at Fort 
Hood, Texas; and at Fort Carson, Colorado. VA looks forward to their 
objective, third-party assessment.
    Section 401 would require that as part of the hiring process for 
health care providers VA reach out to state medical boards to ascertain 
whether a prospective employee has any violations over the past 20 
years, or has entered into a settlement agreement for a disciplinary 
charge related to the employee's practice of medicine. VA does not feel 
that additional legislation is needed to accomplish this. VHA policy, 
already in place, requires the verification of all current and 
previously held licenses for all licensed health care providers. At the 
time of initial appointment all current and previously held licenses 
are verified with the state licensing board issuing the license. 
Verification requires querying the state licensing board for not only 
the issue date and expiration date, but also any pending or previous 
adverse actions. If an adverse action is identified, the verification 
requires obtaining all documentation available associated with such 
action, including but not limited to copies of any agreements. At the 
time of expiration of a license, as well as at the time of reappraisal, 
VHA policy requires querying the state licensing board to confirm 
renewal of the license, as well as whether or not there are any pending 
or previous adverse actions. If the license is not renewed, VHA policy 
requires confirmation that the license expired in good standing and, if 
not, what was not in good standing.
    At the time of initial appointment, all health care providers are 
queried through the National Practitioner Data Bank (NPDB). The NPDB is 
a national flagging system that serves as a resource for hospitals and 
other healthcare entities during the provider credentialing process. 
The NPDB provides information about past adverse actions of health care 
providers. VHA also enrolls all independent, privileged providers in 
the NPDB's Continuous Query program for ongoing monitoring of not only 
adverse actions taken against a credential, but also paid malpractice. 
VHA receives notification of a new report within 24 hours of the report 
being filed with the NPDB.
    Additionally, at the time of initial appointment, all physicians 
are queried through the Federation of State Medical Boards (FSMB) 
Federation Physician Data Center, a nationally recognized system for 
collecting, recording and distributing to state medical boards and 
other appropriate agencies data on disciplinary actions taken against 
licensees by the boards and other governmental authorities. The report 
returned from the FSMB Physician Data Center not only identifies if 
there are any adverse actions recorded against a physician's license 
but also lists all of the physician's known licenses, current or 
previously held, serving as a double-check that the physician reported 
all licenses during the credentialing process. In addition, the 
licenses of all physicians are monitored through a contract with the 
FSMB's Disciplinary Alert Service (DAS). Through this contract, all 
physicians are enrolled in the DAS, which offers ongoing monitoring of 
physician licensure. If a new action against a physician's license is 
reported to the FSMB DAS, VHA receives a notification of the report 
within 24 hours. The staff at the physician's facility then contacts 
the reporting state licensing board to obtain the details of the 
action.
    If the facility learns of an adverse action taken against a 
provider license, the staff at the facility must obtain information 
from the provider against whom the action was taken and consider it as 
well as the information obtained from the state licensing board. This 
review is documented to include the reasons for the review, the 
rationale for the conclusions reached, and the recommended action for 
consideration and appropriate action by the facility.
    Section 402 would require VA to provide the relevant state medical 
boards detailed information about any VA health care provider that has 
violated a requirement of his or her medical license. We also believe 
in this case additional legislation is not required. VA has broad 
authority to report to state licensing boards those employed or 
separated health care professionals whose behavior or clinical practice 
so substantially failed to meet generally-accepted standards of 
clinical practice as to raise reasonable concern for the safety of 
patients. The authority to report those professionals is derived from 
VA's long-standing statutory authority, contained in 38 U.S.C. Sec.  
7401-7405, which authorizes the Under Secretary for Health, as head of 
VHA, to set the terms and conditions of initial appointment and 
continued employment of health care personnel, as may be necessary, for 
VHA to operate medical facilities. This authority allows VA to require 
health care professionals to obtain and maintain a current license, 
registration, or certification in their health care field.
    The Veterans Administration Health-Care Amendments of 1985; Public 
Law 99-166; and Part B of Title IV of Public Law 99-660, the Health 
Care Quality Improvement Act of 1986, are acts requiring VHA to 
strengthen quality assurance and reporting systems to promote better 
health care. Pursuant to section 204 of Public Law 99-166, VA 
established a comprehensive quality assurance program that includes 
reporting any licensed health care professional to state licensing 
boards who:

    (1)Was fired or who resigned following the completion of a 
disciplinary action relating to such professional's clinical 
competence;
    (2)Resigned after having had such professional's clinical 
privileges restricted or revoked; or
    (3)Resigned after serious concerns about such professional's 
clinical competence had been raised, but not resolved.

    The provisions of 38 U.S.C. Sec. Sec.  7401-7405, augmented by 
Public Laws 99-166 and 99-660, provide VHA ample authority to make 
reports to state licensing boards when exercised consistent with 
Privacy Act requirements for release of information. VHA policy 
requires the VA medical facility Director to ensure that within 7 
calendar days of the date a licensed health care professional leaves VA 
employment, or, information is received suggesting that a current 
employee's clinical practice has met the reporting standard, an initial 
review of the individual's clinical practice is conducted to determine 
if there may be substantial evidence that the individual so 
substantially failed to meet generally accepted standards of clinical 
practice as to raise reasonable concern for the safety of patients.
    Usually this review is conducted and documented by first and second 
level supervisory officials. When the initial review suggests that 
there may be substantial evidence that the licensed health care 
professional so failed to meet generally-accepted standards of clinical 
practice as to raise reasonable concern for the safety of patients, the 
medical facility Director is responsible for immediately initiating a 
comprehensive review to determine whether there is, in fact, 
substantial evidence that this reporting standard has been met. This 
review involves the preparation of a state licensing board reporting 
file. VHA policy defines the process for collecting evidence, notifying 
the provider of the intent to report, which affords the provider the 
opportunity to respond in writing to the allegations, and the review 
process to ensure that VHA has complied with the Privacy Act prior to 
reporting.
    It is VA's policy to cooperate whenever possible with an inquiry by 
a state licensing board. VA medical facilities must provide reasonably 
complete, accurate, timely, and relevant information to a state 
licensing board in response to appropriate inquiries.
    Section 403 would require VA, within 2 years of the date of the 
enactment of this Act, to submit to the Committees on Veterans' Affairs 
a report on its compliance with the policy outlined by this Act to 
conduct a review of each health care provider who transfers to another 
VA medical facility or leaves VA to determine whether there are any 
concerns, complaints, or allegations of violations relating to the 
medical practice of the health care provider and to take appropriate 
action with respect to any such concern, complaint, or allegation.
    VA does not support section 403 because appropriate reporting 
systems are already in place. VA has broad authority to report employed 
or separated health care professionals to state licensing boards when 
their behavior or clinical practice so substantially failed to meet 
generally accepted standards of clinical practice as to raise 
reasonable concern for the safety of patients. VA medical facility 
Directors are required to ensure that a review is conducted of the 
clinical practice of a licensed health care professional who leaves VA 
employment or when information is received suggesting that a current 
employee's clinical practice has met the reporting standard. As 
previously noted, VA has established a comprehensive quality assurance 
program for reporting any licensed health care professional to state 
licensing boards who was fired or resigned following the completion of 
a disciplinary action relating to such professional's clinical 
competence, resigned after having had such professional's clinical 
privileges restricted or revoked, or resigned after serious concerns 
about such professional's clinical competence had been raised but not 
resolved. When a report is made to a state licensing board, a copy of 
that letter is also forwarded to VA Central Office. VA would be happy 
to provide this information upon request, but we do not believe a 
statutory requirement to submit this information is warranted.

    Draft Bill Department of Veterans Affairs Purchased Health Care 
Streamlining and Modernization Act
    On May 1, 2015, the Adminsitration transmitted to the Congress 
adraft bill, the ``Department of Veterans Affairs Purchased Health Care 
Streamlining and Modernization Act.'' We greatly appreciate the 
Committee placing this measure on today's agenda. The draft bill would 
clarify VA's authority to purchase care and services in the community 
when such services are not reasonably available from VA or through 
contracts or sharing agreements. Accomplishment of this goal is VA's 
top legislative priority.
    VA is developing its plan to consolidate and improve VA purchased 
care programs in accordance with Public Law 114-41 and will be engaged 
with the Committee in a far-reaching discussion of this comprehensive 
plan. While those ideas are being considered, enactment of purchased 
care reform will provide important clarifications and improvements that 
can serve as a cornerstone for further consolidation and streamlining.
    Section 2 of the draft bill would amend chapter 17 of title 38, 
U.S.C., by adding a new section 1703A. Section 1703A, ``Agreements with 
eligible providers; certification processes,'' would authorize VA to 
purchase care in certain circumstances through agreements (Veterans 
Care Agreements or VCA) that are not subject to certain provisions of 
law governing Federal contracts, so that providers are treated 
similarly to providers in the Medicare program. The draft bill would 
provide explicit protections for procurement integrity, provider 
qualifications, price reasonableness and employment protections while 
ensuring that VA is able to provide local care to Veterans in a timely 
and responsible manner.
    Specifically, subsection (a) of section 1703A would authorize VA to 
enter into VCAs with certain providers when the needed care is not 
feasibly available within VA or though contracts or sharing agreements. 
Subsection (a) would require VA to review VCAs of a material size every 
2 years to determine whether it is practical or advisable to provide 
the necessary care through VA facilities or contracts or sharing 
agreements.
    Subsection (b) would specify that VCAs are exempt from certain 
provisions of law governing Federal contracting, specifically, 
competitive procedures and certain laws to which providers and 
suppliers of health care services through the Medicare program are not 
subject. At the same time, it is important that providers entering into 
these agreements are subject to any law that addresses integrity, 
ethics, fraud, or civil and criminal penalties, as well as those that 
ensure equal employment opportunity.
    Subsection (c) would clarify that care provided under VCAs is 
subject to the same terms and conditions as though provided in a VA 
facility.
    Subsection (d) would provide that, to the extent practicable, the 
rates paid for care under this section shall be in accordance with the 
rates paid by the United States under the Medicare program.
    Subsection (e) would define eligible providers to include: 
providers, physicians, and suppliers that have enrolled with Medicare 
and entered a provider agreement or a participation agreement with 
Medicare; providers participating in Medicaid; and other providers the 
Secretary determines to be qualified under subsection (f).
    Subsection (f) would require the Secretary to establish a process 
for certification and re-certification of certain providers. This 
process would include procedures for screening providers according the 
risk of fraud, waste, and abuse and must require the denial of 
applications from providers excluded from certain Federal programs.
    Subsection (g) would specify that providers must agree to, among 
other things, accept the rates and terms of VA payment, provide 
services only in accordance with VA's authorization, and provide 
medical records to VA.
    Subsection (h) would outline when an agreement may be terminated by 
VA or the provider.
    Subsection (i) would require the Secretary to establish through 
regulation a mechanism for monitoring the quality of care provided to 
Veterans under this section.
    Subsection (j) would require the Secretary to establish through 
regulation administrative procedures for providers to present disputes 
relating to VCAs. Providers would be required to exhaust these 
administrative procedures before seeking judicial review.
    Subsection (k) would direct the Secretary to prescribe regulations 
to carry out section 1703A.
    Section 3 of the draft bill would make conforming amendments to 38 
U.S.C. Sec.  1745 to permit VA to enter into similar agreements with 
State Veterans Homes. Section 3 would establish a separate effective 
date for State Veterans Homes.
    On continuing review since the time VA transmitted the draft bill 
to Congres, we believe there are drafting improvements that can be made 
to clarify aspects of the bill. We note that the Administration 
strongly supports S. 2179, the ``Veteran Care Agreements Rule 
Enhancement Act'', or ``the Veteran CARE Act,'' which was based on this 
draft bill and provides what we believe is clearer language regarding 
equal employment opportunities. We'd appreciate the opportunity to 
discuss those improvements with your staff.
    Mr. Chairman, this concludes my statement. Thank you for the 
opportunity to appear before you today. We would be pleased to respond 
to questions you or other members may have.

                                 
                       Statements For The Record

                    AMERICAN COUNSELING ASSOCIATION
    The American Counseling Association is privileged and honored to 
submit additional testimony in support of various legislation being 
considered by the House Veterans Affairs Committee that would improve 
access to care for millions of men and women that served our nation. At 
the American Counseling Association, we hold our profession's service 
to the veteran population in the highest regard and strive to provide 
critical mental health care and access to those most in need.

    HR 1319 - The Ask Veterans Act

    With all of the recently documented issues at the VA in terms of 
providing timely mental health care and other services, it is vital 
that the agency understand the demands and outcomes directly from the 
population it is serving. As a system, the VA is highly regarded but it 
should be able to shift to demands in care and any other process issues 
that might arise. Given the expected influx of veterans coming into the 
system as the US brings additional troops home from stations overseas, 
the VA needs to understand where the need for care is and the best way 
to address it. This legislation is the first step in achieving that 
goal.

    HR 1603 - The Military Sexual Assault Victims Empowerment Act

    As an organization representing licensed professional counseling, 
our members and thousands of mental health professionals across the 
country talk with patients dealing with trauma resulting from sexual 
assault every day. Such a traumatic event needs to be addressed and 
dealt with in a manner of urgency. We support the intent of this 
legislation in bringing parity to sexual assault incidents within the 
VA.

    HR 3234 - The Failing VA Medical Center Recovery Act

    As a nation, we should accept nothing less than the best for our 
veterans. If there is a VA hospital that is not meeting the highest of 
standards, it should be made public so that changes can be made. This 
legislation represents a common sense solution to bring more 
transparency to the care received by veterans to ensure their needs are 
met.

    VA Legislative Proposal - VA Purchased Healthcare Streamlining and 
Modernization Act

    We believe that the process that veterans go through to receive 
care should be as streamlined and efficient as possible. We also know 
from recent data that access to health care in rural areas is something 
that the VA is focusing on intently. We support the Secretary entering 
into agreements with providers outside the VA system but would caution 
against a blanket reliance on other federal programs, such as Medicare. 
The licensed professional counseling profession has been hit by this 
inequity under the Choice Program, which overwhelmingly passed Congress 
last year. There are 150,000+ LPCs across the country, predominantly in 
rural areas, and they cannot participate in the Choice program because 
they are currently not recognized by Medicare. Licensed Professional 
Counselors ARE recognized by third party insurance providers, the DoD, 
TRICARE, the VA, Medicaid, Indian Health Service; essentially all other 
major healthcare payers in this country. In this proposal, there should 
be flexibility provided to the Secretary to enter into agreements with 
those providers recognized by the VA. A reliance on another federal 
program could actually reduce access to veterans while trying to pass 
legislation that is aimed at increasing that access.

    Draft Bill - The PROMISE Act

    Mental health care delivery has begun to change in this country 
into a more integrated environment. There have been many pieces of 
legislation passed in the last five years that brings mental health 
care to parity with physical health care. There are numerous studies 
showing a direct connection between treatment of mental issues and 
physical ailments. Perhaps that is best understood with the veteran 
population; PTSD and other mental health issues may become co-morbid 
with a physical ailment such as a loss of a limb or other chronic pain. 
A veteran suffering from PTSD or depression is less likely to keep up 
with their physical needs if the mental issues are not being treated. 
We must ensure that the VA is looking at the patient in their entirety 
and consider the impact of the mental on the physical. The PROMISE Act 
would put the VA on a path to creating that integrated environment that 
will lead to more stable/predictable patient outcomes as well as a 
healthier and more cost-efficient system overall.
    One of the main issues facing veterans today is the over-
prescription of pharmaceuticals. The licensed professional counseling 
profession is trained to treat patients suffering from mental disorders 
without the use of pharmaceutical drugs. Too often, veterans are 
medicated when all they may need is a talk therapy session that focuses 
on their underlying issues/problems. Many mental health professionals 
are comfortable working with physicians in private practice and can 
refer a patient if advanced treatment is needed. The VA could put a 
system in place that begins the treatment at the therapeutic level 
while increasing treatment for those in need of that remedy.
    We also support the PROMISE Act seeking to recognize other 
variations of therapeutic delivery. There are a number of options 
available to patients and people will respond differently to other 
treatments. As an organization, the American Counseling Association 
would like to work with Rep. Bilirakis and the Committee to educate 
members on the availability and positive outcomes related to the other 
types of therapy listed in the legislation.
    Thank you again for the opportunity to provide testimony. We 
cherish our ability to serve veterans and hope to increase the number 
of highly qualified licensed professional counselors available to the 
VA so that we can finally address mental health workforce access issues 
across the system.
    Please contact me with any further questions or clarifications.
    Sincerely,
    Art Terrazas
    Director of Government Affairs
    American Counseling Association
    (703) 823-9800 ext 242
    [email protected]

    About The American Counseling Association

    The American Counseling Association is a not-for-profit, 
professional and educational organization that is dedicated to the 
growth and enhancement of the counseling profession. With more than 
55,000 members, we are the world's largest association representing 
professional counselors in various practice settings.

                                 
             AMERICAN ORTHOTICS AND PROSTHETICS ASSOCIATION
    Chairman Benishek, Ranking Member Brownley, and Members of the 
Committee,
    Thank you for including HR 1904, the Wounded Warrior Workforce 
Enhancement Act, for consideration in your hearing today, and for 
offering AOPA the opportunity to submit this testimony in strong 
support of this much-needed legislation.
    AOPA is a national trade association that represents over 2,000 
orthotic and prosthetic patient care facilities and suppliers that 
design, fabricate, fit, and supervise the use of orthoses and 
prostheses. Our members serve Veterans and civilians in the communities 
where they live, and our goal is to ensure that every patient has 
access to the highest standard of O&P care from a well-trained 
clinician.

    Wounded Warrior O&P Care Needs

    Amputation and Traumatic Brain Injury have become signature 
injuries of the wars in Iraq and Afghanistan. Although the death rate 
is much lower than previous wars, the amputation rate has doubled: 
according to the Department of Defense and the Department of Veterans' 
Affairs, 6% of those wounded in Iraq have required amputations, 
compared with a rate of 3% for past wars. The Congressional Research 
Service reported that, as of November 2014, US service members had 
undergone 1,573 major limb amputations; more than 80% of the amputees 
lost one or both legs. The majority of these are young men and women 
who, with continued, high quality prosthetic care, should be able to 
live long and active lives.
    Traumatic Brain Injury often manifests itself in the same way as 
stroke, with drop foot and other challenges balancing, standing and 
walking that require orthotic intervention. As has been widely 
reported, the number of service members diagnosed with TBI is far 
greater than those undergoing amputation. The Department of Defense 
reports that from 2000-2014, there were 320,344 diagnosed cases of TBI 
among service members. These service members and Veterans are also 
predominantly young adults who may need decades of high quality care to 
maintain their independence and quality of life.

    Other Veteran Health Trends Add to the Need for O&P Care

    The number of Veterans undergoing amputation is increasing 
dramatically, and is expected to increase at an even more rapid pace in 
the future. According to Dr. Joseph Webster, the Medical Director for 
the VHA Amputation System of Care, between 2008-2013, an average of 
7,669 new amputations were performed for Veterans every year. In the 
year 2000, 25,000 Veterans with amputations were served by the VA. By 
2013, that number had climbed to more than 80,000 Veterans.
    As Dr. Webster describes, the majority of Veterans with amputations 
have required an amputation because of diabetes or vascular disease. 
Nationwide, 7% of the US population, or more than 22 million Americans, 
are veterans. The VA reports that one out of every four Veterans 
receiving care from the VA has diabetes; 52% of the Veterans in the VHA 
primary care population have hypertension; 36% have obesity. All of 
these conditions are associated with orthotic or prosthetic care needs 
due to stroke, neuropathy, and amputation.

    Additional Highly Qualified Clinicians are Needed to Meet Growing 
Demand

    From the battlefield to the aging Veteran population at home, 
medical conditions requiring prosthetic and orthotic care have become 
more complex and more challenging to treat. The technologies available 
to address them are more sophisticated, and require more training and 
experience to fit and maintain. In recognition of these challenges, 
entry level qualifications for prosthetists and orthotists were changed 
to require master's degrees. At the same time, many experienced 
professionals in the field are themselves getting ready to retire. 
Providing high quality services to our Wounded Warriors, Veterans, 
seniors, and civilian amputees is going to require more master's degree 
programs at American universities to prepare the next generation of 
practitioners.
    The National Commission on Orthotics and Prosthetics Education 
(NCOPE) commissioned a study of the field, which was completed in May 
of 2015. The evaluation reported that in 2014, there were 6,675 
licensed and/or certified prosthetists and orthotists in the United 
States. The study concluded that, by 2025, ``overall supply of 
credentialed O&P providers would need to increase by about 60 percent 
to meet the growing demand.''
    Currently, there are thirteen schools in the US that offer master's 
degrees in orthotics and prosthetics. The largest program, 
Northwestern, accepts 48 students. The majority of programs have 
classes of 20 or fewer students per year. A total of 230 students are 
anticipated to graduate with master's degrees in orthotics or 
prosthetics in 2015.
    This means that current accredited schools will barely graduate 
enough entry-level students with master's degrees to replace the 
clinicians who will be retiring in coming years. Current class sizes 
aren't adequate to prepare sufficient numbers to meet the growing 
demand for prosthetic and orthotic care created by an aging population 
and increases in chronic disease that often require prosthetic and 
orthotic care.

    The Wounded Warrior Workforce Enhancement Act

    Despite the need for additional clinicians with advanced degrees, 
O&P master's programs are costly and challenging to expand. The need 
for lab space and sophisticated equipment, and the scarcity of 
qualified faculty with PhDs in related fields, contribute to the 
barriers to expanding existing accredited programs. Under current law, 
there are no federal resources available to schools to help create or 
expand advanced education programs in O&P. Funding is available for 
scholarships to help students attend O&P programs, but do not assist in 
expanding the number of students those programs can accept.
    The Wounded Warrior Workforce Enhancement Act is a limited, cost-
effective approach to assisting universities in creating or expanding 
accredited master's degree programs in orthotics and prosthetics. The 
bill authorizes $5 million per year for three years to provide one-time 
competitive grants of $1-1.5 million to qualified universities to 
create or expand accredited advanced education programs in prosthetics 
and orthotics. Priority is given to programs that have a partnership 
with Veterans' or Department of Defense facilities, including 
opportunities for clinical training, to help students become familiar 
with the unique needs of service members and Veterans.

    The Act in the 113th Congress

    The Wounded Warrior Workforce Enhancement Act was first introduced 
in the 113th Congress and gained bipartisan support. The bill was 
endorsed by Vietnam Veterans of America and VetsFirst, which recognized 
the need for additional highly qualified practitioners to care for 
wounded warriors.
    In May of 2013, the Senate Committee on Veterans Affairs held a 
hearing to consider the Wounded Warrior Workforce Enhancement Act and 
other Veterans' health legislation. The VA testified that the grants to 
schools were not necessary because it did not anticipate any difficulty 
filling its seven open internal positions in prosthetics and orthotics. 
The VA described its O&P fellowship program, which accepted nineteen 
students that year, as a sufficient pipeline to meet its need for 
internal staff.
    The Senate committee rejected the VA's argument because it did not 
represent the reality of how Veterans access O&P care. Acknowledging 
that more than 80% of prosthetic and orthotic care to Veterans is 
provided by community-based facilities, the committee concluded that 
the nineteen students enrolled in the VA fellowship program could not 
meet the system-wide need for highly qualified O&P staff. Committee 
members also agreed that increasing the number and pool of clinicians 
with master's degrees benefitted Veterans, whether they were hired 
internally at the VA or by community-based providers, particularly if 
those students had clinical experience working with service members and 
Veterans.
    Responding to the need for highly qualified clinicians in every 
setting that provides care to Veterans, the Senate committee included 
provisions of the Wounded Warrior Workforce Enhancement Act in S. 1950, 
which passed Senate VA Committee unanimously. Due to factors unrelated 
to O&P, the omnibus bill did not advance and no resources for advanced 
education in prosthetics and orthotics were made available to schools.

    The Need and the Opportunity Are Present Today

    That need for a larger pool and pipeline of highly qualified 
prosthetists and orthotists to care for Veterans with limb impairment 
and limb loss has only become more pressing. The competitive grants 
created under the Wounded Warrior Workforce Enhancement Act could spark 
the expansion necessary to meet Veteran needs for high quality care, in 
Veterans' Administration facilities and community-based settings.
    No Veteran should suffer from decreased mobility because of lack of 
access to high quality care. The Wounded Warrior Workforce Enhancement 
Act is a limited, cost-effective approach to training the skilled 
clinicians who will care for Veterans for decades to come. Thank you 
for considering this bill today, and for your commitment to providing 
the highest level of O&P care for our Veterans. If you have any 
questions or would like more information, please do not hesitate to 
contact AOPA.
    Respectfully Submitted,
    Charles H. Dankmeyer, Jr., CPO, President
    American Orthotic and Prosthetic Association

                                 
                                 AMVETS
    Distinguished members of the House Veterans' Affairs Committee, on 
behalf of the 23 million American Veterans in this country, AMVETS, a 
leader since 1944 in preserving the freedoms secured by America's armed 
forces and providing support for Veterans, Active Duty military, the 
National Guard/Reserves, their families and survivors, it is my 
pleasure, to offer this `Statement for the Record' concerning the 
following pending legislation:
    HR 1319, the Ask Veterans Act -AMVETS supports this bill which 
requires the VA Secretary to commission an survey, over a five-year 
period, to determine veteran's patient experiences at every VA medical 
facility. Importantly, the results of this survey are to be made 
publically available.
    The survey, which would include questions relating to:
      timely access to hospital care and medical services;
      the length of time between the request and the 
appointment;
      the frequency of appointment cancellation;
      the quality of care received
    These are the pillars that any health care system should meet and 
be measured by. If these areas have poor metrics, then there's a major 
problem with that facility. Additionally, it was help to identify both 
the good and the bad. Those facilities with positive rankings should be 
acknowledged and they should be required to share their best practices 
system-wide. Those facilities with negative rankings should be 
identified so that corrective action can be taken.
    HR 1603, the Military SAVE Act -AMVETS supports this legislation 
which amends the Veterans Access, Choice and Accountability act of 2014 
to make victims of MST eligible for treatment in a non-VA entity. Since 
victims of MST are scattered all over the country, including highly 
rural areas, the option to seek care within their own communities would 
be an amazing benefit and would encourage more victims to access care.
    HR 1904, the Wounded Warrior Workforce Enhancement Act -AMVETS 
supports this legislation which:
      directs the VA to award grants to eligible entities to 
establish a master's or doctoral degree programs in orthotics and 
prosthetics;
      seeks to expand existing programs in orthotics and 
prosthetics;
      requires a grant priority for institutions partnering 
with VA medical facilities;
      provides grants from $1 and $ 1.5 million;
      requires the VA to establish a Center of Excellence in 
Orthotic and Prosthetic Education; and
      seeks to improve orthotic and prosthetic outcomes for 
members of the military and veterans.
    Though the `Choice' Act was no doubt crafted with the best 
intentions, in practice, many flaws have surfaced. This legislation 
gratefully attempts, at least in part, to address some of those 
deficiencies.
    HR 2639, the Marriage and Family Therapists for Veterans Act -
AMVETS supports this legislation which seeks to provide additional 
qualification requirements for VA family therapy practitioners. Our 
veterans and their families deserve world-class support services and it 
is our belief that the quality of the practitioner is of the utmost 
importance to the positive outcome of any therapy.
    HR 3234, the Failing VA Medical Center Recovery Act -AMVETS 
wholeheartedly supports this very important legislation which seeks to 
improve poor-performing VA medical facilities by establishing an Office 
of Failing Medical Center Recovery and an Under Secretary position to 
head the Office. This dedicated Office which would take over the 
managerial and day-to-day operations of every failing VA medical center 
and would also:
      publish, both in the Federal Register and on the VA 
website the key health metrics for each VA medical center;
      certify semiannually that each failing VA medical center 
is subject to managerial and day-to-day operational control by the 
Office;
      would only revoke the certification of a VA medical 
center as failing medical center on after achieving a rating of 
`satisfactory' or better for three consecutive quarters;
      submit to Congress a quarterly report on the office, 
including corrective actions taken by the Under Secretary;
      transfer direct control of each failing medical center 
out of the pertinent VISN to the Under Secretary; and perhaps most 
importantly,
      establish rapid deployment teams to each failing medical 
to ensure that each failing VA medical is returned to a `satisfactory' 
status as quickly as possible.
    The focus, expertise and rapid response of the deployment team, 
under the direction of the Under Secretary should be very effective in 
correcting deficiencies in a cost effective and timely manner. It is 
our hope too, that this would help to improve the continuity of 
services across the VA system.
    HR 3471, the Veteran Mobility Safety Act of 2015 -AMVETS supports 
this legislation which seeks to add a layer of security for eligible 
disabled veterans who, due to their sacrifice, are provided a vehicle 
or other conveyance by the VA by:
      requiring the certification of any provider of adaptive 
equipment modification services;
      requiring the certification of any individual who 
performs such modifications; and
      requiring both the automobile/adaptive equipment provider 
and the provider of modification services to adhere to specified 
requirements of the ADA of 1990.
    HR 3549, the VA Billing Accountability Act -AMVETS supports this 
very important legislation which protects veterans from being billed by 
the VA for certain medical expenses when those expenses are incurred as 
a result of improper billing and notification on the VA's behalf. 
Furthermore, it limits the ability of the VA to collect these payments, 
unless a veteran has first been provided with information about 
applying for a waiver (which takes between 45 - 90 days to process) and 
given the opportunity to establish a payment plan (which takes the same 
amount of time to process as a waiver).
    I have recently had a personal experience with this exact situation 
which I unsuccessfully attempted to resolve for several months. I 
called the central VA billing office numerous times about the situation 
and each time had to re-explain the situation after which I was told 
that the problem would be solved. Unfortunately, the problem wasn't 
resolved and the next time I called, I was told that my case would be 
escalated. Eventually I was informed that if the balance on my account 
was not paid, that it would be subtracted from my disability 
compensation in November. It wasn't until early October, that any 
mention was made about a possible payment plan, which I authorized 
pending the resolution of the problem. When November rolled around, 
even though I had agreed to a payment plan, the full amount of the 
outstanding balance had been removed from my disability compensation. 
When I called the VA to ask about why the full amount of the balance 
had been taken, I was told that it takes 45 - 90 days to set up a 
payment plan. It wasn't until the very end of this ordeal or 
immediately after the money was taken, that anyone even mentioned the 
possibility of a waiver and of course by then it was too late.
    No veteran should be given the run around and mistreated in this 
manner; it is our hope that this legislation will prevent this type of 
situation going forward.
    Draft Legislation, the Promoting Responsible Opioid Management and 
Incorporating Scientific Expertise or ``Promise Act'' -AMVETS is 
extremely grateful for the recognition of this critically important 
issue which, in part, directs both VA and DoD to jointly update the VA/
DoD Clinical Practice Guideline for Management of Opioid Therapy for 
Chronic Pain, including guidelines regarding:
      prescribing opioids for outpatient treatment of chronic, 
non-cancer pain;
      contraindications for opioid therapy;
      treatment of patients with post-traumatic stress 
disorder, psychiatric disorders or a history of substance abuse or 
addiction;
      case management for patients transitioning between 
inpatient and outpatient health care;
      routine and random urine drug tests to help prevent 
substance abuse; and
      options to augment opioid therapy with other clinical and 
complementary and integrative health services to minimize opioid 
dependence.

    The bill further specifies that VA shall:

      expand the Opioid Safety Initiative to include all VA 
medical facilities, including providing employees with pain management 
training and establishment of pain management teams;
      track and monitor opioid use, including through the use 
of state program information;
      increase the availability of Food and Drug 
Administration-approved opioid receptor antagonists;
      modify the Computerized Patient Record System to ensure 
that any health care provider that accesses a veteran's record will be 
immediately notified whether the veteran is receiving opioid therapy 
and has a history of substance use disorder or opioid abuse;
      establish a Pain Management Board in each VISN;
      conduct a feasibility study for a program under which 
veterans at risk for prescription drug abuse receive prescription drugs 
only from certain VA pharmacies;
      establish the Office of Patient Advocacy;
      expand research and education on, and delivery and 
integration of, complementary and integrative health services into 
veterans' health care services, including services provided to veterans 
with mental health or chronic conditions;
      assess the feasibility of using wellness programs to 
complement pain management and related health care services to veterans 
and their families;
      carry out a program of internal audits to improve health 
care services to veterans and their families; and
      provide to the medical board of each state in which a VA 
health care provider is licensed information about such provider's 
medical license violations.
    The VA's own office of the Inspector General has issued numerous 
reports over the years indicating that overmedication, including the 
use of a wide variety of opioids, is a systemic problem at VA medical 
centers. With this in mind, no reasonable person can doubt that there 
must be some connection between the problem of over medicating veterans 
and the tragic veteran suicide rate.
    While AMVETS would never deny the benefits that some medications 
may provide for certain patients, we must equally acknowledge that the 
VA's reliance on a strictly pharmacological approach to treating the 
health issues affecting our veterans, is certainly not the only option 
and may not even be the best approach. Medication, in and of itself, 
merely masks symptoms and does nothing to eradicate any under lying 
mental or physical health problems. This then can lead to a life 
threatening dependence on medications, many of which have side effects 
more serious than the conditions they are meant to treat.
    Acknowledging that many medical conditions require some level of 
pharmaceutical interventions, AMVETS would encourage the VA in part to:
      increase use of complementary, alternative and 
integrative health practices;
      use an interdisciplinary team approach to healthcare that 
would more holistically treat patients with the goal being an improved 
quality of life; and
      require clinicians, prior to issuing prescriptions, to 
fully inform veterans of both traditional and non-traditional therapies 
that are available and appropriate alternatives for treating their 
conditions.
    This completes my statement and I thank you again for the 
opportunity to offer our comments on pending legislation. Feel free to 
reach out to me at [email protected] if have any questions.
                            Diane M. Zumatto
                  AMVETS National Legislative Director
    Diane M. Zumatto of Spotsylvania, VA joined AMVETS as their 
National Legislative Director in August 2011. Zumatto a native New 
Yorker and the daughter of immigrant parents decided to follow in her 
family's footsteps by joining the military. Ms. Zumatto is a former 
Women's Army Corps/U.S. Army member who was stationed in Germany and 
Ft. Bragg, NC, was married to a CW4 aviator in the Washington Army 
National Guard, and is the mother of four adult children, two of whom 
joined the military.
    Ms. Zumatto has been an author of the Independent Budget (IB) since 
2011. The IB, which is published annually, is a comprehensive budget & 
policy document created by veterans for veterans. Because the IB covers 
all the issues important to veterans, including: veteran/survivor 
benefits; judicial review; medical care; construction programs; 
education, employment and training; and National Cemetery 
Administration, it is widely anticipated and utilized by the White 
House, VA, Congress, as well as, other Military/Veteran Service 
Organizations.
    Ms. Zumatto regularly provides both oral and written testimony for 
various congressional committees and subcommittees, including the 
House/Senate Veterans Affairs Committees. Ms. Zumatto is also 
responsible for establishing and pursuing the annual legislative 
priorities for AMVETS, developing legislative briefing/policy papers, 
and is a quarterly contributor to `American Veteran' magazine. Since 
coming on board with AMVETS, Ms. Zumatto has focused on toxic wounds/
Gulf War Illness, veteran employment and transition, military sexual 
trauma, veteran discrimination and memorial affairs issues.
    Zumatto, the only female Legislative Director in the veteran's 
community, has more than 20 years of experience working with a variety 
of non-profits in increasingly more challenging positions, including: 
the American Museum of Natural History; the National Federation of 
Independent Business; the Tacoma-Pierce County Board of Realtors; The 
Washington State Association of Fire Chiefs; Saint Martin's College; 
the James Monroe Museum; the Friends of the Wilderness Battlefield and 
The Enlisted Association of the National Guard of the United States. 
Diane's non-profit experience is extremely well-rounded as she has 
variously served in both staff and volunteer positions including as a 
board member and consultant. Ms. Zumatto received a B.A. in Historic 
Preservation from the University of Mary Washington, in 2005.

    AMVETS, National Legislative Director
    4647Forbes Blvd, Lanham, MD 20706
    301-683-4016 / [email protected]
    16 November 2015

    The Honorable Jeff Miller, Chairman
    Committee on Veterans' Affairs
    U.S. House of Representatives
    335 Cannon Office Building
    Washington, DC 20515

    Dear Chairman Miller:

    Neither AMVETS nor I have received any federal grants or contracts, 
during this year or in the last two years, from any federal agency or 
program.

    Sincerely,

    Diane M. Zumatto
    AMVETS National Legislative Director

                                 
                KENTUCKY DEPARTMENT OF VETERANS AFFAIRS
    H.R. 1603 - (House Veterans Affairs Committee) - An Act Concerning 
Healthcare for Military Sexual Trauma Survivors
    Good afternoon. I am Heather French Henry, Commissioner of the 
Kentucky Department of Veterans Affairs (KDVA). I come before you today 
in support of the Karen Tufts Military Sexual Assault Victims 
Empowerment Act (SAVE).
    As the Commissioner, I am responsible for the health and wellbeing 
of more than 330,000 veterans within the Commonwealth of Kentucky 
including approximately 24,000 women veterans. While we don't operate 
the VA Medical Centers within our state, we are responsible for 4 
Veterans Nursing Facilities, 5 State Veterans Cemeteries and statewide 
programming staffed by more than 740 employees in 120 counties. We are 
also responsible to resolve complaints regarding the negligence of 
veterans, especially when it comes to access of their healthcare. As 
the daughter of a Vietnam Veteran who suffered for many years with co-
occurring issues with PTSD and substance abuse I take my job 
personally. My father came home with physical wounds as well as 
spiritual wounds. As Miss America 2000, I came before this committee on 
numerous occasions addressing the issues facing our homeless veterans 
and in 2001 the Heather French Henry Homeless Veterans Assistance Act 
was passed. Today, once again, I want to address this committee in 
support of those veterans who have suffered silently from Military 
Sexual Trauma.
    According to the Department of Defense, 19,000 service members 
endure sexual assault while in the military. Most of those are never 
reported. Of those that are reported, most offenders are never 
prosecuted. Therefore, survivors do not feel confident our system will 
provide them with the protection and services they require.
    Of Kentucky's 330,000 veterans, 24,000 of who are women, we are 
unaware how many may be survivors of Military Sexual Trauma. As these 
cases go unreported and veterans choose to suffer in silence rather 
than come forward.
    The VA Health Care system is rightly lauded by both medical 
professionals and the veterans who use it. But as we reach out to MST 
survivors and persuade them to get help, their needs are proving 
overwhelming for the VA health care system.
    Appropriate care for MST survivors is available from private 
medical providers throughout Kentucky. Preventing these veterans from 
getting care from available private providers adds to the burdens they 
already shoulder as MST survivors.
    KDVA strongly supports the Karen Tufts Military Sexual Assault 
Victims Empowerment Act, the SAVE Act.
    With SAVE, KDVA's Women Veterans Coordinator and field staff can 
reach out to MST survivors throughout the Commonwealth of Kentucky with 
confidence that these veterans will be able to access appropriate care 
close to home.
    KDVA agrees with Congressman Barr that we need to ``put MST 
survivors in control of their own healthcare. MST survivors have unique 
needs and it is important that they feel comfortable sharing this 
emotionally painful and very personal life-changing experience with 
professionals who are trained and have the expertise to properly handle 
these complex cases.''
    Veterans are our greatest asset. Today, with so many pressures on 
our local communities, we need our veterans to work and to lead. To do 
that, they must be healthy both physically and mentally. And to make 
and keep them healthy, we must remove the barriers they face in getting 
health care.
    On behalf of Kentucky's veteran community and veterans across this 
nation, I urge you to pass the SAVE Act. Nothing less will fulfill the 
commitment our country made to them in return for their service and 
sacrifice.
    Thank you for your time and consideration.
    Sincerely,
    Heather French Henry
    Commissioner
    Kentucky Department of Veterans Affairs

                                 
            NATIONAL MOBILITY EQUIPMENT DEALERS ASSOCIATION
    Chairman Benishek, Ranking Member Brownley, and esteemed Members of 
the Subcommittee:
    The National Mobility Equipment Dealers Association (NMEDA) thanks 
you for this opportunity to comment on H.R. 3471. NMEDA stands in full 
support of this legislation, which will establish enforceable minimum 
standards for vendors participating in the Automobile Adaptive 
Equipment (AAE) program administered by the Department of Veterans 
Affairs (VA). For far too long, the VA has allowed unqualified vendors 
performing unsafe and/or unreliable vehicle modifications and equipment 
installations to participate in the AAE program. The Veterans Mobility 
Safety Act of 2015 will put an end to this dangerous and costly 
practice.
    The VA aims to assist disabled veterans by providing reimbursement 
(either to the vendor or to the qualifying veteran) for the sale, 
installation, maintenance, and repair of automobile adaptive equipment 
through the AAE program. Automobile adaptive equipment (which includes 
but is not limited to platform wheelchair lifts, under vehicle lifts, 
power door openers, lowered floors, raised roofs, raised doors, hand 
controls, reduced- and zero-effort steering and braking systems, 
digital driving systems, inside and outside power-chair/scooter lifts 
and environmental controls) then enables veterans with disabilities to 
accomplish daily tasks and participate in work, education, and 
recreational activities. The AAE program has wonderful potential but 
the current administration of the program is alarming, due in large 
part to the absence of enforceable standards for vendors who wish to 
participate.
    Under current VA regulations, a JCAHO certification is required in 
order to sell a bottle of oxygen to a veteran yet an individual is not 
required to posses any certification (or to demonstrate any AAE 
knowledge or expertise) in order to install a $30,000 high-tech 
electronic driving control system on a disabled veteran's vehicle. In 
practical terms, this means that virtually any individual or business 
is currently able to provide - and currently able to receive payment 
from the VA for providing - AAE services to disabled veterans.
    The quality and safety of VA-funded vehicle modifications is 
directly compromised by the VA's lack of AAE program requirements for 
vendors. The VA currently pays for disabled veterans to have their 
vehicles modified and serviced by inferior vendors (e.g., vendors 
operating out of home garages/parking lots/mobile trucks; vendors 
lacking insurance coverage; vendors employing uncertified welders and 
technicians; vendors lacking the specialized tools, training 
certificates, and equipment necessary to perform AAE vehicle 
modifications; vendors unwilling to provide emergency service, etc.). 
Quality concerns range from poor customer service to faulty wiring to 
chronically unreliable power, steering, and braking systems. Such poor 
quality installations have very real safety implications and can result 
in automobile accidents, vehicle fires, injuries, or worse.
    Unnecessary spending is another consequence of the VA's lack of AAE 
program requirements for vendors. AAE installations often require a 
significant financial commitment. When a veteran complains to the VA 
about an unsatisfactory or unsafe installation, the VA has a history of 
referring the repair work to a vendor certain to complete the job 
properly. It often costs the VA more money to fix the inferior 
installation than it costs to have the installation performed properly 
to begin with. Congress can reduce this wasteful spending by 
implementing H.R. 3471 and requiring the VA to establish standards for 
vendors participating in the AAE program.
    Automotive mobility products can be extremely complex. Even simple 
installations, if performed incorrectly, can have a disastrous effect. 
Current VA AAE program policy jeopardizes the quality and effectiveness 
of installations, wastes taxpayer dollars, and puts the disabled 
veteran - as well as the driving public - at risk. Through the 
establishment of minimum standards for vendors participating in the AAE 
program, H.R. 3471 will force the VA to address disabled veterans' 
mobility needs responsibly and with long-overdue concern for quality, 
performance, and safety.
    Respectfully Submitted,
    National Mobility Equipment Dealers Association

                                 
                     PARALYZED VETERANS OF AMERICA
    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 broad array of 
pending legislation impacting the Department of Veterans Affairs (VA) 
that is before the Subcommittee. No group of veterans understand the 
full scope of care provided by the VA better than PVA's members--
veterans who have incurred a spinal cord injury or disease. Most PVA 
members depend on VA for 100% of their care and are the most vulnerable 
when access to health care, and other challenges, impact quality of 
care. These important bills will help ensure that veterans receive 
timely, quality health care and benefits services.
                  H.R. 1319, the ``Ask Veterans Act''
    PVA generally supports H.R. 1319, the ``Ask Veterans Act.'' This 
bill would direct the Secretary of the Department of Veterans Affairs 
to contract with a non-government entity to conduct annual surveys on 
veteran experiences in obtaining medical care through VA. The focus of 
the survey would be patient wait times, access to health care, and the 
quality of the care provided. The experience of the veterans receiving 
care must be consistently included in order for VA to provide veterans-
focused care.
   H.R. 1603, the ``Military Sexual Assault Victims Empowerment Act''
    PVA supports the intent of H.R. 1603, the ``Military Sexual Assault 
Victims Empowerment Act.'' This bill would allow survivors of military 
sexual trauma (MST) to seek specialized care outside the Veterans 
Health Administration through the Choice program by setting aside wait 
time and distance eligibilities. While the VA continues to build its 
capacity in mental health providers and clinical competency in treating 
military sexual trauma there may be cases where VA cannot provide the 
mental health services clinically indicated. In such instances VA 
already has the authority to contract out such care in the community. 
MST survivors have needs that often include more than mental health 
services, such as primary care services, substance abuse treatment, 
housing, and travel assistance. MST coordinators are available at every 
VA medical center to assist veterans access services. Direct care in 
the community cannot provide the veteran-specific, comprehensive care 
many MST survivors need. VA must do more to ensure that all survivors 
who seek care are able to receive it in a timely and competent manner. 
While we understand the intent of this bill, we are concerned that 
direct care in the community will fractionate the veterans health care 
and prevent the receipt of benefits and support services they would 
otherwise have access to.
      H.R. 1904 ``The Wounded Warrior Workforce Enhancement Act''
    PVA supports the goal of this legislation to the extent that it 
attempts to rejuvenate a declining orthotics and prosthetics workforce. 
We have a concern, however, as to whether the veteran community will 
truly capitalize on the return on this investment if the legislation 
does not require some level of service commitment from student 
beneficiaries.
    Quality orthotic and prosthetic care is of the utmost importance to 
PVA members. No group of veterans understands the importance of 
prosthetics and orthotics more than veterans with spinal cord injury or 
disease. The Independent Budget Veteran Service Organizations maintain 
that the VA must ensure that prosthetics departments are staffed by 
certified professional personnel or contracted staff that can maintain 
and repair the latest technological prosthetic devices. A key component 
to this is continued support for the VA National Prosthetics Technical 
Career Program which aims to address the projected personnel shortages.
    In June of 2015, the National Commission on Orthotic and Prosthetic 
Education (NCOPE) released its analysis projecting orthotics and 
prosthetics workforce supply and patient demand over the next ten 
years. The analysis showed that the overall number of credentialed O&P 
providers will need to increase approximately 60 percent by 2025 to 
meet the growing demand. This is in part due to the fact that attrition 
rates from the profession will surpass the graduation rates of those 
entering the field, ultimately resulting in a decreasing supply of O&P 
providers. Failure to address both the decreasing supply of providers 
and the increasing demand for their services will very likely cause the 
workforce to shift toward non-credentialed providers. Our veterans 
deserve to be cared for by competent and highly trained individuals.
    This legislation is an important step toward ensuring that our 
veterans continue to be treated by credentialed providers. It promotes 
the expansion of a qualified teaching and faculty pool which will 
provide the foundation to accommodate and train a growing number of 
students seeking to become providers. In addition to the expected 
dissemination of best practices and knowledge from the proposed Center 
of Excellence, the legislation also provides eligible institutions 
built-in flexibility to tailor the use the funds for educational areas 
where they can achieve the goal of expanding the O&P workforce most 
effectively. PVA also supports the proposed veterans preference in the 
admissions process. As the Independent Budget VSOs have stated before, 
employing veterans in this arena will ensure a balance between the 
perspective of the clinical professionals and the personal needs of the 
disabled veterans.
    PVA's concern, though, is that the bill misses an opportunity to 
capture a more predictable and tangible return on investment. Requiring 
scholarship recipients to serve a commitment with the VA is a way to 
strengthen the precision with which these funds are allocated without 
reducing the previously mentioned institutional flexibility. The goal 
of this legislation is, after all, to expand the orthotics and 
prosthetics workforce in order to better serve veterans. While the 
proposed approach of expanding the overall pool of qualified service 
providers within the community writ large might have a trickle effect 
of ensuring that the VA continues to offer certified providers, we 
believe this suggested change would have a stronger and more immediate 
impact.
     H.R. 2639 ``Marriage and Family Therapists for Veterans Act''
    PVA supports the ``Marriage and Family Therapists for Veterans 
Act.'' When a veteran suffers a spinal cord injury, this life-changing 
event not only impacts the veteran, but his or her family as well. PVA 
members appreciate the importance of maintaining and strengthening 
relationships with their spouses who so often step into the role of 
being the veteran's primary caregiver. As the Independent Budget VSO's 
have stated consistently, family caregivers supporting severely 
wounded, injured, and ill veterans require considerable strength to 
tend to the needs of family and home, assist their veterans with 
everyday activities, take their veterans to appointments, or simply be 
there in their veterans' times of need. With proper support, many 
severely injured or ill veterans can benefit from residing at home 
instead of being institutionalized. Support from family caregivers 
plays a crucial role in improving veterans' psychosocial well-being, 
but it takes endurance, commitment, love, and patience. As these 
challenging circumstances test the strength of a veteran's marriage, it 
is supremely important that they and their spouse have quality and 
timely access to Marriage and Family Therapy mental-health services. 
Currently, there are numerous qualified MFT practitioners willing and 
able to serve the VA, but the current law's stringent requirements are 
preventing them from becoming eligible to provide services for the VA. 
This legislation will help eliminate those bureaucratic obstacles and 
provide an important catalyst to the VA's current efforts to expand 
access to MFT mental-health professionals.
       H.R. 3234, the ``Failing VA Medical Center Recovery Act''
    PVA does not have a position on H.R. 3234, the ``Failing VA Medical 
Center Recovery Act.'' This bill would create within VA a new ``Office 
of Failing Medical Center Recovery.'' The new office would be headed by 
an Under Secretary for Failing Medical Center Recovery charged with 
assembling VA's top managers and `deploying' them to fix Medical 
Centers that are deemed `failing'. PVA understands frustration inherent 
in the intent of this bill toward VA Medical Centers for not completing 
patient appointments in a timely manner. However, the bill does not 
address how the creation of a new bureaucracy within the existing one 
will improve the access and quality of veterans health care.
           H.R. 3471 ``Veterans Safety Mobility Act of 2015''
    The adaptive automobile equipment grant is an important issue for 
PVA members, as they are the highest users of this particular benefit. 
Those veterans with catastrophic disabilities have a critical need for 
mobility to help maintain a high quality of life and allow them to 
continue to be active members of their community despite their 
disability. PVA supports the effort to ensure veterans with mobility 
impairment receive adaptive equipment and adaptations that meet 
industry standards and specifications. As technology advances, new 
automotive adaptive devices continue to open the door to more drivers 
with disabilities. Each person with a mobility issue is unique and has 
individual requirements and specific features that will allow them to 
feel confident and comfortable while they drive. The law as it is 
currently written requires that before providing an automobile under 
this section, the Secretary determine that the eligible person is able 
to operate the vehicle safely. In response to this provision, Veterans 
currently receive training from the VA's Driver's Rehabilitation 
Program on how to safely operate their new vehicle or equipment before 
embarking out onto public roadways. The bulk of the training, however, 
is rendered meaningless if the adaptive equipment itself fails. 
Requiring that vendors offering such services be certified is simply a 
matter of due diligence in line with the previously mentioned 
requirements. One can easily recognize the gravity of harm that can 
ensue upon not only the veteran, but other motorists, passengers and 
pedestrians when this type of equipment fails due to faulty 
installation or repairs. While competition and innovation provoke the 
establishment of putative best practices and product benchmarks, this 
legislation is an important step in ensuring that as the industry 
evolves, veterans who are mobility-impaired can rest assured that 
companies meet industry-determined certification standards for selling, 
servicing and repairing adaptive vans and equipment. There are also 
secondary benefits to this policy. It prevents duplicative costs 
associated with failing to appropriately vet the vendor the first time 
around. And in addition to limiting potential waste of VA funds, it 
limits the financial exposure of already vulnerable veterans.
            H.R. 3549, the ``VA Billing Accountability Act''
    PVA supports H.R. 3549, the ``VA Billing Accountability Act.'' This 
bill would authorize the Secretary of Veterans Affairs to waive the 
requirement of certain veterans to make copayments for hospital care 
and medical services in the case of an error by the VA. Many VA Medical 
Centers struggle to send billing statements for co-payments to veterans 
in a timely manner. For some veterans this means being sent a bill 
years after the service. H.R. 3549 would mandate that a veteran receive 
their bill within 120 days from receiving care at a VA Medical Center 
and within 18 months if seen at a non-VA facility. Further, the bill 
grants the Secretary the authority to waive the co-payment altogether 
if these billing timelines are not adhered to. If the bill is sent 
after the required time VA must notify the veteran of the option to 
receive a waiver or create a payment plan before the payment can be 
collected. Veterans and their families should not be burdened with 
unknown debts resulting from mistakes in VA's own processes.
                        VA Legislative Proposal
    PVA supports the VA Legislative Proposal ``Department of Veterans 
Affairs Purchased Health Care Streamlining and Modernization Act.'' 
This bill is a necessary tool to allow the VA to meet the wide-ranging 
and unique health care needs of veterans, particularly veterans with 
spinal cord injury and dysfunction. Through various authorities VA 
purchases private sector health care services for veterans, their 
families and survivors. Among veterans and community providers, the 
multiple avenues for procuring care often creates more confusion than 
resources. Under this proposed rule, VA would be able to obtain 
extended care services for veterans from providers who are closer to 
veterans' homes and communities. The proposed legislation would protect 
VA's ability to continue to purchase private medical care when not 
otherwise available through VA, contracts, or sharing agreements. This 
allows VA to purchase care through agreements that are not subject to 
provisions of law governing federal contracts, ensuring providers are 
treated similar to Medicare providers. This would enable VA to meet the 
needs of veterans in an effective manner. This measure preserves the 
protections against waste, fraud and abuse, based on the Federal and VA 
Acquisition Regulations. However, this legislation will also accelerate 
the purchasing process of a veteran's care by avoiding some of the 
complicated contracting rules governed by Federal Acquisition 
Regulations. This authority should prove extremely appealing to solo 
practitioners and small practices.
                    Draft bill, the ``Promise Act''
    PVA supports the ``Promising Responsible Opioid Management and 
Incorporating Scientific Expertise Act'' discussion draft. This bill 
targets problems identified in the VA's use of opioids in treating 
veterans. Additionally, it seeks to improve patient advocacy by the 
Department and expand availability of complementary and integrative 
health Services.
    This bill would require the Department of Defense (DOD) and the VA 
to jointly update the VA/DOD Clinical Practice Guideline for Management 
of Opioid Therapy for Chronic Pain that has not been updated since 
2010. VA would adopt safe opioid prescribing guidelines for chronic, 
non-cancer pain in outpatient settings. It would require each health 
care provider of VA and DOD to use VA's Opioid Therapy Risk Report tool 
before starting opioid therapy, emphasizing discussions with patients 
about alternative pain management therapies. The education and training 
of health care professionals would be improved for identifying patients 
at-risk for addiction and effective tapering programs for patients on 
an opioid regimen.
    Additionally, the VA would be given the authority to increase the 
availability of naloxone, or ``Narcan,'' a highly effective opioid 
antagonist. This drug is on the World Health Organization's list of 
essential medicines in a basic health system. Naloxone reverses the 
effects of an opioid overdose (typically depression of the central 
nervous system). When one is prescribed opioids there is always a 
possibility of an overdose. The ability to respond to a worst case 
scenario of overdose, accidental or otherwise, must be available at 
every medical facility. According to a 2011 VA study based on 2005 
data, veterans ages 30-64 who received care at VA died of accidental 
overdoses at two times the rate of their civilian peers. Naloxone has 
no risk of dependency and can be administered by a layman in the nasal 
spray form. It is a critical tool that can save lives while the 
department works to address the widespread use of opioids.
    VA would also be required to develop mechanisms for real-time 
patient information on existing opioid prescriptions from VHA as well 
as patient prescription information from the state drug monitoring 
program. This mechanism would alert pharmacists of potential ``double-
prescribing.'' A pain management board would be established in each 
Veterans Integrated Service Network (VISN). It would serve as a 
resource of best practices recommendations for veterans, families, and 
providers alike.
    Finally, this bill would require VA to incorporate alternative pain 
management therapies like yoga and acupuncture. PVA fully supports the 
use of complementary and alternative medicine and believes such care 
options will give veterans with catastrophic injuries and disabilities 
additional options for pain management and rehabilitative therapies.
    This concludes PVA's statement for the record. We would be happy to 
answer any questions for the record that the Committee 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, the 
following information is provided regarding federal grants and 
contracts.
                            Fiscal Year 2015
    Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events--Grant to support rehabilitation sports 
activities--$425,000.
                            Fiscal Year 2014
    No federal grants or contracts received.
                            Fiscal Year 2013
    National Council on Disability--Contract for Services--$35,000.
                     Disclosure of Foreign Payments
    Paralyzed Veterans of America is largely supported by donations 
from the general public. However, in some very rare cases we receive 
direct donations from foreign nationals. In addition, we receive 
funding from corporations and foundations which in some cases are U.S. 
subsidiaries of non-U.S. companies.

                                 
                           Heather Simcakoski
    I am Heather Simcakoski, the wife/widow of Jason Simcakoski and 
mother of our now 13 year old daughter Anaya Simcaksoki. Jason I met 
while both serving on active duty in the United States Marine Corps and 
later settled in Stevens Point, Wisconsin, where we currently reside.
    By passing this law, we protect our most courageous and honored 
citizens - our veterans, their families and our communities. I cannot 
think of anything more important or valuable than saving lives - 
veteran's lives. The moment we even consider putting the cost of 
passing a law before the lives of our veterans is the moment we have 
confirmed that America values money more than human lives - all 
veteran's lives. It tells us our country valued money more than it 
valued Jason's life - my family's life.
    In August of 2014, I physically lost my husband to what we now know 
was caused by mixed drug toxicity (a lethal combination of drugs 
prescribed to him while inpatient at the Tomah VA). However, I actually 
began ``losing'' my husband long before that.
    For years I watched Jason being prescribed insanely large amounts 
of medications along with extremely high doses. I never could 
understand why someone who originally checked in for an opioid 
addiction would be prescribed these medications or the amount of 
medication (dosages) he was given; however, it was the side effects of 
the medication that confirmed something was terribly wrong with their 
proposed treatment plan,
    We watched Jason go from an honorable overachieving United States 
Marine to someone we barely knew. Throughout the years we watched Jason 
struggle to complete very basic tasks, due to the side effects of the 
medication. We watched Jason fall asleep at the wheel of the car - 
driving up on the median, one time ending up in a ditch, as well as 
many times watching him nod off at the wheel. There were times when 
Jason would sleep nearly all day - every day for weeks at a time. He 
would miss very important family events such as sports games for his 
daughter, holiday events, and even his grandfather's funeral. He would 
have significant mood swings and at times could barely speak clearly as 
his words were slurred. At times he would spend weeks in the Tomah VA 
seeking help, yet it seemed like many times he would only continue to 
come home with large quantities and doses of medications.
    We watched Jason's health deteriorate right before our eyes, 
eventually impacting his overall health and ability to function in 
society. He was no longer dependable to work full-time, he refused to 
go in most stores and his ability to interact with friends and family 
was taken away, due to the impact of the medications both mentally and 
physically causing significant difficulties in our family life. We 
could no longer rely on Jason's ability to function or perform any 
task.
    It was almost a celebratory moment if we were able to get him to 
leave the house to participate in any family event - even it if it was 
just going to dinner on a Friday night. Anaya and I had to learn to 
plan on him not being awake or able to participate in any plans we made 
- as he was mentally and physically no longer able to commit to even 
the simplest of things.
    I watched him hurt because he did not want to be like that, as well 
as the suffering it was causing his relationship with his daughter and 
I. ultimately causing Jason to die a very slow, and miserable death.
    I feel all of this was avoidable. I would encourage anyone 
prescribing a patient these medications or any other similar cocktail 
of medications to spend a full 24-48 hours with the individual. It will 
not only break your heart but completely justify the reason we need to 
change the way these medications are prescribed. Simply checking on an 
individual or spending a little bit of time with them here and there 
checking on them will never show the full picture of the destruction 
caused to the individuals, families and society by over-prescribing.

                                 
                           Marvin Simcakoski
    The Jason Simcakoski PROMISE Act is an important piece of history. 
Helping our veterans get the best care possible is the ultimate goal. 
The guidelines in the Jason Simcakoski PROMISE Act will help the VA 
give our veterans and service men and women the best health care they 
deserve. Our family doesn't want to see what happened to our son Jason 
happen to another veteran our service person. Our family is proud to 
support this bill.

                                 
                             Susan Moseley
    My name is Susan Moseley and I am a veteran of the U.S. Army. I was 
the typical young adult trying to find my way in the world and had 
wasted a year of my parent's money on college with no goal or direction 
in my life. I decided to enter the military and chose the Army. Most of 
my family thought I would never make it through basic training much 
less thrive in military setting.
    I arrived to my permanent duty station in Ft. Bliss, Texas and my 
joy was short lived when I arrived to the Battalion S-4 and I was told, 
``Oh, I'm sorry but you will in Foxtrot Battery.'' I was perplexed and 
I'm sure it read on my face when she said and I paraphrase Top 1SGT is 
into girls like you and I should find a boyfriend of rank quickly or I 
would be his. Fear did not kick in until I was introduced to him. 
Little did I know, he would own me - mind and body and he tried to take 
my soul.
    My unit deployed to Saudi Arabia twice as a Patriot Missile system 
was in place from the first Gulf War. This was a time that grooming and 
manipulation began when he was with me by myself during Scud Alerts 
training. That was the first time he touched me and kissed me. I still 
trained at a high level and did well in my position; I always wanted to 
be the best. When we returned he made a drastic change placing me as 
his assistant in Head Quarters. I became a pro at dodging or planning 
people to be in the CQ so I was with someone or on the phone until I 
heard other voices to lower my stress levels.
    He informed me that we would inspect the barracks and when we 
arrived in the laundry room he locked the door. That pit in your 
stomach that just makes you uneasy dropped. I had learned if I took 
control and performed oral sex it was not as bad as the other things he 
did to me. He had more than just me he did this to but I was his as he 
always told me.
    My parents had come to see me on their way to a national park, I 
almost told my Mom but fear over took me. I had 18 months left on my 
time in service and I had that feeling that I was owned by him. To say 
no was to say I want to be placed on extra duty or jobs that everyone 
would pass down the line and he could punish me for not giving him what 
he wanted. I had no control and it was always in my mind evasion 
tactics were used against my chain of command not on an enemy.
    As time passed, I found that the one thing I could control was what 
went in my mouth or did not for me it depended on the day. After a PT 
test you are weighed in and they noticed how the number had lowered and 
my physical appearance changed. My best friend knew without saying it 
out loud what was happening to me. He kept me full of as much hope as 
he could with we were close to ETS and then I could go home.
    The last time he raped me with my face on my desk I was beyond 
broken I wanted to die. Later that night I tried.
    My section chief called my phone after I did not show up to PT and 
I thought, ``oh no, it did not work, what will happen to me now?'' I 
told him I tried to die and failed and he took me to the army hospital 
and I was admitted. My doctor was trying to find me a facility for long 
term treatment for bulimia when my commander and my 1SGT aka my 
assailant came to the floor as we waited for the doctor to tell them 
what was happening he whispered in my ear ``we are good right?'' By 
this time, I had little tone in my voice and I nodded.
    I was sent to my unit and I knew that I had little time left to 
report him. After I left the Psych floor, I walked into Captain Duer's 
office and broke down but he began the process. I was returned to the 
hospital and was sedated.
    I was sent to an inpatient facility and began to heal. When I 
returned I was given a lie detector test and spoke to the CID and a 
Master Sergeant and was doing all I could to get home. I was told I was 
to mentally unstable to be given a trial. After a week of fellow 
battery soldiers telling me and calling me horrid names because he had 
been moved when I returned.
    Finally, the last day had come, and I WAS GOING HOME!
    When I walked out of my units doors a major in the S-3 called me a 
whore and many other names but I was free. I was told about the VA but 
never put too much thought into it. When I left the army, I was seen by 
a doctor and even a dentist but no psych staff. I never knew what had 
happened to me had a name.
    I did not assimilate back into my home life and lost my soul. I 
worried I would see him everywhere I looked. I had flashbacks and 
nightmares. I separated myself from my family and friends, and was 
quite reckless in my life. I was bounced from doctor to doctor and 
never got the care I needed for several years.
    I was welcomed into the LGBT community by a friend and I began to 
work for a group that raised money for HIV groups and found a community 
I felt safe. I was part of a group and that was what I needed.
    I have had relationship problems for a long time and had one with a 
great man whom was as broken as I was. In looking back, we coexisted 
and I had turned away from my family not even showing up for my 
birthday one year because I could not deal with my family trying to 
help but not understanding what the reminders of MST did to me on a 
daily basis.
    The day I found out I was pregnant was when my mind allowed me to 
want to live. My child saved my life. I know I would be dead today if I 
had not been blessed with her.
    I became a part of a MST survivors' group 9 years ago after seeing 
a therapist named Karen Tufts. I worked on the skills I lacked and made 
goals. I could only see her every 3 weeks but she gave up her lunch 
every Friday for a group of girls (she also saw men) that helped each 
other through thee trials and tribulations of daily life.
    I was a people finder obsessed on my 1ST SGT or top to see if he 
was still where it said he was many times a day. I would panic if I 
even though that I had seen him. I can't count how many times I have 
left a buggy at the grocery or left a University of Kentucky basketball 
game only 2 times, but hypervigilant was my version of calm. At my 
home, participating in activities, or when being with my daughter are 
the only times I don't have that feeling of slight fear.
    This has been hard on my family but with my therapist teaching my 
Mother that this never goes away it's managed. My daughter is with me 
when I have to leave my home and I don't feel anxiety. She has been 
with me and understands that mommy can't always be ok and she knows I 
love her and will always learn more ways to try.
    Karen passed after the bill was introduced of lung cancer she was a 
huge supporter to us all and hopes that VA uses money for more female 
clinics and female doctors. Last month, a member of our group killed 
herself by shooting herself in the stomach so she could die slowly 
because she thought she deserved it and bled out over an hour. I was 
told at VA I was lucky a female was on duty after a 7 hour wait. I am 
still called ``Mr. Moseley'' and I can ask to be separated from males 
but many don't have the voice I do and wait in the women clinic with 
men.
    I am triggered by VA every time I open the elevators by a sea of 
men in various camouflages. I must walk by the walls with my sunglasses 
on so I don't become overwhelmed by triggers of men that resemble my 
assailant. I sit with my back to a wall and must see a door or know my 
way out.
    I was in the emergency room and waited and told the nurse I wanted 
only female staff and after I was in the room a male nurse came in to 
start an IV, I am sure he only had a healing hand but not even 20 
minutes was my request upheld.
    I have been in the psych ward and signed myself out many times as 
other men walked around or into your room that cannot be locked and 
have no program to go to PTSD and Substance Abuse programs don't fill 
my needs. Only two VA facilities have a MST program in California and 
Bay Pines, Florida. This was never a time I would be able to be so far 
from my child and be able to be active in the program.
    After Karen left the VA, we few that knew she saw patients at her 
home had much luck with bonding and feeling like they could do core 
work on MST and trauma based therapy. How could we when once a month 
you couldn't even see a therapist. The VA gives travel pay and seeing 
Karen at her home you had to pay for gas, this was a hardship for many.
    The heart of VA is to help veterans get quality care but many 
survivors avoid going for care other than Karen's Group. One of the 
major reasons is that many specialists at the VA in my city are males. 
Being touched by a male can be a huge trigger for us.
    One of our group members died from heart disease which she would 
not treat because she would have to take her blouse off. Many postpone 
treatment until it becomes a major problem and don't attend preventive 
care to avoid triggers the VA leaves with them.
    I am asking you all to pass the Military Save Act for the men and 
women who have suffered through the predators within our military. This 
legislation would help to give hope to begin to be healthy, productive, 
members of society. Directing my own care with great female healthcare 
providers in my hometown and not fear going to the doctor is necessary. 
Unfortunately, there are veterans across this country who suffers from 
MST and if they don't get help they need, they could become a burden at 
the state level when we have already fought for our country and help 
these victims have a chance to be productive members of society.
    I have finally received the approval I need for services outside 
the VA to be seen only by female doctors. However, I still have 
problems with prescriptions and follow-up testing in fear of having a 
bill if it has not been approved.
    I love the military and even with the circumstances of my time in 
the Army, I would do it over and over again. I urge you to do 
everything in your power to help ensure the passage or implementation 
of the Military SAVE Act.
    Thank you for your time and for allowing me to speak before you 
today.

    Respectfully,
    Susan K. Moseley
    Diane M. Zumatto
    AMVETS National Legislative Director

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