[House Hearing, 114 Congress] [From the U.S. Government Publishing Office] LEGISLATIVE HEARING ON: DRAFT LEGISLATION TO IMPROVE REPRODUCTIVE TREATMENT PROVIDED TO CERTAIN DISABLED VETERANS; DRAFT LEGISLATION TO DIRECT THE DEPARTMENT OF VETERANS AFFAIRS (VA) TO SUBMIT AN ANNUAL REPORT ON THE VETERANS HEALTH ADMINISTRATION; H.R. 271; H.R. 627; H.R. 1369; H.R. 1575; AND, H.R. 1769 ======================================================================= HEARING BEFORE THE SUBCOMMITTEE ON HEALTH OF THE COMMITTEE ON VETERANS' AFFAIRS U.S. HOUSE OF REPRESENTATIVES ONE HUNDRED FOURTEENTH CONGRESS FIRST SESSION THURSDAY, APRIL 23, 2015 Serial No. 114-17 __________ Printed for the use of the Committee on Veterans' Affairs [GRAPHIC NOT AVAILABLE IN TIFF FORMAT] Available via the World Wide Web: http://www.fdsys.gov ______________ U.S. GOVERNMENT PUBLISHING OFFICE 98-634 WASHINGTON : 2016 _______________________________________________________________________________________ For sale by the Superintendent of Documents, U.S. Government Publishing Office, http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center, U.S. Government Publishing Office. Phone 202-512-1800, or 866-512-1800 (toll-free). E-mail, [email protected] 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 ---------- Thursday, April 23, 2015 Page Legislative Hearing on: Draft Legislation to Improve Reproductive Treatment Provided to Certain Disabled Veterans; Draft Legislation to Direct the Department of Veterans Affairs (VA) to Submit an Annual Report on the Veterans Health Administration; H.R. 271; H.R. 627; H.R. 1369; H.R. 1575; and, H.R. 1769...................................................... 1 OPENING STATEMENT Dan Benishek, Chairman........................................... 1 Julia Brownley, Ranking Member................................... 3 Hon. Jeff Miller Prepared Statement........................................... 35 WITNESSES Hon. Gus Bilirakis, U.S. House of Representatives 12th District, Florida........................................................ 4 Prepared Statement........................................... 36 Hon. Janice Hahn, U.S. House of Representative, 44th District, California..................................................... 6 Prepared Statement........................................... 38 Hon. Jackie Walorski, U.S. House of Representative, 2nd District, Indiana........................................................ 7 Prepared Statement........................................... 39 Blake Ortner, Deputy Government Relations Director, Paralyzed Veteran of America............................................. 14 Prepared Statement........................................... 41 Louis J. Celli Jr. Director, National Veterans Affairs and Rehabilitation Division, The American Legion................... 15 Prepared Statement........................................... 50 John Rowan, National President, VVA.............................. 17 Prepared Statement........................................... 60 Adrian Atizado, Assistant National Legislative Director, DAV..... 19 Prepared Statement........................................... 67 Rajiv Jain M.D., Assistant Deputy Under Secretary for Health for Patient Care Services, VHA, U.S. Department of Veterans Affairs 28 Prepared Statement........................................... 73 Accompanied by: Janet Murphy, Acting Deputy Under Secretary for Health for Operations and Management, VHA, U.S. Department of Veterans Affairs And Jennifer Gray, Attorney, Office of the General Counsel, U.S. Department of Veterans Affairs FOR THE RECORD Hon. Corrine Brown, FC Ranking Member Prepared Statement........................................... 92 American Health Care Association................................. 93 American Society for Reproductive Medicine....................... 94 Concerned Veterans for America................................... 96 RESOLVE: National Infertility Association........................ 97 Veterans of Foreign Wars of the United States.................... 98 Wounded Warrior Project.......................................... 104 LEGISLATIVE HEARING ON: DRAFT LEGISLATION TO IMPROVE REPRODUCTIVE TREATMENT PROVIDED TO CERTAIN DISABLED VETERANS; DRAFT LEGISLATION TO DIRECT THE DEPARTMENT OF VETERANS AFFAIRS (VA) TO SUBMIT AN ANNUAL REPORT ON THE VETERANS HEALTH ADMINISTRATION; H.R. 271; H.R. 627; H.R. 1369; H.R. 1575; AND, H.R. 1769 ---------- Thursday, April 23, 2015 U.S. House of Representatives, Committee on Veterans' Affairs, Subcommittee on Health, Washington, D.C. The subcommittee met, pursuant to notice, at 10:00 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, Takano, Ruiz, Kuster, and O'Rourke. Also present: Representatives Walorski and Titus. OPENING STATEMENT OF CHAIRMAN DAN BENISHEK Mr. Benishek. The subcommittee will come to order. Before we begin, I would like to ask unanimous consent for my friends, colleagues, and members of the full committee, Congresswoman Jackie Walorski of Indiana and Congresswoman Dina Titus of Nevada, to sit on the dais and participate in today's proceedings. Without objection, so ordered. Thank you all for joining us today as we discuss seven bills that will impact the healthcare provided to our Nation's veterans by the Department of Veterans Affairs' healthcare system. The bills on our agenda today are draft legislation to improve reproductive treatment provided to certain disabled veterans; draft legislation to direct VA to submit to an annual report on the Veterans Health Administration; H.R. 271, the Creating Options for Veterans Expedited Recovery or COVER Act; H.R. 627 to expand the definition of homeless veteran for purposes of benefits under the laws administered by VA; H.R. 1369, the Veterans Access to Extended Care Act of 2015; H.R. 1575 to make permanent the pilot program on counseling in retreat settings for women veterans newly separated from service; and, H.R. 1769, the Toxic Exposure Research Act of 2015. I am proud to sponsor two of the bills on our agenda, the draft bill to direct VA to submit an annual report on the Veterans Health Administration and H.R. 1769, the Toxic Exposure Research Act of 2015. The draft bill would require the VA to submit an annual report to Congress regarding the provision of hospital care, medical services, and nursing home care by the VA healthcare system. The annual report would contain information regarding access to care, quality of care, workload, patient demographics and utilization, physician compensation and productivity, purchased care, and pharmaceutical prices. This measure is the result of the subcommittee's oversight hearing in January where the Congressional Budget Office testified that VA provided limited data to Congress and the public about its costs and operational performance and that if it was provided on a regular and systemic basis could help inform policymakers about the efficiency and cost effectiveness of VA's services. Similar sentiments were echoed by witnesses from The American Legion and the Independent Budget. VA must become more transparent and forthcoming about the care that it provides to our Nation's veterans so that Congress, stakeholders, taxpayers, and veterans can make informed determinations about the services that the department is offering and how they can be improved. The intent of our hearing in January was to determine the cost and value of VA care. But during our discussion, it became painfully obvious that the department leaders were unable to provide basic information about, say, how much the VA spends on a single patient encounter in a VA primary care clinic. As a doctor myself, it is unfathomable to me that the VA either does not have or is unwilling to share granular data about the cost of the services it provides. This bill and the free flow of information that it will require of the VA on a yearly basis will fix that once and for all, resulting in a better, stronger VA healthcare system that our veterans deserve. My other bill, the Toxic Exposure Research Act of 2015, would establish a national center for research into the health conditions experienced by the descendants of veterans exposed to toxic substances. It would also create an advisory board who would be responsible for advising the national center, determining health conditions that result from toxic exposure, and studying and evaluating the cases of exposure. In addition, it would authorize the Department of Defense to declassify documents related to a known incident in which at least a hundred servicemembers were exposed to a toxic substance that resulted in at least one case of related disability. Finally, it would create a national outreach campaign jointly led by VA, DoD, and the Department of Health and Human Services on the potential long-term health effects of exposure to toxic substances by servicemembers, veterans, and their descendants. As I said before, injuries or illnesses that result from exposure to toxic chemicals can have life-long and generational effects, the impacts of which we do not yet fully understand, but are nevertheless painfully prevalent to the veterans and family members who experience them. For them and for future generations, we must do more to recognize, research, and treat toxic exposure issues and thoroughly evaluate the long-term effects exposure can have not just on those who serve but on their children and grandchildren as well. Mr. Benishek. Enough about my bills. In addition to those bills, I am proud to be an original cosponsor for H.R. 627 which would expand the definition of a homeless veteran to include veterans and their families who are fleeing from domestic or dating violence, sexual assault, stalking or other life-threatening conditions in their current home and lack the resources to obtain other permanent housing. Veterans who are living in a violent home deserve our support as they recover from the devastating effects of intimate partner violence and begin to reclaim their lives. I am grateful to my friend and colleague, Congresswoman Janice Hahn from California, for championing their cause with this legislation and I urge all my colleagues to join us in cosponsoring H.R. 627. The draft bill 1769, H.R. 1769 and H.R. 627 are supported by a number of our veteran service organizations and I thank them all for their support and comments and recommendations. I look forward to working closely with them, the department, and other stakeholders beginning with today's hearing to strengthen these and all the bills on our agenda where needed and advance them through the subcommittee without delay. I thank all of our witnesses and the audience members for being here today and I will now yield to the Ranking Member Brownley for any opening statements she may have. OPENING STATEMENT OF RANKING MEMBER JULIA BROWNLEY Ms. Brownley. Thank you, Mr. Chairman, for calling this hearing this morning. I don't have any bills to speak to today personally, but I do look forward to hearing from members and witnesses today regarding the five bills and two pieces of draft legislation that are on the agenda this morning including yours, Mr. Chairman. As we deliberate on the multitude of issues and concerns that are before us each and every Congress, it is critical that we are as informed as we possibly can be on all of the issues. We rely on the information we receive during these legislative hearings to improve upon the services and benefits that the Department of Veterans Affairs provides to our veterans and their families. It is also important that we are made aware of any unintended consequences that may arise from these different bills. Today we will hear, as the chair has already stated, we will hear from the panels on a variety of bills concerning the subcommittee's jurisdiction. We have two bills addressing the treatment of mental health, one on domestic violence and on homeless veterans, one on research and to toxic exposures, and a bill that addresses the provision of extended care services to veterans. In addition to the five bills, we will hear about two pieces of draft legislation. The first would authorize VA to provide in vitro fertilization services to eligible veterans and spouses. The second requires the VA to submit a report to Congress on hospital care, medical services, and nursing homes. I am on the record as a supporter of reproductive rights for all our veterans. Too many of our young men and women have been injured so severely that having children is now not an option. IVF might not be the solution for these families and we need to be sensitive to their needs also. Hopefully we can work together to find a way forward to ensure that all veterans who want a family including same sex veterans will have all the support and assistance they may need to do that. I appreciate all the witnesses being here today. I appreciate the chair calling this meeting and I look forward to everyone's testimony. I yield back. Mr. Benishek. Thank you. Well, we are this morning to be joined by several other of our members who are sponsoring legislation this morning. Mr. Miller, the chairman of the committee, will be in, Congressman Gus Bilirakis from the 12th District of Florida, Congresswoman Janice Hahn from the 44th District of California, Congresswoman Jackie Walorski from the 2nd District of Indiana. I think I will start with Mr. Bilirakis. Would you please go ahead with your legislation. STATEMENT OF HON. GUS BILIRAKIS, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF FLORIDA Mr. Bilirakis. Mr. Chairman, I appreciate it very much and I want to thank the ranking member as well. Thank you for holding this very important hearing and giving me the opportunity to discuss my bill, H.R. 271, the Creating Options for Veterans Expedited Recovery Act, the COVER Act. Statistics show that one in five veterans who serve in Iraq and Afghanistan have been diagnosed with the posttraumatic stress. Now, we must responsibly ask ourselves are we doing enough when it comes to addressing mental health in our veterans' population. I don't think so. Recent data has shown that every day in this country, approximately 18 to 22 veterans take their own lives. This statistic answers the question I posed earlier. It is obviously more--Mr. Chairman, more needs to be done in my opinion. That is why I introduced the COVER Act in the 114th Congress. The COVER Act will establish a commission to examine the Department of Veterans Affairs' current evidence-based therapy treatment model for treating mental illness among veterans. It will also analyze the potential benefits of incorporating complementary, alternative treatments available within our communities. The duties of the commission designated under the COVER Act include conducting a patient-centered survey within each Veteran Integrated Service Network. The survey will examine several different factors related to the preferences and experiences of veterans when they have dealt with the Department of Veterans Affairs. Instead of presuming to know what is best for veterans, we should just ask the veteran. It is as simple as that. Then we can work with veterans on finding the right solution that best fits their own unique needs. Not one size fits all. The scope of the survey will include the experience of a veteran when seeking medical assistance within the Department of Veterans Affairs, the experience of veterans with the non-VA medical facilities and health professionals for treating mental health illness, the preferences of a veteran on available treatments for mental health and which they believe to be most effective, the prevalence of prescribing prescription drugs within the VA as remedies for treating mental illnesses, and outreach efforts by the VA secretary on available benefits and treatments. Additionally, the commission will be tasked with examining the available resources on complementary, alterative treatments for mental health. Then the commission will identify what benefits could be attained with the inclusion of such treatments for our veterans seeking care at the VA. Some of the alternative therapies include among others, of course, accelerated resolution therapy, music therapy, yoga, acupuncture therapy, meditation, outdoor sports therapy, and training and care for service dogs. Finally, the commission will study the potential increase in health claims for mental health issues for veterans returning from the most recent theaters of war. We must ensure that the VA is prepared with the necessary resources and infrastructure to handle the increase in those utilizing their earned benefits to address the mental and physical elements incurred from military service. Once the commission has successfully completed their duties, a final report will be issued. Its recommendations and findings will be made available based on the analysis of the patient-centered survey, alternative treatments, and evidence- based therapies. The commission will also be responsible for creating a plan to implement those findings in a feasible, timely, and cost- effective manner. Last Congress, I was very pleased that the subcommittee considered the COVER Act in a legislative hearing. At this hearing, all the VSOs and organizations testified and have supported the COVER Act. I want to thank all again, all of you really for your support through your testimonies given today. In this year's draft, I was also pleased to incorporate the recommendations offered by the Vietnam Veterans of America. They suggested that appointees on the commission must not have proprietary, financial, or any other conflicting interest in any of the treatment considered, and I think that is very reasonable and I appreciate their recommendations. In closing, we have the support from veterans and the organizations that work closely with them. And it is clear that there is a need to do more and that is what we need to do. We need to do more for our true American heroes. We have that responsibility. We have that duty. The question now is this: What do we intend to do about it? We definitely have to act on this bill and I really appreciate, Mr. Chairman, you agendaing this bill today and I would love to see it marked up very soon. With that, I urge my colleagues again to support this bill and cosponsor this bill. Let's get this done for our heroes. Thank you. [The prepared statement of Gus Bilirakis appears in the Appendix] Mr. Benishek. Thanks, Mr. Bilirakis. Now we will hear from our colleague, Representative Hahn. You are now recognized for five minutes. STATEMENT OF HON. JANICE HAHN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA Ms. Hahn. Thank you. And thank you, Chairman Benishek, for holding this hearing. It is an honor for me to be with Ranking Member Brownley and really all the distinguished members of this committee. Thank you. Homeless veterans are such a pressing problem for this Nation. More than 62,000 veterans are homeless on any given night and over 120,000 veterans will experience homelessness over the course of the year. And while only seven percent of Americans qualify as veterans, they make up nearly 13 percent of the homelessness population in this country. Sadly, my hometown, Los Angeles County, has the most homeless veterans in the Nation. And today I wanted to address one segment of homeless veterans, those who are homeless because of domestic violence. Currently the Department of Veterans Affairs' definition of homeless veterans does not include veterans who are homeless because of domestic violence. And across the country, we know too many victims of domestic violence feel there is nowhere for them to turn. And lacking resources, help, and a safe place to go, many of these victims feel like their only choice is to remain with their abusers. And tragically too often women veterans are among those who find themselves in this horrible situation. According to the VA, 39 percent of our women veterans report experiencing domestic violence. That is well above the national average. And, however, because of antiquated laws on the books, they have not been eligible to access resources designated for homeless veterans. I approached Chairman Benishek with my legislation, H.R. 627, which updates the definition of homeless veteran to include victims fleeing domestic violence. And not only was he extremely supportive, but he joined me in introducing it. And for that, I really thank you, Chairman. Our legislation will update the definition of homeless veteran to include veterans fleeing domestic violence and will correct what I believe is an oversight and ensure that veterans fleeing domestic violence can receive benefits from the VA. This is a minor change, but it has great importance to ensure that our veterans do not feel trapped in dangerous situations. H.R. 627 is endorsed by countless veterans' organizations such as the Veterans of Foreign Wars, AMVETS, the National Coalition for Homeless Veterans, the Servicewomen's Action Network, Blinded Veterans Association, and we have many more on that list. Providing benefits to veterans driven to homelessness by domestic violence is, I think, something we should all support and we have supported that in the past. In fact, I have worked with House Appropriations Veterans Affairs' subcommittee to include report language the past two years to make these benefits available. But that process only helps until the next year and has to be repeated every year to provide this temporary help. I think it is time to stop making temporary fixes. This legislation permanently fixes this loophole for veterans. And while it is unknown how many veterans will be helped by this bill, I just believe if it helps one veteran get the support they need and to leave a dangerous situation, then our work here will be worth every minute. Let's step up to provide these heroes who have protected us with the resources they need including a place where they can be safe and protected. In conclusion, I want to thank you for working with me to solve an urgent problem and I yield back the balance of my time. [The prepared statement of Janice Hahn appears in the Appendix] Mr. Benishek. Thank you very much. Representative Walorski, you are recognized for five minutes. STATEMENT OF HON. JACKIE WALORSKI, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF INDIANA Ms. Walorski. Good morning. Thank you. Chairman Benishek, Ranking Member Brownley, members of the committee, thank you for the opportunity to discuss H.R. 1369, the Veterans Access to Extended Care Act. This important bill would expand veterans' access to certain healthcare services and allow former servicemembers to receive those services from local providers. Currently VA offers a variety of long-term services and support to veterans including nursing home care, adult day care, respite care. Non-VA providers at community organizations must contract with the VA under the Service Contract Act to provide these services. The Service Contract Act's burdensome reporting requirements, the Department of Labor, along with the compliance costs discourage local providers from entering into contracts with the VA. This situation has left many veterans and their families without the ability to find providers close to home. In February of 2013, the VA issued a proposed rule which would have allowed providers to enter into these agreements with the VA under the same guidelines that providers for Medicare enter into agreements with CMS. Non-VA providers would no longer be considered federal contractors, relieving them from the burdensome reporting requirements. In conjunction with a Senate letter that was sent June of 2014, Congresswoman Tulsi Gabbard and I along with 107 of our colleagues in the House sent a letter in August of 2014 to Secretary McDonald encouraging the release of the final VA provider agreement rule. Unfortunately, despite the willingness of the department, the VA never had the legislative authority to begin to enact the rule. In response, Representative Gabbard and I introduced H.R. 1369, Veterans Access to Extended Care Act. This commonsense bill gives the VA the legislative authority, the fix it needs to follow through the original proposed rule. Specifically this bill exempts extended care service providers from being treated as federal contractors for the acquisition of goods or services. The bill also relieves providers from certain reporting requirements to the Department of Labor. Lastly, it includes quality assurance provisions to ensure the safety and a high standard of care our veterans deserve. Incentivizing more local providers to work with the VA will increase access to care that is closer to home, allowing family and friends to provide additional support structures to our veterans. The family structure during these times is vital to ensuring a veteran's quality of life. These individuals have sacrificed so much in the name of liberty, they should not have to worry about being able to find care close to home because their hometown providers don't have the necessary resources to qualify as a government contractor. Eliminating this designation will encourage more extended service providers to enter into agreements which will provide much more options, many more options to our veterans. Providing veterans with the care they need and deserve continues to be a top priority of mine and most of us on this committee. I am grateful to work with Representative Gabbard, Senator Hoeven, Senator Manchin, and the committee in addressing this critical issue for our veterans. And I thank you again, Mr. Chairman, Ranking Member Brownley, for the opportunity to be here today. I yield back my time. [The prepared statement of Jackie Walorski appears in the Appendix] Mr. Benishek. Thank you very much for your testimony. The chairman of the committee is expected to be here to testify on behalf of his legislation as well, but I am not going to ask any questions of the members here in the reference of time because I know I am going to have adequate time to talk to them as time goes by here in the House. Ms. Brownley, do you have any questions? Any questions for the panel members from any of the members? And thank you. The first panel is excused. And then we will proceed with the second panel. Mr. Takano. Dr. Benishek, just a real quick question of Mr. Bilirakis and Mr. Ruiz, Dr. Ruiz. Your commission that you are trying to set up is a very interesting one to me and I commend you for the bill. And I gather the big impetus is to try and find ways to not necessarily--I mean, former Secretary Shinseki I remember talking about the use of medications and how we are using too much of them with our veterans. I want to share with you that I was at an event probably last session with a California Commission for the Humanities and Professor Emeritus David Glidden of University of California Riverside is a professor of philosophy. And one of the participants was a female veteran who had taken part in his philosophy class which explored the big moral questions about life, you know. And it strikes me that a lot of veterans face not just the mental issue, mental health issues but the spiritual issues. We send young people into battle, many of them not really thinking about the moral consequences of war, and they come back with all that weighing on their minds. And rather than medications, many of them just really could benefit by going to a well- considered course put together by a very talented person in humanities. And I wonder if you might consider looking at including a perspective, say, from the National Endowment for the Arts or the National Endowment for the Humanities ways to leverage those budgets and encouraging our humanities and arts community to think about how they can engage with our veterans. And this is also providing a pathway that is different than medication. And one of the things that this veteran mentioned was that sometimes there is a stigma attached to seeking mental health and this is another pathway that a veteran can take that, you know, doesn't necessarily mean that they have to feel like they are stigmatized by that. And, of course, we want to remove the stigma period. Mr. Bilirakis. Absolutely. Mr. Takano. But it is a thought I wanted to offer. Mr. Bilirakis. Oh, I would be willing to discuss that with you. Mr. Takano. Yes. Thank you. Mr. Bilirakis. Again, you know, the examples that I used are just examples and we are not limiting it to that. And I would like to hear maybe from Dr. Ruiz, too, because he is a cosponsor of my bill, the prime cosponsor. But I would take that into consideration. I would be happy to discuss that with you. Mr. Ruiz. Thank you. I think that the commission will be looking at events like that and that is why want to form the commission---- Mr. Bilirakis. Absolutely. Mr. Ruiz [continuing]. Because then they can look at what the state-of-the-art mental health counseling and therapy exist out there and start to incorporate those for our veterans. And I think it will be helpful. Mr. Takano. Yes. With all respect to the medical background, and I don't want to diminish any--we don't want to diminish the role of medication or therapy, but thinking of also the nonmedical ways of also treating folks even with the existing budgets or even a tiny bit of leverage from Federal Government to try these other--so I was hoping that you would look at representing on the commission folks within the humanities and the arts as well. Mr. Coffman. Mr. Chairman. Mr. Benishek. Yes. Mr. Coffman. Mr. Bilirakis, one thing I would like the--my concern as a combat veteran is that the largest cost driver I think probably in VA healthcare is posttraumatic stress disorder in terms of disability payments. In talking to professionals in psychiatry and psychology and the different therapists seem to think that with the proper treatment that the stress disorders from being in a combat zone could be brought down to a level where it is no--that those stressors are no longer debilitating, yet one of the considerations I think your commission should look at is should there be a requirement or what can we do to encourage those who are on disability for posttraumatic stress disorder to receive treatment because I think it is a disservice to those veterans and it is, quite frankly, as a taxpayer, it is a disservice to the taxpayers of this country. We have got to figure out how to help people. We have got two different definitions. The Department of Defense sees posttraumatic stress as a wound and the Veterans Administration sees it as a disability. I think we have got to link those two up. As a combat veteran, I see it as a wound and wounds are treatable. Some may not be. But the system makes no effort or little effort and so I think that it ought to be a factor to say what can we do to restructure the system going forward, or does it need to be restructured going forward, I don't know, that creates a mechanism whereby people are encouraged or required to participate in treatment. Mr. Bilirakis. That is definitely worthy of a discussion. And, again, the idea behind this bill is we need to give the veteran the choice because not one size fits all with regard to the therapy. So I will take all these matters under consideration, but we got to pass the bill first. Thank you. Mr. Benishek. Mr. Ruiz, Do you have a comment? Mr. Ruiz. Yeah. I would like to make a statement regarding this bill and applaud Mr. Bilirakis for the work that you are doing for our veterans in improving their mental health services. So I would like to thank Mr. Chairman and Ms. Ranking Member and thank also the panelists that we are going to hear from today, the veteran service organizations for joining us. The VA's mission is to care for those that, quote, ``shall have borne the battle.'' And the most essential part of that task is to heal our wounded warriors, our wounded veterans. However, more and more our soldiers are returning with psychological wounds, illnesses that do not present as obviously as physical maladies but are just as damaging. That is why I am an original cosponsor of H.R. 271, the COVER Act, which I am glad to see included in today's hearing. This bill will ensure that no stone is left unturned in exploring ways to provide timely, effective, veteran-centered mental healthcare for those who have served in our Armed Forces. I am proud to have worked with outstanding veteran service organizations and the veterans in my district to ensure that the VA listens to the foremost experts on what veterans need, the veterans themselves. In that same spirit, this bill will help give veterans a voice in their treatment by requiring a comprehensive survey of veterans' experiences and preferences. To achieve real progress towards improving mental healthcare in the VA, we must incorporate veterans' recommendations. As a physician who has treated the whole range of patients that come into the emergency department, I know that one-size- fits-all approach doesn't work for veterans with mental health needs. This bill will help give our veterans mental healthcare options that work for them and will lay the groundwork for future solutions that are the product of listening to our veteran community. I look forward to working with Vice Chairman Bilirakis and other members of this committee to create an inclusive process where veterans' voices and views are heard and I urge my colleagues to support this bill. Thank you and I yield back. Mr. Benishek. All right. Thanks. Does anyone else have any questions or comments? Mr. Roe. Just very briefly I guess to just second what two of my colleagues have said. One, Mr. Coffman, I think you are absolutely right on. We should stop calling this posttraumatic stress disorder and posttraumatic stress and look at how we heal these veterans and get them back into the workforce and have productive lives, not to say that I have this condition. If you have been in war, I have said this many times here, and somebody shoots at you, that is going to make you anxious. There would be something wrong with you if you didn't. And you are going to--I mean, I would think there would be something really wrong if you didn't get scared if somebody shot at you. And I think the goal ought to be with the commission is how do we, and I think this is a, Mr. Bilirakis, a tremendous idea that you all have come up with, to finally get in one arena a group of people, experts to put together some ideas about how we do what you are saying, about how we get these folks who are on disability, get them back in the workforce and get them back at productive lives. I think that is something we absolutely have to do. And, Mr. Takano, I could not agree more with you in including some alternative things like the arts, music. I can tell you it is very beneficial for people and can be very healing to people. And having used that myself, I know it works. And so I think it is a phenomenal idea. I am very supportive and I think we need to expand, Mr. Bilirakis, what you are doing and with all these ideas that have come in. I think this it is a wonderful idea. And with that, I yield back. Mr. Benishek. Great. Okay. Ms. Kuster, Do you have a question as well? Ms. Kuster. Just a quick comment. I wanted to thank you, the chair. I have been an adoption attorney for 25 years and worked with a lot of people in the area of reproductive health and just wanted to say I support the effort in your bill. And I think it is an important point. And then I think Representative Walorski is gone, but I just wanted to thank her for her efforts and also Representative Hahn, the bill about women and her homelessness issue, about domestic violence and women trying to seek shelter and safety. So I just want to commend the chair and the panel for some great legislation and look forward to working with you all. Mr. Benishek. Well, thanks. Ms. Kuster. Thank you. Mr. Benishek. Appreciate that. Mr. Miller has arrived, so he wants to present his legislation as well. Mr. Miller, you are recognized. Mr. Miller. Thank you very much, Mr. Chairman, to the ranking member. And I apologize for being late this morning, but it is always good to be in the Subcommittee on Health. I appreciate all the members' attention and your diligence at the full committee level and certainly with what is going on here today. I want to talk with you about issues as it relates to reproductive treatment that is provided to certain disabled veterans. Now, currently the conflicts in Iraq and Afghanistan over the last decade have resulted in significant increases in reproductive organ and spinal cord injuries among our servicemembers. These wounds can have serious and life-long repercussions on the daily lives of our veterans and their families, not the least of which can be the inability to conceive a child. While the Department of Veterans Affairs does provide a number of fertility services to veterans, VA is currently prohibited via regulation from providing in vitro fertilization, one of the most well-known and arguably most effective assisted reproductive technologies. The VA is prohibited also by statute from providing any such treatment to a veteran's spouse. In contrast, the Department of Defense has been providing IVF to severely-wounded servicemembers since 2010. What this disparity results in is having severely-disabled veterans having to decide whether or not to pursue a family through IVF before they separate from the service while still actively recovering from their wounds and during what can be a highly stressful transition period or pay for the procedure out of pocket once they move to veteran status. Because IVF can be costly, for some veterans waiting until they are in VA care can mean having to choose between a financial free-fall or foregoing their dreams of having a child altogether. This is an agonizing and unacceptable choice that this draft bill would help prevent veterans with these disabilities from ever having to make. The draft bill would authorize VA to provide assisted reproductive technology in addition to any fertility treatment already authorized to enroll veterans whose service-connected disability includes an injury to the reproductive organs or spinal cord that directly results in the inability to procreate without the use of assisted reproductive technology. Assisted reproductive technology is defined in the bill to include IVF as well as other technologies determined by VA as appropriate to be used to assist reproduction. In furnishing IVF or similar procedures to an eligible veteran, VA would also be authorized to provide services to that veteran's spouse. Like DoD, VA would be limited to providing eligible veterans three in vitro fertilization cycles resulting in a total of not more than six implantation events. The draft bill would further stipulate that VA is authorized to provide for storage of genetic material for three years after which the veteran and his or her spouse is responsible for the cost of such storage, that VA cannot process or make any determinations regarding the disposition of genetic material, and that VA is required to carry out activities relating to the custody or disposition of genetic material in accordance with the relevant state law. Finally, the draft bill would prohibit VA from providing any benefits relating to surrogacy or third-party genetic material donation. So in short, this legislation mirrors the IVF benefit that is provided to active-duty servicemembers in DoD, creating parity between the two departments while opening the door for parenthood for disabled veterans who may otherwise not have the resources to pursue such a path. And I am proud to say that this proposal is supported many of our VSOs, by resolve the National Infertility Association and by the American Society for Reproductive Medicine. And I want to thank all of them for their support, for this draft, and for their thoughtful comments and recommendations for how it could be improved. I look forward to working hand in hand with each of you subcommittee members to address those suggestions and otherwise strengthen the language in the draft bill before it is introduced and moved forward. This draft is derived partly from the recent subcommittee roundtable wherein fertility among disabled veterans was discussed in depth. And I am grateful to you, Dan, for holding the roundtable as well as this hearing today. And I urge my colleagues support this draft bill and I yield back. Thank you for your time. Mr. Benishek. Thank you very much, Mr. Chairman. Any other comments for the chairman? Mr. Roe. Mr. Roe. Just very briefly some history. In vitro fertilization came along in my career as an obstetrician/ gynecologist. Dr. Patrick Steptoe in England did a hundred laparoscopic in vitro implantations before he had one success. Egg gatherings, he did a hundred. It is now standard medical therapy. And I wholeheartedly support this legislation. It is past due. We should do this for our very, very seriously-wounded veterans who want to have families. I can't think of anything more honorable to do than this. I yield back. Mr. Benishek. Thank you. I think with that, we will ask the second panel to take the stage here. Joining us on the second panel is Blake Ortner, the Deputy Government Relations Director for the Paralyzed Veterans of America; Louis Celli, Jr., the Director of the National Veterans Affairs and Rehabilitation Division for The American Legion; John Rowan, the National President of the Vietnam Veterans of America; and Adrian Atizado, the Assistant National Legislative Director for the Disabled American Veterans. Thank you all for being here and for your hard work and advocacy on behalf of our veterans. I appreciate you being here to present your views of your members. And I think we will begin with Mr. Ortner. Mr. Ortner, you are recognized for five minutes. STATEMENTS OF BLAKE ORTNER, DEPUTY GOVERNMENT RELATIONS DIRECTOR, PARALYZED VETERAN OF AMERICA; LOUIS J. CELLI JR., DIRECTOR, NATIONAL VETERANS AFFAIRS AND REHABILITATION DIVISION, THE AMERICAN LEGION; JOHN ROWAN, NATIONAL PRESIDENT, VIETNAM VETERANS OF AMERICA; ADRIAN ATIZADO, ASSISTANT NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS STATEMENT OF BLAKE ORTNER Mr. Ortner. Chairman Benishek, Ranking Member Brownley, and members of the subcommittee, Paralyzed Veterans of America would like to thank you for the opportunity to present our views on legislation before the subcommittee. PVA supports the draft legislation to provide assisted reproductive technology or ART such as in vitro fertilization to certain disabled veterans. For many disabled veterans, one of the most devastating results of spinal cord injury or dysfunction is the loss of or compromised ability to have a child. While the Department of Defense does provide ART to servicemembers and retired servicemembers, VA does not. When a veteran has a loss of reproductive ability due to a service- connected injury, they must bear the total cost for any medical services should they attempt to have children. Procreative services provided through VA would ensure that disabled veterans are able to have a full quality of life that would otherwise be denied them due to their service. The bill also offers veterans the option of cryopreservation of genetic material for three years to protect their viability to have a family in the event medical treatments or medications affect the quality of their genetic materials. While PVA strongly supports this draft legislation, it is limited in addressing the needs of women veterans. Some women veterans with a catastrophic injury may be able to conceive through IVF but be unable to carry a pregnancy to term due to their disability. In such an instance, implantation of a surrogate may be their only option. The current draft of the bill is not inclusive of all women veterans with a catastrophic reproductive injury and we believe clarification is necessary where the draft prohibits any benefits relating to surrogacy or third-party genetic material donation. PVA generally supports draft legislation to require a yearly evaluation of overall effectiveness of the Veterans Health Administration in improving access to care and the quality of it. In order to improve this bill, PVA strongly encourages adding language to reinstate the reporting requirement that expired in 2008 on the capacity of VHA to provide specialized services to disabled veterans. The VA has not maintained its capacity to provide for the unique healthcare needs of severely-disabled veterans, veterans with spinal cord injury or disease, blindness, amputations, and mental illness. Currently within the SCI system of care, VA not meeting capacity requirements for staffing or number of inpatient beds is consistently reported throughout the system. VA has eliminated staffing positions or operated with vacant healthcare positions for prolonged periods of time. When this occurs, veterans' access to VA decreases, remaining staff become overwhelmed with increased responsibilities, and the overall quality of healthcare is compromised. As a component of its workplace planning, VA tracks this information and is able to compile and use the collected data for annual reports, so this should not be an undue burden. PVA understands the intent of and generally supports the Toxic Exposure Research Act of 2015. However, the bill does not discuss the processes should the advisory board conflict with the findings of IOM. We encourage the subcommittee and VA to work together to ensure legislation fulfills the IOM Committee recommendations. PVA supports H.R. 271, the Creating Options for Veterans Expedited Recovery Act. PVA believes that effective medical care, traditional or alternative, ought to be readily available to a veteran in need and that all VA mental healthcare should meet the specific individual need of the veteran on a consistent basis. Complementary and alternative medicines give veterans with mental illness as well as catastrophic disabilities additional treatment options and the commission could offer an opportunity to identify additional best practices across medical disciplines. PVA supports H.R. 627 to expand the VA's definition of homeless to match the definition used by the Department of Housing and Urban Development since 1987. Domestic violence is just as much a public health matter as homelessness and for women veterans, it is a major cause. Thirty-nine percent of women veterans report experiencing domestic violence, well above the national average. As a result of definitions outlined in Title 38, these veterans are not eligible to access resources for homeless veterans. PVA generally supports H.R. 1369, the Veterans Access to Extended Care Act of 2015, which would allow veterans to obtain non-VA long-term services and supports from local providers. The bill would also allow LTSS providers to enter the VA provider agreement rather than contracting with VA, thereby avoiding the complex processes required under the Service Contract Act. Finally, PVA supports H.R. 1575, a bill to make permanent the pilot program on counseling in retreat settings for women veterans newly separated from service in the Armed Forces. The bill would provide VA with the authority to extend the program using the same measurements and eligibility requirements. It is essential that Congress reauthorize this program as we believe the value and efficacy is undeniable. Mr. Chairman, PVA thanks the subcommittee for the opportunity to submit our views and I would be happy to answer any questions. [The prepared statement of Blake Ortner appears in the Appendix] Mr. Benishek. Thank you very much for your testimony, Mr. Ortner. Mr. Celli, you may begin your statement, five minutes. STATEMENT OF LOUIS J. CELLI, JR. Mr. Celli. I can't remember a hearing in recent history where The American Legion completely supported and stood behind every bill being offered for consideration. What this demonstrates is an overwhelming bipartisan partnership with veteran service organizations and with veterans to ensure the Congress gets it right. On behalf of our National Commander Mike Helm and the millions of veterans that make up The American Legion, thank you. Good job. The World Health Organization defines reproductive health as a state of complete physical, mental, and social well-being at all ages and stages of life and not merely the absence of reproductive disease or infirmity. According to a study of veterans who served during OIF and OEF, 15 percent of women and nearly 14 percent of men reported that they had experienced infertility. As a result of more than a decade of war, thousands of male and female servicemembers are returning home with physical and/ or psychological wounds resulting in a variety of fertility and reproductive health issues. Many young servicemembers have been documented with low testosterone levels that can be attributed to the medications that they take for their physical injuries or conditions such as TBI or PTSD. That is why The American Legion supports the draft bill to amend Title 38 to improve the reproductive treatments provided to certain disabled veterans. The American Legion has always been a vocal advocate of transparency and open communication between the American people and government. Last December, CBO suggested that an annual report similar to the one that DoD produces relative to TRICARE would help policymakers evaluate cost efficiencies. And The American Legion agrees. Additional data, particularly if it was provided on a regular basis, could help inform policymakers about the efficiencies and cost effectiveness of VHA services. The American Legion through testimony and resolution has consistently called upon VA to maintain transparency in all aspects of data reporting. This is why we not only support this draft legislation, but we also continue to support H.R. 216 introduced by Ranking Member Brown, the Department of Veterans Affairs' Budget and Planning Reform Act. Last month, The American Legion commander sent a team of six experts to Los Angeles to work with veterans and learn more about the West Los Angeles land usage agreement. While in LA, we reached out to and worked directly with homeless veterans so that we could get a firsthand sense of the homelessness problem in Los Angeles. What we discovered was that while expanding the definition of what it means to be a homeless veteran as 627 seeks to do and is something we support, we also realize that there is a large number of homeless veterans that do not qualify for VA services and who are completely overlooked in the administration's goal to eradicate veteran homelessness this year. Veterans who have less than honorable discharges due to struggles with PTSD or other service-connected issues are not eligible for HVRP or other VA services. The American Legion calls on VA and this committee to address this issue and work with VA to ensure these veterans are properly served. And finally, in September 2013, The American Legion published our report, The War Within. This report was a result of comprehensive research conducted by our PTSD/TBI Ad Hoc Committee which found that, one, VA and DoD have no well- defined approach toward the treatment of TBI; two, providers are merely treating the symptoms; and, three, DoD and VA research studies are weak in the area of new non- pharmacological treatments and therapies such as virtual reality therapy, hyperbaric oxygen treatment, and other complementary and alternative medicine therapies. In February of last year, The American Legion conducted a TBI and PTSD veteran survey to evaluate the efficacy of VA's TBI and PTSD medical care and to see how veterans who are suffering from these signature wounds are being treated. The survey showed that 59 percent reported either feeling no improvements or feeling worse after undergoing treatments for their TBI and PTSD symptoms. Thirty-three percent have terminated their treatments and therapies prior to completing them. And the veterans we surveyed reported that they were taking up to ten different medications for PTSD and TBI symptoms. In June 2014, The American Legion along with military.com sponsored a TBI and PTSD symposium and again focusing on complementary and alternative therapies. More information about this symposium can be found in my written testimony. In closing, The American Legion strongly supports the use of complementary and alternative medicines and supports the funding necessary to assist veterans suffering with PTSD and TBI with complementary, non-pharmacological treatments that allow our returning veterans to actively participate in their own recovery programs without unnecessary sedation or over- medication. Thank you. [The prepared statement of Louis J. Celli, Jr. appears in the Appendix] Mr. Benishek. Thank you very much for your comments, Mr. Celli. Mr. Rowan, you can proceed with your testimony. STATEMENT OF JOHN ROWAN Mr. Rowan. Chairman Benishek and Ranking Member Brownley, excuse my voice. I have been dealing with a cold for the last week. The change in weather is just driving me crazy. We, too, support all of the proposed legislation before us this morning. The reproductive treatment issue is certainly one we are concerned about. One of the problems that we saw with the Agent Orange issue was the fact that a lot of veterans because of exposure to Agent Orange had reproductive rights issues, that they had terrible problems. When we had our town hall meetings on Agent Orange, there was a lot of complaints by the wives of miscarriages and stillborns. And so any effort at all to work in that area is a blessing. The annual report on VHA, I don't understand why that hasn't always been done, quite frankly, and it is just another area that we have been supporting for a long time which is as much congressional oversight as possible is a good thing. And the more information that you have to make your oversight worthwhile will certainly work in that direction. We support Representative Bilirakis's COVER Act. It is an interesting area for us. One of the things we always complained about years ago when the Vietnam veterans came home, frankly, was the over-medication of Vietnam veterans, way too much Thorazine and not enough treatment, and led to all kinds of problems, not the least of which was some serious issues that ended up with people being put away in jail for a long time. So the only caveat we might add, we thank the congressman for adding the issue on the membership, but we would also ask that any review may ensure that any alternative treatment have a real scientific evidence background. Unfortunately, I hate to say it, but there is a lot of people running around saying they have got a cure for PTSD. And while they may have some reasonable alternative medicine or alternative process, some of these things get a little overblown and, unfortunately, can become real scams. So we appreciate the effort, though, and I think this commission can go a long way on that. Expanding the definition of homeless, that is an issue, you know, not surprising. We need to do more on that issue. There was even a problem out in Long Island where we got homeless veterans a place to live and because they had a place to live, they couldn't get funding because now they had a place to live even though the place was a homeless program. I mean, the VA didn't make sense. They didn't want to fund it. Finally they did, thank God, and I think Congressman Zeldin, one of your colleagues, had a lot to do with that. So I have been working on homeless veterans since 1981 when they were first discovered in the City of New York. And we applaud the efforts in LA County and we really applaud the efforts of the VA in West LA. They really are starting to make some changes out there. And I am sure Congresswoman Hahn will be pleased to see that. We support the other programs, the women's treatment program and the retreat sounds extremely interesting. And the expansion of extended care, of course, is something near and dear to us. Unfortunately, many of my members are becoming older obviously and need more of that assistance. But the main bill we are here for is 1769. We believe this may be the most important bill for veterans since the Agent Orange Act of 1991. And the key to this is the fact that we would begin to finally look at what happens to toxic exposure not only to the veterans but to veterans' families because interestingly enough, if you look at what the VA has already agreed to, male veterans only get children with spina bifida. Female veterans have a much longer list of diseases that affect their children that has been agreed to by the VA often, again, with reproductive issues being the forefront. So our firm belief that this is so important and having gone out again, we have had over 200 town halls across the country and it has really been discouraging about what we have been hearing from the veterans. But the key aspect of this act is the multi-generational issue. So we not only talk about Vietnam veterans and the effects of Agent Orange, but we talk about the effects of all the folks that went to the Persian Gulf in 1991 and we talk about all the folks who have been in and out of Iraq and Afghanistan to this day. We are already getting concerns about some of the folks coming home and some of the effects on their children. So we really, really look forward and we thank you all for the support for this act. Thank you. [The prepared statement of John Rowan appears in the Appendix] Mr. Benishek. Thank you for your comments, Mr. Rowan. Mr. Atizado, please proceed with your testimony. STATEMENT OF ADRIAN ATIZADO Mr. Atizado. Thank you, Mr. Chairman, members of the subcommittee. I want to thank everybody here for inviting the DAV to testify at this legislative hearing. As many of you know, DAV is a 1.2 million service-disabled veteran service organization and our mission is to empower veterans to live high-quality lives with respect and dignity. Many of these bills aim to do just that. We are pleased to present our views on the bills under consideration, but for the sake of brevity, I will only talk about three bills and refer the subcommittee to our written testimony for our position and comments on the others. First, DAV supports the intent of H.R. 271, the COVER Act. As has been discussed here before, this is a bill that would allow for complementary, alternative medicines to grow in the VA healthcare system. Our resolution from our members calls for access to a complete continuum of services for complementary and alternative medicine. As part of the Independent Budget, we have long supported the advent of the availability of these therapies in the VA healthcare system for all generations of wounded, ill, and injured veterans, although we do call the subcommittee's attention to the bill's language that may need just a little bit of clarification as to whether the commission that would be established by the bill is expected to study Veterans Benefits Administration claims with regards to mental health disability or whether the claims the bill language uses should be replaced by maybe a more clinically differentiated expression. The second bill is H.R. 1369 which DAV really does thank Representatives Walorski and Gabbard for introducing. It is a necessary bill. The bill would actually help to address adverse effects that many veterans are feeling right now in the community. A lot of service-connected disabled veterans who are in nursing homes and skilled nursing facilities are facing very precarious situations where they are not sure who is going to be able to pay for their care because VA is having a little bit of difficulty trying to address their provider agreement authority. Now, this bill is in line with our resolution and our resolution talks about enhancing long-term services and supports for our members. Our members like with the Vietnam veteran generation and the newest generation are facing services that need to be provided closer to their home and that is one of the weaknesses in the bill that we ask that the committee consider. Some of these services deal with a specific VA program that is just beginning to expand and because there are problems with VA's authority to implement its provider agreement with private sector providers, that program is being adversely affected. Finally, we would like to thank the subcommittee for its continued efforts in improving VA's women veterans' healthcare programs and services. We are pleased, definitely pleased to support H.R. 1575. Now, Congress mandated VA to assess the pilot program which is the subject of this bill and in that assessment, the results describe it as a successful program that improves the ability for women veterans to reintegrate into civilian life. Making permanent VA's pilot program for counseling treatments for newly-separated women veterans is keeping with our resolution which calls for enhanced medical services and benefits for women veterans. Equally important is the bill would fulfill a key recommendation to Congress in DAV's report, Women Veterans' Long Journey Home. This report reveals that America's nearly 400,000 women veterans using VA are at risk by a system historically focused on caring for male veterans. The report paints a compelling picture of federal agencies and community service providers that consistently fail to understand that women are impacted differently by military service and deployment when compared to male experiences. It also points to challenges that are needed in overall culture and services provided by Federal Government and local communities and it lists 27 specific recommendations. Mr. Chairman, this concludes my statement. I would be pleased to answer any questions you or other members of the subcommittee may have. [The prepared statement of Adrian Atizado appears in the Appendix] Mr. Benishek. Thank you very much for your testimony, Mr. Atizado. We have just called for votes, so I was going to ask my questions and then maybe let the ranking member ask and then we will reconvene after votes to conclude. Sorry about the delay here, but they moved votes up apparently. So I just have a few questions. I want to talk just a minute about the legislation I talked about, to get this annual report. I am trying to figure out what data to get, and I want to try to be able to determine what is the cost of the care that we are providing our veterans through the VA? You know, we don't know; they are spending a billion dollars on a hospital here, a billion dollars on a hospital there, and what does it actually cost them to take care of a patient coming through the door? And I want to find that out because I think we need to, give our veterans maybe more for the money that we are spending in the VA. So, Mr. Rowan, do you have any further information that you want to present, because you did comment on the bill? Mr. Rowan. Yeah, I think that the issue is where our spending is. I mean one of the things that we have had concerns about has been this massive growth of bureaucracy, you know, with the VISNs and other things, rather than the money being spent on care providers. You know, how much are we actually spending on doctors, rather than managers? How much are we spending on nurses, rather than managers? And that would be an interesting breakdown to see how that works in the actual provision of services. I mean if we just-- if we take the overall budget and just whack it up by the number of veterans, you get a number, but that doesn't give you an idea of what it is being spent on, and that has really been our concern for a long time. Mr. Benishek. Well, it is my concern, too, because I mean if you take the whole budget and the number of veterans that are in the system and you come up with a thousands-of-dollars- per-veteran number. Mr. Rowan. Right. Mr. Benishek. But you can't figure out what it actually costs. Does anyone else have any comment on that? Mr. Atizado. Mr. Chairman, if I remember correctly, CBO's report and their testimony, that you have referred to in your statement when we reviewed that, it was very easy to come to the realization that what you are trying to do is compare one health testimony to another, and in CBO's report they basically say it is nearly impossible. Now, even if VA were to provide a report like DoD does for TRICARE, CBO even says that might not even do it. There may be some information that VA would be able to provide that is either unavailable or partially available or just nonexistent in the private sector. I believe this is an important question and it is one that really is at the heart of the subcommittee's oversight responsibility. It should be answered, but perhaps it should be posed to the research community. Most of the seminal studies in CBO's report about comparing costs talk about research studies done in the early 1980s, 1990, as early--as late as 2001 and is probably something that should be sent back to them for a little bit closer examination. Mr. Benishek. I appreciate your input because I am trying to get, the right stuff, the right numbers, the right data, so that we can, make some changes to the VA to make it better a0nd more responsive to the needs of veterans. So I am hoping that we can continue to work together to help me find the right data. Does anyone else have any input there? Mr. Celli. I do, thank you. And The American Legion agrees that while it may be difficult, it is not impossible. And while it may be difficult to completely formulate the type of data that we would need in order to make informed decisions, that doesn't preclude us from starting and gathering some form of data and that has to be a partnership with VA. VA has to be open enough to be able to provide that data when requested and right now we are not seeing that type of transparency when it comes to efficiencies of cost. We also need to make sure that VA is projecting and programming out efficiently so we can look back then, three, four, five years from now and say, well, this is what VA said that they wanted to do and what they wanted to spend their money on and this is what they wanted to do as far as new projects goes and be able to look at that and say, well, how did that go? And it is okay for it to change, but without a plan, then it is almost reckless. Mr. Benishek. Thank you. I am going to yield back my time, and we will give Ms. Brownley some time here before we run off to votes. Thanks. Ms. Brownley. Thank you, Mr. Chairman. Mr. Rowan, you testified or mentioned the fact that based on some data that women were suffering a lot more in terms of their reproductive health because of exposure to any kind of toxic material. Do we have any hard data on that in terms of exposure for women, specifically? Mr. Rowan. You know, I don't know if there is exact data, but when you look at the presumptive illnesses that VA has agreed to, men only have spina bifida where the women have several, most associated with their reproductive organs and their issues and effects on those, and that is intriguing to me, why the women have that problem, but not the men. I mean, you know, because there is really a lot of concern about the genetic effect of toxic exposure which may lead to all kinds of genetic problems carried over into the next generations. So that is why we think that it is important that we take a look at all of that. You know, there were several states that were starting to do that many years ago back in the 1970s and 1980s, New York, New Jersey, Michigan, I think, started to look at that, but then, unfortunately, there was no funding for it and nobody wanted to keep up with it. And they were starting to look at the data of the children of Vietnam veterans, and they may need to go back to try to find some of that, if it still exists or take a look at new ones. And we are really concerned not only about us, but looking forward. Persian Gulf have been out 20 years now, so there should be a lot of data on them. And the new folks, we should start tracking them now, you know. I always tell the anecdotal story, I have a cousin who is, you know, in his early 40s as a Seabee Reservist, went to Iraq twice, dealt with all kinds of horrible cleanup stuff, dealt with all kinds of exposures. He came home, and after his second tour, he got non-Hodgkin's lymphoma and his third child was born with downs syndrome. Now, is there a connection? I am not a scientist. I can't tell you for sure, but somebody ought to study it and that is what we are just saying. One of the problems we have had with the whole Agent Orange issue is for all these years, they have never really done a decent study. They have never really done a decent scientific review. IOM has been relying on all kinds of extraneous studies done around the world to come up with all of these things and we have waited all these years. I mean I am going to be 70 in September and, you know, it only took three years ago when they added ischemic heart condition. I mean I don't want to see that happen to the Persian Gulf vets and I certainly don't want to see that happen to the new vets, that they have to wait 40 years to find out that they have problems with their children, that they need to take a look at. Ms. Brownley. Absolutely. I couldn't agree more with your comments. I also wanted to just ask the whole panel, based on Ms. Brown's bill, H.R. 1575, what are your thoughts--the VA made a suggestion, I think, that we should, in terms of expanding the population of eligible veterans, that we should also include men, as opposed to strictly women. Does anybody have a comment with regards to that? Mr. Rowan. I will be honest, I am not an expert in this field--I never really followed up on it--but that was my first reaction when I read the bill and looked at that pilot program as, gee, a retreat form. That is not a bad idea, but why do we do it just for women? Why not men as well? I remember former Chairman Filner when he was here, one of the things he talked about was reverse boot camp. You know, the idea of we bring people home--we spend all this time and effort and money to make people into warriors and then when they come back, we don't spend a nickel to make them into civilians again; that is an interesting concept. Ms. Brownley. Any other comments from---- Mr. Celli. Yes, I would like to dovetail on what Mr. Rowan said. During World War II, after veterans left combat, they had a three-or-four-week journey back on a boat to reintegrate with their platoons and really decompress. Right now, you can go from the battlefield to your living room in 15 days, 10 days, 5 days in some cases, and veterans really need that time to decompress. And I think that is a huge component of some of the illnesses that we are seeing now just being exasperated; they don't have time to deal with it. Ms. Brownley. Do you think that if we included men and women, that we should keep them separate, men going together to one place and women going together in another? Mr. Celli. Congresswoman Brownley, I cannot answer definitively whether it should be a separate cohort in each retreat. But I do know this, the idea of having a retreat specifically for women veterans really came out of the idea that they are such a small population compared to the overall veteran population, and because they are so small, their ability to support each other and have some kind of peer support group to learn from each other's experiences became all the more important. Now, whether that would apply to male veterans with that specific respect may not necessarily be the case, but I would hope that VA would have some kind of reasoning, other than, well, that is another part of the population for male veterans to be put in a retreat setting. Ms. Brownley. Thank you. I am over my time and I yield back. Mr. Rowan. If I might add, Congresswoman, the other issue here is I would remiss--my vice president would take me to task--she ran a program in Philadelphia for women veterans and she would be the first one to tell you that unfortunately homeless women veterans have a high-rate of military sexual trauma and that may be a perfect reason why they need to be taken on separately, as from the men, to give them that space to be able to deal with those issues that they may not be willing to deal with. Ms. Brownley. Thank you. Mr. Benishek. Gentlemen, I am going to ask your indulgence. We are going to have to go into a recess to do the votes, and we will reconvene as soon as possible after the votes are over. Thank you. [Recess.] Mr. Benishek. The subcommittee hearing is back in session. Since we don't have any other members, I am going to ask a few more questions of this panel here, since I have some time, and I think Ms. Brownley may have a few more questions, too, and see if any other folks show up to ask their questions. I was just going into this question of the reproductive treatment that we hope to provide for disabled veterans. Some of the testimony in the record suggested that, there should be included surrogates and third-party donations. I understand the reason for those, but the DoD doesn't provide those benefits and the VA has expressed some concern in previous hearings, on this issue. So I am just wondering how we are going to deal with this going forward, and does anyone here have any other concerns about the complexities that would be involved with the addition of a surrogacy provision in the draft bill. I know, Mr. Ortner, you probably have another comment to make on that. Mr. Ortner. Yes, Mr. Chairman. You know, the approach of PVA has always been to--that the VA and DoD should try and bring someone with a disability, especially a catastrophic disability, as much of a recovery as they can. Their quality of life should be back to as much as normal as it can be. Now, of course, you know, in our written testimony, we commented on the challenges of the individual's who has got a catastrophic SCI where they may have been able to have IVF, but they are not going to be able to carry it to term. And the concern we have on this situation, is that even though DoD doesn't supply it, we think DoD should. Because you have still got a situation of an individual that lost the ability to have children due to their service and we also see it as being probably a very, very small number of individuals that are going to have this condition, which is primarily why we, in our testimony, we talked about there needs to be a little clarification. Because, obviously, it is probably not something you just say, well, we are going to open it up and anybody can have a surrogate. But we probably think there are those situations where you have got those situations where that individual is unable to carry the child that should have a consideration. Regarding the genetic material, that is another thing, third-party genetic material. We think there is probably a very unique situation where you are going to have, possibly, you know, individuals that are going to suffer from something that causes a damage to the genetic material. But as we saw with Gulf War syndrome, as we have seen with the various toxic substances is that you experience in service, you can have that situation. Essentially, what we are doing is because if someone serves, they have lost that ability to have children and we think they should have that. Mr. Benishek. All right. Thank you. Anyone else have anything further on that? Mr. Rowan. No, I would just concur with what the gentleman was saying in that regard. Clearly, the in vitro fertilization is one aspect of it, but our concern is going back to the toxic exposure issue is the effect of genetic material on exposures. But the issue of women, especially who have been hurt in the military and the impact on them is interesting. Because, I was relating a story, I had a client when I was doing service-prep work back in the twos, early twos, who, she had only been in the Army like a year and a half and then broke her hip severely and they did a mediocre job in putting her back together, quite honestly, and she was having some issues with it. We got that dealt with, but then when she got pregnant, she was very concerned about whether or not she was going to be able to carry a baby to term, whether it would affect her--what the hip would do, how she would get around. And, unfortunately, this was the early days of women's programs inside the VA, but we managed to get her help. But it, clearly to me is one of those things that the PVA people are well-aware of and we would support any effort to assist those folks. Mr. Benishek. Well, thank you very much. I will yield back the remainder of my time. Ms. Brownley, do you have any more questions for the panel? Ms. Brownley. Just one quickly. I just wanted to first comment that--and to applaud Mr. Bilirakis and Dr. Ruiz and Ms. Walorski for their bill on alternative approaches to mental health issues. You know, one part of that bill is looking at outreach efforts to veterans for mental health services, and in my mind, I feel as though that is an extremely, extremely important component because, I think particularly for our Vietnam veterans and our older veterans, getting them to mental health, but getting them to the place where they feel comfortable seeking the help is probably 90 percent of the issue. And so, you know, how do we encourage and make it feel right and say for our veterans to seek that health out. So I think that is really, really important. I just wanted to ask the panel, and really all of you, you know, the VA continues to talk about the work that they have been doing and continue to do around alternative therapies for mental health. I know we have an extraordinary program in my district with equine therapy that has been very successful for our veterans. I am just wondering, at this juncture, how would you grade the VA in terms of how well they are/we are doing with regards to alternative approaches to mental health. Just, you know, a quick response, no--it doesn't have to be evidence- based, just your general reaction to what would you give the-- what grade would you give the VA? Mr. Celli. I can tell you that based on the firsthand research that The American Legion has done, the grade would not be superior. I think there is a lot of work to be done. I think that the VA is looking at those options and it is something that we are interested in looking at with them, similar to things like this bill. You know, the VA has come a long way with things like the vet centers, which have really taken this issue head-on, during the time of Vietnam, when Vietnam veterans were coming back. They have vocational rehabilitation, which has almost an endless supply of resources to help veterans rehabilitate back into society. Maybe they could look at some kind of mental health center that is unique to PTSD. You know, maybe if there was a specific PTSD program that charged these centers with looking at alternative therapies, trying to get them off medications and graded them based on success rates, maybe there would be some more out-of-the-box type of thinking. Ms. Brownley. Do you still believe that outreach is a critical component to---- Mr. Celli. Absolutely. Ninety percent of the veterans that we spoke to did not know what their options were. And we need to make sure that stakeholders, Congress, VA, the American public in general, knows that--or is able to communicate to veterans and participate in that outreach to let them know what their options are. And, again, vet centers is a wonderful tool to help do that; it is probably the best kept secret in VA. Mr. Rowan. Clearly, the vet centers, we helped establish those things, and I remember back in the Reagan years, trying to fight back the OMB from killing them. Thankfully we succeeded, but the problem we always had with them is they only focused on the veteran. They didn't do enough to bring the family into the picture. I must tell you that my colleagues in Australia--I have been doing family counseling with the veterans for 35 years-- and that would help a lot if that was added, so that they would be able to work with spouses, children, whatever; the whole secondary PTSD issue is a big issue. As far as outreach, the VA has got a very bad mark. I would give it an F. I don't think they do anywhere near enough of outreach. And, frankly, all the alternative stuff is done by private- sector organizations, and the one thing about--hopefully with Bilirakis' proposal with this commission is that they would review all of those things and really try to understand what are really scientifically attainable and what are not, and what are just figments of people's imagination. I mean, don't get me wrong, I love my dog and, you know, if I hang out with my golden retriever, he has a lot of fun and he can certainly lower my anxiety levels, but the bottom line is that without a treatment program on top of that, it is not enough. So complementary is the keyword there and alternative, not instead of. Ms. Brownley. Yes. Any other comments from any other panelists? Mr. Ortner. Well, we have only got a couple of seconds, but I think the biggest challenges with the VA--I kind of go a little more with the Legion. I would give them maybe a C. But I think it is--I think part of the challenge with the VA is it is a huge bureaucracy; bureaucracies are resistant to change. And I think in the case of the VA, they are more concerned about having an embarrassment from a fraudulent program than they are necessarily helping every veteran. And that sounds negative, but I don't mean it in that way. It is just like Mr. Rowan mentioned, which I worked on back in the 1990s, a lot of fraudulent things going on and quack medicine. There is reason to be resistant, but I think that is one of the challenges with the alternative things. As for outreach, that is absolutely critical. I worked homeless issues back in the mid-1990s, and the outreach was key, but it really wasn't the VA doing the outreach; it was the homeless centers and things like that, that were doing the outreach, funded by the VA. But a lot of that has to do with mental illness, getting out there and interacting with those people, and that can be challenging because there is a lot of fear going into those environments to deal with that. Ms. Brownley. Thank you for watching the clock for me. I yield back. Mr. Benishek. Thanks. Ms. Titus, you are recognized for five minutes. Ms. Titus. Well, thank you, Mr. Chairman. And thank you and the ranking member for allowing me to sit in today. I want to agree with the ranking member, Ms. Brownley's comments, that we need to expand this legislation. I hope that we can work together to be sure these treatment options are available for all our veterans. As it is currently written, it is possible that there are veterans who meet all the requirements contained in this draft legislation, such as having a service-connected disability that prohibits procreation, but due to their sexual orientation, they won't be able to receive this assistance. Now, I would like to ask the members of the panel if they have any concerns that this legislation fails to offer services to legally married same-sex couples. Mr. Ortner, you mentioned some exceptions that might be needed to be considered. You mentioned surrogacy and third-party genetic donations, but what about same-sex couples, if they are denied these benefits as veterans, is that really fair? So I would ask you all to comment on that. Mr. Ortner. Well, Ms. Titus, PVA does not have a position on that, and I am not in a position to comment due to that. Mr. Benishek. Who wants to jump in? Okay. Mr. Rowan. The bottom line for us has been when we have dealt with gay rights issues, quite frankly, is if the law allows it, we are in favor of it. I mean it started when they finally allowed people to come into the military openly gay. Ms. Titus. Yes. Mr. Rowan. I mean if you are going to let them in, they are a veteran when they come out. So if they are a gay veteran, they are a gay veteran. I mean I think that there is a lot of adjustment society is going to be making over the next decade or so on these issues. We got involved when we talked about the spousal benefits questions and that got interesting real fast. And, you know, obviously, some people have very strong opinions on that and they are not going to be in favor of it, but our feeling was just simple: if it is the law, then it is the law and it ought to cover every veteran, not one or--some veterans yes, some veterans, no. Ms. Titus. Okay. Mr. Celli. The American Legion has a similar view. We have a resolution that states that there should be equality amongst all veterans and all generations of veterans. So if they are a veteran and they apply for VA services, they should be entitled to the same VA services as any other veteran. Ms. Titus. I am glad to hear you say that. Mr. Atizado. Thank you, Congresswoman Titus. I will tell you this, the mission of the DAV is very clear. What we are about is making sure that any service injury that a veteran sustains while performing honorable service for this nation, should be given the opportunity to be given high-quality life, and as I mentioned, to lead it with respect and dignity. So if a servicemember happens to have a certain sexual orientation, but they are injured and unable to have a--are injured and have reproductive difficulties, while we don't have a specific resolution on it, based on our mission, we would like to ensure that that member have the same and enjoy the same benefits as their counterparts. Ms. Titus. Well, thank you. That seems to me only fair: A veteran is a veteran is a veteran, and all veterans deserve equal benefits. Many states now recognize marriage equality and it is very likely that the Supreme Court is going to be making that decision here this summer, so we want to be sure that we don't enact policy that discriminates and doesn't provide benefits that all our veterans have earned. So I appreciate hearing your comments on that and I yield back. Mr. Benishek. Thank you, Ms. Titus. In the absence of any further questions, the panel is excused. Thank you very much, gentlemen. I will now call up the third panel. This is Dr. Rajiv Jain; he is the assistant deputy under secretary for health for VA Patient Care Services. Thank you, Dr. Jain for coming and waiting for awhile as we concluded our voting procedures there. You may proceed with your testimony when you are ready. STATEMENT OF RAJIV JAIN, M.D., ASSISTANT DEPUTY UNDER SECRETARY FOR HEALTH FOR PATIENT CARE SERVICES, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY JANET MURPHY, ACTING DEPUTY UNDER SECRETARY FOR HEALTH FOR OPERATIONS AND MANAGEMENT, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND JENNIFER GRAY, ATTORNEY, OFFICE OF THE GENERAL COUNSEL, U.S. DEPARTMENT OF VETERANS AFFAIRS STATEMENT OF RAJIV JAIN, M.D. Dr. Jain. Well, thank you, Mr. Chairman, Ranking Member Brownley, and Members of the Committee. Thank you for inviting me here today to present our views on several bills that would affect the Department of Veterans Affairs programs and services. Joining me today to my right is Ms. Janet Murphy, acting deputy under secretary for health for operations and management, and to my left is Ms. Jennifer Gray, attorney in the Office of General Counsel. I would like to start with Chairman Benishek's bill, to amend the Title 38 United States Code to direct the secretary of veterans affairs to submit an annual report on furnishing of hospital care, medical services, and nursing home care by the Department. We support this bill and are already providing much of this information on our Web site and through the mandated reports to Congress. The costs associated with this and other bills on the agenda are included in my written statement, so I won't go through them now. The VA also supports H.R. 627, a bill to amend Title 38 that expands the definition of homeless veteran for purposes of benefits under the laws administered by the secretary of veterans affairs. This will align us with HUD's definition of homeless. Regarding H.R. 1369, VA appreciates the Committee's interests in updating our authority to purchase extended care services from the community providers. We are currently developing a legislative proposal to address our authority to purchase hospital care, medical services, and extended care services. We look forward to working with the Committee on this vital legislation. We support the concept Congressman Miller's draft bill to amend Title 38 to improve the reproductive treatment provided to certain disabled veterans. We would like to expand the language, however, to include all veterans who might be eligible. VA supports H.R. 271, a bill to exam the efficacy of VA treatment of mental disorders and the potential benefits of incorporating complementary alternative treatments available in non-Department of Veteran Affairs medical facilities within the community; however, we have concerns with some of the language that may interfere with the stated goals of the bill. We would like to work with the Committee to amend the language. We support the intent of H.R. 1575, a bill to amend Title 38 to make permanent the pilot program on counseling and retreat settings in women veterans, newly separated from their service in the Armed Forces. While VA agrees that providing these retreats is beneficial to women veterans, it should be made permanent. Other veteran and servicemember cohorts could benefit from this treatment modality. As discussed in previous hearings, while we support the efforts to enhance research on the diagnosis and treatment of health conditions of the descendants of veterans exposed to toxic substances during service in Armed Forces, we are unable to support this bill because a center would duplicate the efforts of other federal agencies and other reasons that are discussed further in our written testimony. Finally, I would like to say to give the VA its best view, we have worked in collaboration with many agencies to solidify the views provided on many of the bills discussed today. Thank you, Mr. Chairman, 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 Rajiv Jain, M.D. appears in the Appendix] Mr. Benishek. Thank you, Dr. Jain, for coming and for your testimony and comment. I am going to yield myself five minutes for questions. Dr. Jain, the VA opposes this H.R. 1769 on the grounds that other federal departments and agencies are poised to support research on multi-generational health effects of toxic exposures. The VA's research programs have been praised elsewhere in this hearing and are, I am sure, more than up to the tasks set forth in the bill. What is more, the VA's testimony lists the VA War Related Illness and Injury Study Center, the VA Office of Research and Development, and the VA Office of Public Health, among those whose work would be duplicated, according to the VA by the national center proposed in H.R. 1769. I have a couple of questions that follow up with that. What other departments or agencies do you think are better positioned to study the effects of toxic exposure on veterans and their descendants than the VA and why? Dr. Jain. So, thank you, Mr. Chairman, for that question. I think I wanted to, again, make it very clear that we certainly support all of the work that needs to be done to find out if there are any impacts from the exposure to toxic agents for veterans and their descendants. So, in general, we are completely in agreement in doing whatever we can do and we must do. The concern comes into play, sir, if you really look at these disorders that happen from exposure to toxic agents, they are extremely rare. So you need large populations to really come to any meaningful conclusion of the cause and effect. So a lot of our experts feel that the exposure in the civilian setting and the exposure in the military setting has a lot of parallels where we can learn from both sets of exposures. And so having, for example, the national center for--the National Institute of Environmental Health Sciences or The Center for Disease Control that also have significant efforts in looking at that, if we could structure a solution that could collaborate and partner with those agencies, we could maybe have a better chance in achieving scientifically proven impacts that I think would---- Mr. Benishek. I don't think there is anything in the bill that excludes. Dr. Jain. Right. Mr. Benishek. You know, it is a research coordination bill; although, I don't think it excludes getting data from anywhere. Dr. Jain. It wasn't clear, sir, but I think if the intent is that the Center could work with other agencies and could begin to have that broader sense, then that could be something we can definitely look at. Mr. Benishek. Okay. Then let me ask you another question here. What does it say about what is going on in the VA War Related Illness and Injury Study Center and the VA Office of Research and Development and the VA Office of Public Health? I mean shouldn't we coordinate all of that in one place to explore toxic exposure issues? Dr. Jain. That, we would agree with you, sir. The only point that we were making is that we have these areas, the war related centers, the ORD, all of these departments are constantly looking at the published literature. They are trying to understand what is going on. Mr. Benishek. I understand why you say that, but, you know, they also said that focusing solely on military exposures would likely result in inconclusive research. Well, a lot of people in the civilian life weren't exposed to Agent Orange. Most people were exposed in the military setting. And it is similar--and it is very difficult--I would say in the burn-pit situation, most of the people that were exposed to toxic fumes in burn pits, that doesn't seem, to me, a very common civilian exposure. Now, there may be other exposures that are more common in the civilian life than there are in the military; I would say maybe lead exposure would be maybe an example of that. But there is lead exposure in the military, and maybe that could be coordinated. You know, depleted uranium exposure doesn't occur that often. I mean there are lots of things that are kind of specific to the military, Dr. Jain, and that I think really doesn't--you know, your argument really doesn't wash with me, okay. So I think that is not a very good reason to be advocating against a legislation, in my opinion. Do you have any rebuttal for my comment there? Dr. Jain. No, sir. The only thing that I would offer that I was going to suggest, sir, is that if we could have an opportunity to work with you and the Committee, to work with some of this language, so that we can achieve some of the goals that we are looking for. That is all we are saying. But we agree with what you are saying. Mr. Benishek. Yes. Well, I am happy to have you involved in the process, Dr. Jain. We just want to make some progress here. Dr. Jain. Absolutely. Mr. Benishek. In view of time, I am going to ask--I am going to ask the ranking member if she has any questions. Ms. Brownley. Thank you, Mr. Chair. And I will just follow up on your line of questioning regarding your bill. Mr. Jain, you have testified that these exposures are so rare it is hard for you to come up with a scientific response. But what exposures do you define as rare? Dr. Jain. Well, I am not talking about the exposure is rare, but what I am saying is that the science indicates that when you look at diseases or conditions caused by toxic agents, those are rare, because you get into play the genetic factors, heredity, age, the time of exposure, duration of exposure, the type of agents, so there are a lot of agents. So I think my only point is that these are rare conditions, so you need larger sets of populations. So whatever solution we come up with, I think as long as we have access to the largest population base that we can think of so that we can get to the real bottom of this, I think is all we are saying. So, we are supportive of that. Ms. Brownley. Yeah. I would just say that I think in this case, you know, it is the VA and government in general that I think has to take a lead on these issues, and if we don't, who will? I think it is just our responsibility, you know, to do so. So another question I wanted to ask with regards to H.R. 627 with homelessness, in response to domestic violence in veterans' homes, you are saying that you are already serving these veterans; it is not so much of a problem, yet you lacked the detailed data regarding the size and the characteristics of this population. So, can you explain to us how you know that you are already serving this population? Dr. Jain. So, I think I am going to turn to my colleague, Ms. Murphy. She is more familiar with this topic. Janet? Ms. Murphy. Thank you, Congresswoman. So, we collect a lot of data on the veterans that we serve in our homeless programs and, fundamentally, any veteran who needs--we don't turn down veterans who need homeless services, so we don't distinguish that you are fleeing domestic violence, so we can't serve you. So we are already serving those veterans. How many? We would have to come back--take a look at that and come back with that information for you. I think this is really a technicality, is correcting the law so it is codified in law and consistent with HUD language, the language in HUD's regulations, that we are all--because that is our very strong partner in all of this. But we are already serving those women veterans and men as well, because men also flee from domestic violence. So we will continue to do that and we will see if we can find information which quantifies that for you. Ms. Brownley. So when you say you don't turn anyone down, a homeless veteran who needs permanent housing or temporary housing, you don't turn anyone down, but there is not enough housing for the homeless veteran population, at least in Los Angeles County there is not, and I think in my county, in Ventura County, it is the same. Ms. Murphy. We don't turn anyone down in terms of access to services, then the challenge becomes to find them the housing. We have plenty of HUD vouchers. We have vouchers available to provide them housing. The challenge is finding the housing, particularly in areas like Los Angeles, San Francisco, Seattle, but, you know, we continue to work the problem. Ms. Brownley. And you are also saying that you don't collect that data in terms of bifurcating within the homeless population of veterans, who of the veterans are--who have--who are there because of domestic violence. Ms. Murphy. I need to verify that. We collect a lot of data on our population that we serve and I would need to clarify whether we collect that specific data and whether that was--we were able to tease that out and make that available. Ms. Brownley. Well, I would appreciate it. Ms. Murphy. We certainly should be collecting it, if we are not. Ms. Brownley. And if you would, get back to me or the Committee with that information, I would appreciate it. Ms. Murphy. Absolutely. Ms. Brownley. I yield back. Mr. Benishek. Thank you. Ms. Titus, you are recognized. Ms. Titus. Thank you, Mr. Chairman. Dr. Jain, I would just go back to the point that I was making earlier that I worry that Chairman Miller's bill is written in such a way that it denies benefits to certain veterans. And I appreciated your comment that you would like to see it expanded so that you could serve all veterans. Do you agree that the legislation, as written now, would not offer options to same-sex couples who might need help starting a family? Dr. Jain. Thank you for that question, Congresswoman. This has a lot of legal implications, so I am going to turn to my OGC colleague, Jennifer, to address that. Ms. Titus. Okay. Ms. Gray. Yes, thanks, Congresswoman. You have raised some important questions on an important issue with this legislation, and we will need to research this further, but we are more than happy to discuss the applicability of this provision with you at a later date once we have looked into it a little bit more. Ms. Titus. You needed help to say that, Dr. Jain. Dr. Jain. Let me just clarify. I think that there is no question that we feel that restoring the physical and mental capability of our veterans is a very important mission of the VA. And the ability to be a biological parent is very important for one's mental and physical well-being and sense of well- being, so we are very much in support of this concept and I think that if the thought is to begin with the most severely injured veterans first, we certainly understand that. But at some point, we do feel that the who IVF technologies should be made available to a broader group of veterans who have medical and other reasons for not being able to be a biological parent. So I am just stating to you the broader sense that we have, but there are some legal issues with that, and that is why I wanted to turn to my colleague. Ms. Titus. I appreciate that, and I would thank you very much if you could get back to me on that so we could work together on this to be sure that all our veterans receive the benefits that they serve. Thank you, I yield back, Mr. Chairman. Mr. Benishek. Thank you, Ms. Titus. I have just another question I want to ask Dr. Jain, too. In the written testimony, Dr. Jain, you stated that the VA appreciates the intent of the draft bill to direct VA to submit an annual report on the Veterans Health Administration, but notes that the bill may be unnecessary as the data and related measures contemplated by the bill are already compiled as part of an ongoing, automated process for data that are available publicly; yet, in the testimony before the subcommittee in January, the Congressional Budget Office stated that the VA provided limited data to the Congress and the public about its costs and operational performance, and that if it was provided on a regular and systemic basis, it could help inform policymakers about the efficiency and cost-effectiveness of VHA's services. So similar sentiments were also issued by the Independent Budget and The American Legion and by others during testimony on the first panel. Can you explain the discrepancy between what you said in your testimony and the testimony of the Congressional Budget Office and the others regarding the VA's record of transparency? Dr. Jain. Sir, so this, you could consider this, in part, an evolution, I guess, you could say in our thinking. But the current secretary has made it very clear that we want to be transparent. And as you know, sir, the impact of a lot of the Choice Act legislations, we are in the process of preparing a lot of the reports, so when we saw your bill, we certainly understand the intent of what you want, but our only clarification that we would like to work with you and the Committee, is to understand what you are looking for so at the end of the day we can give you and you are satisfied with the report. That is the only hesitation of the---- Mr. Benishek. Right. Right. Dr. Jain. Yes. Mr. Benishek. Well, I think, you know, if you are already compiling the data that is required in the bill, presumably that information could be compiled into a report and provided to us. Dr. Jain. We are and, yes, that is correct. Mr. Benishek. It seems to me that the information--that you may have the information, but it is not compiled in a way that makes any sense to us. And, basically, what I am trying to figure out is what somebody else mentioned here, too: How much money are we spending on nurses and doctors and how much money are you spending on bureaucrats? Most hospitals and other people around the country who provide healthcare, they can define those kinds of numbers. The VA doesn't. I want to be sure that the billions of dollars that we are sending to the VA gets spent in the most effective way that gives the most care to our veterans and it is not being eaten up by a bureaucracy. And I think that we don't have access to those kinds of numbers, Dr. Jain, and those are exactly the kinds of numbers that I am asking you for. Where is the money going and how are you compared to everybody else in spending these billions of dollars that we send to the veterans healthcare? Dr. Jain. Absolutely, sir. I think once we can work with you and the Committee to understand your needs--we don't have that data ready-made; that is the difference, I think, is what I believe what was stated in the previous testimony. And we don't have it today, either. We have pieces of that, but if we understand your needs, we are willing to work with you and to provide to you---- Mr. Benishek. Well, I am glad that you agree with me that there is more data---- Dr. Jain. Right. Mr. Benishek [continuing]. That VA needs to provide to policymakers so we can make better decisions. Dr. Jain. Yes, sir. Mr. Benishek. So I am happy to hear that from you. I am going to yield back, and does anyone else have any other questions that they would like to ask? Well, thank you very much, Dr. Jain for being on the panel. Thank you for being here, and all the others, and for those who attended as well. We may be submitting additional questions for the record, and I would appreciate your assistance in ensuring that an expedient response to these inquiries is given. And with that, if there are no further questions, the third panel is excused. I ask unanimous consent that all members have five legislative days to revise and extend their remarks and exclude extraneous material. Without objection, so ordered. I would like to thank, again, all the witnesses. The hearing is now adjourned. [Whereupon, at 12:46 p.m., the subcommittee was adjourned.] APPENDIX Prepared Statement of the Chairman Jeff Miller It is a pleasure to be here today with you, Subcommittee Ranking Member Brownley, and other Members of the Subcommittee on Health as well as with representatives from our Veterans Service Organizations (VSOs), interested stakeholders, and audience members to discuss my draft bill to improve the reproductive treatment provided to certain disabled veterans. The conflicts in Iraq and Afghanistan over the last decade have resulted in significant increases in reproductive organ and spinal cord injuries among our servicemembers. These wounds can have serious and life-long repercussions on the daily lives of our veterans and their families, not the least of which can be the inability to conceive a child. While the Department of Veterans Affairs (VA) does provide a number of fertility services to veterans, VA is currently prohibited via regulation from providing In Vitro Fertilization (IVF), one of most well-known and arguably most effective assisted reproductive technologies. The VA is also prohibited by statute from providing any such treatment to a veteran's spouse. In contrast, the Department of Defense has been providing IVF to severely wounded servicemembers since 2010. What this disparity results in is severely disabled veterans having to decide whether or not to pursue a family though IVF before they separate from service-while still actively recovering from their wounds and during what can be a highly stressful transition period-or pay for the procedure out-of-pocket once they move to veteran status. Because IVF can be costly, for some veterans, waiting until they are in VA care can mean having to choose between financial freefall or forgoing their dreams of having a child altogether. That is an agonizing and unacceptable choice that this draft bill would help prevent veterans with these disabilities from ever having to make. The draft bill would authorize VA to provide assisted reproductive technology, in addition to any fertility treatment already authorized, to enrolled veterans whose service- connected disability includes an injury to the reproductive organs or spinal cord that directly results in the inability to procreate without the use of assisted reproductive technology. Assisted reproductive technology is defined in the bill to include IVF as well as other technologies determined by VA as appropriate to be used to assist reproduction. In furnishing IVF or similar procedures to an eligible veteran, VA would also be authorized to provide services to that veteran's spouse. Like DoD, VA would be limited to providing eligible veterans three in vitro fertilization cycles, resulting in a total of not more than six implantation attempts. The draft bill would further stipulate that VA is authorized to provide for storage of genetic material for three years, after which the veteran and his or her spouse is responsible for the costs of such storage; that VA cannot possess or make any determinations regarding the disposition of genetic material; and, that VA is required to carry out activities relating to the custody or disposition of genetic material in accordance with the relevant state law. Finally, the draft bill would prohibit VA from providing any benefits relating to surrogacy or third-party genetic material donation. In short, this legislation mirrors the IVF benefit that is provided to active-duty servicemembers in DoD, creating parity between the two Departments while opening the door to parenthood for disabled veterans who may otherwise not have the resources to pursue such a path. I am proud to say that this proposal is supported by many of our VSOs, by RESOLVE: The National Infertility Association, and by the American Society for Reproductive Medicine. I thank them all for their support of this draft and for their thoughtful comments and recommendations for how it may be improved. I look forward to working hand-in-hand with Subcommittee Members to address those suggestions and otherwise strengthen the language in the draft bill before it is introduced and moved forward. This draft is derived partly from the recent Subcommittee roundtable where infertility among disabled veterans was discussed in depth and I am grateful to you, Dan, for holding that roundtable as well as this hearing today. I urge all of my colleagues to join me in supporting this draft bill and, with that, I yield back.
Prepared Statement of the Hon. Gus M. Bilirakis Chairman Benishek, Ranking Member Brownley, and members of the Health Subcommittee, Thank you for holding this very important hearing and for the opportunity to discuss my bill, H.R. 271, the Creating Options for Veterans' Expedited Recovery (COVER) Act. With statistics showing that one in five Veterans who served in Iraq and Afghanistan have been diagnosed with Post- Traumatic Stress, we must responsibly ask ourselves--are we doing enough when it comes to addressing mental health in our Veteran population? Recent data has shown that every day in this country--an estimated 18-22 Veterans take their own lives. This statistic answers the question I posed earlier. It is obvious more needs to be done. That is why I reintroduced the COVER Act in the 114th Congress. The COVER Act will establish a commission to examine the Department of Veterans Affairs current evidence-based therapy treatment model for treating mental illnesses among veterans. Additionally, it will analyze the potential benefits of incorporating complementary alternative treatments available within our communities. The duties of the commission designated under the COVER Act include conducting a patient-centered survey within each Veterans Integrated Service Network. The survey will examine several different factors related to the preferences and experiences of Veterans with regard to their interactions with the Department of Veterans Affairs. Instead of presuming to know what is best for Veterans, we should simply ask them and work with them on finding the right solutions that best fits their unique needs. The scope of the survey will include: the experience of a Veteran when seeking medical assistance with the Department of Veterans' Affairs; the experience of Veterans with non-VA medical facilities and health professionals for treating mental health illnesses; the preferences of a Veteran on available treatments for mental health and which they believe to be most effective; the prevalence of prescribing prescription drugs within the VA as remedies for treating mental health illnesses; and outreach efforts by the VA Secretary on available benefits and treatments. Additionally, the commission will be tasked with examining the available research on complementary alternative treatments for mental health and identify what benefits could be attained with the inclusion of such treatments for our Veterans seeking care at the VA. Some of these alternative therapies include, among others: accelerated resolution therapy, music therapy, yoga, acupuncture therapy, meditation, outdoor sports therapy, and training and care for service dogs. Finally, the commission will study the potential increase in health claims for mental health issues for Veterans returning from the most recent theatres of war. We must ensure that the VA is prepared with the necessary resources and infrastructure to handle the increase in those utilizing their earned benefits to address the mental and physical ailments incurred from military service. Once the Commission has successfully completed their duties, a final report will be issued and made available outlining its recommendations and findings based on their analysis of the patient-centered survey, alternative treatments and evidence-based therapies. The Commission will also be responsible for creating a plan to implement those findings in a feasible, timely, and cost effective manner. Last Congress, I was very pleased this subcommittee considered the COVER Act in a legislative hearing. At this hearing, all the Veterans Service Organizations (VSOs) and organizations testifying had supported the COVER Act. I want to thank you all again for your support through your testimonies given today. In closing, we have the support from Veterans and the organizations that work closely with them. And it is clear that there is a need to do more in how we--as a nation--address these challenges. The responsibility is ours. The question now is--what do we intend to do about it. With that, I urge all my colleagues to show your support for our nation's heroes by signing onto H.R. 271. Let's get this done for our Veterans and let's work together on finally getting them ``covered.'' Prepared Statement of Hon. Janice Hahn I would like to thank this Subcommittee, especially Chairman Benishek and Ranking Member Brownley--two friends of mine--for holding this important hearing. Homeless veterans are a pressing problem for this nation. More than 62,000 veterans are homeless on any given night, and over 120,000 veterans will experience homelessness over the course of the year. While only 7% of Americans qualify as veterans, veterans make up nearly 13% of the homelessness population. Sadly, my home of Los Angeles County has the most homeless veterans in the nation. Today, I want to address one segment of homeless veterans-- those who are homeless because of domestic violence. Currently, the Department of Veterans Affairs' definition of homeless veterans does not include veterans who are homeless because of domestic violence. Across the country, too many victims of domestic violence feel that there is nowhere for them to turn. Lacking resources, help and a safe place to go, some victims stay with their abusers. Tragically, too often women veterans are among those who find themselves in this horrible situation. According to the VA, 39% of our women veterans report experiencing domestic violence, well above the national average. However, because of antiquated laws on the books, they have not been eligible to access resources designated for ``homeless veterans.'' I approached Chairman Benishek with my legislation--H.R. 627, which updates the definition of ``homeless veteran'' to include victims fleeing domestic violence, not only was he extremely supportive of it, he joined me in introducing it. For that, I thank you Mr. Chairman. Our legislation will update the definition of homeless veteran to include veterans fleeing domestic violence, and will correct this oversight and ensure that veterans fleeing domestic violence can receive benefits from the VA. This is a minor change of great importance to ensure veterans do not feel trapped in dangerous situations. H.R. 627 is endorsed by countless veterans organizations, such as Veterans of Foreign Wars (VFW), AMVETS, The National Coalition for Homeless Veterans, The Service Women's Action Network, Blinded Veterans Association, and the list goes on and on. Providing benefits to veterans driven to homelessness by domestic violence is something we all should support--and have supported in the past. In fact, I have worked with the House Appropriations Veterans Affairs Subcommittee to include report language the past two years to make these benefits available. That process, however, only helps until the next year and has to be repeated every year to provide temporary help. Now is the time to stop making temporary fixes. This legislation permanently fixes this loophole for veterans. While it is unknown how many veterans will be helped by this bill, if it provides one veteran the support they need to leave a dangerous situation, our work here will be worth every minute. We must step up to provide these heroes who have protected us with the resources they need including a place where they can be safe and protected. In conclusion, I want to thank you for working with me to solve an urgent problem, and I yield back the balance of my time. Prepared Statement the Hon. Jackie Walorski Good morning Chairman Benishek, Ranking Member Brownley, and members of the Committee. Thank you for the opportunity to discuss H.R. 1369, the Veterans Access to Extended Care Act. This important bill will allow the Department of Veterans Affairs (VA) to enter into provider agreements for extended care services. VA offers a variety of long-term services and supports to veterans in the form of nursing home care, adult day care, respite care, domiciliary services, hospice and palliative care. Care is provided through VA medical centers, State Veterans Homes, or other community organizations. Currently, non-VA providers at community organizations must contract with the VA to provide these kinds of services. Under the Service Contract Act (SCA), these community providers are considered federal contractors, a designation that imposes burdensome reporting requirements relating to the demographics of contractor employees and applicants, ultimately discouraging numerous providers from entering into contracts with the VA. For these organizations, reimbursement from the VA for caring for veterans is simply not worth the cost of compiling and reporting the data required by general federal contract law. This situation has left many veterans and their families without the ability to find providers close to their homes. On February 13, 2013, the VA released proposed rule, RIN 2900-A015, which would have increased access to these non-VA extended care services from local providers,\1\ by permitting these providers to enter into agreements with the VA under the same guidelines that providers for Medicare enter into agreements with the Centers for Medicare & Medicaid Services (CMS). This means that non-VA providers would no longer be considered federal contractors. Non-VA providers would still have to comply with all federal hiring laws, but they would be relieved from the burdensome reporting requirements. --------------------------------------------------------------------------- \1\ Use of Medicare Procedures To Enter Into Provider Agreements for Extended Care Services, Proposed Rule: RIN 2900-AO15. Federal Register Vol. 78, No. 30 (February 13, 2013). --------------------------------------------------------------------------- In conjunction with a Senate letter that was sent in June of 2014, Congresswoman Tulsi Gabbard and I, along with 107 of our colleagues in the House sent a letter in August of 2014 to Secretary McDonald encouraging the release of the final VA provider agreement rule. Unfortunately, despite the willingness of the Department, the VA never had the legislative authority to begin with to enact this rule. In response, Representative Gabbard and I introduced H.R. 1369, Veterans Access to Extended Care Act. This commonsense bill gives the VA the legislative authority it needs to follow through with the original proposed rule. Specifically, this bill amends subparagraph (B) of section 1720(c) (1) of Title 38 of the U.S. Code by adding an exemption for extended care service providers from being treated as federal contractors for the acquisition of goods or services. The bill also modifies section 6702(b) of Title 41 of the U.S. Code, which relieves providers from certain reporting requirements to the Department of Labor. Lastly, it includes quality assurance provisions to ensure the safety and a high standard of care our veterans deserve. Should a provider fail to comply with a provision of the agreement, VA has the authority to terminate the agreement. Eliminating this contractor designation will encourage more extended care service providers to enter into agreements, which will provide veterans with more options in the community. Incentivizing more local providers to work with the VA will increase access to care that is closer to home allowing nearby family and friends to provide an additional support structures to our veterans. The family structure during these times is a vital part of ensuring a veteran's quality of life. These individuals have sacrificed so much in the name of liberty; they should not have to worry about being unable to find care close to home because their hometown providers do not have the resources necessary to qualify as a government contractor. Eliminating this designation will encourage more extended care service providers to enter into agreements, which will provide veterans with more options in the community that will allow their family, friends to provide an additional support structure for them. Providing veterans with the care they need and deserve continues to be a top priority of mine and every member of this committee. I am grateful to work with Representative Gabbard, Senator Hoeven, Senator Manchin, and the Committee in addressing this critical issue for veterans. I thank you again for this opportunity to speak today. [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] Statement for the Record Statement of Hon. Corrine Brown, Full Committee, Ranking Member Women Veterans Readjustment and Reintegration Mr. Chairman and Members of the Committee, I would like to offer this testimony on behalf of H.R. 1575, legislation to honor the service and sacrifice of our heroic women veterans recently separated from military service after prolonged deployments. This bill extends and makes permanent a very successful pilot program at the Department of Veterans Affairs which provides psychiatric and psychological counseling and support in retreat settings for newly returned women veterans. This legislation follows the release of a report by the Veterans Health Administration showing that this limited, 2- year pilot program, run by the Readjustment Counseling Service, has shown positive, measurable results helping returning women veterans experiencing post-traumatic stress, depression, sleep disturbances and isolation. Many of these servicewomen have been evaluated as service connected for severe PTSD. In surveys, participants have consistently reported experiencing a marked decrease in stress symptoms and an increase in coping skills, including understanding better how to develop support systems and to access available resources at VA and in their communities following the program and as they reenter civilian life. The Veterans Health Administration has completed six retreats in the two year pilot period. Post 9/11 women veterans, often combat veterans, are brought together in groups of about 20, in outdoor settings. Transportation is paid for. These one-week sessions were held in California, Colorado, New Mexico and Connecticut. The veterans, most of whom are coping with the effects of severe PTS, some as a result of sexual trauma while in the military, participated in trust building exercises and worked with counselors and psychological educators to build peer support. Other services offered on an as-needed basis are financial and occupational counseling and conflict resolution training. H.R. 1575 provides VA with permanent authority to extend the program using the same measurements and eligibility requirements in the original law, P.L. 111-163. This expansion will mean an increase in the number of sessions and locations for the program. VA must submit a report to Congress every two years on the program. This program is limited, well run and highly successful thereby providing us with a bit of good news and, more importantly, a chance to ensure a healthier, more successful transition back to civilian life for a specific group of heroic women warriors. I appreciate the opportunity to provide this testimony on behalf of H.R. 1575, invite my colleagues' support, and look forward to its enactment as soon as possible. American Health Care Association Dear Chairman Dan Benishek: I serve as the president and chief executive officer of the American Health Care Association (AHCA), the nation's largest association of long term and post-acute care providers. The association advocates for quality care and services for the frail, elderly, and individuals with disabilities. Our members provide essential care to millions of individuals in more than 12,000 not for profit and for profit member facilities. AHCA, its affiliates, and member providers advocate for the continuing vitality of the long term care provider community. We are committed to developing and advocating for public policies which balance economic and regulatory principles to support quality of care and quality of life. Therefore, I appreciate the opportunity today to submit a statement on behalf of AHCA for the hearing record in strong support of the Veterans Access to Extended Care Act (H.R. 1369/S. 739), which would grant the U.S. Department of Veterans Affairs (VA) the legislative authority to enter into Provider Agreements for extended care services. The VA released a proposed rule, RIN 2900-A015, on Provider Agreements in February of 2013. This important rule, among other things, increases the opportunity for veterans to obtain non-VA extended care services from local providers that furnish vital and often life-sustaining medical services. This rule is an example of how government and the private sector can effectively work together for the benefit of veterans who depend on long term and post-acute care. Last Congress, close to half of the U.S. Senate chamber and 109 U.S. House members signed onto a letter to the VA encouraging the release of the final VA provider agreement rule. It was determined that the VA needs the legislative authority to enter into these agreements, which the Veterans Access to Extended Care Act provides. It is long-standing policy that Medicare (Parts A and B) or Medicaid providers are not considered to be federal contractors. However, if a provider currently has VA patients, they are considered to be a federal contractor and under the Service Contract Act (SCA). The Veterans Access to Extended Care Act would ensure that providers could enter into VA Provider Agreements, and would therefore not have to follow complex federal contracting and reporting rules that come with being deemed a federal contractor or under the SCA. Federal contracts come with extensive reporting requirements to the Department of Labor on the demographics of contractor employees and applicants, which have deterred providers, particularly smaller ones, from VA participation. The use of Provider Agreements for extended care services would facilitate services from providers who are closer to veterans' homes and community support structures. Once providers can enter into Provider Agreements, the number of providers serving veterans will increase in most markets, expanding the options among veterans for nursing center care and home and community- based services. Services covered as extended care under the proposed rule include: nursing center care, geriatric evaluation, domiciliary services, adult day healthcare, respite care, and palliative care, hospice care, and home healthcare. AHCA endorses H.R. 1369/S. 739, and applauds Congresswomen Jackie Walorski (R-IN-2nd) and Tulsi Gabbard (D-HI-2nd) and Senators John Hoeven (R-ND) and Joe Manchin (D-WV) for introducing this important legislation that will ensure that those veterans who have served our nation so bravely have access to quality healthcare. Thank you again for the opportunity to comment on this important matter. Sincerely, Mark Parkinson, AHCA/NCAL President & CEO ------ American Society for Reproductive Medicine Dear Chairman Dan Benishek: Thank you for the opportunity to offer comments regarding draft legislation to allow the Department of Veterans Affairs to provide reproductive treatment to disabled veterans that includes in vitro fertilization. The American Society for Reproductive Medicine is pleased that you have considered this bill for a public hearing. It is nothing but unjust to send our military personnel into harm's way and to not provide health care services to address health care needs that arise due to their service and dedication to our country. ASRM solidly supports the provision of fertility services to severely wounded veterans, particularly given that similarly situated individuals with coverage under TRICARE are allowed this covered benefit. ASRM is a multidisciplinary organization of nearly 8,000 medical professionals dedicated to the advancement of the science and practice of reproductive medicine. ASRM members include obstetrician/gynecologists, urologists, reproductive endocrinologists, nurses, embryologists, mental health professionals and others. As the medical specialists who present treatment options for patients and perform procedures during what is often an emotional time for them, we recognize how important a means to addressing their medical condition can be for those hoping to build their families. The draft legislation would direct the Secretary of Veterans Affairs to provide fertility treatment, including in vitro fertilization, to a disabled veteran who has an injury to his/her reproductive organs or spinal cord and such injury directly results in the veteran being unable to procreate without assisted reproductive technology. Importantly, the draft bill provides the same treatment for the veterans' spouse. We find that the coverage regarding number of in vitro fertilization attempts and number of years of storage of genetic material is reasonable. In providing for the coverage of cryopreservation of genetic material, we would recommend the bill specifically include gametes (sperm and egg) and also embryos that may be created as part of the assisted reproduction procedure. It is important that the cryopreservation of genetic material include gametes because the disabled veteran may not be in a position to begin the part of fertility treatment that includes in vitro fertilization until he/she is better able to emotionally and physically prepare for that treatment. The cryopreservation of gametes allows for the processes of fertilization and transfer of any resulting embryos to occur when the patient is ready for that process. The bill could go further to specifically include coverage of services to those affected by infertility caused by exposure to toxins during their deployment as these exposures can also compromise one's ability to reproduce. So too, fertility preservation is a common concern for military personnel with orders to deploy. While this is not currently a covered benefit under TRICARE and it is not within this panel's jurisdiction to make requirements of the TRICARE program, fertility preservation is an important topic to raise. The technology exists to provide these services. The nature of the promises we make to those individuals who risk everything for our country warrants a thoughtful examination of whether this benefit should also be part of the covered services for military personnel. ASRM would further recommend that the bill allow for the use of donor gametes as part of the covered treatment options. For some severely injured veterans, sperm or egg retrieval may be impossible. The desire to have a family is no less important to those individuals and third party collaboration as a family building option is an appropriate medical option for some infertile patients. The bill limits required treatments to disabled veterans or their spouse. Until such time that every state legally recognizes the marriage of same sex partners, the effect of this bill will be that only those veterans whose marriage is deemed legal will be furnished those services outlined in the bill. This effectively denies coverage to injured veterans who are single or who are in same sex partnerships. It is no longer a stigma to reproduce outside of the context of marriage, or a male/female marriage, and ASRM would recommend that holding veterans to a standard that is not the norm any longer in today's society is discriminatory just as denying to these individuals the ability to serve in the military. Thank you for the opportunity to comment on this bill and for your attention to this important public health issue. Our nation's military personnel and veterans deserve to have access to the full complement of infertility treatments that are available and we are pleased that this committee has recognized the need to correct the inequities that exist between the health plans available under the DoD and the Veterans' Health plans. Sincerely, Rebecca Z. Sokol, MD, MPH, President, American Society for Reproductive Medicine Concerned Veterans For America Draft Legislation on Reproductive Treatment for Disabled Veterans To amend title 38, United States Code, to improve the reproductive treatment provided to certain disabled veterans. CVA has no position on this legislation. Draft Legislation Requiring an Annual VHA Report To amend title 38, United States Code, to direct the Secretary of Veterans Affairs to submit an annual report on the Veterans Health Administration and the furnishing of hospital care, medical services, and nursing home care by the Department of Veterans Affairs. CVA supports the principles of the legislation, which requires more detailed reporting from VHA in important areas where data have been lacking. In order to ensure accountability, it is important that VHA report its performance numbers in a way that enables decision-makers and veterans to assess their efficiency and efficacy. A CBO report released last December which examined the comparative cost of VA-provided healthcare versus and private- sector healthcare notes that ``Comparing health care costs in the VHA system and the private sector is difficult partly because the Department of Veterans Affairs (VA), which runs VHA, has provided limited data to the Congress and the public about its costs and operational performance''. \1\ --------------------------------------------------------------------------- \1\ Congressional Budget Office. (2014). Comparing the Costs of the Veterans' Health Care System With Private-Sector Costs (CBO Publication No. 49763). Washington, DC: U.S. Government Printing Office. Retrieved from https://www.cbo.gov/sites/default/files/cbofiles/attachments/ 49763-VA--Healthcare--Costs.pdf. --------------------------------------------------------------------------- This legislation would be an important step towards making sure that the VHA and the VA become more transparent institutions, which would benefit both the taxpayers and the veterans. While CVA remains committed to comprehensive reform of VHA and the Department of Veterans Affairs, these reporting requirements are an important step toward more accountability and better care for our veterans. CVA supports this legislation. Draft Legislation: The Toxic Exposure Research Act of 2015 To establish in the Department of Veterans Affairs a national center for research on the diagnosis and treatment of health conditions of the descendants of veterans exposed to toxic substances during service in the Armed Forces that are related to that exposure, to establish an advisory board on such health conditions, and for other purposes. CVA has no position on this legislation. HR 271: The Cover Act To establish a commission to examine the evidence-based therapy treatment model used by the Secretary of Veterans Affairs for treating mental illnesses of veterans and the potential benefits of incorporating complementary alternative treatments available in non-Department of Veterans Affairs medical facilities within the community. CVA has no position on this legislation. HR 627: To Expand of Definition of Homelessness To amend title 38, United States Code, to expand the definition of homeless veteran for purposes of benefits under the laws administered by the Secretary of Veterans Affairs. CVA has no position on this legislation. HR 1369: Veterans Access to Extended Care Act of 2015 To modify the treatment of agreements entered into by the Secretary of Veterans Affairs to furnish nursing home care, adult day health care, or other extended care services, and for other purposes. CVA believes that this legislation represents a good step forward in alleviating the problems that the Department of VA has in providing veterans access to the care that they need and increasing the partnership between VA and private sector care, by simplifying the process that non-VA providers must go through to enable them to provide extended care to veterans. CVA strongly believes that it is important to ensure that there are more choices for veterans regarding the services that are available to them within the current overall institutional arrangement, and that VA should work with private-sector healthcare providers in effective ways to ensure that veterans receive the quality of care they deserve. This legislation is in keeping with that goal. CVA supports this legislation. HR 1575: Retreat Counseling for Women Veterans To amend title 38, United States Code, to make permanent the pilot program on counseling in retreat settings for women veterans newly separated from service in the Armed Forces. CVA has no position on this legislation. ---- RESOLVE: The National Infertility Association Dear Chairman Dan Benishek: Thank you for the opportunity to provide this statement regarding draft legislation to improve reproductive treatment provided to certain disabled veterans. This is incredibly important legislation for our wounded warriors who expect our government to care for them if they are injured in their service to our country. The ability to procreate is the most basic and fundamental desire of human beings. If that ability is damaged as a result of their service, then we owe it to them to provide access to medical treatments that will allow them to become a parent. RESOLVE: The National Infertility Association was founded in 1974 to provide information, support, awareness and advocacy for women and men living with infertility. RESOLVE is the oldest and largest patient advocacy organization in the U.S. and the only patient organization advocating for access to infertility services for our active duty military and veterans. We applaud the committee for discussing this important topic. The draft legislation provides for certain disabled veterans to access in vitro fertilization (IVF). Right now the Veterans Administration is prohibited from providing access to IVF, which causes a critical gap in coverage since that same benefit is offered to wounded service-members still covered under TRICARE. While the TRICARE supplemental benefit for certain wounded service-members is needed, most of those who could benefit from IVF transition to the Veteran's health system and by the time they are ready to become a parent, they discover that the VA does not provide access to IVF. This draft legislation will fix this gap in service and solve a major problem facing our disabled veterans. This bill also provides for access to reproductive care for the spouse of a veteran. While the VA is not responsible for the healthcare of spouses and dependents, reproduction is unique in that male and female gametes (sperm and egg) are needed as well as a female to carry the pregnancy. Only providing care to the male or female does not work--both must be treated. We do ask that the committee consider all of the injuries that may result in infertility, as the bill only covers injury to the reproductive organs or spinal cord. Amputations, Traumatic Brain Injuries and exposure to toxins and chemicals can also impact the ability to procreate without assisted reproductive technologies. All of our wounded veterans with infertility should have access to this coverage. We applaud the committee for this important first step in opening up advanced reproductive care to veterans. We are hopeful that this first step will lead to further coverage in the future for all veterans, not just those with a service related injury; access to IVF for service-members covered under TRICARE; coverage for fertility preservation before deployment (the freezing of sperm, eggs and/or embryos); access to care for those who are single or not married with infertility; and coverage for the use of donor gametes (donated sperm, egg or embryos) for those who can no longer produce viable gametes to have a child. We stand ready to work with Congress to get this important legislation passed as quickly as possible. Our Veterans are waiting--we owe it to them to fix this coverage gap with the VA and let them access the advanced medical care that they need and so deserve. Sincerely, Barbara L. Collura, President & CEO RESOLVE: The National Infertility Association, 7918 Jones Branch Drive, Suite 300, McLean, VA 22102, www.resolve.org [email protected], 1-703-556-7172 ---- Veterans of Foreign Wars of the United States Statement of Carlos Fuentes, Senior Legislative Associate National Legislative Service, Veterans of Foreign Wars of the United States APRIL 23, 2015 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. 271, Creating Options for Veterans Expedited Recovery (COVER) Act: The VFW supports this legislation, which would establish a commission to examine the efficacy of the Department of Veterans Affairs' (VA) mental healthcare and identify ways to improve outcomes. Too often, the VFW hears stories of veterans who have been prescribed high doses of ineffective medications to treat their mental health conditions. Many of these medications, if incorrectly prescribed, have been known 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 complementary and alternative medicine (CAM) therapies, VA must ensure it affords veterans the opportunity to access effective mental health treatments that minimize adverse outcomes. VA has made a concerted effort to change its mental healthcare 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 veterans alternative--non- pharmacotherapy--modalities for pain management. Last month, VA deployed the Opioid Therapy Risk Report, a byproduct of the Opioid Safety Initiative, to enable providers to better track and manage their patients' high-dose prescriptions. Timely and accessible mental healthcare 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 progress in reducing its dependence on pharmacotherapy to treat mental health conditions and manage pain. However, more can be done to ensure veterans have access to CAM therapies that minimize side effects and improve outcomes. H.R. 627, to expand the definition of homeless veteran for purposes of benefits under the laws administered by the Secretary of Veterans Affairs: The VFW is pleased to support this legislation, which would clarify the definition of homeless, thereby aligning it with the McKinney-Vento Act to include those displaced by domestic violence. No veteran should ever be homeless, and expanding the definition of homeless to include veterans who are fleeing situations of domestic abuse is the right thing to do. This change would ensure veterans who have the courage to leave their abusive and sometimes life-threatening situations receive access to the benefits VA already provides to thousands of homeless veterans. The VFW believes this legislation will significantly improve the lives of those who become homeless as a result of difficult circumstances outside of their control, and help them begin a new chapter in their lives. H.R. 1369, Veterans Access to Extended Care Act of 2015: The Veterans Access to Extended Care Act of 2015 would strengthen VA's authority to enter into provider agreements with extended care facilities, while ensuring such facilities meet certain safety and quality standards. The VFW supports this legislation, but urges the Subcommittee to ensure it provides VA the authority it needs to properly administer all of its nursing home, assisted living, patient-directed and extended care authorities and programs. VA has the authority to enter into provider agreements with extended care facilities to provide long-term care to veterans who need nursing home level services. However, a recent opinion by the Department of Justice found that VA provider agreements must comply with Federal Acquisition Regulations (FAR). Thus, VA has been unable to proceed with its plans to use its provider agreement authority to expand the extended care services it provides veterans. The VFW has heard from many private sector extended care facilities that want to care for veterans, but do not have the staff to comply with the onerous compliance requirements under the FAR. As a result, veterans throughout the country received notice that they may be uprooted from the nursing homes they have called home for many years. For example, the VFW has received assistance requests from nearly a dozen family members of veterans in a nursing home in Lincoln, NE, that may no longer be able to provide services to veterans if its provider agreement with VA is not renewed. One of the veterans has rapidly progressing multiple sclerosis and needs comprehensive healthcare services. His family tells us he is satisfied with the ``excellent care'' he receives and was looking forward to calling the nursing facility ``his home for the remainder of his days.'' This legislation would ensure this veteran and many like him are able to remain in the extended care facilities they call home, and authorize VA to provide the same opportunity for countless veterans. H.R. 1575, to make permanent the pilot program on counseling in retreat settings for women veterans newly separated from service in the Armed Forces: This legislation would make retreat counseling services permanent for transitioning women veterans. The VFW supports this legislation and would like to offer suggestions to strengthen it, which we hope the Subcommittee will consider. VA's counseling retreat program has served as an invaluable tool to help newly discharged women veterans seamlessly transition back into civilian life. The VFW supported the original program established by the Caregivers and Veterans Omnibus Health Services Act of 2010 and is happy to see this program continue. Another successful program created by the Caregivers and Omnibus Health Services Act of 2010 is the childcare pilot program. This program has been well received by veterans at all four pilot sites and has also contributed to the success of the counseling retreat program. The VFW has heard from veterans who say they could not have completed their treatment programs if not for the services offered through VA's childcare pilot program. When extending successful mental healthcare programs, such as the retreat counseling program for women veterans, the Subcommittee must ensure external barriers to access are removed to grant veterans the opportunity to receive the VA healthcare and services they need. The VFW urges the Subcommittee to amend this legislation to extend and expand the childcare program to every VA medical center to ensure newly discharged women veterans with children are not precluded from obtaining the benefits and services they have earned and deserve. H.R. 1769, Toxic Exposure Research Act of 2015: The Toxic Exposure Research Act of 2015, which would establish an advisory board and a national center for research, would begin to address the multiple health issues faced by veterans and their descendants as a result of service-related toxic wounds. The VFW is pleased to offer its strong support for this legislation. This nation has a long history of offering healthcare and compensation benefits to veterans who suffer traditional wounds on the battlefield. Veterans who suffer from toxic wounds, however, have traditionally faced a much more difficult road towards accessing the healthcare and benefits they have earned and deserve. The VFW believes that toxic wounds are wounds just the same and should be treated just as seriously as physical or mental wounds. Veterans who suffer from conditions as a result of service-related toxic exposure are equally deserving of VA healthcare and benefits. Toxic wounds are different than other wounds, since toxic exposures have the potential to affect a veteran's descendants for several generations. For this reason, we strongly support the provision of this bill that would establish a national center for research to study the health effects service-related toxic wounds have on the descendants of individuals who were exposed to toxic substances during their military service. Children of Vietnam veterans who were exposed to Agent Orange receive VA care and benefits for spina bifida, a debilitating health condition associated with a parent's exposure to dioxins found in Agent Orange. The VFW suspects that descendants of Vietnam veterans may suffer from additional health conditions that may be associated with exposure to Agent Orange. In addition, exposure to toxic substances is not limited to Vietnam veterans. The descendants of veterans who were exposed to toxic chemicals during the Gulf War, veterans of Iraq and Afghanistan exposed to open air burn pits, and service members exposed to contaminated water in Camp Lejeune, just to name a few, may all be suffering from diseases at a higher rate than the general population. This legislation is a step toward ensuring veterans' descendants can finally get the care and benefits they need. Draft Legislation to Improve the Reproductive Treatment Provided to Certain Disabled Veterans: This important legislation would expand VA's authority to furnish fertility treatments to veterans who have lost their ability to start a family as a direct result of their service- connected injuries. The VFW supports this legislation and would like to offer suggestions to strengthen it, which we hope the Subcommittee will consider. Due to the widespread use of improvised explosive devices during the wars in Iraq and Afghanistan, both female and male service members have suffered from spinal cord, reproductive, and urinary tract injuries. Many of these veterans hope to one day start families, but their injuries prevent them from conceiving. When these veterans seek fertility treatment from VA, they are told VA services are very limited. In fact, VA is prohibited from providing certain fertility treatments like In Vitro Fertilization. This legislation would expand VA's authority by aligning it with the Department of Defense's authority to furnish assisted reproductive treatments to severely injured service members. However, service-connected infertility is not limited to those who have suffered reproductive organ and spinal cord injuries. Other injuries and illnesses such as Traumatic Brain Injuries and other mental health conditions are known to cause infertility. Such veterans deserve the same opportunity to start a family as their fellow veterans who have suffered injuries to their reproductive organs. For that reason, the VFW urges the Subcommittee to expand the eligibility for infertility treatment to severely wounded, ill, or injured veterans who have infertility conditions incurred or aggregated by their military service. Additionally, veterans may have personal objections to assisted reproductive technologies such as In Vitro Fertilization and would like to pursue other options, such as adoption. However, VA is not currently authorized to help veterans cover the cost of adoption. The VFW believes that VA must have the authority to provide veterans the fertility treatment options that are best suited for their particular circumstances. For that reason, we urge the Subcommittee to grant VA more expansive fertility treatment authorities. This legislation takes several steps toward ensuring veterans who have lost their ability to reproduce have the ability to start a family. It would authorize VA to cryopreserve a veteran's genetic material for up to three years. Starting a family is a life changing decision that takes time and should not be hastily made. The VFW strongly supports giving veterans the opportunity to delay such a decision. However, we urge the Subcommittee to expand the three year window. When totaled, a veteran's recovery, education and career advancement may cause them to wait years before they are physically and financially prepared to start a family. The VFW recommends that veterans be allowed to cryopreserve their genetic material for a minimum of 10 years. This will prevent veterans from feeling rushed into making family planning decisions before they are ready. Additionally, many severely wounded, ill, and injured veterans have not lost the ability to produce gametes, but have lost the ability to conceive. The VFW strongly supports the provision that would authorize VA to furnish fertility treatments to non-veteran spouses. Draft Legislation to Direct the Secretary of Veterans Affairs to submit an annual report on the Veterans Health Administration: The VFW supports this legislation, which would require VA to report the utilization and efficiency of the healthcare it provides America's veterans. Such reports would enable Congress to conduct proper oversight of the department's Veterans Health Administration. 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 2014, 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. [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] [all]