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

     LEGISLATIVE HEARING ON: H.R. 272; H.R. 353; H.R. 359; H.R. 421; H.R.
    423; H.R. 1356; H.R. 1688; H.R. 1862; H.R. 2464; H.R. 2914; H.R. 2915;
        H.R. 3016; AND, DRAFT LEGISLATION TO AUTHORIZE VA MAJOR MEDICAL
        FACILITY CONSTRUCTION PROJECTS FOR FY 2015 AND TO MAKE CERTAIN
    IMPROVEMENTS IN THE ADMINISTRATION OF VA MEDICAL FACILITY CONSTRUCTION
                                    PROJECTS

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

                                    HEARING

                                   BEFORE THE

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

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

                        ONE HUNDRED FOURTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                             TUESDAY, JULY 14, 2015

                                   __________

                               Serial No. 114-31

           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
    98-686                       WASHINGTON : 2016
    ________________________________________________________________________________________
    For sale by the Superintendent of Documents, U.S. Government Publishing Office,
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                         COMMITTEE ON VETERANS' AFFAIRS

                         JEFF MILLER, Florida, Chairman

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

                             SUBCOMMITTEE ON HEALTH

                        DAN BENISHEK, Michigan, Chairman

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

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

                                C O N T E N T S

                                  ----------

                             Tuesday, July 14, 2015

    Legislative Hearing on: H.R. 272; H.R. 353; H.R. 359; H.R. 421;
      H.R. 423; H.R. 1356; H.R. 1688; H.R. 1862; H.R. 2464; H.R.
      2914; H.R. 2915; H.R. 3016; and, Draft Legislation to Authorize
      VA Major Medical Facility Construction Projects for FY 2015 and
      to Make Certain Improvements in the Administration of VA

      								    Page

      Medical Facility Construction Projects.........................     1

                               OPENING STATEMENTS

    Dan Benishek, Chairman...........................................     1
    Julia Brownley, Ranking Member...................................     2
        Prepared Statement...........................................    39

                                   WITNESSES

    Hon. Tim Walberg, U.S. House of Representatives, 7th
      Congressional District; Michigan...............................     4
        Prepared Statement...........................................    50
    Hon. Steve Stivers, U.S. House of Representatives, 15th
      Congressional District, Ohio...................................     5
        Prepared Statement...........................................    50
    Hon. Kyrsten Sinema, U.S. House of Representatives, 9th
      Congressional District, Arizona................................     7
    Hon. Doug Collins, U.S. House of Representatives, 9th
      Congressional District, Georgia................................     9
        Prepared Statement...........................................    51
    Hon. Sean Duffy, U.S. House of Representatives, 7th Congressional
      District, Wisconsin............................................    11
        Prepared Statement...........................................    53
    Hon. Mike Coffman, U.S. House of Representatives, 6th
      Congressional District, Colorado...............................    12
        Prepared Statement...........................................    54
    Hon. Charles Boustany, U.S. House of Representatives, 3rd
      Congressional District, Louisiana..............................    14
        Prepared Statement...........................................    55
    Hon. Jeff Denham, U.S. House of Representatives, 10th
      Congressional District, California.............................    15
        Prepared Statement...........................................    56
    Hon. Brad Wenstrup, U.S. House of Representatives, 2nd
      Congressional District, Ohio...................................    16
    Ian de Planque, Legislative Director, American Legion............    20
        Prepared Statement...........................................    57
    Adrian Atizdo, Assistant National Legislative Director, Disabled
      American Veterans..............................................    21
        Prepared Statement...........................................    67
    Carlos Fuentes, Senior Legislative Associate, National
      Legislative Service, Veterans of Foreign Wars of the United
      States.........................................................    23
        Prepared Statement...........................................    78
    Madhulika Agarwal MD, MPH, Deputy Under Secretary for Health for
      Policy and Services VHA, U.S. Department of Veterans Affairs
      States and Janet P. Murphy MBA, Acting Deputy Under Secretary
      for Health for Operations and Management, VHA, U.S. Department
      of Veterans Affairs............................................    30
        Prepared Statement...........................................    86

        Accompanied by:

            Jessica Tanner, General Attorney, Office of General
                Counsel, U.S. Department of Veterans Affairs

                            STATEMENT FOR THE RECORD

    American Academy of Audiology and the American Speech-Language
      Association....................................................   104
    Children of Vietnam Veterans Health Alliance.....................   105
    International Hearing Society....................................   106
    National Medical Association.....................................   110
    Paralyzed Veterans of America....................................   111
    VetsFirst, a Program of the United Spinal Association............   118
    Warrior Canine Connection........................................   122

     LEGISLATIVE HEARING ON: H.R. 272; H.R. 353; H.R. 359; H.R. 421; H.R.
    423; H.R. 1356; H.R. 1688; H.R. 1862; H.R. 2464; H.R. 2914; H.R. 2915;
        H.R. 3016; AND, DRAFT LEGISLATION TO AUTHORIZE VA MAJOR MEDICAL
        FACILITY CONSTRUCTION PROJECTS FOR FY 2015 AND TO MAKE CERTAIN
    IMPROVEMENTS IN THE ADMINISTRATION OF VA MEDICAL FACILITY CONSTRUCTION
                                    PROJECTS

                                  ----------

                             Tuesday, July 14, 2015

                 U.S. House of Representatives,
                        Committee on Veterans' Affairs,
                                        Subcommittee on Health,
                                                       Washington, D.C.
        The subcommittee met, pursuant to notice, at 10:31 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,
    Kuster, and O'Rourke.
        Also Present: Representative Walz.

               OPENING STATEMENT OF CHAIRMAN DAN BENISHEK

        Dr. Benishek. The subcommittee will come to order.
        Before we begin, I would like to ask unanimous consent for
    my friend and colleague and member of the full committee, Mr.
    Walz from Minnesota, to sit on the dais and participate in
    today's proceedings. Without objection, so ordered.
        Good morning, and thank you all for joining us today as we
    discuss legislation that would impact and improve the
    healthcare provided to our veterans by the Department of
    Veterans Affairs.
        Our agenda this morning is ambitious. It includes 13 bills
    ranging in scope from ensuring quality healthcare outcomes for
    the growing number of women veterans to reforming VA's
    management of major medical facility construction projects.
        Given that we have a lengthy hearing ahead of us, I will
    limit my opening comments to discussing the bill on our agenda
    that I am proud to sponsor, H.R. 2464, the Demanding
    Accountability for Veterans Act.
        This bill would address a troubling pattern that we have
    seen repeatedly in subcommittee hearings and roundtables where
    the VA inspector general identifies a recommendation to resolve
    a serious issue, the VA fails to take appropriate action, and
    veterans suffer as a result.
        Such negligence and inaction would be unacceptable for any
    organization, but it is particularly unacceptable for a
    taxpayer funded Federal Government department that is charged
    with caring for the men and women who have served our Nation in
    uniform.
        The Demanding Accountability for Veterans Act would require
    the IG to provide the Committee on Veterans' Affairs of the
    House and the Senate with copies of all reports submitted to
    the VA to including an explanation of any changes made to the
    report that were recommended by the VA during the drafting
    process and the name of the VA employee responsible for taking
    action in response to the report's content.
        In turn, the VA will be required to promptly notify each
    named employee of his or her responsibility to take action,
    direct that the employee resolve the issue at hand, and provide
    the employee with counseling and a mitigation plan to support
    him or her in fully addressing the inspector general's
    recommendations.
        The bill would further require the VA to include an
    evaluation of whether or not the employee took appropriate
    action in his or her annual performance review, prohibit the VA
    from paying a bonus or performance award to any employee who
    failed to resolve an issue under their purview.
        An earlier version of the Demanding Accountability for
    Veterans Act passed the House resoundingly last Congress. I
    look forward to similar passage this Congress. We owe it to our
    veterans and to the taxpayers who pay VA's bills to ensure that
    poor-performing VA bureaucrats are held accountable for failing
    to provide the high-quality care that our veterans have earned
    and deserve.
        The Demanding Accountability for Veterans Act is critical
    to doing just that and I encourage all my colleagues to join me
    in supporting it.
        With that, I would like to thank all of our witnesses and
    audience members today for being here and I yield to Ranking
    Member Brownley for any opening statement she may have.

           OPENING STATEMENT OF RANKING MEMBER JULIA BROWNLEY

        Ms. Brownley. Thank you, Chairman Benishek, and thank you
    for calling this hearing today.
        These hearings are an important part of the legislative
    process. It is essential to our responsibilities to advance
    worthy legislation that addresses and improves medical services
    available to our veterans. Access to safe, quality healthcare
    is and must be the priority for the subcommittee.
        I am particularly pleased to see so many of my colleagues
    here today to testify on their legislation and I thank you so
    much for your interest in the well-being of veterans across our
    country.
        Mr. Chairman, while there are many worthy bills on the
    agenda today, I will focus on just three that are being
    considered at this hearing today.
        H.R. 421, the Classified Veterans Access to Care Act,
    introduced by Congresswoman Sinema would ensure that veterans
    with classified experiences have appropriate access to mental
    health services from the Department of Veterans Affairs.
        This bill was introduced in the last Congress and passed
    this committee as part of H.R. 4971 introduced by our
    colleague, Congressman O'Rourke. However, this bill was never
    considered by the full House, and I would like to thank the
    chairman for including it on the agenda today and would like to
    express my full support for this bill.
        I have two bills on the agenda today that I have recently
    introduced. The first one, H.R. 2914, the Build a Better VA
    Act, is a bill that would modify the current process for
    approving Department of Veterans Affairs' medical facility
    leases.
        Under current law, every major medical facility lease which
    incurs yearly rental costs of over a million dollars must be
    authorized by Congress. In addition, recent changes made to
    VA's leasing process require the VA to submit leasing proposals
    to the General Services Administration for delegation to the
    VA.
        This requires approval by the Committee on Transportation
    and Infrastructure in the House. Therefore, VA leases must be
    approved by the Transportation and Infrastructure Committee and
    be approved by Congress.
        In 2012, the Congressional Budget Office changed its method
    of scoring VA leases. Instead of scoring the annual cost of the
    lease, CBO scores now reflect the cost for the duration of the
    lease, often 20 or more years.
        For instance, CBO now scores a 20-year lease which costs
    the department $5 million a year at $100 million. Prior to
    2012, CBO's score would have reflected the true cost of $5
    million, a considerable difference.
        CBO's new scoring mechanism has made it impossible for the
    Veterans' Affairs Committee to authorize leases within the
    current budget caps despite the fact that no new money is
    actually spent. The result has been significant delays in
    leasing of new facilities, further delaying needed care for
    veterans across the country.
        The population of veterans is growing. The demand for VA
    healthcare is increasing and many veterans trying to access VA
    care face long wait times and crumbling infrastructure at
    outdated VA clinics and medical centers.
        CBO's actions have made authorizing new leases for
    veterans' medical facilities which are desperately needed in
    under-served veteran communities across the United States cost
    prohibitive.
        This bill would simply allow major medical facility leases
    to be authorized by a committee resolution rather than the
    legislation. It would return the authorization process to the
    Veterans' Affairs Committee to what it was before requiring a
    committee resolution. It would also harmonize this process with
    the requirement of the General Services Administration and the
    longstanding practice of the Transportation and Infrastructure
    Committee for federal buildings.
        This more rational approach would ensure that veterans have
    the facilities they need to get the healthcare they have earned
    and deserve and will help address the unacceptable wait times
    faced by many of our veterans.
        I have also introduced H.R. 2915, the Female Veterans
    Suicide Prevention Act. This bill would direct the secretary of
    Veterans Affairs to identify mental healthcare and suicide
    prevention programs and metrics that are effective in treating
    women veterans as part of the evaluation of such programs by
    the secretary.
        By analyzing data from 23 states and VA's suicide
    repository of more than 170,000 adult suicides over a ten-year
    period, VA researchers found in a May 2015 report that suicides
    among women veterans increased by 40 percent from 2000 to 2010
    compared to a 13 percent increase in suicide among civilian
    women.
        In fact, female veterans are nearly six times as likely as
    other women to commit suicide. My bill is intended to ensure
    that the VA addresses these tragedies by requiring that VA's
    evaluations of mental healthcare and suicide prevention
    programs include specific metrics on women veterans and by
    requiring the VA to identify the mental healthcare and suicide
    prevention programs that are the most effective and have the
    highest satisfaction rates among our female veterans.
        While I am disappointed that the department has not
    submitted views on my two bills before us today, I look forward
    to receiving those views in the not too distant future.
        Mr. Chairman, I look forward to the testimony from our
    witnesses today and their views on how to improve upon the many
    bills that we are considering. Thank you, and I yield back the
    balance of my time.

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

        Dr. Benishek. Thank you, Ms. Brownley.
        I am honored this morning to be joined by several of my
    colleagues to speak in support of their legislation. Joining us
    this morning is the Honorable Tim Walberg from Michigan; Sean
    Duffy from Wisconsin I imagine will be joining us here shortly;
    Steve Stivers from Ohio; Honorable Kyrsten Sinema from Arizona;
    the Honorable Doug Collins from Georgia; the Honorable Mike
    Coffman from Colorado; the Honorable Jeff Denham will probably
    be joining us as well; and the Honorable Charles Boustany from
    Louisiana; as well as the Honorable Brad Wenstrup from Ohio.
    Thank you all for being here today.
        Mr. Walberg, we will begin with you. You have five minutes
    to present your testimony.

      STATEMENT OF HON. TIM WALBERG, A REPRESENTATIVE IN CONGRESS
                       FROM THE STATE OF MICHIGAN

        Mr. Walberg. Chairman Benishek, Ranking Member Brownley,
    and members of the subcommittee, I thank you for allowing me
    the time to speak this morning in support of my legislation,
    H.R. 272, the Medal of Honor Priority Care Act of 2015, which
    raises the Medal of Honor recipients to Priority 1 level of
    care, I believe to be a common-sense, I hope noncontroversial
    and certainly bipartisan piece of legislation.
        As members of this committee are well aware, the
    Congressional Medal of Honor is the highest award for valor
    which can be bestowed upon an individual serving in the United
    States Armed Forces and is awarded to soldiers who have
    displayed conspicuous gallantry and intrepidity at the risk of
    life above and beyond the call of duty.
        The Medal of Honor is a distinguished award given to a
    select few. Less than 3,500 have been awarded and 16 awards
    have gone to soldiers who fought in the recent conflicts in
    Iraq and Afghanistan. Currently there are only 79 living Medal
    of Honor recipients.
        My State of Michigan, as you know, Mr. Chairman, is
    privileged to have two living recipients. Corporal Duane E.
    Dewey and Private First Class Robert Simanek both received the
    declaration for their heroic action in the Korean War and
    hearing of the harrowing stories of bravery has reminded me of
    the sacrifices American soldiers are willing to make to protect
    their comrades and their country.
        Medal of Honor recipients are brought most appreciation and
    I believe the small portion of our servicemembers who have gone
    above and beyond the call of duty and earned the highest honor
    in our Nation's Armed Forces have earned the right to be placed
    in the top priority group to receive their healthcare benefits.
        I would be remiss if I did not mention the idea for this
    legislation came from a veteran who lives in my district and
    works with the veteran community. All veterans deserve access
    to the healthcare they have earned. But as you all know, the VA
    uses a priority system to determine eligibility for these
    healthcare services.
        Some of the factors that will affect a soldier's priority
    group ranking are whether the soldier has service-connected
    disability, whether they were a former prisoner of war, the
    time and place of service as well as income level.
        Currently Medal of Honor recipients are in Priority Group
    3. This bill is very similar to legislation approved by this
    committee during the 113th Congress. I am proud to have support
    of the VFW, Paralyzed Veterans of America, The American Legion,
    IAVA, and to once again have the support of my colleagues from
    both sides of the aisle on this bill.
        I thank the chairman for permitting me to appear before the
    subcommittee today, and I certainly would appreciate your
    support. Thank you.

        [The prepared statement of Tim Walberg appears in the
    Appendix]

        Dr. Benishek. Thank you, Mr. Walberg.
        Mr. Stivers, you are recognized for five minutes.

     STATEMENT OF HON. STEVE STIVERS, A REPRESENTATIVE IN CONGRESS
                         FROM THE STATE OF OHIO

        Mr. Stivers. Thank you, Mr. Chairman.
        I want to thank Chairman Benishek and Ranking Member
    Brownley for including my bill, the bipartisan Veteran Dog
    Training Therapy Act, in today's legislative hearing.
        As the committee members probably know, 22 veterans commit
    suicide every day. The ranking member just talked about her
    bill that she is working on on female suicide. This is a deeply
    personal issue for me. I am a colonel in the Ohio Army National
    Guard, served in Operation Iraqi Freedom, and I have known
    people who have sadly taken their own lives.
        This epidemic requires immediate action. I appreciate what
    you are already doing, but I know there is more we can do. The
    tie between posttraumatic stress disorder and traumatic brain
    injury and suicide is well-documented, and I know you are
    taking steps to improve treatments for both those conditions.
        However, every individual is unique and different people
    respond differently to different therapies. That is why I have
    introduced the Veterans Dog Training Therapy Act with my
    colleague, Tim Walz from Minnesota.
        Thank you for your work on this. I appreciate it.
        Our bill seeks to expand access to an alternative therapy
    that is proven effective and it works for a lot of people.
    Anybody that owns a dog knows that when you are petting your
    dog, hanging out with your dog, you know, your emotions just
    kind of ease away.
        So essentially what our bill does is it creates three to
    five pilot programs in VA facilities around the country and
    then that pilot would be studied for expansion if it works or
    elimination if it doesn't work.
        These veterans would essentially get a chance to help learn
    occupational skills while training a service dog and on
    completion of the dog's training, that dog would then be given
    to a disabled veteran for future service.
        This is not a program we made from scratch. It emulates and
    copies a very successful model of a nonprofit called the
    Warrior Canine Connection which is at several Department of
    Defense medical facilities and one VA facility already in Menlo
    Park.
        So it works and it is a model that we know will work. That
    is why we decided to copy it. Veterans that are enrolled in
    this program have shown significant improvements and I believe
    that this pilot would bear out the same results.
        And it is important to note that some of the wounded
    warriors who benefit from service dog therapy had not been
    responding to other treatments. So this is something that works
    when a lot of other things fail.
        Kaiser Permanente actually did some research on the
    effectiveness of service dogs in treating PTSD and traumatic
    brain injury related symptoms. The study has shown that
    veterans who own service dogs have fewer symptoms of PTSD and
    depression, better interpersonal relationships, and an overall
    improvement in mental health. Maybe we should get some service
    dogs in Congress.
        It should also be noted that Congress did direct a research
    study in the 2010 NDAA which was signed into law in 2009, but
    that study won't be completed until 2019. There is already
    research out here that shows this works. We need to get this in
    the field as soon as possible.
        Twenty-two suicides a day, almost one an hour. If we can do
    things to prevent it, we should not wait ten years. So that is
    why Mr. Walz and I have introduced this bill. Again, this is
    not made up from scratch. It emulates the Warrior Canine
    Connection successful model and tries to emulate it and expand
    it for the future into VA facilities.
        I met one of the dogs from Warrior Canine Connection just
    last week and, you know, when she was in the office, everybody
    was calm. These service dogs just work. And so I know that this
    bill will make a difference. I know that the study won't be
    completed until 2019, but I implore you don't wait on a study
    that we all know what it is going to say.
        And I am a little disappointed I will say in the VA study.
    They have been training these dogs as like guard dogs and that
    is not what a service dog is. They need to train them in being
    gentle and, you know, very docile. And that is what Warrior
    Canine Connection has done.
        Again, this bill will help us as we try to address some of
    these people that have traumatic brain injury and posttraumatic
    stress disorder that aren't responding to other therapies and
    it will help keep their mental health in a better state. The
    results have been proven in this Kaiser Permanente study.
        I know my time is up, but I really appreciate you hearing
    my testimony today and I hope you will take this bill and help
    us get it done because it is really important and it can really
    help save lives.
        Thank you so much. Again, I want to thank Tim Walz for his
    work on it. I want to thank the chairman and ranking member
    again for allowing me to be here. And I implore you to please
    take action on this bill. Thank you.

        [The prepared statement of Steve Stivers appears in the
    Appendix]

        Dr. Benishek. Thank you very much.
        Representative Sinema, please go ahead.

    STATEMENT OF HON. KYRSTEN SINEMA, A REPRESENTATIVE IN CONGRESS
                       FROM THE STATE OF ARIZONA

        Ms. Sinema. Thank you, Chairman Benishek, and thank you,
    Ranking Member Brownley, for holding today's hearing.
        I want to first start by saying thank you to my colleagues
    who have introduced important bills to improve the quality of
    care available to veterans, especially Chairman Benishek's
    legislative, the Demanding Accountability for Veterans Act.
        We introduced this important bill together to improve
    accountability and to hold VA employees responsible for solving
    problems at the VA.
        I am here today to discuss H.R. 421, the Classified
    Veterans Access to Care Act. And thank you, Chairman Benishek,
    for allowing me time to speak today and to both the ranking
    member and the chairman for cosponsoring this legislation.
        The Classified Veterans Access to Care Act ensures that
    veterans with classified experiences can access appropriate
    mental health services at the Department of Veterans Affairs.
    Our bill directs the secretary of the VA to establish standards
    and procedures to ensure that a veteran who participated in a
    classified mission or served in a sensitive unit may access
    mental healthcare in a manner that fully accommodates the
    veteran's obligation to not improperly disclose classified
    information.
        The bill also directs the secretary to disseminate guidance
    to employees of the Veterans Health Administration including
    mental health professionals on such standards and procedures on
    how to best engage these veterans during the course of mental
    health treatment with respect to classified information.
        And, finally, this bill directs the secretary to allow
    veterans with classified experiences to self-identify so they
    can quickly receive care in an appropriate setting.
        I am working on this issue because just over two years ago,
    a veteran in my district, Sergeant Daniel Somers, failed to
    receive the care he needed and tragically lost his life to
    suicide. No veteran or family should go through the same
    tragedy that the Somers family experienced.
        Sergeant Somers was an army veteran of two tours in Iraq.
    He served on Task Force Lightning, an intelligence unit. He ran
    over 400 combat missions as a machine gunner in the turret of a
    Humvee. Part of his role required him to interrogate dozens of
    terrorist suspects and his work was deemed classified.
        Like many veterans, Daniel was haunted by the war when he
    returned home. He suffered from flashbacks, nightmares,
    depression, and additional symptoms of posttraumatic stress
    disorder made worse by a traumatic brain injury. Daniel needed
    help and he and his family asked for help.
        Unfortunately, the VA enrolled Sergeant Somers in group
    therapy sessions which Sergeant Somers could not attend for
    fear of disclosing classified information. Despite repeated
    requests for individualized counseling or some other reasonable
    accommodation to allow Sergeant Somers to receive appropriate
    care for his PTSD, the VA delayed providing Sergeant Somers
    with appropriate support and care.
        Like many, Sergeant Somers' isolation got worse when he
    transitioned to civilian life. He tried to provide for his
    family, but he was unable to work due to his disability.
    Sergeant Somers struggled with VA bureaucracy. His disability
    appeal had been pending for over two years in the system
    without resolution, but he didn't get the help he needed in
    time.
        On June 10th, 2013, Sergeant Somers wrote a letter to his
    family. In the letter, he said I am not getting better. I am
    not going to get better and I will most certainly deteriorate
    further as time goes on. He went on to say I am left with
    basically nothing, too trapped in a war to be at peace, too
    damaged to be at war, abandoned by those who would take the
    easy route and a liability to those who stick it out and thus
    deserve better. So you see, not only am I better off dead, but
    the world is better without me in it. This is what brought me
    to my actual final mission.
        Sergeant Somers' parents, Howard and Jean, were devastated
    by the loss of their son, but they bravely shared Sergeant
    Somers' story and created a mission of their own. Their mission
    is to ensure that Sergeant Somers' story brings to light
    America's deadliest war, the 22 veterans that we lose every day
    to suicide.
        Many of you have met with Howard and Jean. They are working
    closely with Congress and the VA to share their experiences
    with the VA healthcare system and find ways to improve care for
    veterans and their families.
        Our office worked closely with Howard and Jean to develop
    the Classified Veterans Access to Care Act. And if the
    committee moves this bill forward, I ask on behalf of Dr. and
    Mrs. Somers that the committee amend the title of the bill to
    the Sergeant Daniel Somers' Classified Veterans Access to Care
    Act in memory of Sergeant Somers' service and sacrifice.
        I appreciate the support this committee gave to our bill
    during the 113th Congress. I look forward to continuing to work
    with the committee to ensure that no veteran feels trapped like
    Sergeant Somers did and that all veterans have access to
    appropriate mental healthcare.
        Thank you, Chairman Benishek and Ranking Member Brownley,
    for including H.R. 421 in today's hearing. Thank you.
        Dr. Benishek. Thank you.
        Mr. Collins.

     STATEMENT OF HON. DOUG COLLINS, A REPRESENTATIVE IN CONGRESS
                       FROM THE STATE OF GEORGIA

        Mr. Collins. Thank you, Mr. Chairman.
        Chairman Benishek, Ranking Member Brownley, and
    distinguished members of the subcommittee, thank you for the
    opportunity to testify on H.R. 423, the Newborn Care
    Improvement Act.
        My legislation amends Title 38 of the United States Code to
    improve the care provided by the secretary of Veterans Affairs
    to newborn children. And I am very appreciative of the
    subcommittee's consideration of this legislation.
        The motto of the VA comes straight from Abraham Lincoln's
    second inaugural. He got that idea straight from scripture. So
    the challenge for us is to care for him who shall have borne
    the battle and for his widow and his orphans. This isn't new as
    we have already heard this morning.
        Since September 11th, 2011, more than a quarter of a
    million women have answered the call to serve. They face
    terrorism in the deserts and in the mountains of Iraq and
    Afghanistan. So in the 21st century, we must also consider she
    who shall have the borne the battle. When she returns, what of
    her children?
        The finest military in the world is powered by men and
    women in their physical prime. Young women who decided to serve
    this country in the Armed Forces aren't immune from the same
    questions that all young women face about whether to pursue a
    career, a family, or both, yet they are offered a healthcare
    system that for so many years has been designed to serve men.
        With the increasing number of female veterans, the VA must
    expand its care and services to meet their needs. Maternity
    care tops that list of needs and I have offered one of the ways
    that we can help.
        In 2010, Congress passed and the President signed the
    Caregivers and Veterans Omnibus Health Services Act of 2010 to
    provide short-term newborn care for women veterans who receive
    their maternity care through the VA. Signed into law on May
    5th, 2010, this legislation authorized up to seven days of
    newborn care.
        On January 27th, 2012, the Department of Veterans Affairs
    published a regulation officially amending VA's medical
    benefits package to include up to seven days of medical care
    for newborns delivered by female veterans who are receiving VA
    maternity care benefits. The rule which became effective
    December 19th applied retroactively to newborn care provided to
    eligible women vets on or after May 5th, 2011.
        Since the seven-day authorization was enacted by Congress
    in 2010, we have learned about the unique challenges facing
    female veterans and changing trends in the veterans seeking
    maternity and newborn care from the VA. According to a study
    published in the Women's Health Journal this past year, 2008 to
    2012, the overall delivery rate by female veterans utilizing VA
    maternity benefits increased by 44 percent and a majority of
    the women using VA maternity benefits had service-connected
    disability.
        Just last week, the U.S. Navy announced that it has tripled
    the amount of paid maternity leave for personnel in the navy
    and marine corps. Effective immediately, 18 weeks of maternity
    leave will be available.
        Secretary Mabus stated in a press release with increased
    maternity leave, we can demonstrate the commitment of the navy
    and marine corps to the women who are committed to serve.
        In the same way, unless Congress extends the authorization
    for length of newborn care coverage provided by the VA, there
    will be veterans who face difficult financial decisions and
    complexities in navigating insurance options at the same time
    that their newborn is fighting for their life.
        This is why I introduced H.R. 423 to demonstrate Congress's
    commitment to meeting the needs of female veterans and
    providing a little longer for their newborn care. My
    legislation extends the authorization of care from seven to 14
    days and provides for an annual report on the number of newborn
    children who receive such services during such fiscal year.
        Improved data on the trends in female veterans utilizing
    newborn care will help Congress and the VA better meet their
    needs in years to come. Should this subcommittee place my
    legislation on their markup calendar, which I hope they will
    do, I would request an amendment be adopted adding the
    reporting requirement to an existing report the VA is required
    to produce.
        Although it is vitally important that Congress and the VA
    have this data, I don't want the VA to produce yet another
    report when instead we could add this requirement to an
    existing report.
        Some may ask why the VA should provide more newborn care
    coverage to female veterans than the average private sector
    employee receives. These women have risked their lives to
    protect our Nation. Just because they are no longer serving in
    active duty does not mean that our responsibility to them ends.
    In fact, their service to our country may jeopardize the very
    lives of their future children, thus responsibility to them is
    even greater.
        A recent study examined more than 16,000 births to female
    veterans. Having PTSD in the year before delivery increased a
    woman's risk of spontaneous premature delivery by 35 percent
    research showed. This study gives us a convincing
    epidemiological basis to say that, yes, PTSD is a risk factor
    for pre-term delivery
        The study's senior author said an investigator at the March
    of Dimes prematurity research center at Stanford University
    said mothers with PTSD should be treated as having high-risk
    pregnancies. Premature infants often need longer
    hospitalizations after they are born and are more likely than
    full-term infants to die. These premature infants who survive
    may face long-term developmental problems and, unfortunately,
    the number of female veterans with PTSD is not insignificant.
        According to the VA, 20 percent of female veterans in
    conflicts in Iraq and Afghanistan have been diagnosed with PTSD
    and these are not just the female veterans serving in combat.
        And on a personal note, I know what it is like to be a
    parent of a little baby who needs intensive medical care. For
    an extended period of time after my daughter was born, I could
    not even hold her until she was over ten days old.
        So it is my hope that any new mother who has given
    selflessly to her country wouldn't have to worry about Congress
    standing in her way if she tries to give selflessly to her own
    child. And our goal should always be to provide the mother with
    the best prenatal care she needs to give the newborn the best
    chance of healthy delivery.
        To the members of the subcommittee, I know my time is short
    and I have submitted a statement. This is something that we can
    do to support those who supported us. In a new and changing
    world with women serving proudly and strongly, this is
    something we can do to protect them and also give best care to
    them and their newborns when they have served us and into a new
    world of the VA.
        And with that, Mr. Chairman, I yield back.

        [The prepared statement of Doug Collins appears in the
    Appendix]

        Dr. Benishek. Thank you, Mr. Collins.
        I think I am going to go back to Mr. Duffy.
        Mr. Duffy, could you give your testimony, please.

    STATEMENT OF HON. SEAN DUFFY, A REPRESENTATIVE IN CONGRESS FROM
                         THE STATE OF WISCONSIN

        Mr. Duffy. Yes. Good morning. Thank you, Chairman Dr.
    Benishek and Ranking Member Brownley, for holding today's
    hearing and I appreciate the opportunity to testify on H.R.
    353, the Veterans Access to Hearing Health Act.
        I introduced this bill along with Representative Walz from
    Minnesota and Ruiz from California to address the long wait
    times and lack of access to care for our veterans for audiology
    services.
        Our aging and younger veterans are returning home from the
    battlefield and they are seeking care from the VA in regard to
    hearing loss and tinnitus more than any other disability facing
    them today, yet the VA does not have the capability to keep up
    with the demand of these services.
        A recent Washington Post article cited that since the VA
    scandal broke last year, the number of veterans on wait lists
    for appointments has actually increased by 50 percent.
    Audiology services are a major factor in those wait times.
    According to the VA, nearly half of all patients waiting for
    care are waiting for audiology services.
        So we are all talking about personal stories today and I
    have one from my district. Roger Ellison, a 70-year-old Vietnam
    vet from Marshfield, Wisconsin, he is having hearing problems.
    So he goes to the VA and tries to set up an appointment. And
    they tell him he has to wait six months to get an appointment.
        I don't know how someone could go six days let alone six
    months when you can't hear. So instead he paid out of pocket,
    went to someone in his local community, a hearing aid
    specialist, and was able to get fitted for hearing aids. Pretty
    simple solution, but it would have been nice if the VA could
    have actually cared for him.
        Audiology services not only affect our older generation,
    but they are also affecting our younger generation too. Roger
    and thousands of other veterans are in situations because the
    VA, they are only allowed to use audiologists and not other
    capable providers to fulfill hearing aid services for our
    veterans.
        While audiologists are great resources for the VA to
    provide good services for our veterans, there is just not
    enough of them. There is too much demand. And so if you look
    for solutions on the committee, you can say let's try to spend
    more money and hire more audiologists. Well, that is great, but
    it is pretty tough to hire people into the VA and we don't have
    a lot of money.
        So what could we do that could actually resolve this
    problem, care for our veterans, and not spend really any more
    money? The answer is let's use hearing aid specialists. They
    are qualified. Veterans can get these services in their own
    communities. They can get their hearing aids fitted, adjusted,
    make minor repairs. And then we are going to lift the burden
    off the audiologists so they can actually focus on the more
    serious cases.
        But why are we backing up audiology appointments with
    hearing aid tweaks, hearing aid fittings? This can happen
    actually in the home community. This is a simple solution that
    doesn't cost money that is going to help our veterans out and
    it lifts the burden. And I think that is why we have such a
    bipartisan coalition that has come together on this bill.
        I would ask for you to respectfully consider a simple
    solution to a really big problem for veterans who can't hear.
    And if we come together, it is one of those small fixes that
    again makes a big difference.
        So I thank you for allowing me to testify and thank you for
    your consideration. I yield back.

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

        Dr. Benishek. Thank you, Mr. Duffy.
        Mr. Coffman, are you ready to go ahead?

     STATEMENT OF HON. MIKE COFFMAN, A REPRESENTATIVE IN CONGRESS
                       FROM THE STATE OF COLORADO

        Mr. Coffman. Yes, Mr. Chairman.
        Thank you, Chairman Benishek and Ranking Member Brownley,
    for holding this legislative hearing and including my
    bipartisan bill, the Women Veterans Access to Quality Care Act.
        Although the Department of Veterans Affairs has made some
    progress in recent years, the fact remains that the VA is a
    system largely designed for male veterans.
        A recent comprehensive study conducted by the Disabled
    American Veterans entitled Women Veterans, The Long Journey
    Home found serious gaps in almost every aspect of programs that
    serve women vets.
        In recent years, the active-duty military has made
    incredible strides towards fully incorporating women into the
    ranks. Though more work needs to be done, those long overdue
    changes in the Department of Defense have increased the pool of
    eligible recruits, raising the standards to make our military
    the most professional that our country has ever had.
        As more and more of these women leave military service and
    become veterans, it is critical that the VA quickly adapt its
    facilities and culture. The aim of my bill is to increase
    gender-specific access to healthcare within the VA, improve
    healthcare outcomes for our women veterans, and improve VA's
    facilities to ensure that they protect the privacy and dignity
    of all veterans.
        The need for this bill is largely illustrated simply by
    reviewing the rapidly changing demographic composition of the
    VA patient population. Between 2003 and 2012, the number of
    women veterans using VA healthcare nearly doubled. In 2012,
    women made up only 6.5 percent of the VA patient population,
    but are estimated to encompass over ten percent by 2020.
        Meanwhile, nearly 20 percent of all new recruits in the
    military are women. The women veteran patient population also
    has unique characteristics when compared to the male VA
    population. The median age of a female patient in the VA is 49
    years old compared to 64 for male patients. Only 13 percent of
    men within the VA were 45 years old or younger compared to 45
    percent of women.
        These are dramatic changes to the VA's patient population
    and the former almost exclusively male VA healthcare system
    simply hasn't kept up with the changes. My bill addresses the
    VA's lapses in healthcare quality and access for its women
    patients in five ways.
        First, my bill requires the VA to establish standards to
    ensure VA facilities meet the specific needs of women and
    integrates those standards into its strategic capital
    investment planning process. The Government Accountability
    Office found in 2010 that none of the VA hospitals it surveyed
    were compliant with the VA's own policies related to privacy
    for women veterans.
        Just to cite a few examples, the audit found that check-in
    desks were in busy mixed-gender areas and gynecological
    examination tables faced towards doorways. Additionally,
    despite VA's requirements that gynecological exam rooms have
    immediately adjacent restrooms, often women were required to
    walk down long hallways in high traffic, mixed-gender corridors
    to access restrooms.
        At a hearing in this room in April, I asked a panel of
    veteran service organizations' experts whether these conditions
    have improved in the past five years. And the committee learned
    that these problems continue to persist nationwide.
        Second, my bill holds VA medical facility directors
    accountable to performance measures which include women's
    healthcare outcomes and it requires the reporting of those
    outcomes. As with many other areas in the VA, there is an
    incredible lack of accountability which is hindering true
    progress and reform.
        Third, my bill ensures the availability of OB/GYN services
    at VA medical centers and requires the VA to conduct a pilot
    program to increase residents and graduate medical education
    positions.
        In 2010, nearly half of the women veterans who use VA
    healthcare had at least one reproductive health diagnosis. It
    is absolutely essential that these veterans have quick and
    reliable access to appropriate gender-specific care.
        Fourth, my bill improves outreach to women veterans by
    requiring the VA to provide state and veterans' agencies with
    contact information for veterans. One of DAV's findings in its
    report was that information on veterans' programs and
    eligibility is often difficult to access and scattered across
    various programs or Web sites. Increasing outreach to women
    veterans through collaboration with VA's state agency partners
    is vital.
        Finally, my bill mandates a new comprehensive GAO study of
    the VA's ability to meet the needs of women veterans including
    an examination of wait times, gender-specific care
    availability, VA training, differences in health outcomes, and
    security and privacy within VA facilities.
        During my own military career, I have witnessed quite a
    number of challenges that the military has had to confront.
    Each time it overcame the obstacles and always emerged as a
    more effective fighting force. I have full confidence that the
    VA can do the same.
        I hope my bill can jumpstart the cultural sea change
    required at the VA to ensure our women veterans are provided
    the same benefits they earned in service to our Nation just
    like their male counterparts. I am grateful for the support of
    many of our Nation's veterans and veteran service organizations
    have provided for this bill and I urge all of my colleagues on
    the committee today to join me in this effort.
        Thank you, Mr. Chairman. I yield back.

        [The prepared statement of Mike Coffman appears in the
    Appendix]

        Dr. Benishek. Thank you, Mr. Coffman.
        Dr. Boustany, could you begin your testimony.

        STATEMENT OF HON. CHARLES BOUSTANY, A REPRESENTATIVE IN
                  CONGRESS FROM THE STATE OF LOUISIANA

        Mr. *Boustany.* Thank you, Chairman Benishek, Ranking
    Member Brownley, and members of the subcommittee, for inviting
    me to testify before you today.
        As the committee considers reforms to the Department of
    Veterans Affairs operations, I really appreciate the
    opportunity to speak on behalf of my legislation, H.R. 1862,
    the Veterans Credit Protection Act.
        Unfortunately, the VA's long history of delayed payments
    has brought me here to testify before you today. Too many
    veterans are forced to contact offices across our districts to
    resolve credit issues caused by the VA's refusal to pay claims
    for emergency medical care.
        When these brave Americans require a trip to the emergency
    room because they have a serious illness or they fear that
    their lives are in danger, the last thing on their minds should
    be fear that the VA will fail to pay their claims. The last
    thing that should be on their mind are concerns about the VA
    damaging their credit rating.
        One such veteran in my district, Al Theriot of Abbeville,
    Louisiana, waited over two years for the VA to finally process
    and pay his emergency medical care bills which the agency did
    only after Mr. Theriot contacted my office and appeared on
    local television twice to describe his experience. This is just
    unacceptable. It is terrible and disrespectful service for our
    veterans.
        I submitted documentation from the VA to the subcommittee
    early in June demonstrating the scale of this problem. Just to
    reiterate some of the findings, data provided to me as of April
    2015, the VA's chief business office indicated that only 14, 14
    percent of emergency medical care claims originating from VISN
    16, which includes my home State of Louisiana, were being
    processed within 30 days. In total, the data demonstrates a
    national backlog of over $878 million.
        The Veterans Credit Protection Act is an important step to
    rooting out the problems within the VA that caused this out of
    control backlog. First, the legislation mandates the VA to set
    up a toll-free hotline for veterans to report credit issues
    caused by delayed emergency medical care claims.
        It also requires the VA to conduct outreach alerting
    veterans of how to resolve these issues. Too often veterans
    tell me they cannot get in touch with the VA or that the
    employees they speak with cannot adequately answer their
    questions.
        Creating a dedicated call line and ensuring the VA
    implements a better framework for communicating solutions with
    veterans is an absolutely necessary step toward eliminating the
    backlog.
        My bill also requires VA to report annually to Congress on
    the chief business office's effectiveness with respect to
    timely claims processing. Their report must include information
    on the number of veterans who have reported credit issues due
    to delayed payments, the number of proper invoices submitted,
    the amounts owed on those invoices, and how long it took the VA
    to pay those claims, among other bits of information.
        In addition to requiring the VA to report on the status of
    claims, H.R. 1862 aims to improve the chief business office
    operations by requiring the VA to examine comments made by
    medical providers regarding the claims processing system and
    delayed payments and report these comments to Congress along
    with a description of best practices to ensure timely claims
    payment in the future.
        No veteran should ever have to decide whether or not to
    sacrifice their health and safety to avoid a potential
    financial burden if the VA fails to pay for a trip to the
    emergency room.
        I want to sincerely thank the subcommittee for your efforts
    to ensure better care for America's veterans and for inviting
    me to be a part of this important discussion. Thank you.

        [The prepared statement of Charles Boustany appears in the
    Appendix]

        Dr. Benishek. Thank you, Dr. Boustany, for your wise use of
    your time.
        Mr. Denham, would you please begin your testimony.

      STATEMENT OF HON. JEFF DENHAM, A REPRESENTATIVE IN CONGRESS
                      FROM THE STATE OF CALIFORNIA

        Mr. *Denham.* Thank you, Mr. Chairman.
        Committee members, eye clinics staffed by the VA doctors of
    optometry including residents are among the busiest primary
    care settings in the veterans healthcare system.
        This bill, 1688, is aimed at improving access to primary
    eye care in the VA by making a modest increase in the number of
    optometry residency positions in the VA.
        My bill seeks to amend the Choice Act by designating 20 of
    the 1,500 new graduate medical education residency positions to
    the field of optometry. Although VA optometrists provided
    comprehensive eye exams and other essential care to more than
    1.2 million veterans last year, the need for eye health and
    vision care is expected to grow further in the coming years.
        Serious eye trauma is the second most common injury among
    those who served in Iraq and Afghanistan, with 16 percent of
    all wounded servicemembers experiencing problems ranging from
    distorted vision to blindness. Additionally, up to 75 percent
    of all TBI patients experience vision problems.
        Increasing the number of optometry residents at the VA is
    one of the ways to enhance the VA's ability to address chronic
    patient care backlogs as well as train new doctors of optometry
    in advanced practices.
        Since the VA established its first optometry residency in
    the 1970s, the program has proven to be an essential, cost-
    effective force multiplier to boost eye care teams and make
    veterans healthier and more engaged in their own care.
        I would appreciate your support on H.R. 1688 to improve
    access to this important care for our veterans by adding 20
    additional optometry residents to the VA over the next ten
    years.
        Thank you, and I yield back.

        [The prepared statement of Jeff Denham appears in the
    Appendix]

        Dr. Benishek. Thank you, Mr. Denham.
        Dr. Wenstrup, present your bill.

     STATEMENT OF HON. BRAD WENSTRUP, A REPRESENTATIVE IN CONGRESS
                         FROM THE STATE OF OHIO

        Dr. Wenstrup. Good morning, Chairman Benishek, Ranking
    Member Brownley, and members of the committee. Thank you for
    the opportunity to speak on the VA Provider Equity Act, H.R.
    3016.
        This bipartisan legislation which is currently cosponsored
    by every doctor on the VA Committee and the ranking member of
    this subcommittee would increase access to care for our
    veterans by changing outdated standards to move VA podiatrists
    to the same fee schedule as doctors of medicine and osteopathy
    within the VA.
        After years of war, we have a new generation of Iraq and
    Afghanistan veterans returning with lower extremity injuries.
    These needs along with diabetic-related complications,
    peripheral neuropathy often linked to Agent Orange exposure,
    orthopedic maladies, vascular compromise, and many other
    conditions require ongoing care from the Veterans Health
    Administration that podiatrists are uniquely trained to
    provide.
        The need is dramatic. The Department of Veterans Affairs
    treats more than 45,000 veterans who have lost limbs and 1.8
    million more veterans within the VA are at risk of amputation,
    but the wait times remain unacceptable.
        For those veterans seeking podiatric care within the VA, 93
    percent of new podiatry patients wait more than 15 days for an
    appointment. More than two-thirds of them wait more than 30
    days. These wait times exist because the VA is struggling to
    recruit and retain experienced podiatrists.
        Forty-two percent of VA podiatrists leave the VA system
    within five years of being hired and every time a podiatrist
    leaves, the average time to fill a vacant podiatry position is
    one year. The problem, a self-imposed one, is that the VA is
    not competitive with the private sector when it comes to hiring
    and retaining podiatrists.
        While the maximum salary for a VA podiatrist is $132,000,
    the average salary for podiatrists in the profession is
    $183,269 according to a 2013 APMA survey. That is a $50,000
    difference between the industry average and the maximum that
    our VA podiatrists can make. It is no wonder that many of our
    veterans are losing their VA podiatrists to the private sector.
        The VA Provider Equity Act would place podiatrists on the
    same fee schedule as doctors of medicine and osteopathy within
    the VA. Since the VA first established podiatric pay standards
    in 1976, podiatric education, training, and practice have
    increased exponentially. Medicare recognized these changes over
    20 years ago and implemented fee schedule reform in 1991. I
    think it is time for the VA to do the same.
        Additionally, H.R. 3016 would make podiatrists eligible for
    the same promotions in leadership positions within hospital
    systems that they often currently hold in the private sector.
        I thank the chairman and ranking member for their support
    and the commitment to increasing access to healthcare for our
    Nation's veterans. I ask for the support of my colleagues in
    advancing this important legislation. Let's ensure that access
    to podiatric care is included in the comprehensive first-class
    healthcare that all veterans deserve.
        Thank you.

        [The prepared statement of Brad Wenstrup appears in the
    Appendix]

        Dr. Benishek. Thank you, Dr. Wenstrup.
        And I want to thank all the members of the first panel, all
    my colleagues for their interest in improving veterans'
    healthcare and thanks for the great ideas.
        I am not going to ask any questions, but I think Mr. Walz
    had asked to go first because he is on a tight schedule for
    comment. Is that true, Mr. Walz?
        Dr. Walz. Well, I don't want to irritate my colleagues, Mr.
    Chairman, but I would be honored and appreciative if I could.
        Dr. Benishek. Yeah, go ahead.
        Dr. Walz. Well, thank you to the chairman and thank you to
    the ranking member, first for allowing me to be here, more
    importantly to all of my colleagues for putting forth
    thoughtful legislation to improve the lives of veterans and
    families.
        I think it is really important that this committee, while
    we simultaneously hold people accountable for the failings that
    are unacceptable, we also provide alternatives, provide
    solutions.
        And I think that that old adage of we can sit around and
    curse the darkness or we can light a few candles, there is
    certainly some cursing that needs to be done on some of these
    things, but I think each of these pieces of legislation provide
    the VA opportunities to partner and to do things and continue
    to build on things that are working right.
        I would just spend a minute. The two bills that I was lead
    cosponsor on with my colleagues, Mr. Duffy's bill on getting
    the hearing aids and the backlog, this makes good sense. It is
    smart. It is cost effective. It gets veterans out there. And we
    are doing it in many cases. I think this codifies it to the
    point where we can more effectively use our private sector and
    local providers to get folks out there.
        This one is personal to me, too, as nearly 25 years in the
    artillery, hearing loss is something that all of my peers
    experience and I know that the quality of life that improves
    when you get quality care makes a big difference.
        And then Mr. Stivers was here to talk about it. It may seem
    like a small thing, but he is exactly right. The therapy dogs
    make a huge difference. And if it provides solace and care for
    one veteran and we have the opportunities to be out there and
    do that, I think he is right. His piece of legislation starts
    to move that forward.
        And I know most of my colleagues here all have witnessed
    this with veterans. It is a very powerful thing. And there is
    research to support it, but this is one of those that seeing is
    believing with what happens.
        So I thank the chairman again for a very productive hearing
    and my colleagues for bringing up thoughtful legislation. And,
    again, I do think it's incumbent upon us to provide our
    oversight, help provide that accountability, but then also to
    provide and partner with ways that find solutions. And each of
    these pieces of legislation we heard today, I think, does
    exactly that.
        So thank you, Chairman, for the courtesy, and I certainly
    look forward to the support on all these pieces of legislation.
        Dr. Benishek. Thank you, Mr. Walz.
        I don't have any questions myself or further comments other
    than my statement.
        Do any of my colleagues on this side? Dr. Roe, you have a
    comment----
        Dr. Roe. Just a couple. Thank you.
        Dr. Benishek [continuing]. Or question?
        Dr. Roe. Thank you. I will be very brief.
        But certainly Tim Walberg's, Congressman Walberg's, his
    bill ought to be passed. That is just so common sense. Those
    Medal of Honor winners ought to have Secretary McDonald on
    speed dial. We should honor them. That should be no question.
        I think one of the things I think on Congressman Collins
    that caught my attention was I found it a little bit surprising
    that we only provide two weeks' care for the baby that is born
    of the mother and we provide her six weeks of care. I don't
    know why we wouldn't just parallel those, marry those up and
    say, look, the baby goes for a six-week checkup just like the
    mother does. And why in the world are we putting two weeks? I
    would encourage us to have the same thing for the baby, that
    the first six weeks of care--exactly like the mother. That
    makes no sense to me.
        So I would ask my colleague if he would consider an
    amendment to his bill just to do that, if that would be
    something we would like to discuss. It makes absolute sense.
        And I know that on the therapy dogs that Congressman Walz
    brought up, they can be very relaxing unless you have a Sheltie
    like I did which chewed up over a thousand dollars worth of my
    shoes. That was very stressful to me personally. I had to have
    therapy to keep from strangling that dog. Anyway, he is still
    at the house. And that wasn't all he chewed up either. I could
    go into a whole book on that. But I totally agree with that
    bill.
        And I don't think we ought to be prescribing just as he
    was--congressman walks in, how many residency slots that--I
    don't think Congress ought to be doing that. I think those
    residency slots are--those 1,500 slots, the VA can see where
    their needs are. I believe the VA people can decide that. I
    truly believe that.
        I think it would be very bad if I walked up and said we
    need six OB/GYN slots and 14 internal medicine slots. I don't
    think we need to micromanage that. I think the VA has the
    ability to see where their needs are. I would let them make
    those decisions. And just to comment there, I think that is a
    bad thing to get into for us to be telling those just how many
    they should have.
        Other than that, I will yield back my time.
        Mr. Takano. Mr. Chairman, before he yields back, would you
    yield just ten seconds to me?
        I want to associate myself with your remarks on the GMEs.
    That is all. Thanks.
        Dr. Benishek. Thank you, Dr. Roe.
        Do you have any questions?
        Ms. Brownley. No.
        Dr. Benishek. Ms. Kuster.
        Ms. Kuster. Thank you, Mr. Chair.
        I just want to associate myself with the bills introduced
    by my colleague, Julia Brownley, and in particular the Female
    Veterans Suicide Prevention Act. And I wanted to address an
    issue.
        I want to join Dr. Roe in the six weeks. I agree matching
    that up makes sense. I would imagine most of the babies are
    going home healthy in the first week, but the ones who stay,
    that is the most stressful situation and they should get the
    care that they need.
        And I just had a few questions, but I don't need to get
    into the details right now on Mr. Coffman's bill because I know
    there was some question from the VA. This is more by way of a
    comment.
        In White River Junction, Vermont, we have a new women's
    treatment facility that I would love to include if we get to do
    some kind of a hearing, field hearing from our oversight
    committee, but they had a chance to have a group of women
    veterans that participated in the planning of that. And so they
    were able to bring out some of the psychological issues for
    them about seeking care.
        And even the architecture was designed--it is a renovation,
    by the way. We have nothing new up there, but it is a
    renovation of a very old facility. But they took into account
    their feelings of being safe and protected, even the way they
    designed the entrance, the way they designed the waiting room,
    the way they designed the actual physical rooms where they, you
    know, have their medical exams.
        Obvious things once you think about it, but just very, very
    helpful. So I would love to work further with you on this. I
    think it is really important and I appreciate our colleagues on
    the other side and how much interest they have in women, health
    for women veterans in the VA system.
        So thanks.
        Dr. Benishek. Thank you.
        Any comments or questions? Dr. Abraham.
        Dr. Abraham. I just want to say I was a very proud
    cosponsor of Dr. Wenstrup's bill. The hearing aid, the
    accountability, the credit protection, I think they are great
    bills, and I just look forward to them advancing very quickly.
        Dr. Benishek. Thank you, Dr. Abraham.
        Any other comments?
        All right. I guess the first panel is over with.
        Let's invite the second panel to the witness table. Joining
    us on the second panel today is Ian de Planque, the Legislative
    Director for The American Legion; Adrian Atizado, the Assistant
    National Legislative Director for the Disabled American
    Veterans; and Carlos Fuentes, Senior Legislative Associate for
    the National Legislative Service of the Veterans of Foreign
    Wars of the United States.
        I thank you all for being here this morning and for all
    your hard work and advocacy on behalf of our veterans. I look
    forward to hearing the views of your members.
        And if you are ready, Mr. de Planque, you may begin.

                      STATEMENT OF IAN DE PLANQUE

        Mr. de Planque. Good morning, Chairman Benishek, Ranking
    Member Brownley, and members of the committee. I am fortunate
    to be here today and speak on behalf of the American Legion,
    our National Commander Mike Helm, and more than two million
    members in over 14,000 posts across the country that make up
    the backbone of the nation's largest wartime service
    organization.
        There are many excellent pieces of legislation for
    consideration today. You have our full written remarks and in
    the interest of time I would like to focus on a couple of key
    bills.
        H.R. 1356, the Women Veterans Access to Quality Care Act of
    2015, addresses critical needs the American Legion has worked
    to raise awareness of for many years. Women are currently the
    fastest growing demographic serving in the military; however,
    the VA healthcare system is still based on an older design from
    a time period when women did not represent a substantial
    portion of veterans seeking care. And the legacy of that older
    design is obstacles for women who seek care. The American
    Legion has surveyed women veterans and we have dedicated
    special focus of our System Worth Saving Task Force report to
    the experiences of women using the VA healthcare system.
        We have learned women veterans often do not self-identify
    as veterans and that VA staff often do not see women as
    veterans. Women veterans do not need to be asked, how did your
    husband serve in the military? They need to be asked, how can
    VA serve you to thank you for your service?
        This legislation should go a long way towards establishing
    consistency by establishing standards for all facilities. The
    reporting mechanisms in the bill will help all of the
    stakeholders keep apprised of VA's progress on better
    integrating women's healthcare. More transparency leads to
    better communication between stakeholders.
        Everyone wants to ensure all veterans are well served in
    VA. This legislation will help work to close gaps and ensure
    all veterans are served with equal attention to their care.
        The American Legion is also glad to see attention being
    given to serious reform in VA large scale construction
    projects. The Construction Reform Act attempts to ensure
    competent management of serious large scale construction
    projects such as major hospitals so that those projects do not
    spiral out of control as they have in years past. The American
    Legion believes VA should be allowed to focus on what they do
    well, providing care to veterans, and that large scale
    construction management should go to organizations that are
    dedicated solely to that mission of construction. It only makes
    sense that a doctor to treat patients, select carpenters,
    masons, electricians for building the places to treat those
    patients. Keep VA in the business of treating patients.
        Finally we are happy to see that attention is being given
    to fixing the long standing problem with CBO scoring of leases
    for community based outreach clinics. CBOCs are a critical
    component of the 21st Century model for delivery of care within
    the VA and for the last couple of years we have had to scramble
    to find slapped--together--work around measures once the
    Congressional Budget Office changed the manner in which the
    leases for CBOCs are scored. H.R. 2914, the Build a Better VA
    Act, will create a more permanent solution to the problems
    created by the change in scoring. Just last year the
    uncertainty surrounding leases for 27 CBOCs created doubt,
    concern, and fears of lost coverage for hundreds of thousands
    of veterans until a short term solution was worked into the
    Veterans Access to Care, Choice, and Accountability Act. As the
    American Legion has been involved in working towards a solution
    since the beginning we knew that last year the 27 leases only
    represented a temporary reprieve from the bigger problem. We
    still have to find a long term fix. The American Legion
    believes this legislation can work towards that fix.
        Again, I thank the committee for their hard work and for
    your consideration of this large slate of legislation, as well
    as your dedication to finding solutions for problems that stand
    in the way of delivery of healthcare for veterans. I am happy
    to answer any questions.

        [The prepared statement of Ian de Planque appears in the
    Appendix]

        Dr. Benishek. Thank you, Mr. de Planque. Mr. Atizado, you
    may begin.

                      STATEMENT OF ADRIAN ATIZADO

        Mr. Atizado. Chairman Benishek, members of the
    subcommittee, thank you for inviting DAV to testify at this
    legislative hearing. As you know, DAV is a nonprofit veterans
    service organization. We are comprised of 1.2 million members
    and we are all dedicated to one goal, and that is to empower
    veterans to lead high quality lives with respect and dignity.
        So today nearly 2.3 million women are veterans of the
    military service and that number is expected to continually
    grow into the future as they comprise 50 percent of active duty
    personnel and 18 percent of the Guard and Reserve. There are
    three bills on today's agenda directed to improve healthcare
    and services to women veterans, H.R. 423, the Newborn Care
    Improvement Act; H.R. 1356, Women Veterans Access to Quality
    Care Act of 2015; and H.R. 2915, the Female Veterans Suicide
    Prevention Act.
        H.R. 423 will provide a newborn child of certain women
    veterans receiving VA maternity care with post-delivery care
    for up to 14 days after the child's birth. H.R. 1356 seeks to
    improve the VA healthcare system to provide safe, comfortable,
    and high quality care to women veterans. It would establish
    standards for VA to meet in this regard and requires an
    accounting of those parts of VA that do not meet these
    standards. H.R. 2915 would direct VA to identify mental
    healthcare and suicide prevention programs that are most
    effective and have the highest satisfaction among women
    veterans.
        These bills are in line with DAV Resolutions 39 and 40,
    both of which support program improvements and enhanced
    resources for VA mental health programs as well as medical
    services for women veterans. And as Mr. Coffman had mentioned,
    they are also in line with the recommendations put forth by DAV
    in our 2014 report, ``Women Veterans: the Long Journey Home.''
    For these reasons DAV is pleased to support all of these
    measures.
        DAV also supports H.R. 3016, which would reclassify VA
    podiatrists for purposes of appointment and compensation in the
    same category as other VA physicians. Now podiatrists play a
    critical role in maintaining foot health and dealing with
    injuries and diseases of the foot and ankle, however doctors of
    podiatry were inexplicably excluded when Congress enacted VA
    physician pay reform back in 2004. We believe their
    appointments and compensation should be made commensurate with
    those of other physicians in the VA.
        H.R. 2914, the Build a Better VA Act, would prohibit the
    appropriation of funds to support any VA major medical facility
    lease unless the Committee of Veterans' Affairs of both
    chambers adopt resolutions approving the lease. We thank the
    bill's sponsor for the intention of improving the authorizing
    committees' role in overseeing VA's leasing program and to
    provide more specific guidance to the Appropriations Committees
    in funding VA leases. DAV is aware of issues surrounding VA
    infrastructure and capital planning matters and our national
    resolution calls for modernizing aging VA facilities and to do
    so in a timely manner. It specifically calls on Congress to
    resolve, as my colleague Ian de Planque from the American
    Legion had referred to, as a delay of dozens of major medical
    facility leases for several years due to disagreements in the
    administration over out year costs for such leases.
        While we oppose the bill in its current form, DAV stands
    ready to work with the bill's sponsor and the subcommittee and
    VA to ensure this legislation will indeed provide the
    improvements that it purports. We already understand that VA is
    experiencing delays ranging from six months to 13 years for
    major facility leases with an average delay of more than three
    years.
        This concludes my testimony, Mr. Chairman. I would be happy
    to answer any questions you or members of the subcommittee may
    have. Thank you.

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

        Dr. Benishek. Thank you, Mr. Atizado. Mr. Fuentes, you may
    begin.

                      STATEMENT OF CARLOS FUENTES

        Mr. Fuentes. Chairman Benishek, Ranking Member Brownley,
    and members of the subcommittee, on behalf of the men and women
    of the VFW and our auxiliaries, I would like to thank you for
    the opportunity to present our views on legislation pending
    before this subcommittee.
        The bills we are considering today are aimed at improving
    the healthcare the VA provides our nation's veterans and we
    thank the subcommittee for bringing them forward. I would limit
    my remarks to bills we have recommendations to improve.
        The VFW supports the Veterans Credit Protection Act, which
    would assist veterans with credit issues resulting from unpaid
    healthcare claims. In the past year VA has made organizational
    changes to the claims process to improve timeliness and
    accuracy of healthcare claims, however the VFW continues to
    hear that non-VA care providers continue to bill veterans for
    care VA is obligated to pay. The VFW believes that the best way
    to prevent veterans from being wrongfully charged is to ensure
    VA pay the claims on time and accurately. This is why we
    recommend that the GAO report include an evaluation of the
    accuracy of VA's healthcare claims process.
        This legislation also requires VA to assist veterans with
    credit issues that result from any healthcare claim, regardless
    of if VA is authorized to pay such a claim. While the VFW
    believes the VA should assist veterans in achieving financial
    independence, we do not support overwhelming VA's chief
    business office with claims it is unable to resolve. We
    recommend that the subcommittee limit assistance through the VA
    toll free hotline to healthcare claims VA is authorized to
    resolve.
        The VFW supports the Building a Better VA Act, which would
    streamline the congressional process for authorizing VA major
    facility leases. This legislation would authorize the
    Committees of Veterans' Affairs of the Senate and the House of
    Representatives to approve VA major facility leases without
    requiring legislation. However, it does not eliminate the
    requirement for the House Transportation and Infrastructure
    Committee to pass similar resolutions. The VFW recommends that
    the subcommittee exempt VA leases from such a requirement.
        This legislation also fails to address other factors that
    hinder VA's ability to enter into major facility leases.
    Currently VA lacks a revolving fund to insure its major
    facility leases in the case it is unable to abide by
    contractual agreements and is required to pay out the full cost
    of the lease without receiving appropriations. VA currently
    relies on the GSA revolving fund to insure major VA facility
    leases. We urge the subcommittee to establish a VA revolving
    fund for VA leases.
        The VFW supports the Female Veterans Suicide Prevention
    Act, which would improve VA mental healthcare and suicide
    prevention programs offered to women veterans. As VA and
    Congress work to expand availability of women--specific care at
    VA medical facilities, they must also focus on expanding
    research on the psychological and physical effects war has on
    women veterans. Without such research women veterans may go
    unnecessarily undiagnosed or untreated for serious conditions.
    The VFW strongly supports this legislation and recommends that
    the subcommittee expand it to include evaluation of which
    mental healthcare and suicide prevention programs produce the
    best healthcare outcomes for women veterans. VA and Congress
    have already identified several programs that are proven to
    work and are well received by women veterans, such as the
    childcare pilot program and the retreat counseling program for
    women veterans. The VA and Congress must ensure these programs
    are expanded and successfully implemented.
        The VFW supports the Construction Reform Act of 2015, which
    would require VA to enter into project management agreements
    for major construction projects over $100 million; calls on VA
    to apply industry standards when constructing medical centers;
    and authorizes the funding of four major construction projects.
    While the VFW agrees that VA's role in managing construction
    projects should be reduced, establishing a specific cap with no
    waiver process would lead to VA managing projects that would be
    better suited for third party managers, or prevent it from
    managing projects that are over the cap which they could
    clearly manage. We recommend that the subcommittee establish a
    waiver process in the plan and design phase that would allow VA
    to manage larger projects when appropriate and authorize the
    committee's jurisdiction to require appropriate below cap
    projects to be managed by the third party.
        Mr. Chairman, this concludes my testimony. I look forward
    to any questions you or the members of the subcommittee may
    have.

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

        Dr. Benishek. Thank you, Mr. Fuentes. I yield myself five
    minutes for questions. Mr. Atizado, I read your written
    statement about my bill 2464 was sort of surprising and
    different from some of your colleagues on your comments. You
    wrote, demanding accountability for veterans acts would result
    in a major chilling effect on candidates for VA management
    positions, as well as those already occupying those positions.
    Do you think that VA employees really are adverse to
    accountability, Mr. Atizado?
        Mr. Atizado. Well Mr. Chairman, thank you for the question.
    I do not believe that the chilling effect and holding folks
    accountable in federal agencies are mutually independent. I
    think part of the problem here may be that applying this
    standard just to one federal agency will discount consideration
    of managers and SESers.
        Dr. Benishek. Well believe me, I would like to have
    everybody in the government be accountable. Trust me. But this
    is a problem that really identified, you know, through this
    hearing process that, you know, the VA agrees there is a
    problem, and agrees they are going to fix it, and yet they
    never name anybody to be accountable and it never gets fixed. I
    mean, you have seen this yourself, haven't you?
        Mr. Atizado. Yes, sir.
        Dr. Benishek. How would I, other than holding somebody
    accountable and naming them, do you have any suggestions as to
    how else I should do this?
        Mr. Atizado. Well I think one of the questions that we have
    asked which we have a hard time getting a straight answer for
    is, why is the current structure not working properly? It seems
    to me that--I believe it was a hearing in the Senate where it
    was intimated that the tools are there but VA seem to not be
    able to use them the way they are intended.
        Dr. Benishek. Well maybe you are right about that. It is
    just that whenever I try to identify the person who is
    responsible for not making things happen within the VA, nobody
    seems to be that person. Do you understand what I mean? The
    reason I am doing this is that for 30 years the IG has told the
    VA, you need a plan to hire physicians. Eight different times
    the IG has told the VA that. And the VA has agreed with them
    every time. And yet, they never developed a central plan to
    hire physicians and nobody seems to know why. You understand my
    frustration here? I mean, I am just trying to solve this
    problem.
        Mr. Atizado. Yes, Mr. Chairman. If you will notice in our
    testimony, we do not have specific resolutions to support or
    oppose the bill. We just raise concerns because of what it may
    do to the healthcare system, both good and bad. We understand,
    believe me, we understand on a daily basis that when we
    encounter employees in the VA healthcare system who do not meet
    the standards that we normally see in caring, compassionate
    employees, everywhere from the janitors to the surgeons. And we
    would like to have those individuals held accountable, whether
    it is for poor performance or just----
        Dr. Benishek. Right. Right. Mr. Fuentes or Mr. de Planque,
    do you have any comments you would like to make on about Mr.
    Atizado's comments?
        Mr. Fuentes. I do, Mr. Chairman. One of the things that I
    think is overlooked when it comes to accountability is the
    difficulties VA faces when hiring physicians and staff to
    replace the ones that they hold accountable. I mean, what we
    have seen is VA would rather have an underperforming employee
    than to have no employee for a year. So when it comes to
    accountability our recommendation is to also take a look at
    hiring practices and Congress should assist VA in addressing
    why it takes so long to hire a new employee.
        Dr. Benishek. Mr. de Planque.
        Mr. de Planque. I would agree with what he just said in
    that if you are going to be looking at removing employees you
    also have to look at shortening the amount of time it takes to
    bring new ones on. I think that is a critical component. But I
    also agree with kind of the point of this legislation. And that
    is, you know, taken from the example of, you know, if you come
    across somebody and you need to start performing CPR you look
    at somebody and say specifically, Dr. Benishek, go call 911.
    Because if you put it out to the group then everybody in that
    crowd standing around watching you is going to assume somebody
    else is going to do it. And we have seen this so many times
    with IG reports and GAO reports. There are all these
    recommendations, and VA agrees to them, but it is not
    specifically tasked to any sort of thing.
        Dr. Benishek. Right.
        Mr. de Planque. And I think this is what you are trying to
    get to.
        Dr. Benishek. Right.
        Mr. de Planque. That notion that in a crisis give the task
    to somebody. And I think the legislation as you talked through
    it and as we looked at it, it is not necessarily about firing
    people if they do not do it. It is putting together a plan and
    giving those people who are tasked with fixing that thing that
    a report identified with a plan and if they cannot follow
    through that plan then there are follow up measures. And at
    some point down the road possibly if they continue to be unable
    to do it then you are talking about----
        Dr. Benishek. Right.
        Mr. de Planque. [continuing]. Removing that person. But it
    is more about assigning an individual accountability. And I
    think that is actually a pretty strong idea.
        Dr. Benishek. Ms. Brownley.
        Ms. Brownley. Mr. Chairman, again, I thank everyone for
    being here today and being our partners in trying to move
    forward good policy for our veterans across the country. And I
    appreciate all of you for your support of the Female Veterans
    Suicide Prevention Act. I appreciate it very much. I think it
    is, if we are going to serve all veterans, and serve them well
    when it comes particularly to mental health, that we must with
    regard to our women veterans disaggregate the data, get the
    right metrics, get the best practices. Because I feel convinced
    and compelled that in many, many cases women are going to
    respond differently than men will and it is important for us to
    get that right and get the right data to inform us. So thank
    you for that.
        And Mr. Atizado, I know that my bill has not been out for
    very long, on the Build a Better VA Act. I appreciate your
    willingness to sit down and work with us on it. And I would
    welcome that and look forward to it. Because I think, I mean I
    think this is a problem that has to be solved. I mean we, we go
    through all of the studying to determine where the needs are
    across the country, to have health clinics and CBOCs across the
    country. And yet the way we are addressing this issue now and
    the way it is scored, we have got a long list of needs but we
    cannot satisfy them because they are scored sort of
    outrageously and unrealistically. And I think that we need to
    help to streamline the process. I think we had a process that
    worked. I think we have a process right now that is not working
    for veterans. And that is what we are trying to do here, is to
    streamline it to bring some similarity about how we treat
    federal buildings and treat sort of health clinics for veterans
    in a similar fashion and bring the responsibility I think
    closer to this committee and to the, and to Congress itself.
        So I appreciate your willingness to sit down and help. I
    appreciate the support from the other two panelists and really
    look forward to working with you to be able to solve this
    problem that we know the need out there is tremendous. We have
    talked a lot in testimony over the course of the years, is we
    want to push out and bring clinics to more rural areas and to
    areas that are going to reach our veterans, make it easier for
    our veterans to access health services from the VA. And I think
    if we can fix the process we can meet our objective. So I thank
    you very much and appreciate your testimony today. And I yield
    back.
        Dr. Benishek. Thank you, Ms. Brownley. Dr. Roe.
        Dr. Roe. Just one. First of all, thank you all for
    advocating for veterans, what you do every day of your life.
    And it has got to be rewarding work. Thank you for doing it. My
    only question, Mr. Chairman, is on the Construction Reform Act.
    I am really, I am not sure, as I said here before, that I can
    vote to let the VA build another major project because they
    include us in the--I want to make sure that I understand this
    bill very carefully and I understand the intent of it. But
    there have been, I mean, there have been some fiascos out there
    that are beyond comprehension. The one in Aurora, Colorado
    where $1 billion dollars was spent. And now we are, now this
    committee is part of it. I have to go back home and to talk to
    veterans and talk to taxpayers there that want to help
    veterans. But when they see these excesses they think, my gosh,
    I mean how much healthcare, how many visits could we have had
    to doctors and to the medical centers based on a $1 billion
    dollar overrun? And I am afraid if we let the VA get in control
    of these again, the same thing is going to happen again. We
    will be sitting here talking about the same thing.
        So I just want to understand this bill better. I certainly
    have read it and it does have a lot of good things in it. But I
    want us to really have incredible oversight over that process.
    Or as I think Mr. Coffman has recommended, the Corps of
    Engineers have done a great job. They bring these projects in
    on time, under budget. And that is what we need to look at. I
    do not know how in the world Aurora ever happened. I, to this
    day I cannot explain. And now we are going to have to provide
    $1 billion in taxpayer funding, and it is not through yet, to
    get this project done. And we will finally get it done. I know
    we are going to, for the veterans that are waiting on care in
    Colorado. And that whole region, it will be a referral area.
    But that is just a comment. And I certainly look for help on
    the committee. And I yield back.
        Dr. Benishek. Thank you, Doctor. Ms. Kuster? Do you have
    any questions? Mr. Coffman.
        Mr. Coffman. Thank you, Mr. Chairman. And first on the
    construction, and I think, you know, obviously the bill is a
    step in the right direction. But I agree with Dr. Roe, it does
    not go far enough. And I think that the, having Aurora,
    Colorado in my district, the biggest cost overrun. But let me
    tell you, there have been a lot of other horrible cost
    overruns, although they do not exceed Aurora. I think there was
    a GAO report from 2013, April, 2013, that said that all major
    construction projects at that time were each hundreds of
    millions of dollars over budget and years behind schedule.
        I think that they should be stripped of all new
    construction authority, period, and that should revert to the
    Army Corps of Engineers. And this bill, I think, has that $100
    million and below. But I think, you know, if you give them $100
    million it could be, you know, what is that in terms of cost
    overruns? Is that $300 million by the time the project is done?
    And there is no ability to revert automatically once there is
    cost overruns to, say, an entity like the Army Corps of
    Engineers who have built similar projects, you know, as you
    mentioned, Dr. Roe, on budget, within schedule.
        Let me ask a question on H.R. 1356, the Women Veterans
    Access to Quality Care Act. I asked this question at a hearing
    in April and I would like to ask it again. Because there is a
    different representation on this panel today than there was
    then. In 2010 the GAO found that VA was not complying with its
    own privacy policies and facility standards for women veterans.
    These are policies designed to ensure the safety, dignity, and
    privacy of women patients at the VA. Based on the feedback of
    your membership, if GAO did the same review today, what would
    they find? Would anybody like to comment on that? Yes, Mr.
    Fuentes?
        Mr. Fuentes. Thank you for the question, Congressman.
    Before drafting testimony for women specific hearings, we have
    actually reached out to women veterans in leadership roles in
    our organization and many other women veterans who have reached
    out to us. And they see and the ones that attend a women's
    clinic feel that they are appropriate and that it is great
    service. But there is a long way to go. One of the things that
    we heard consistently was when there are OB/GYNs on staff, many
    times they are part-time. Right? And they do not have the time
    or the staff to take care of all the women veterans that that
    facility serves.
        Mr. Coffman. Thank you. Anyone else?
        Mr. de Planque. I was going to say that is also very
    consistent with what we found and that we continue to go there.
    And you see that these things are not improving. I know
    Sergeant Major Walz once made a point about, you know, the VSOs
    come in and they say the same things over and over and people
    have criticized that, but if they say the same things over and
    over it means it is not getting fixed. And this is, to see this
    and to see legislation that is attempting to address that, to
    us, that is heartening because it means the message is getting
    through that these problems are still out there. When we talk
    to women veterans who are out there, I mean, we have them
    integrated on our staff, we have them, you know, throughout all
    levels. And you know, they just want to be treated right and
    that is not so crazy a thing to ask. And so when you go out
    there and you see that they still do not have the operating, or
    the examination tables aligned correctly, it is a basic fix
    that cannot be that hard to fix. And it is just not being done.
    That is a consistency factor. And so there has been an attempt
    to address it and they are getting better, but VISNs are
    inconsistent. From VISN to VISN, you know, you do not know what
    you are going to get. And I think that is kind of a watchword
    for VA.
        Mr. Coffman. Okay. The 2010 GAO report also found that some
    of the VA medical centers surveyed offered specialized gender
    specific healthcare services, things like abnormal cervical
    cancer screening, obstetric care, and infertility evaluations
    only two or fewer days per week. Are you finding that your
    female membership is having difficulties getting appointments
    for gender specific healthcare services at the VA? Yes?
        Mr. Atizado. Mr. Coffman, thank you for that question. I
    think that ties back to your original question. I think for the
    most part VA is doing better. It is doing better as a matter of
    policy. I think the field is really trying to catch up to what
    the policy that comes out of VA headquarters is attempting to
    instill in the healthcare system.
        As far as access to care, yes, at VA facilities, especially
    for those that do not have the critical number of women veteran
    patients, access at that facility can be a little, not as good,
    it could be much better. But what we do find out is they are
    much more apt to be able to provide that service in the
    community if they cannot provide it in the VA facility.
        Mr. Coffman. Okay. Thank you, Mr. Chairman. I yield back.
        Dr. Benishek. Mr. O'Rourke.
        Mr. O'Rourke. Mr. Chairman, I would just like to join my
    colleagues in thanking the representatives from the veterans
    service organizations for being here. I think they were very
    clear in their comments on the proposed legislation. And I
    would just join my colleagues in asking that where we find
    fault in how we are trying to achieve accountability, that we
    offer improvements and certainly not lose the urgency of
    addressing some of these issues and boldly working to change
    the culture and the performance and outcomes for veterans that
    we see at the VA today. But I know that that is what you are
    interested in doing and have made proposals to do that. So I
    thank you.
        And I want to thank the chairman for his efforts to ensure
    accountability and my colleagues for the bills that they have
    proposed. And I think we are doing our best to strike that
    balance in ensuring accountability without being punitive and
    working constructively with the VA, and ensuring that
    ultimately that we serve the veteran and see improved
    performance outcomes. And I think that is what we are all
    interested in doing. And I hope, and I am looking forward to
    hearing the testimony of the VA, I hope that is the spirit in
    which the VA approaches this issue. Because the VSOs, the VA,
    the members of Congress, this is the team that is going to be
    able to fix this. And we need to make sure that each partner is
    willing to do that. So thank you and the ranking member for
    putting this hearing together today.
        Dr. Benishek. Thank you. If there are no further questions,
    the second panel is now excused. And I will welcome our third
    and final panel to the witness table. Joining us from the
    Department of Veterans Affairs is Dr. Madhulika Agarwal, the
    Deputy Under Secretary for Health for Policy and Services; and
    Janet Murphy, the Acting Deputy Under Secretary for Health for
    Operations and Management. They are accompanied by Jessica
    Tanner, General Attorney with the Officer of General Counsel.
    Dr. Agarwal and Ms. Murphy, you are recognized for five
    minutes.

    STATEMENT OF MADHULIKA AGARWAL, MD, MPH, DEPUTY UNDER SECRETARY
          FOR HEALTH FOR POLICY AND SERVICES, VETERANS HEALTH
    ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND JANET
     P. MURPHY, MBA, ACTING DEPUTY UNDER SECRETARY FOR HEALTH FOR
    OPERATIONS AND MANAGEMENT, VETERANS HEALTH ADMINISTRATION, U.S.
    DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY JESSICA TANNER,
    GENERAL ATTORNEY OFFICER OF GENERAL COUNSEL, U.S. DEPARTMENT OF
                            VETERANS AFFAIRS

                     STATEMENT OF MADHULIKA AGARWAL

        Dr. Agarwal. Good morning, well it is almost good
    afternoon, Chairman Benishek, Ranking Member Brownley, and
    members of the subcommittee. We appreciate your continued
    efforts to support and improve veterans healthcare. Thank you
    for the opportunity to testify on the bills on today's agenda
    and to discuss their impact on VHA's healthcare. Joining me
    today is Ms. Janet Murphy, Acting Deputy Under Secretary for
    Health for Operations and Management; and Ms. Jessica Tanner,
    Attorney in the Office of General Counsel.
        Mr. Chairman, we appreciate the committee's attention to
    many subjects that are important to veterans. We support many
    of the bills on the agenda today, beginning with the Medal of
    Honor Priority Care Act which will ensure responsive and
    appropriate healthcare for Medal of Honor recipients.
        We support H.R. 421, the Classified Veterans Access to Care
    Act. Currently veterans who serve in classified missions can
    receive mental health services with VA medical treatment
    facilities safely and at minimal to no risk to national
    security. We agree that it would be beneficial to establish
    standards and procedures to ensure that veterans have access to
    mental healthcare in a manner that accommodates the veteran's
    obligation to not improperly disclose classified information.
        We agree that the Newborn Care Improvement Act should
    provide additional inpatient treatment for a full term newborn
    facing complications such as fever or respiratory distress
    after delivery. This support comes with a caveat for additional
    resources that are going to be needed to implement the bill.
        We support the Veterans Credit Protection Act. The
    reporting required in this bill would result in improved
    relationships between veterans and providers by decreasing
    negative reporting of financial information on a veteran's
    credit history as a result of delayed payment by VA. It will
    also improve timeliness of payments to providers, decrease
    interest payments by VA, and protect veterans credit ratings.
    We also support the draft bill to amend the role of podiatrists
    in the VA.
        At this time the department is still reviewing H.R. 2914,
    H.R. 2915 and the draft bill on construction reform. We would
    be glad to follow up with your staff to address any technical
    concerns.
        In reference to H.R. 2464, the Demanding Accountability for
    Veterans Act of 2015, I would like to state that the vast
    majority of VA employees who come to work do their best serving
    veterans everyday. Ninety thousand of the 300,000 VA employees
    are veterans themselves, which is the largest percentage of
    veterans employed by any civilian agency. Accountability
    remains a top priority for the Secretary and we would want to
    make sure that these accountability bills have no unintended
    consequences. This bill may affect the Secretary's ability to
    manage effectively and could adversely impact the collaborative
    process between the Inspector General and the Secretary.
        VA supports the intent of H.R. 353, Veterans Access to
    Hearing Health Act of 2015, however we feel that this bill is
    unnecessary because the Secretary already has the authority to
    appoint other specialists such as licensed hearing aid
    specialists and to prescribe standards for these specialties.
    Similarly, the Secretary has the authority to accomplish the
    goals of H.R. 1688. VA currently has the ability to create
    additional optometry residency positions and therefore
    legislation is not needed.
        As for the Women Veterans Access to Quality Care Act of
    2015, we support the intent of the bill and are taking several
    actions already to address the issue of the structural
    standards. VA regularly outperforms the private sector in both
    cervical cancer screening and the breast cancer screening, and
    has significantly improved internally in closing the gender
    disparity in areas such as lipid screening, depression
    screening, and immunizations.
        H.R. 359, the Veterans Dog Training Therapy Act, we value
    the identification of effective treatment modalities to address
    PTSD and other post-deployment mental health symptoms. However,
    VA has significant concerns about the provisions in this bill.
    These concerns are detailed in our written testimony.
        Thank you, Mr. Chairman and Ranking Member for the
    opportunity to testify before you today. My colleagues and I
    are pleased to answer any questions that you all may have.

        [The prepared statement of Madhulika Agarwal appears in the
    Appendix]

        Dr. Benishek. Thank you, Dr. Agarwal, I appreciate it. I
    will yield myself five minutes for a few questions. Apparently
    the VA failed to provide views of our cost estimates for many
    of the bills on today's agenda, including Chairman Miller's
    draft bill on construction and both of Ranking Member
    Brownley's bills. When can the subcommittee expect to receive
    the official views and cost estimates for these bills?
        Dr. Agarwal. Chairman, that is a good question. They are
    currently under review in the department itself and as
    expeditiously as we can we will get it to you.
        Dr. Benishek. Is there a date you have in mind?
        Dr. Agarwal. I----
        Dr. Benishek. Because we always try to get, you know, Dr.
    Agarwal, a specific date.
        Dr. Agarwal. You know, sir, we will do our best to get it
    out as early as we possibly can. I could not give you a date.
        Dr. Benishek. All right. Regarding my bill, 2464, the
    Demanding Accountability for Veterans Act, I believe that the
    VA's objections are a little overstated. I understand your
    concerns about how the bill will impact situations where the
    department does not concur with the IG and/or the IG's finding
    involve other federal agencies with the VA. Would you be
    willing to work with me to provide technical assistance to
    address these issues?
        Dr. Agarwal. Yes sir, we will.
        Dr. Benishek. Can you tell me how often the VA requests
    changes to draft IG reports?
        Dr. Agarwal. VA recognizes the independent role of the OIG
    and the draft changes, there are no changes made to the
    recommendations except to provide technical correction if that
    is needed or necessary. So it is not a matter of how many times
    we change the draft. We never do. The IG's recommendations
    remain the IG's recommendations. We only provide some technical
    corrections if they are needed.
        Dr. Benishek. All right. How exactly do you think that the
    Demanding Accountability for Veterans Act would negatively
    impact the relationship between the VA and the Inspector
    General?
        Dr. Agarwal. So as I stated earlier, Chairman, most, I
    would say the vast majority of our employees continue to serve
    the veterans every single day with great integrity and care.
    The concern that has been expressed in relationship to the bill
    is the technical corrections that are necessary sometimes
    before any misinformation is communicated further down the
    road. And it is essential that----
        Dr. Benishek. Well, I guess I do not understand that. What
    does that mean? Misinformation communicated down the road, what
    is that? I do not understand that.
        Dr. Agarwal. I, let me see, for Ms. Murphy, if you could
    provide some examples?
        Ms. Murphy. Thank you, Chairman Benishek. So I think what
    Dr. Agarwal is talking about is when we get the draft report we
    check, we look to see if there are misstatements. So for
    example, it might be 1,000 patients and when we go back and
    look at our data it is 859. I mean, and it is those kinds of
    changes. The IG's recommendations are their recommendations.
    And you know, they do not change them for us. But we sometimes
    can provide information to clarify, strengthen the
    recommendations, make them, make them more complete. And so
    those are the kinds of things that we try to work with the IG
    on.
        Dr. Benishek. All right. Well you know, and my point of
    this legislation, which you have heard me speak of many times,
    is that we have a very difficult time here sometimes finding
    why something has not been implemented when you yourselves know
    that IG reports are often concurred with but not really
    implemented, the changes that are recommended in the IG report.
    And we want to move that process forward and have the changes
    that the IG recommends implemented on a timely basis and have
    someone's name we can identify who is responsible for that. Do
    you have a strong aversion to that idea, Dr. Agarwal?
        Dr. Agarwal. No, sir. Every employee is accountable and
    should be held accountable for their actions because we have a
    responsibility towards the organization and the veterans that
    we serve. But in many instances it is not one single individual
    who is responsible for some outcome.
        Dr. Benishek. Well, but maybe there should be, though. That
    is the whole point of this. Because otherwise they all raise
    their hands and say it was not my fault and then nobody ends up
    being accountable. Do you understand?
        Dr. Agarwal. And there are instances when it is necessary
    that there is only one entity or one individual who is
    responsible, then that person is, there are actions that are
    taken subsequently.
        Dr. Benishek. It has been difficult for us to determine
    that. I am sorry. I am out of time, doctor. But I am going to
    yield to Ms. Brownley. Maybe she will be able to follow up,
    thanks.
        Ms. Brownley. Thank you, Mr. Chairman. And thank you both
    for, well three of you, for being here this morning. And you
    know, I just wanted to speak to the two bills that are, I have
    put forward that we have heard about today in the hearing. And
    I understand that you have not weighed in on either H.R. 2914
    or H.R. 2915. But just wondering if you could just comment
    briefly about the intent of each one of those? And if you
    generally agree or generally disagree?
        Dr. Agarwal. I will comment on H.R. 2915 and I will ask Ms.
    Murphy to comment on H.R. 2914. With H.R. 2915, which is an
    amendment to the Clay Hunt in focusing on women's mental health
    and suicide prevention, we agree with the intent. In fact, we
    are going to be doing the evaluation as part of the Mental
    Health Act. And we believe that with that intent we can
    certainly see on how that can be accomplished.
        Ms. Brownley. And H.R. 2914, Ms. Murphy.
        Ms. Murphy. Thank you, ranking member. The, I will just
    start by stating that we will take all the help we can get on
    leases. It is a process now that we struggle with. I have
    something to do with leases everyday, where someone is having
    difficult getting leases through. We have, so it is a
    complicated process.
        I would also say that Deputy Secretary Gibson has stood up
    a VHA-wide, VA-wide, excuse me, including VHA, process to
    really look at our lease process from start to finish. And we
    would really welcome working with you on this bill to see where
    we could provide technical assistance to help us get the help
    we need with our leasing process. It is partly on us but it is
    also partly a function of the current process and the
    requirements that we are, the hoops that we are required to go
    through for our leases.
        Ms. Brownley. Do you know what Secretary Gibson's timeline
    is?
        Ms. Brownley. Deputy Secretary Gibson? We have been meeting
    for about the past month. I do not know the exact timeline but
    he always likes things done fast. So I am presuming he has got
    a month timeline or thereabouts but I know he is all about
    getting it done fast.
        Ms. Brownley. Well I welcome your offer and would like very
    much to work with you. Because I do feel like we are, I think
    we are, you know, we are making progress in terms of what some
    of our objectives are of wait time, access to healthcare, so
    forth and so on. We understand where the needs are, we have
    identified where the needs are. And we have got a process that
    is just standing in the way where we had a process that seemed
    to work. And this was supposed to be the improved upon process
    but yet it is just putting us further behind. So I appreciate
    that.
        I just wanted to comment briefly on H.R. 359, too, the Dog
    Training Therapy Act. And you know, I know that we are waiting
    for data to be able to make some decisions on this. I guess,
    you know, the first question would be when do you anticipate
    having results of a research study so that we can finally
    formulate and move forward on this decision? And I, you know,
    my comment would be is that I think all of us are always
    pressing for, you know, data driven, decision making here, up
    here on the dais. On the other hand, you can get to a place
    where you have the data or you let the data stand in the way
    from what a common sense solution might be for our veterans.
    And we talk a lot about alternative options for folks who are
    suffering from mental health. And I think we could all agree
    that this is common sense, that working with dogs is a very
    positive thing for some of our veterans and for the veterans
    that it works for it works for very, very well. So if you could
    just answer, you know, what your intention is in terms of
    moving forward on this concept?
        Dr. Agarwal. Ranking member, as you probably are aware
    there were several complications that took place in the pilot
    in Tampa with the paired dog study related to the service dogs
    and PTSD. And so right now there is a multi-site study going on
    in three places where the dogs are being paired as service dogs
    and the emotional support dogs. And the outcomes we believe
    would be available, the results would be available in three
    years.
        Similarly there is a Department of Defense study which is
    about the dog training as a treatment modality for veterans
    with PTSD and other mental health related conditions. That is
    something that the Department of Defense is doing and we, I do
    not know exactly when to expect the results from that
    particular study.
        Ms. Brownley. Well, thank you. And I just would comment I
    think that there is plenty of data out there, probably outside
    of the VA there are a lot of nonprofits across the country that
    are providing dogs and utilizing dog therapy. And I just think
    that if we are going to wait three more years, you know, to
    make a determination on this, is just, you know, I think that
    we should find a way to really streamline this. And it has been
    something that I think our veteran community really wants,
    people believe in it, and we should move forward on it. So
    thank you, I yield back.
        Dr. Benishek. Thank you, Ms. Brownley. Mr. Coffman.
        Mr. Coffman. Thank you, Mr. Chairman. Dr. Agarwal, if I
    said it right, can you tell me why the Department of Veterans
    Affairs, why the leadership insists on being involved in
    construction management going forward after the incredible
    debacle in my congressional district with a VA hospital that is
    now projected to be over $1 billion in cost overruns? I mean,
    with all the problems that we have identified in this committee
    on the healthcare side, why do you not want to focus on that?
    Instead of something you obviously, that the Department of
    Veterans Affairs obviously cannot do?
        Dr. Agarwal. So we certainly appreciate all the help that
    Congress, you and others have been providing our top leadership
    in helping manage the construction issues, especially in
    Denver. I do not know very much about construction. But I will
    ask and see----
        Mr. Coffman. Well nobody in the department does so you are
    not alone.
        Dr. Agarwal. I certainly probably am the least informed
    about----
        Mr. Coffman. You might know more than the folks that were
    managing the project in Aurora, but go ahead please.
        Ms. Murphy. Well, I did renovate my kitchen, sir.
        Mr. Coffman. Oh, well I do not want to know how much it
    cost.
        Ms. Murphy. But truthfully, I think we would agree that
    some of the projects have been less than well managed. But I
    would say that hearkening back to Deputy Secretary Gibson's
    testimony at the recent hearing where he mentioned that we have
    an independent group looking at our construction process. That
    report will come to Congress at the end of September. I think
    it will help us understand where our issues are.
        I think we have also put some things in place in the
    meantime that will help us, just things that you would commonly
    find in the industry. Thirty-five percent of design done before
    we give out a dollar. We have a construction advisory group, a
    project review board, it is called, that is helping us look at
    our projects. So I think better oversight, better management of
    the projects, bringing in more experts to help us, engineering,
    medical equipment experts, so that we are planning these things
    early on in the process. So I guess I would say there is
    information coming to Congress about our construction process
    from the independent third party and I think that will be
    revealing in terms of where we need to go.
        Mr. Coffman. Well I would ask you to take a message back to
    your leadership, and that is that the Veterans Administration
    needs to focus on what their core responsibilities are, and
    that is taking care of our nation's veterans. Squandering $1
    billion on a single project that was supposed to cost $600
    million is simply inappropriate and is offensive to our
    nation's veterans. Because that could have gone to caring for
    our veterans. That could be, that could be in healthcare, or
    that could be in providing benefits for our veterans in terms
    of making sure that they get the care and the benefits that
    they deserve through their military service. And so, and the
    fact, and how many people have been fired in the construction
    management section besides one whistleblower? How many people
    have been fired in the Veterans Administration for, I mean, if
    we look at the GAO report for 2013, this is not a new issue. I
    mean, in 2013 it was identified that not only was the Aurora
    project hundreds of millions of dollars over budget and years
    behind schedule, but every major construction project that the
    VA was doing at that time was each hundreds of millions of
    dollars over budget and each years behind schedule, the four
    projects that were identified there. And at that time VA
    leadership took no action in terms of correcting its problems.
    And now the American people are somehow supposed to trust you,
    the Veterans Administration know that, oh, everything is going
    to be okay. Everything is not going to be okay. Please tell me
    how many people have been fired.
        Dr. Agarwal. I do not know the answer to that, sir.
        Mr. Coffman. Can you get that information back to the
    committee?
        Dr. Agarwal. We could take it for the record.
        Mr. Coffman. I believe the answer is zero. The answer,
    except for one whistleblower, the answer is zero outside of
    that. And if not for the whistleblowers in the VA, the rank and
    file, men and women who really care about serving our nation's
    veterans, let me tell you this committee would not be aware of
    all the problems that have come forward in the VA. It is that
    rank and file who truly want to care and some in leadership,
    but mostly just the rank and file. Men and women who work in
    the VA who fundamentally care about taking care of our nation's
    veterans. With that, Mr. Chairman, I yield back.
        Dr. Benishek. Thank you, Mr. Coffman. Mr. O'Rourke.
        Mr. O'Rourke. Thank you, Mr. Chairman. For Dr. Agarwal, the
    concerns that you have about the chairman's bill Demanding
    Accountability for Veterans Act are understandable. I would
    like to know what the counter proposal is, though. Because it,
    I think it is easy and fair enough to point out from the VA's
    perspective weaknesses in a proposal to address accountability.
    But what is more important is actually getting that
    accountability. So what is the VA's proposal to address this
    issue that Dr. Benishek is trying to get at?
        Dr. Agarwal. Congressman, let me attempt to answer a fairly
    complex question as briefly as I can. I think it is very clear
    that we lay very, clarify all expectations of our employees up
    front, especially when we recruit them as to what is expected
    of them. And I know that it is done on somewhat, I would hope
    on a routine basis, but I think we have to be very consistent
    in how we sort of establish that. We need to have very specific
    and measurable goals that our employees understand on how they
    are going to help serve the veterans and achieve the goals of
    the department. We need to make sure that all the barriers that
    they face are eliminated and that is the support of the
    management and leadership in helping solve that.
        I am not sure if I am exactly answering your question the
    way you have intended it to be. But I think those are some of
    the very specific things that we can begin to do.
        Mr. O'Rourke. Yes, I think for me at least the larger point
    is that I believe I have heard the Assistant Secretary and the
    Secretary both acknowledge the need for greater accountability
    within the VA. And that is important, admitting that you have a
    problem. But then the very next important step is detailing a
    plan to resolve that problem that has a defined goal and end
    date so that we can in turn know what the progress the VA is
    making towards that goal.
        To date I have not heard that. Or at least, I have not
    heard it succinctly and in a way that I can understand and
    communicate to the veterans that I represent. And in the
    absence of that I think proposals like the one presented by our
    chairman are very compelling. And I think there is a natural
    tension between the VA and its oversight committee, or this
    committee which has oversight responsibility and authority and
    that is probably healthy. When it becomes adversarial and the
    proposals that we make are rejected, again, perhaps for good
    technical, legal, and reasons of function and form within the
    VA, and are not then answered with a proposal from the VA
    itself, it makes it very hard not to move forward with
    something in the absence of anything else from the VA.
        So I understand your, the answer that you just gave. But it
    is not a proposal or a plan that I can take back to my veterans
    who ask me, hey Beto, what are you guys doing about the VA?
    There is a steady drumbeat of unfortunate news from the VA, not
    because we have on the whole bad employees. And I agree with
    you. I think the vast majority of those who work for the VA are
    spectacular people doing very difficult jobs who could be
    making much more doing something else but they do it because
    they share that same mission that you and I have, which is to
    serve that veteran who has served this country. But we do have
    some people who are in the way of progress or who are actively
    stopping our ability to serve veterans and those people need to
    be held accountable. And so I think that is what we are looking
    for.
        Let me quickly move to a statement that Ms. Murphy made in
    answer to Ms. Brownley's question about needing all the help
    you can get when it comes to leases. Beyond what Ms. Brownley
    has offered, do you have any other requests from Congress that
    would help you and give you additional statutory authority that
    you need to be able to execute leases more quickly and more
    effectively, and get more facilities online and more veterans
    treated sooner rather than later?
        Ms. Murphy. Thank you, Congressman. I am not an expert on
    leases. I am an expert in trying to get healthcare services up
    and running. So my interaction with leases is at that nexus. I
    certainly think we could get our really skilled and informed
    lease people with you and with this group to help figure out if
    there are other things that we need besides what Ranking Member
    Brownley has proposed. I mean, obviously we want to make sure
    that what we end up with actually works, and I think that is
    your goal too, and actually facilitates the process. So I would
    love to come back and provide more technical assistance and
    additional input that you might need. I am very glad to do
    that, and get the right people here to do that.
        Mr. O'Rourke. Mr. Chairman, let me just conclude by saying
    that I appreciate that answer. I look forward to working with
    you. I also appreciate your answer on the question about the
    Construction Reform Act and that the Secretary is going to be
    coming forward with something in September, at least having
    more information that can help us better understand the issue.
        We are not likely to get a major facility in El Paso in
    part because of the royal screw up in Colorado, in Louisiana,
    in Nevada, in Florida. I mean, hundreds of millions of dollars,
    over $1 billion in overage in all of those projects. And in
    part because of that being able to execute these leases with
    willing partners in communities like El Paso that are sorely
    underserved and have some of the worst performance metrics in
    the country are incredibly critical for our success. So I just
    want to let you know that you have a partner in our office in
    getting those leases done. Because if we do not that veteran in
    El Paso and other parts of the country will not be served. So
    we look forward to working with you on that. And with that I
    yield back to the chairman.
        Dr. Benishek. Thank you, Mr. O'Rourke. Does anyone have any
    other questions they would like to ask? Well, I think we can
    excuse the third panel then. Thank you very much for coming
    this morning.
        I ask unanimous consent that all members have five
    legislative days to revise and extend their remarks and include
    extraneous material. With no objection, so ordered.
        I would like to once again thank all of our witnesses and
    audience members for joining this morning and this afternoon.
    This hearing is now adjourned.
        [Whereupon, at 12:29 p.m., the subcommittee was adjourned.]

                                    APPENDIX

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Prepared Statement of Rep. Walberg Testimony for Medal of Honor
                          Priority Care Act (H.R.272)

        Chairman Benishek, Ranking Member Brownley and Members of the
    Subcommittee, I thank you for allowing me the time to speak this
    morning in support of my legislation, H.R.272, the Medal of Honor
    Priority Care Act of 2015.
        As the Members of this Committee are well aware, the Congressional
    Medal of Honor is the highest award for valor which can be bestowed
    upon an individual serving in the United States Armed Forces and is
    awarded to soldiers who have displayed conspicuous gallantry and
    intrepidity at the risk of life above and beyond the call of duty. The
    Medal of Honor is a distinguished award given to a select few. Less
    than 3,500 have been awarded, 16 awards have gone to soldiers who
    fought in the recent conflicts in Iraq and Afghanistan. Currently there
    are only 79 living Medal of Honor recipients.
        My state of Michigan is privileged to have two living recipients,
    Corporal Duane E. Dewey and Private First Class Robert E. Simanek. Both
    received the decoration for their heroic action in the Korean War, and
    hearing of their harrowing stories of bravery has reminded me of the
    sacrifice American soldiers are willing to make to protect their
    comrades and their country.
        Medal of Honor recipients deserve our utmost appreciation, and I
    believe the small portion of our servicemembers who have gone above and
    beyond the call of duty and earned the highest honor in our nation's
    Armed Forces have earned the right to be placed in the top priority
    group to receive their healthcare benefits. I'd be remiss if I did not
    mention the idea for this legislation came from a veteran who lives in
    my district and works with the veteran community.
        All veterans deserve access to the healthcare they have earned, but
    as you all know, the VA uses a priority system to determine eligibility
    for these healthcare services. Some of the factors that will affect a
    soldier's priority group ranking are whether the soldier has a service-
    connected disability, whether they were a former prisoner of war, the
    time and place of service, as well as income level. Currently, Medal of
    Honor recipients are in Priority Group 3.
        This bill is very similar to legislation approved by this committee
    during the 113th Congress, which was supported by the VFW, Vietnam
    Veterans of America, IAVA, the American Legion, and AMVETS. I'm proud
    to once again have the support of my colleagues from both sides of the
    aisle on this bill.
        I thank the Chair for permitting me to appear before the
    Subcommittee today.

                                     ---------

                      Prepared Statement of Steve Stivers

        I want to thank Chairman Benishek for including my bipartisan bill,
    the Veterans Dog Training Therapy Act, in today's legislative hearing.
        As the Committee Members are well aware, it is estimated that 22
    current and former service members commit suicide each day. This is a
    tragedy that requires immediate action and I want to commend the
    Committee Members for their commitment to addressing this matter.
        It is known that post-traumatic stress disorder (PTSD) contributes
    to suicide among the veteran population and Congress has taken steps to
    improve treatments of the condition. However, every individual is
    unique and responds differently to available therapies and treatments.
        That is why I introduced the Veterans Dog Training Therapy Act with
    my colleague and good friend, Tim Walz. Our bill seeks to expand access
    to an alternative therapy that has been proven effective for many
    veterans who suffer from the invisible scars of war.
        Specifically, our legislation would establish a service dog
    training pilot program at 3-5 VA facilities as selected by the VA
    Secretary. Results of the pilot would be studied for consideration of
    expanding the program. Under the pilot program, veterans suffering from
    PTSD would be connected to service dog training organizations. These
    veterans would learn useful occupational skills while training service
    dogs. Upon completion of their training, each dog would be provided to
    a disabled veteran--enabling veterans to help other veterans.
        This program is not made from scratch; it is an almost identical
    model to the successful service dog training program conducted by the
    non-profit organization Warrior Canine Connection at several Department
    of Defense medical facilities and one VA Hospital location. Veterans
    enrolled in this program witnessed significant improvements in PTSD and
    TBI-related symptoms. It is also important to note that some of the
    wounded warriors who benefited from the service dog training therapy
    program had not been responding successfully to other treatment
    options.
        The effectiveness of service dogs in treating PTSD and TBI-related
    symptoms is supported by preliminary research from Kaiser Permanente,
    which has shown that veterans who own service dogs have fewer symptoms
    of PTSD and depression, better interpersonal relationships, a lowered
    risk of substance abuse and better overall mental health.
        It should also be noted that Congress directed the VA to conduct a
    research study on the efficacy of service dogs in treating these
    injuries in the 2010 NDAA, which was signed into law in September of
    2009. Since then, the agency has blundered so badly in the design and
    implementation of its own study that research results are not expected
    until 2019--10 years after the study was ordered by Congress. These
    veterans cannot wait any longer.
        I do not claim that my bill will completely solve PTSD. But it is
    clear that many veterans have been helped by service dog training
    therapy programs and that it has promising potential to significantly
    aid in the treatment of many individuals who are struggling with
    invisible wounds in the VA system --brave men and women who are not
    responding to other treatment methods.
        Lastly, psychological conditions like PTSD are not new. These
    conditions have confronted American soldiers returning from all wars.
    We must address this issue now so that we can end the current suicide
    epidemic and to ensure that the best treatments are available for
    soldiers returning from future conflicts.
        Again, I appreciate the Chairman for allowing me to testify today
    and holding this hearing.

                                     --------

                      Prepared Statement of Doug Collins,

        Chairman Benishek, Ranking Member Brownley, and distinguished
    members of subcommittee, thank you for the opportunity to testify on
    H.R. 423, the ``Newborn Care Improvement Act''. My legislation amends
    title 38, United States Code, to improve the care provided by the
    Secretary of Veterans Affairs to newborn children. I am very
    appreciative of the Subcommittee's consideration of this legislation.
        The motto of the Veterans Administration comes straight from
    Abraham Lincoln's Second Inaugural. He got the idea straight from
    scripture. So the challenge for us to ``care for him who shall have
    borne the battle, and for his widow, and his orphan,'' isn't a new one.
        Since September 11, 2001, more than a quarter of a million women
    have answered the call to serve. They've faced terrorism in the deserts
    and mountains of Iraq and Afghanistan. So in the 21st century, we must
    also consider she who shall have borne the battle.
        When she returns, what of her children?
        The finest military in the world is powered by men and women in
    their physical prime. The young women who decide to serve this country
    in the armed forces aren't immune from the same questions that all
    young women face about whether they pursue a career, a family, or both.
    Yet they are offered a healthcare system that for so many years has
    been designed to serve men.
        With the increasing number of female veterans, the VA must expand
    its care and services to meet their needs. Maternity care tops that
    list of needs, and I've offered one way we can help. In 2010, Congress
    passed and the President signed the ``Caregivers and Veterans Omnibus
    Health Services Act of 2010'' to provide short-term newborn care for
    women veterans who received their maternity care through the VA. Signed
    into law on May 5, 2010, this legislation authorized up to seven days
    of newborn care.
        On January 27, 2012, The Department of Veterans Affairs published a
    regulation officially amending VA's medical benefits package to include
    up to seven days of medical care for newborns delivered by female
    Veterans who are receiving VA maternity care benefits. The rule, which
    became effective Dec. 19, applied retroactively to newborn care
    provided to eligible women vets on or after May 5, 2011.
        Since this seven day authorization was enacted by Congress in 2010,
    we've learned more about the unique challenges facing female veterans
    and the changing trends in these veterans seeking maternity and newborn
    care from the VA. According to a study published in the Women's Health
    Issues Journal this year, from 2008-2012 the overall delivery rate by
    female veterans utilizing VA maternity benefits increased by 44 percent
    and a majority of the women using VA maternity benefits had a service-
    connected disability.
        Just last week, the U.S. Navy announced it has tripled the amount
    of paid maternity leave for personnel in the Navy and Marine Corps.
    Effective immediately, 18 weeks of maternity leave will be available.
    Secretary Mabus stated in a press release that ``with increased
    maternity leave, we can demonstrate the commitment of the Navy and
    Marine Corps to the women who are committed to serve.''
        In the same way, unless Congress extends the authorization for
    length of newborn care coverage provided by the VA, there will be
    veterans who face difficult financial decisions and complexity in
    navigating insurance options at the same time that their newborn is
    fighting for their life.
        This is why I introduced H.R. 423--to demonstrate Congress'
    commitment to meeting the needs of female veterans by providing a
    little longer for their newborn. My legislation extends the
    authorization of care from seven days to 14 days and provides for an
    annual report on the number of newborn children who received such
    services during such fiscal year. Improved data on the trends in female
    veterans utilizing newborn care will help Congress and the VA better
    meet their needs in the years to come.
        Should this subcommittee place my legislation on their markup
    calendar, which I hope they do, I would request an amendment be made to
    add the reporting requirement to an existing report that the VA is
    already required to produce. Although it's vitally important that
    Congress and the VA have this data, I don't want VA to produce yet
    another report when instead we could add this requirement to an
    existing report.
        Some may ask why the VA should provide more newborn care coverage
    to female veterans than the average private sector employee would
    receive. These women have risked their lives to protect our nation.
    Just because they are no longer serving in active duty does not mean
    our responsibility to them ends. In fact, their service to our country
    may jeopardize the very lives of their future children and thus our
    responsibility to them is even greater. A recent study examined more
    than 16,000 births to female veterans. Having PTSD in the year before
    delivery increased a woman's risk of spontaneous premature delivery by
    35 percent, the research showed.
        ``This study gives us a convincing epidemiological basis to say
    that, yes, PTSD is a risk factor for preterm delivery,'' said the
    study's senior author, Ciaran Phibbs, PhD, associate professor of
    pediatrics and an investigator at the March of Dimes Prematurity
    Research Center at Stanford University. ``Mothers with PTSD should be
    treated as having high-risk pregnancies.''
        Premature infants often need long hospitalizations after they are
    born and are more likely than full-term infants to die. Those premature
    infants who survive may face long-term developmental problems. And
    unfortunately, the number of female veterans with PTSD is not
    insignificant. According to the VA, 20% of female veterans of the
    conflicts in Iraq and Afghanistan have been diagnosed with PTSD. And
    these are not just the female veterans serving in combat.
        I know what it's like to be the parent of a little baby who needed
    intensive medical care for an extended period the moment she was born.
    It's my hope that any new mother, who has given selflessly to her
    country, wouldn't have to worry about Congress standing in her way as
    she tries to give selflessly to her own child.
        Our goal should always be to provide the mother with the pre-natal
    care she needs to give her newborn the best chance of a healthy
    delivery with no post-natal complications. There are significant needs
    and challenges that a female veteran faces when returning home from the
    battlefield such as homelessness, sexual and physical abuse, and mental
    health conditions such as Post Traumatic Stress Disorder. And this
    legislation won't solve all of those great challenges. But my hope is
    H.R. 423 will give her a little peace of mind knowing her newborn will
    get some extra help from the VA and that Congress is committed to her
    and her family.
        In a focus group conducted on Women Veterans' Reproductive Health
    Preferences and Experiences and published by Women's Health Issues
    Journal in 2011, one Marine said, ``I can essentially say that I gave
    my reproductive years to the Marine Corps. And those are the years you
    can serve . . . You know, you do sacrifice and you say, well, ``mission
    first before a family mission,'' type of thing and the more I think
    about I think, you know, the VA probably should address that part of
    womanhood and have that understanding.''
        There are multitudes of ways that the VA must adapt to better meet
    the needs of female veterans. By increasing the authorization of care,
    we can ensure that Congress is not standing in the way of the VA
    seeking to do just that. Absent the legislative change made by H.R.
    423, the VA cannot provide more than 7 days of care. And I believe that
    is unacceptable.
        In closing, we owe it to our female veterans to expand and improve
    the healthcare services that the VA can provide them and their
    children. Female veterans face unique challenges and barriers,
    including very limited newborn care coverage. While the majority of
    female veterans who receive maternity care from the VA are able to
    return home with their newborn within the current seven day time frame,
    some cannot due to newborn health complications. It is these veterans
    and their children that need Congress' help today.
        Expanding the authorization of care from seven to 14 days will give
    these female veterans more time to make alternate arrangements and
    secure private or public insurance for their newborn's continued health
    needs.
        I thank the Chairman and Ranking Member for holding this hearing
    and I'm happy to discuss this legislation further with any of my
    colleagues. Thank you.

                                     ---------

                        Prepared Statement of Sean Duffy

        Good morning. Thank you, Chairman Benishek and Ranking Member
    Brownley, for holding this hearing today. I appreciate the opportunity
    to testify on behalf of H.R. 353, the Veterans' Access to Hearing
    Health Act. I introduced this legislation, along with Rep. Tim Walz
    (MN-01) and Rep. Raul Ruiz (CA-36), to help address the long wait times
    and lack of access our veterans are facing in regard to audiology
    services.
        Our aging and younger veterans returning from the battlefield are
    seeking help from the VA for hearing loss and tinnitus more than any
    other disabilities facing them today. Yet, the VA does not have the
    capability to keep up with demand for these services.
        A recent Washington Post article cited that since the VA scandal
    broke last year, the number of veterans on wait lists for appointments
    has actually increased by 50%. Audiology services are a major factor in
    the wait times veterans are facing. According to the VA, nearly half of
    all patients awaiting care are waiting for audiology services.
        Veterans, like my constituent Roger Ellison from Marshfield, should
    not be fighting the VA for care. Roger is 70 years old and a veteran of
    the Vietnam War. He suffers from hearing loss, but when he sought help
    from the VA, he was told he could not get an appointment for six
    months. Unfortunately, Roger couldn't wait that long, so he went to his
    local hearing aid specialist - and he was seen that day. Roger was
    willing to pay out of pocket for his hearing aids because six months
    was just too long to wait.
        Audiology services not only affect the older generation, but also
    the younger generation returning from overseas. Roger and thousands of
    other veterans are in this situation today because the VA is allowed to
    use only audiologists--and not other capable providers--to fulfill
    hearing services to veterans. While audiologists are a great resource
    for the VA and provide good service for veterans, there are not enough
    to keep up with the demand.
        Hearing aid specialists are a perfectly viable option and stand at
    the ready to help our veterans in need. Hearing aid specialists have
    gone through a 1-2 year apprenticeship training period, have completed
    a comprehensive written exam, and are certified by the state to test
    hearing, and fit and dispense hearing aids. They are qualified to
    support the specialized services of audiologists by fitting, adjusting,
    and making minor repairs to hearing aids. By allowing hearing aid
    specialists to serve in their licensed role at the VA, the current
    burden audiologists have of performing all hearing services will be
    lifted. With the provisions of H.R. 353 in place, VA audiologists can
    turn their attention to specialized cases and complex conditions, and
    people like Roger won't be waiting six months for hearing aids or
    simple adjustments.
        My legislation also asks for a detailed report from the VA on the
    timely access of hearing health services, the contracting policies in
    regard to providing services outside the VA, the staffing levels in the
    audiology department, and a description of performance metrics.
        H.R. 353 has the support of the National Guard, the Retired
    Enlisted Association, Veterans' Health Council, Vietnam Veterans of
    America, the American Academy of Otolaryngology, the Wisconsin American
    Legion Executive Committee, and 27 of our colleagues.
        As Americans, we can never repay our debt to veterans like Roger,
    but Congress can pass common-sense measures like H.R. 353 to help make
    their lives back home a little easier. I urge the Committee to pass my
    legislation quickly and appreciate your support today.
        I yield back the balance of my time.

                  Prepared Statement of the Hon. Mike Coffman

        Thank you Chairman Benishek for holding this legislative hearing
    and including my bipartisan bill--the Women Veterans Access to Quality
    Care Act.
        Although the Department of Veterans Affairs has made some progress
    in recent years, the fact remains that the VA is a system largely
    designed for male veterans. A recent comprehensive study conducted by
    the Disabled American Veterans (DAV) entitled ``Women Veterans: The
    Long Journey Home,'' found serious gaps in almost every aspect of
    programs that serve women vets.
        In recent years the active-duty military has made incredible
    strides towards fully incorporating women into the ranks. Though more
    work needs to be done, these long-overdue changes in the Department of
    Defense have increased the pool of eligible recruits, raising the
    standards to make our military the most professional that our country
    has ever had. As more and more of these women leave military service
    and become veterans, it is critical that the VA quickly adapt its
    facilities and culture.
        The aim of my bill is to increase gender-specific access to care
    within the VA, improve healthcare outcomes for our women veterans, and
    improve VA's facilities to ensure they protect the privacy and dignity
    of all veterans.
        The need for this bill is largely illustrated simply by reviewing
    the rapidly changing demographic composition of the VA patient
    population:
        1. Between 2003 and 2012, the number of women veterans using VA
    healthcare nearly doubled.
        2. In 2012 women made up only 6.5% of the VA patient population,
    but are estimated to encompass over 10% by 2020.
        3. Meanwhile, nearly 20% of new recruits are women.
        The women veteran patient population also has unique
    characteristics when compared to the male VA population:
        1. The median age of a female patient in VA is 49 compared to 64
    for male patients.
        2. Only 13% of men within VA were 45 years old or younger compared
    to 45% of women.
        These are dramatic changes to the VA's patient population, and the
    former--almost exclusively male--VA healthcare system simply hasn't
    kept up with the changes.
        My bill addresses the VA's lapses in healthcare quality and access
    for its women patients in five ways:
        First, my bill requires the VA to establish standards to ensure VA
    facilities meet the specific needs of women and integrates those
    standards into its Strategic Capital Investment Planning process.
        The Government Accountability Office (GAO) found in 2010 that none
    of the VA hospitals it surveyed were fully compliant with the VA's own
    policies related to privacy for women veterans. Just to cite a few
    examples, the audit found that check-in desks were in busy mixed-gender
    areas and gynecological examination tables faced towards doorways.
    Additionally, despite VA requirements that gynecological exam rooms
    have immediately adjacent restrooms, often women were required to walk
    down long hallways in high-traffic, mixed-gender corridors to access
    restrooms.
        At a hearing in this room in April, I asked a panel of Veteran
    Service Organization (VSO) experts whether these conditions have
    improved in the past five years, and the Committee learned that these
    problems continue to persist nationwide.
        Second, my bill holds VA medical facility directors accountable to
    performance measures which include women's health outcomes and requires
    the reporting of those outcomes. As with many other areas in the VA,
    there is an incredible lack of accountability which is hindering true
    progress and reform.
        Third, my bill ensures the availability of OB-GYN services at VA
    medical centers and requires VA to conduct a pilot program to increase
    residency and graduate medical education positions. In 2010, nearly
    half of the women Veterans who used V-A healthcare had at least one
    reproductive health diagnosis. It is absolutely essential that these
    veterans have quick and reliable access to appropriate gender-specific
    care.
        Forth, my bill improves outreach to women veterans by requiring the
    VA to provide state veterans agencies with contact information for
    veterans. One of the DAV's findings in its report was that information
    on veteran programs and eligibility is often difficult to access and
    scattered across various programs or Web sites. Increasing outreach to
    women veterans though collaboration with VA state agency partners is
    vital.
        Finally, my bill mandates a new comprehensive GAO study of the VA's
    ability to meet the needs of women veterans, including an examination
    of wait times, gender-specific care availability, VA training,
    differences in health outcomes, and security and privacy within VA
    facilities.
        During my own military career, I have witnessed quite a number of
    challenges that the military has had to confront. Each time, it
    overcame the obstacles, and always emerged as a more effective fighting
    force. I have full confidence that the VA can do the same.
        I hope my bill can jump-start the cultural sea change required at
    VA to ensure our women veterans are provided the same benefits they
    earned in service to our nation just like their male counter-parts.
        I'm grateful for the support many of our nation's veterans and
    Veteran Service Organizations have provided for this bill, and I urge
    all of my colleagues on the Committee today to join me in this effort.

                                     ---------

         Prepared Statement of the Hon. Charles W. Boustany, Jr., M.D.

        Chairman Benishek, Ranking Member Brownley and Subcommittee
    Members:
        First, thank you to Chairman Benishek, Ranking Member Brownley and
    all Subcommittee members for inviting me to testify before you today.
    As the Committee considers reforms to Department of Veterans Affairs'
    operations, I appreciate the opportunity to speak on behalf of my
    legislation, H.R. 1862, the Veterans' Credit Protection Act.
        Unfortunately, the VA's long history of delayed payments has
    brought me here today. Too many veterans are forced to contact my
    office to resolve credit issues caused by the VA's refusal to pay
    claims for emergency medical care. When these brave Americans require a
    trip to the emergency room because they believe their lives are in
    danger, the last thing on their minds should be fear that the VA will
    fail to pay their claims.
        One such veteran, Mr. Al Theriot of Abbeville, LA, waited over two
    years for the VA to finally process and pay his emergency medical care
    bills, which the Agency only did after Mr. Theriot contacted my office
    and appeared on local television twice to describe his experiences.
    This is absolutely unacceptable.
        I submitted documentation from the VA to the Subcommittee in early
    June demonstrating the scale of this problem. To reiterate those
    findings, as of data provided to me in April 2015, the VA's Chief
    Business Office indicated that only 14% of emergency medical care
    claims originating from VISN 16, which includes my home state of
    Louisiana, were being processed within 30 days. In total, the data
    demonstrates a nationwide backlog of over $878 million.
        The Veterans' Credit Protection Act is an important step to rooting
    out the problems within the VA that caused this out-of-control backlog.
        First, my legislation mandates the VA set up a toll-free hotline
    for veterans to report credit issues caused by delayed emergency
    medical care claims. It also requires the VA to conduct outreach
    alerting veterans of how to resolve these issues. Too often, veterans
    tell me they cannot get in touch with the VA, or that the employees
    they speak with cannot adequately answer their questions.
        Creating a dedicated call line and ensuring the VA implements a
    better framework for communicating solutions with veterans is an
    absolutely necessary step toward eliminating the backlog.
        My bill also requires the VA to report annually to Congress on the
    Chief Business Office's effectiveness with respect to timely claims
    processing. Their report must include information on the number of
    veterans who have reported credit issues due to delayed payments, the
    number of proper invoices submitted, the amounts owed on those invoices
    and how long it took the VA to pay those claims.
        In addition to requiring the VA to report on the status of claims,
    H.R. 1862 aims to improve Chief Business Office operations by requiring
    the VA to examine comments made by medical providers regarding the
    claims processing system and delayed payments, and report these
    comments to Congress, along with a description of best practices to
    ensure timely claims payment in the future.
        No veteran should ever have to decide whether or not to sacrifice
    their health and safety to avoid a potential financial burden if the VA
    fails to pay for a trip to the emergency room. I sincerely thank the
    Subcommittee for your efforts to ensure better care of America's
    veterans, and for inviting me to be part of this important discussion.

                     Prepared Statement of Rep. Jeff Denham

        Despite making improvements in the backlog of veterans' care in the
    VA via the CHOICE Act, there remains long wait times for patients to be
    seen within the VA. Eye care clinics staffed by VA doctors of
    optometry, including residents, are among the busiest primary care
    settings in the veterans' healthcare system. As you know, lengthy wait
    times can make it more difficult and even discourage veterans from
    seeking care they need. H.R. 1688 is aimed at improving access to
    primary eye care in the VA by making a modest increase in the number of
    optometry residency positions in the VA. My bill seeks to amend the
    Choice Act by designating 20 of the 1,500 new graduate medical
    education residency positions to the field of optometry.
        Although, VA optometrists provided comprehensive eye exams and
    other essential care to more than 1.2 million veterans last year, the
    need for eye health and vision care is expected to grow further in the
    coming years. Serious eye trauma is the second most common injury among
    those who served in Iraq and Afghanistan, with 16 percent of all
    wounded service members experiencing problems ranging from distorted
    vision to blindness (according to the Armed Forces Health Surveillance
    Center). Additionally, the joint Department of Defense/Department of
    Veterans Affairs Vision Center of Excellence has reported that up to 75
    percent of all traumatic brain injury patients experience vision
    problems.
        The VA is the largest integrated healthcare provider in the country
    and plays a leadership role in defining the education of future doctors
    of optometry. Through its partnerships with affiliated academic
    institutions, the VA optometry residency program has grown to be the
    largest clinical optometry training program and accounts for 50% of the
    profession's residency training. Optometry residents are valuable
    members of the healthcare team; they can provide early diagnosis and
    treatment for such vision threatening conditions as diabetic eye
    disease and neurological disorders, preventing costly procedures and
    rehabilitation later. Also, optometry residents, as members of the
    primary care team of medical providers, screen and refer veterans for
    untreated hypertension, diabetes and other systemic diseases.
        These much needed primary health services are not available at all
    VA medical facilities and the demand outpaces the supply. Increasing
    the number of optometry residents at the VA is one way to enhance the
    VA's ability to address chronic patient care backlogs as well as train
    doctors of optometry in advanced practices. VA officials recently
    recognized the importance of eye exams in keeping veterans healthy and
    active in a March 2015 advisory they issued stating, ``The eye is the
    only place in the human body that a functioning nerve, arteries and
    veins can be viewed without cutting the body open. These are all
    evaluated during the eye examination and reveal a lot about a person's
    general health. Early signs of diabetes, hypertension, atherosclerosis
    and carotid artery stenosis are often detected with an ocular health
    exam, and lead to diagnosis and management of these life threatening
    conditions.''
        Since the VA established its first optometry residency in the
    1970s, the program has proven to be an especially cost-effective force-
    multiplier to boost the eye care team and make veterans healthier and
    more engaged in their own care. I would appreciate your support on H.R.
    1688 to improve access to this important care for our veterans by
    adding 20 additional optometry residents to the VA over the next 10
    years.
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

      The American Academy of Audiology and the American Speech-Language
                                  Association

        Regarding H.R. 353
        The American Academy of Audiology (Academy) and the American
    Speech-Language-Hearing Association (ASHA) respectfully submit this
    joint statement for the record in opposition to H.R. 353, a bill that
    would permit the VA to hire hearing instrument specialists to deliver
    hearing healthcare services that currently can be provided only by or
    under the supervision of a licensed audiologist. While we appreciate
    and support the intent of the bill's sponsors to ensure appropriate
    access to hearing health services by our nation's veterans, we do not
    believe that the legislation will accomplish this goal or address
    problems that may exist related to wait times for hearing aids or
    hearing healthcare services.
        Hearing loss is one of the top service related disabilities for
    veterans and requires complex and comprehensive treatment. While noise-
    induced hearing loss is common, veterans frequently present with
    complex auditory and vestibular pathologies that may be exacerbated by
    tinnitus, traumatic brain injury, or post-traumatic stress disorder.
    This complexity is further intensified by the increased number of
    veterans with combat-related hearing loss.
        The provision of hearing aids is neither simple nor
    straightforward. As with all technologies, the technology of hearing
    aids is becoming increasingly more complex, and the options beyond
    hearing aids, such as streaming capabilities, direct audio input, or
    Bluetooth coupling, are becoming more numerous. Coupled with advances
    in understanding complex ear-brain interactions, the provision of
    hearing aids requires advanced education and training to effectively
    serve our veterans.
        Audiologists are doctoral-level professionals who are qualified to
    evaluate the effects of acoustic trauma and ear injuries on hearing,
    and to diagnose and treat tinnitus, hyperacusis, vestibular issues,
    auditory processing disorders, and hearing loss. Audiologists can
    determine appropriate sound amplification devices and systems as well
    as select, evaluate, fit and verify the performance of all
    amplification devices, including hearing aids. More importantly,
    audiologists are trained to determine the appropriate treatment program
    for hearing loss--which may or may not include hearing aids--and to
    evaluate the effectiveness of the treatment. The VA currently employs
    more than 1,100 audiologists.
        Hearing aid specialists are trained in the fitting of hearing aids.
    While some states require a college-level associates degree as a
    minimum educational requirement to become a hearing aid specialist,
    many states still require only a high school diploma. Further, there
    are no national standards or dedicated curricula that outline the core
    competencies of a hearing aid specialist. In its testimony before the
    committee last year on legislation similar to H.R. 353, the Veterans
    Affairs Administration expressed concern that the lack of standardized
    education for hearing instrument specialists could lead to fragmented
    hearing healthcare services and limit delivery of comprehensive care.
    Given the minimal training required to become a hearing instrument
    specialist in comparison to the rigor of training for an audiologist,
    this provider type is poorly equipped to deliver the level of care that
    veterans require. Veterans would not be well served by expanding the
    list of eligible providers to include hearing aid specialists. Indeed,
    we believe the legislation could result in a compromise in the quality
    of hearing healthcare services that already exists for veterans.
        Another career classification for hearing aid specialists as
    proposed by H.R. 353 is unnecessary and administratively burdensome.
    Hearing aid specialists can now be hired under the Health Aid and
    Technician Series 0640 of title 5. The level of education and training
    for hearing aid specialists is consistent with the knowledge, skills,
    and abilities of health technicians who work in VA audiology clinics
    under the supervision of an audiologist. Many VA audiology health
    technicians are hearing aid specialists. The VA also has the capability
    to contract services from hearing aid specialists ``where timely
    referral to private audiologists or other VHA facilities is not
    feasible or when the medical status of the veteran prevents travel to a
    VHA facility or a private audiologist''. VHA Handbook 1170.02. Section
    1170.02 defines the role of the audiology health technician, in part,
    to increase productivity by reducing wait times, to enhance patient
    satisfaction, and to reduce costs by enabling health technicians to
    perform tasks that do not require the professional skills of a licensed
    audiologist. The job of these technicians includes, for example, checks
    of hearing aids and other amplification devices, trouble shooting and
    minor repairs to hearing aids, ear molds and other amplification
    devices and electroacoustic analysis of hearing aids. No modification
    of existing law is needed for the VA to hire or contract with hearing
    aid specialists, consistent with their scope of practice.
        The Academy and ASHA are aware that the VA Office of Inspector
    General (OIG) report dated February 20, 2014, found that the VA was not
    timely in issuing new hearing aids to veterans or in meeting timeliness
    goals to complete hearing aid repair services. We are hopeful that the
    Veterans Access, Choice, and Accountability Act, enacted on August 7,
    2014, will help to address access to care issues that may exist within
    the VA. Our organizations stand ready to provide assistance to the VA
    and the committee in developing a sustainable and workable system that
    ensures quality care and outcomes to our veterans. To that end, we
    would propose that the committee consider granting the VA the authority
    to hire more audiologists. There is no shortage of audiologists seeking
    employment with the VA. We would also propose that the committee
    consider authorizing additional funding both to hire additional
    audiologists for the VA and to contract with private audiologists.
        The American Academy of Audiology is the world's largest
    professional organization of, by, and for audiologists. The active
    membership of more than 12,000 is dedicated to providing quality
    hearing care services through professional development, education,
    research, and increased public awareness of hearing and balance
    disorders.
        The American Speech-Language-Hearing Association is the national
    professional, scientific, and credentialing association for 182,000
    members and affiliates who are audiologists; speech-language
    pathologists; speech, language, and hearing scientists; audiology and
    speech-language pathology support personnel; and students. ASHA
    supports its members through professional development, research,
    advocacy and public awareness of communication, hearing and balance
    disorders.

                                     --------

                  Children of Vietnam Veterans Health Alliance

        Chairman Benishek, Ranking Member Brownley, and other distinguished
    members of the subcommittee, thank you for the opportunity to share
    Children of Vietnam Veterans Health Alliance's stance on H.R. 353,
    before you today.
        Children of Vietnam Veterans Health Alliance (COVVHA) is committed
    to serving as a voice for the children of Vietnam veterans, including
    second and third generation victims of Agent Orange and Dioxin
    Exposures worldwide. We believe in empowering each other to hold the
    companies and governments responsible for causing so much devastation
    and suffering to our generations.
        On behalf of COVVHA, I am writing to express our appreciation for
    the House Veteran's Affairs Committee Subcommittee on Health's efforts
    on H.R. 353, which would increase veterans' access to hearing
    healthcare services by enhancing the Department of Veterans Affairs'
    (VA) ability to utilize hearing aid specialists.
        In a February 2014 audit of hearing aid services, the VA's Office
    of Inspector General found that new hearing aids were not being issued
    in a timely manner and that the VA was failing to meet its five day
    timeliness goal. Inadequate staffing was partially attributed to the
    delays in hearing service.
        It is particularly troubling that the VA has not created an
    appropriate staffing model to meet the ever growing need for hearing
    services amongst veterans. With hearing loss and Tinnitus continuing to
    be the most prevalent service-connected disabilities affected veterans
    who receive disability compensation, failure to adjust staffing is
    unacceptable.
        This legislation would allow the VA to hire hearing aid
    specialists--an ability the VA currently does not have the authority to
    do--and ask that the VA report back to Congress on an annual basis
    regarding wait times and the number of audiologists, hearing aid
    specialists and hearing techs hired by the VA. It truly is a common
    sense piece of legislation that would help deal with the current
    backlog faced by many of our nation's veterans.
        As you may be aware, COVVHA expressed our support for H.R. 353 in a
    letter addressed to Congressmen Duffy, Ruiz, and Walz on following the
    bills introduction in the 114th Congress and we continue to strongly
    support the bill. We believe that passage of this bill will help those
    Veterans in need of hearing aids, who are unable to access them due to
    physical limitations, long distances to VA facilities, and long wait
    times for appointments.
        Sincerely,
        Kelly L. Derricks,
        Founder and President,
        Daughter of Vietnam Veteran Harry C. Mackel, Jr., U.S. Air Force
    (deceased).

                   International Hearing Society on H.R. 353

        Chairman Benishek, Ranking Member Brownley, and esteemed Members of
    the Subcommittee:
        International Hearing Society thanks you for the opportunity to
    comment on H.R. 353. IHS stands in full support of the bill, which
    would create a new provider class for hearing aid specialists within
    the Department of Veterans Affairs (VA), thereby enabling the VA to
    hire hearing aid specialists to help deliver hearing aid services to
    Veterans. The bill would also require the VA to report annually to
    Congress on appointment wait times and the utilization of providers for
    hearing-related services, which would make the VA's efforts to address
    the backlog more transparent and provide much needed data to inform
    Congress about Veterans' experiences in accessing hearing aid services
    through the VA.
        The International Hearing Society, founded in 1951, is a
    professional membership organization that represents hearing aid
    specialists, dispensing audiologists, and dispensing physicians,
    including the approximately 9,000 hearing aid specialists who practice
    in the United States. IHS promotes and maintains the highest possible
    standards for its members in the best interests of the hearing-impaired
    population they serve by conducting programs in competency
    accreditation, testing, education and training, and encourages
    continued growth and education for its members through advanced
    certification programs.
        The VA continues to see a dramatic rise in the demand for audiology
    services. According to the VA the number of unique Veterans that
    received VA audiology services in FY 2014 was 903,075, an increase of
    19% since 2011, with 52,138 new Veterans in 2014 alone (a 5.8%
    increase).\1/2\ The number of hearing aids ordered per year by the VA
    has also dramatically increased with more than 800,000 ordered in
    2014,\3\ up 34% since 2011.\4\ With tinnitus and hearing loss being the
    two most prevalent service-connected disabilities for veterans
    receiving federal compensation combined with the aging Veteran
    population, the demand will continue to rise. And despite clinical
    audiologist-hiring within the VA following a similar growth track with
    a 26% increase in staffing between 2011 and 2015,\5\ the high demand
    and subsequent backlog continue to affect the VA's ability to deliver
    timely and high-quality hearing healthcare.\6\
    ---------------------------------------------------------------------------
        \1\ David Chandler, PhD, ``Perspective from Department of Veterans
    Affairs,'' Presentation to the Institute of Medicine's Committee on
    Accessible and Affordable Hearing healthcare for Adults, April 27,
    2015. Lucille Beck, PhD, ``Meeting the Challenges of VA Audiology Care
    in the 21st Century,'' presentation to the Association of VA
    Audiologists, March 19, 2012.
        \3\ Chandler, ``Perspective from Department'' (see footnote 1).
        \4\ Beck, ``Meeting the Challenges'' (see footnote 2).
        \5\ Chandler, ``Perspective from Department'' (see footnote 1).
        \6\ Beck, ``Meeting the Challenges'' (see footnote 2).
    ---------------------------------------------------------------------------
        IHS and its members have a great deal of respect for VA
    audiologists. They provide a wide variety of critical services to our
    Veterans, including compensation and pension exams (over 151,000
    performed in 2012),\7\ programming and providing support for cochlear
    implant implantation and use, vestibular (balance) disorder services,
    tinnitus services, hearing conservation, hearing aid services and
    assistive device use, and advanced hearing testing. They also partner
    with several medical disciplines and are part of the Traumatic Brain
    Injury and Polytrauma teams, addressing balance and auditory issues.
    Further, VA audiologists also responsible for training and supervising
    audiology health technicians.
    ---------------------------------------------------------------------------
        \7\ VA Office of Inspector General, ``Audit of VA's Hearing Aid
    Services,'' February 20, 2014.
    ---------------------------------------------------------------------------
        The high demands on VA audiologists' time and expertise means that
    the VA is not currently able to meet all Veterans' needs for hearing
    healthcare services. To that point, in February 2014, the VA Inspector
    General released a report, ``Audit of VA Hearing Aid Services'' that
    found that ``during the 6-month period ending September 2012, VHA
    issued 30 percent of its hearing aids to veterans more than 30 days
    from the estimated date the facility received the hearing aids from its
    vendors.'' The audit also found that deliveries of repaired hearing
    aids to Veterans were subject to delay partially due to ``inadequate
    staffing to meet an increased workload, due in part to the large number
    of veterans requiring C&P audiology examinations.'' Further, in an
    April 2015 presentation to the Institute of Medicine's Committee on
    Accessible and Affordable Hearing healthcare for Adults, VA
    Rehabilitation and Prosthetic Services Department Chief Consultant,
    David Chandler, PhD, cited that ``nearly half of all patients awaiting
    care in the VA are for audiology services.''
        In a practical sense, as a result of the backlog and delays, many
    Veterans are experiencing long wait times for appointments, shortened
    appointments, and limited follow-up care and counseling. Hearing aid
    specialists are observing an increase in the number of Veterans who
    seek care in their private offices as well. These Veterans request
    hearing aid specialists' help with hearing aid adjustments and repairs,
    oftentimes because they do not want to wait for the next available VA
    appointment, which may be months away, or because the distance to the
    closest VA facility that offers audiology services is too far to
    travel. There are also many Veterans who choose to purchase hearing
    aids at their own expense through a private hearing aid specialist,
    rather than using the benefits they've earned and are entitled to,
    because they want to work with someone local who they trust and ensure
    their hearing aids are properly programmed, address their loss, and can
    be adjusted or repaired in a timely fashion. This relationship also
    enables them to obtain support from their hearing professional on
    demand, which is important to those with daily commitments or who are
    employed, and is especially critical to those who are new users of
    hearing aids. For a point of reference, in the private market, a new
    user would typically see their hearing aid specialist 4-6 times in the
    first three to six months to help them to adapt to a hearing world and
    optimize their success with hearing aids.
        Considering the safety risks involved as well as the impact
    untreated hearing loss can have on one's personal relationships and
    mental well-being, the VA needs an immediate solution to deal with the
    backlog and get Veterans the help they need. We also know that our
    working-age Veterans are anxious to contribute to society through
    employment, and properly fit and programmed hearing aids are necessary
    for their success in obtaining and maintaining meaningful employment.
        H.R. 353 provides the VA a much needed solution by creating a new
    provider class for hearing aid specialists to work within the VA.
    Hearing aid specialists can help the VA hearing healthcare team by
    providing hearing aid evaluations; hearing aid fittings and
    orientation; hearing aid verification and clinical outcome
    measurements; customary after care services, including repairs,
    reprogramming and modification; and the making of ear impressions for
    ear molds--just as they are currently authorized to do in the VA's fee-
    for-service contract network.
        By adding hearing aid specialists to the audiology-led team to
    perform these specialized hearing aid services independently,
    audiologists will be able to focus on Veterans with complex medical and
    audiological conditions, as well as perform the disability evaluations,
    testing, and treatment services for which audiologists are uniquely
    qualified to provide--thereby maximizing efficiency within the system
    and supporting the team-based approach, a common model in the private
    market. Adoption of the hearing aid specialist job classification at
    this juncture will also be advantageous given the fact that VA
    Audiology and Speech Pathology Service management will be developing
    staff and productivity standards as a result of the Inspector General's
    audit and recommendations,\8\ and would be able to consider the use of
    hearing aid specialists as they develop their model.
    ---------------------------------------------------------------------------
        \8\ VA Office of Inspector General report ``Audit of VA's Hearing
    Aid Services,'' February 20, 2014.
    ---------------------------------------------------------------------------
        Also, by virtue of the report language in H.R. 353, which would
    shine a light on the VA's utilization of hearing aid specialists in its
    contract network, it is our hope that the VA would take better
    advantage of this willing and able provider type to help address the
    need for hearing aid services. To open up additional points of access,
    the VA can and should eliminate unnecessary policy restrictions that
    impact VA clinics' abilities to utilize hearing aid specialists in the
    contract network.

    Hearing Aid Specialist Qualifications

        Hearing aid specialists are regulated professionals in all 50
    states and in the non-VA market, hearing aid specialists perform
    hearing tests and dispense approximately 50% of hearing aids to the
    public. They are licensed/registered to perform hearing evaluations,
    screen for the Food and Drug Administration (FDA) ``Red Flags''
    indicating a possible medical condition requiring physician
    intervention, determine candidacy for hearing aids, provide hearing aid
    recommendation and selection, perform hearing aid fittings and
    adjustments, perform fitting verification and hearing aid repairs, take
    ear impressions for ear molds, and provide counseling and aural
    rehabilitation.
        Training for the profession is predominantly done through an
    apprenticeship model, an accepted and appropriate path given the hands-
    on and technical skill involved in the profession. And while licensure
    requirements vary from state to state, in addition to the
    apprenticeship experience, candidates generally must hold a minimum of
    a high school diploma or an associate's degree in hearing instrument
    sciences. These requirements merely create a floor, evident in the fact
    that 87% of hearing aid specialists have obtained some college
    coursework, or an associates or higher academic degree.\9\ In nearly
    every state, candidates must pass both written and practical
    examinations, and in many states a distance learning course in hearing
    instrument sciences is required or recommended. Ultimately, when making
    hiring decisions, the VA will have the ability to determine which
    candidates meet their needs.
    ---------------------------------------------------------------------------
        \9\ International Hearing Society, Health Policy and Payment
    Survey, June 2013.
    ---------------------------------------------------------------------------
        Hearing aid specialists are already recognized by several Federal
    agencies to perform hearing healthcare services. The Standard
    Occupational Classification (SOC) identifies hearing aid specialists
    within the Healthcare Practitioners and Technical Occupations category
    (29-2092), and the Federal Employee Health Benefit program and Office
    of Policy and Management support the use of hearing aid specialists for
    hearing aid and related services. And while Medicare does not cover
    hearing testing for the purpose of recommending hearing aids (a policy
    that applies to all dispensing practitioners), hearing aid specialists
    provide hearing testing, hearing aids, and related services for state
    Medicaid programs around the country. Further, most insurance companies
    contract with hearing aid specialists to provide hearing tests and
    hearing aid services for their beneficiaries.
        Finally, evidence shows that there is no comparable difference in
    the quality and outcomes of hearing aid services based on site of
    service or type of provider (audiologist or hearing aid specialist). A
    well-respected industry study found that instead the best determinant
    of patient satisfaction is whether the provider used best practices
    like fit verification, making adjustments beyond the manufacturer's
    initial settings, providing counseling, and selecting the appropriate
    device for one's loss and manual dexterity.\10\
    ---------------------------------------------------------------------------
        \10\ MarkeTrak VIII: The Impact of the Hearing Healthcare
    Professional on Hearing Aid User Success, The Hearing Review, Vol 17
    (No.4), April 2010, pp. 12-34.

    ---------------------------------------------------------------------------
    VA Strategies to Address Demand

        To address the demand for audiology and hearing aid services, the
    VA has been relying on the use of teleaudiology, audiology health
    technicians, and contract audiologists outside the VA setting. While
    IHS applauds the VA for its efforts to better serve the needs of
    Veterans, each of these strategies has its limitations. Though
    teleaudiology can make audiological services more available in remote
    settings, the cost of staffing and facilities are needlessly high,
    especially given that hearing aid specialists have fully-equipped
    offices, oftentimes operate in rural settings, and perform home and
    nursing home visits. Audiology health technicians have a very limited
    scope of duties, which does not include hearing aid tests or the
    fitting and dispensing of hearing aids, and they must be supervised by
    audiologists. Hiring hearing aid specialists to work as health
    technicians, as the VA currently does, significantly limits their role
    and effectiveness. Finally, increased reliance solely on audiologists
    may also limit access as there are not enough audiologists to fill the
    current and future need for hearing care services. In order to fill the
    need, the number of licensed audiologists needs to double in size
    within the next 30 years to 32,000; however only about 600 are entering
    the profession annually. Even the best case scenarios for increasing
    the number of graduates and reducing attrition still fall short.\11\
    ---------------------------------------------------------------------------
        \11\ Demand for Audiology Services: 30-Yr Projections and Impact on
    Academic Programs, Journal of the American Academy of Audiology, Ian A.
    Windmill and Barry A. Freeman, 24:407-416, 2013.
    ---------------------------------------------------------------------------
        In a June presentation, VA Deputy Chief Patient Care Services
    Officer for Rehabilitation and Prosthetic Services, Dr. Lucille Beck,
    PhD, cited several barriers to the delivery of hearing healthcare
    services for the VA, including ``Some VA sites having space constraints
    that challenge expansion of current audiology services'', ``Some
    veterans are very old or sick and cannot travel outside of the home'',
    and ``Lack of developed hearing healthcare networks and standards for
    VA to partner with the community.'' In each of these areas, hearing aid
    specialists, both internally and through their expanded use in the fee-
    for-service network can help.
        As the federal government seeks to become more efficient and cost-
    effective, we urge the Subcommittee to pass H.R. 353, which will round
    out the VA hearing healthcare team to mirror the private-market model,
    and increase Veterans' access to care, improve overall quality, and
    reduce cost. Again, using hearing aid specialists as health technicians
    is not the answer; this limits service delivery and underutilizes the
    skills and expertise hearing aid specialists can offer to the VA
    hearing healthcare team. Now is the time to embrace hearing aid
    specialists in the role they are trained and licensed to play to help
    meet the hearing healthcare needs of our Veterans, which will only
    continue to rise in the coming years.
        Thank you for your consideration and for your service to our
    Veterans. With questions, please contact government affairs director
    Alissa Parady at 571-212-8596 or aparady@ihsinfo.org.

     National Medical Association, Submitted by Lawrence Sanders, Jr., MD,
                                      MBA

        On behalf of the National Medical Association (NMA), I am pleased
    to express our support for H.R. 353, aimed at improving hearing
    healthcare services and outcomes for our nation's Veterans. We
    acknowledge that Veterans' hearing healthcare needs could be better
    served through increased access to services and improved quality of
    care, and believe that hearing aid specialists can help accomplish this
    goal. Specifically, we support the inclusion of hearing aid specialists
    as a provider class within the Department of Veterans Affairs (VA). NMA
    also supports the lifting of restrictions that currently limit the
    circumstances in which the VA can contract with hearing aid specialists
    to provide hearing aid services to VA-eligible Veterans, and in doing
    so create parity with audiologists for the provision of VA-hearing aid
    services.
        Founded in 1895, the NMA is a national, professional and scientific
    organization representing over 30,000 African American physicians who
    are committed to improving the quality of health among minorities and
    disadvantaged people through its membership, professional development,
    community health education, advocacy, research and partnership with
    federal and private agencies. The NMA advocates for policies that would
    assure equitable and quality healthcare for all people.
        Hearing aid specialists are a member of the hearing healthcare
    team, comprised of otolaryngologists, audiologists, and hearing aid
    specialists; and are credentialed by all 50 states through licensure to
    perform hearing tests and provide hearing aid dispensing and fitting
    services. By integrating this team member into the VA provider system
    and utilizing the team-based approach, NMA believes service delivery
    can become more efficient and effective for the Veterans who are
    currently enrolled and those who will be transitioning into the VA
    system in the years to come. Further, increasing the external network
    of VA hearing healthcare providers to include hearing aid specialists
    would improve Veterans' access to convenient, comprehensive, and timely
    care; and would provide them the standard of care that currently exists
    in the public marketplace.
        It is for the aforementioned reasons, that the National Medical
    Association respectfully urges the Subcommittee and full Committee to
    pass H.R. 353 favorably. Thank you.
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